1) The document discusses sialoendoscopy-assisted sialolithotomy for removing submandibular hilar calculi. 2) It describes the anatomy and diseases of salivary glands, classification of salivary gland stones, and presents several case studies treated with sialoendoscopy. 3) The conclusion is that sialoendoscopy-assisted intraoral removal is a safe and effective gland-preserving technique for patients with large stones located at the hilum of Wharton's duct.

1. SIALOENDOSCOPY – ASSISTED
SIALOLITHECTOMY FOR
SUBMANDIBULAR HILAR
CALCULI
BY
A.BALAJI ,.
DEPT OF OMFS

2. INTRODUCTION
CLASSIFICATION OF SALIVARY GLANDS
FUNCTIONS
ANATOMY
DISEASES

3. CLASSIFICATION
MAJOR
They are paired
glands
OF SALIVARYGLANDS
MINOR
parotid
sub
mandibular
sublingual
They are numerous
widely distributed in the
oral cavity.
600 to 1000 in no. mostly
located at junction of soft
and hard palate

4. Parotid
Gland
Secretions
Are
Serous
In
nature
Sub mandibular
gland
Mixed
But
Mostly
Serous
Sublingual
gland
Mixed
Both
Mucous
And
Serous,
Mostly
Mucous.

5. SALIVA
 1500 ML per day
 PH VALUE:
 RESTING GLAND -7
 ACTIVE SECRETIONS
IS ABOUT 8
FUNCTIONS
 Lubrication for
speech
 Helps in
swallowing and
mastication
 Digestive
properties
 Antibacterial
Immunological
properties

6. COMPOSITIONS
 ORGANIC
proteins
urea
uric acid
lysozymes
IgA
Amylase
 INORGANIC
Sodium
potassium
chloride
bicarbonate
calcium
phosphate

7. EMBROYOLOGY
 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.

9.  Around 7 th or 8 th month in utero secretary
cells called acini begin to develop around
ductal system.
 Acinar cells are classified as
serous cells –produce thin watery serous
secretions.
mucous cells-produce thicker mucous
secretions.

10. Anatomy of submandibular
salivary gland
 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
anteriorly-mylohyoid muscle
middle part-hyoglossus
posteriorly-wall of pharynx

11. ANATOMY OF SUBMANDIBULAR
SALIVARY GLAND

12. surfaces
 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
part.
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.

13. PICTURE SHOWING
SUBMANDIBULAR SALIVARY
GLAND ,WHARTONS DUCT AND
ITS CORELATION WITH
ADJOINING STRUCTURES
Stylohyoid ligament
Inferior alveolar nerve, vessels
Nerve to mylohyoid
Submandibular salivary gland
Sublingual salivary gland
Medial pterygoid
Mylohyoid
genioglossus
Lingual nerve
Anterior belly of digastric

14. 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
nerve.
BLOOD SUPPLY -Branches of facial and lingual
artery
LYMPHATICS – drains into submandibular lymph
nodes ,through them into deep cervical
lymphnodes ,particularly jugulo-omohyoid node.

15. INNERVATION OF FACIAL NERVE TO SMS GLAND

16. INTER RELATIONSHIP BETWEEN DUCTAL
SYSTEM AND LINGUAL NERVE

17. LATERAL VIEW

18. Additional relationships
 Gland is covered by 2 layers of fascia formed
by splitting of investing layer of deep cervical
fascia.
 Superficial layer covers the inferior surface of
the gland and attaches to the lower border of
the mandible.
 Deeper layer covers the medial surface and is
attached to the mylohyoid line of the
mandible.

19. WHARTONS DUCT•2-4mm in diameter & about 5cm in length.
•It opens into the floor of the mouth thru a
punctum.
•The punctum is a constricted portion of the
duct to limit retrograde flow of bacteria-laden
oral fluids.
•Duct arises in the deep lobe and runs antero
medially ,Lingual nerve crosses the duct
inferiorly, after immediately arising from deep
lobe.

