This case report describes a 22-year-old male presenting with a painful swelling in the right submandibular region for 7 days that was aggravated by eating. Clinical examination revealed a sublingual hard mass that was mobile with an irregular surface. Ultrasound showed a sialolithiasis measuring 20 x 8 mm in the right Wharton's duct with secondary sialadenitis of the right submandibular gland. The patient underwent transoral excision of the sialolithiasis and was discharged after recovery with no complications.

1. A Case of
Submandibular Swelling
Arun S Nair

2. Presinting Complaints
• 22/M
• Non smoker / doesn’t consume alcohol admitted on 20 Jan 2014
• Painful swelling sub mandibular region R
• last 7 days
• aggravated by eating

3. No H/o
• Fever
• Trauma
• Significant wt loss
• Purulent discharge
• Tooth Caries

4. Past h/o
• Similar complaints in the past during school/colleg days
• Relieved by massaging over the area

5. Clinical examination
• Pulse : 86/min
• BP : 110/76mmHg
• Temp : afebrile
• RR : 16/min
• No Pallor

6. • Local examination
• Swelling +
• Tenderness
• Bimanual palpation Sublingual hard mass
• Mobile
• Irregular surface
• Systemic examination .. NAD

7. • Blood
• Hb 16.2
• TLC 6400
• DLC N56 L34 M07 E08
• Plt 185000

8. USG
• S/O sialolithiasis (20 × 8 mm) R Wharton’s Duct with sialoadenitis R
SM gland

9. Diagnosis
Sialolithiasis with secondary Sialadenitis R SM Gland

10. Treatment
• Adequate analgesics
• Transoral excision ↓ LA on 23 Jan 2014
• Post OP
• DOD 31 Jan 2014

13. TOPIC DISCUSSION
Sialolithiasis

14. Sialolithiasis (salivary calculi) the presence of stones in the
salivary glands or ducts
• Cacium , phosphate and carbonate , combined with other salts (Mg,Zn,NH3) and
organic material
• 80 to 92 % submandibular
• 6 to 20 % parotid
• 1 to 2 % sublingual as well as minor
• 1 percent incidence is noted in autopsy studies
• M:F = 2:1
• 75 % single
• 3 % bilateral

15. Factor predisposing to Submandibular Sialolithiasis
• Anatomy
1.Lengthy and irregular course of Wharton’s duct
2.Position of ductal orifice
3.Size of orifice smaller than duct lumen
• Physiological
1.High mucin content
2.Alkaline pH
3.High phosphate & calcium

16. Etiology
•Relative stagnation & Concentration of saliva
• 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.
• Most commonly S. aureus or Strep Viridans.
• Trauma / Stricture

17. Stasis of saliva
Duct obstruction
Reduce salivary secretion
Stricture
Stone
Trauma
Oral infection
Cystic fibrosis
Dehydration
Anticholinergic drug
Lack of oral intake

18. • Symptoms
• colicky postprandial pain and swelling
• Local swelling & tenderness at ductal opening if the stone is superficially
• Secondary infection ---> duct stricture
• Diagnosis
• History and Bimanual palpation of duct
• Diagnostic imaging

19. Imaging studies
• Plain films
• Submandibular calculi radiopaque in 80 to 95 % of cases.
• Parotid calculi are radiopaque in 60 % of cases
• Sialography
• Duct is cannulated and radiopaque dye is injected, followed by plain films.
• Invasive & technically demanding
• Contraindicated in patients with acute sialadenitis or contrast allergy.
• May help facilitate a diagnosis other than sialolithiasis such as stricture, sialectasis, and
cystic degeneration of the duct and gland

20. Imaging studies
• Ultrasound
• Stones of 2 mm in diameter or larger
• Better assessment of periglandular structures
• Advantage; Radiolucent stones or radiopaque stones that are superimposed on bone
• Magnetic resonance imaging
• Standard MRI will not visualize stones
• Visualize ducts as an alternative to conventional sialography
• No intraductal contrast is required for MR sialography
• Superior sensitivity compared with ultrasound

