Deep part- passes in interval between the mylohyoid ( laterally ) hyoglossus (medially)
INTER RELATIONSHIP BETWEEN DUCTAL SYSTEMS
STONES WERE VERIFIED TO BE IMPACTED AFTER HILIUM OF THE WHARTONS DUCT UNDER ENDOSCOPIC VIEWAMNEABLE TO BASKET RETRIVAL WERE EXCLUDED
Thereafter the entire duct was re-explored for remnant stones or mucous plugs Hilum then sutured after 4Fr angio catheter had been inserted as a stent, Stent left in situ for 1-2 weeks after surgery.
SIALOENDOSCOPY – ASSISTED
DEPT OF OMFS
CLASSIFICATION OF SALIVARY GLANDS
They are paired
They are numerous
widely distributed in the
600 to 1000 in no. mostly
located at junction of soft
and hard palate
1500 ML per day
RESTING GLAND -7
IS ABOUT 8
All salivary glands develop from embryonic oral
cavity as buds of epithelium that extends into
underlying mesenchymal tissues
These epithelial ingrowths or anlages ,are
apparent at 8 weeks gestation and then branch
to form a primitive ductal system and eventually
become canalized to provide structural salivary
gland unit for drainage of salivary secretions.
This unit consists of a myoepithelial cell ,
intercalated duct , striated duct ,excretory duct.
Around 7 th or 8 th month in utero secretary
cells called acini begin to develop around
Acinar cells are classified as
serous cells –produce thin watery serous
mucous cells-produce thicker mucous
Anatomy of submandibular
Divided into Superficial and deep part
Location-digastric triangle(formed by
anterior and posterior belly of digastric
muscles and inferior border of the mandible)
Surfacesmedial surface rests
posteriorly-wall of pharynx
Inferior surface-is superficial, seen in digastric
triangle, directed downwards and laterally.
Lateral surface-is hidden from view of
mandible, divided into anterior and posterior
Anterior part –lies in contact with medial
surface of body of mandible below the
attachment of mylohyoid muscle.
Posterior part-separated from body of mandible
by medial pterygoid muscle.
GLAND ,WHARTONS DUCT AND
ITS CORELATION WITH
Inferior alveolar nerve, vessels
Nerve to mylohyoid
Submandibular salivary gland
Sublingual salivary gland
Anterior belly of digastric
Deep part - passes in interval between the
mylohyoid ( laterally ) hyoglossus (medially)
NERVE SUPPLY -Submandibular gland is
innervated by the facial nerve through
submandibular ganglion via chorda tymphani
BLOOD SUPPLY -Branches of facial and lingual
LYMPHATICS – drains into submandibular lymph
nodes ,through them into deep cervical
lymphnodes ,particularly jugulo-omohyoid node.
Gland is covered by 2 layers of fascia formed
by splitting of investing layer of deep cervical
Superficial layer covers the inferior surface of
the gland and attaches to the lower border of
Deeper layer covers the medial surface and is
attached to the mylohyoid line of the
WHARTONS DUCT•2-4mm in diameter & about 5cm in length.
•It opens into the floor of the mouth thru a
•The punctum is a constricted portion of the
duct to limit retrograde flow of bacteria-laden
•Duct arises in the deep lobe and runs antero
medially ,Lingual nerve crosses the duct
inferiorly, after immediately arising from deep
Sialolithiasis-process of formation of salivary calculi.
Sialography or sialogram-repeated radiographic
examination of salivary glands after injection of contrast
medium into the salivary duct.
Sialochemistry-examination of electrolyte composition of
Sialoendoscopy-specialized procedure that uses a small
video camera with a light at the end of the flexible
canula, which is introduced into the ductal orifice.
Sialometry-is a measure of salivary flow
2 – dimensional images of
distribution of radio activity in the tissues
after internal administration of a
radiopharmaceutical imaging agent ,the
images are obtained by a scintillation
LITHOTRIPSY-procedure involving the usage
of high energy shock waves to fragment and
disintegrate or destruct the calculi.
They are calcified structure develop with in
ductal system of major and minor salivary
Major cause of both-chronic recurring
sialadenitis ,acute suppurative sialadenitis.
Stones composed of inorganic calcium and
sodium phosphate salts.
They are believed to arise from deposition of
these salts around nides of debris with in duct
Sialoliths continue ……
These debris may include inspissated mucus
, bacteria , ductal epithelial cells or foreign
Prevalent in men than women ratio. 2:1.
Peak incidence age = 30-40 years.
Submandibular gland involvement is 80 %.
PH value of these secretion is 6.8-7 %.