21. Some terminologies
 Sialolith-salivary calculi.
 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
saliva
 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

22.  SCINTIGRAPHY-the production
of,
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
camera,(gamma camera).
 LITHOTRIPSY-procedure involving the usage
of high energy shock waves to fragment and
disintegrate or destruct the calculi.

23. sialolith
 They are calcified structure develop with in
ductal system of major and minor salivary
glands.
 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
lumen.

24. Sialoliths continue ……
 These debris may include inspissated mucus
, bacteria , ductal epithelial cells or foreign
bodies (coagulated).
 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
phosphate ratio.
 Mucous Secretions are more viscous.

25. Pathophysiology
 Dehydration
 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
Viridans.

26. ETIOLOGY OF SIALOLITHS
 EXACT CAUSE OF SIALOLITH FORMATION IS
NOT KNOWN,
 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.

27. Signs and symptoms
 Pain and swelling are exacerbated during




mealtimes
Check for flow of whartons duct
Check for tenderness of submandibular
salivarygland
Palpate for stone in floor of the mouth
Check mandibular occlusal radiograph

28. TREATMENT
 Conservative






Warm compresses
Sour candy
Pain relief- analgesics
Oral fluids
Discontinue anti-histamines
Oral antibiotics- Cefalexin 500mg PO QID X 7d.
 Surgical




Wire basket retrieval under fluoroscopy.
Duct cannulation
Gland removal for recurrent cases
SIALOLITHECTOMY
 Lithotripsy (extra corporeal shockwave lithotripsy)

29. Sialoendoscope ,lithotriper

30. PURPOSE
 TO ACESS THE CLINICAL EFFECTS OF
ENDOSCOPY ASSISTED SIALOLITHECTOMY
FOR SUBMANDIBULAR HILAR CALCULI

31. MATERIALS AND METHODS
 STUDY WAS TAKEN IN 70 PATIENTS WITH
SYMPTOMATIC STONES IN HILUM OF
SUBMANDIBULAR SALIVARY GLANDS.
 FROM : DECEMBER 2005 THROUGH MARCH
2011.
 OPERATIVE DATA WERE ANALYZED
RETROSPECTIVELY AND FOLLOWED
PERIODICALLY POSTOPERATIVELY.
 GLAND FUNCTION WAS INVESTIGATED BY
POST OPERATIVE SYMPTOMS,CLINICAL
EXAMINATIONS,SIALOGRAPHY,AND
SCINTIGRAPHY.

32. DIAGNOSIS
 BY, ONE OR A COMBINATION OF
RADIOGRAPHIC INDICATORS
 CROSS SECTIONAL MANDIBULAR
OCCLUSAL FILMS
 LATERAL PROJECTIONS OF GLAND
 CONE BEAM COMPUTED TOMOGRAPHY

33. CASE SELECTION
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
EXCLUDED

34. SIALOENDOSCOPY
 LADUSCOPE T FLEX PD-HS-0250





ENDOSCOPE
HIGLY FLEXIBLE ,SEMIRIGID ENDOSCOPE
WITH NITINOL SHEATH
80 MM LONG
1.1mm OUTER DIAMETER
0.4 mm WORKING LENGTH CHANNEL
SEPARATE CHANNEL FOR IRRIGATION

35. PROCEDURE
 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.

36. 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.

37. TREATMENT
 Amoxicillin or cefaclor was administrated for 7
days.
 Hydration was achieved by the patient
drinking more than 2 liters of water a day , and
patient advised to avoid sialogogues and spicy
foods.
 After stent and sutures were removed
,frequent self massaging and sialogogues were
recommended.

38. FOLLOW UP
 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
on massage.

39. Siolography
 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.

40. A-Lateral view x-ray showing
large stone
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

41. Different case reports

43. CONCLUSION
 SIALOENDOSCOPY ASSISTED INTRA ORAL
REMOVAL IS SAFE AND EFFECTIVE GLANDPRESERVATION TECHNIQUE FOR PATIENTS
WITH LARGE CALCULI AT HILUM OF THE
WHARTONS DUCT .

44. A short movie…by use of
endoscopy assisted
lithotripsy with a
lithotripter