21. TREATMENT
•Conservative
• < 2mm often pass on their own
• Hydration
• Moist heat
• Massage the gland & milk the duct
• Sialogogues
• Lemon drops
• Bitter/tart hard candies
• d/c Anti-cholinergics / Anti-histamines
• Antibiotics & Analgesics

22. Surgery
• Excision
• Transoral
• Transcervical
• Sialadenectomy
• Recurrent cases only
• chance of facial nerve injury
• Parotidectomy ; 29%
• Submandibular; 12%
• Sialoendoscopy
• Laser lithotripsy via endoscope
• Can reach even small stones not accessible by transoral approach
• < 3mm in the parotid
• < 4mm in the submandibular gland

23. Extracorporeal Shockwave lithotripsy
Effective for stones
that are intraductal
and less than 7 mm &
identifiable by USG

24. Interventional Radiology
• Wire basket retrieval under
fluoroscopic guidance
• Best for extraglandular & Mobile
stones

25. Complications
• Sialadenitis
• Abscess
• Gland Atrophy
• Reccurance

26. D/D
• Viral sialadenitis — Viral parotitis due to mumps virus is characterized by acute pain and
swelling of one or both parotid glands.
• Most common cause of parotid gland swelling.
• Infection is accompanied by a nonspecific prodrome consisting of low grade fever,
malaise, headache, myalgias, and anorexia. These symptoms are generally followed
within 48 hours by the development of parotitis.
• Less common - Coxsackie viruses A and B, Echovirus, Parainfluenzavirus, Influenza A,
and Epstein-Barr virus.

27. D/D
• Acute bacterial sialadenitis — Suppurative sialadenitis commonly affects elderly, malnourished,
or postoperative patients.
• The parotid gland is most commonly involved.
• Sudden onset of a very firm and tender swelling.
• Fever and chills are usually present, generally with fairly marked systemic toxicity.
• Purulent drainage can often be expressed from the effected duct orifice.
• (Staphylococcus aureus {common} ,Streptococcus pneumonia, Streptococcus viridans,
Haemophilus influenzae, and Bacteroides) .

28. D/D
• Chronic bacterial sialadenitis is a low grade chronic infection.
• Can eventually lead to destruction of the salivary gland.
• It may occur more commonly in patients with decreased salivary secretion and
increased mucus content in their saliva.
• Predisposing factors include stones, strictures, and trauma.
• Generally have intermittent exacerbations of acute sialadenitis

29. D/D
• Human immunodeficiency virus — Prone to the development of lymphoepithelial
cysts within the gland.
• These may become superinfected.
• Parotid swelling in HIV infection is typically diffuse and symmetric.
• Cystic lesions on imaging are consistent with the diagnosis of lymphoepithelial
cysts, but solid lesions are concerning for lymphoma or other parotid malignancy.
• Sjögren's syndrome — Chronic inflammatory disorder
• Diminished lacrimal and salivary gland secretions resulting in symptoms of dry
eyes and dry mouth, sicca complex
• Gradual swelling of the parotid or submandibular glands, typically bilaterally.
• Eventually causes parenchymal destruction and dilation of the intraglandular
ducts

30. D/D
•Sarcoidosis — Extrapulmonary sarcoidosis affects the parotid glands in 1 to 6
percent of cases and may be associated with uveitis and facial paralysis
(Heerfordt's syndrome).
• Bilateral painless parotid enlargement due to granulomatous infiltration.
• Radiation sialadenitis — Low-dose radiation to a salivary gland causes acute,
tender, painful swelling.
• C/O of burning, dry mouth with diminished ability to taste

31. D/D
•Malnutrition — Sialadenosis, which is a noninflammatory, non-neoplastic
enlargement of a salivary gland, typically the parotid.
• Associated conditions include anorexia nervosa, bulimia, beriberi, pellagra,
diabetes, and alcoholic cirrhosis.
• Histologic evaluation reveals acinar hypertrophy without an inflammatory
infiltrate.
•Salivary gland tumors – swelling with a significant degree of
asymmetry with diffuse parotid enlargement or any focal parotid mass, raises a
concern for neoplasm