Increased concentration of calcium and
Mucous Secretions are more viscous.
Concentration of saliva
Fasting or Anorexia
Stasis of saliva
Drugs- Anti-histamines, Anti-cholinergics.
Decrease production of saliva
Stone can cause stasis of saliva and subsequent
bacterial ascent into the gland.
Infection most commonly from S. aureus or Strep
ETIOLOGY OF SIALOLITHS
EXACT CAUSE OF SIALOLITH FORMATION IS
But 3 prerequisites stand out as primary etiology
1) NEUROHUMORAL CONDITION> leading to
salivary stagnation .
2) A nidus or matrix for stone formation.
3)some metabolic mechanism may favors
precipitation of salivary salts into the matrix in the
presence of coexisting inflammation.
4) long tortuous duct and situated lower level than
its orifice ,so increased salivary stagnation, so
increased calculus formation.
Signs and symptoms
Pain and swelling are exacerbated during
Check for flow of whartons duct
Check for tenderness of submandibular
Palpate for stone in floor of the mouth
Check mandibular occlusal radiograph
TO ACESS THE CLINICAL EFFECTS OF
ENDOSCOPY ASSISTED SIALOLITHECTOMY
FOR SUBMANDIBULAR HILAR CALCULI
MATERIALS AND METHODS
STUDY WAS TAKEN IN 70 PATIENTS WITH
SYMPTOMATIC STONES IN HILUM OF
SUBMANDIBULAR SALIVARY GLANDS.
FROM : DECEMBER 2005 THROUGH MARCH
OPERATIVE DATA WERE ANALYZED
RETROSPECTIVELY AND FOLLOWED
GLAND FUNCTION WAS INVESTIGATED BY
POST OPERATIVE SYMPTOMS,CLINICAL
BY, ONE OR A COMBINATION OF
CROSS SECTIONAL MANDIBULAR
LATERAL PROJECTIONS OF GLAND
CONE BEAM COMPUTED TOMOGRAPHY
INCLUSION CRITERION WAS THAT ,THE STONES
WERE SITUATED AT OR PROXIMES TO THIRD
MANDIBULAR MOLAR REGIONS
STONES WERE VERIFIED TO BE IMPACTED
AFTER HILIUM OF THE WHARTONS DUCT
UNDER ENDOSCOPIC VIEW
AMNEABLE TO BASKET RETRIVAL WERE
LADUSCOPE T FLEX PD-HS-0250
HIGLY FLEXIBLE ,SEMIRIGID ENDOSCOPE
WITH NITINOL SHEATH
80 MM LONG
1.1mm OUTER DIAMETER
0.4 mm WORKING LENGTH CHANNEL
SEPARATE CHANNEL FOR IRRIGATION
Main duct of the gland is explored and induction
of endoscope done by persistent irrigation.
Small and mobile stones at distal or middle part
of the duct were removed by basket entrapment.
Impacted hilar stones were then removed by as
endoscopy assisted sialolithectomy technique.
After the stone was verified ,a 2-3 cm incision
was made in the floor mucosa according to the
light transmitted through endoscope.
As the assistant raised the floor of the mouth with
digital pressure in submandibular triangle.
The duct was isolated from the surrounding tissues
with particular care to avoid damage to lingual nerve.
Then the hilum was incised at the precise location of
the stone and the stone was removed.
Thereafter the entire duct was re-explored for
remnant stones or mucous plugs
Hilum then sutured after 4Fr angio catheter
had been inserted as a stent, Stent left in situ for
1-2 weeks after surgery.
Amoxicillin or cefaclor was administrated for 7
Hydration was achieved by the patient
drinking more than 2 liters of water a day , and
patient advised to avoid sialogogues and spicy
After stent and sutures were removed
,frequent self massaging and sialogogues were
post operative Clinical assessment was done,
to diagnose, any recurrence and
changes in size of the gland .
Consistency of the affected gland.
Appearance of the ostium ,and the amount
and the nature(clear or milky) of salivary flow
Sialography of submandibular salivarygland
was performed with water soluble contrast
agent , diatrizoate meglumine, using a closed
intravenous catheter (22 gauge),.
After catheter was introduced ,1.5 to 2ml of
contrast solution was injected carefully.
Lateral views and 5-min emptying film were
taken , and appearance of main ducts, branch
ducts and parenchyma were analyzed.
A-Lateral view x-ray showing
B-Stone was removed
through an incision at the
genu of whartons duct
C-Extracted stone fragments
D-Six month follow up
sialogram shows proximal
duct dilation (filling film)
E-No persistent contrast
opacified on functional film