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Sialolithiasis 121

BILATERAL SIALOLITHS

Simultaneous sialolithiasis of more than one sali-vary gland is less common than multiple sialolithsand is estimated to occur in fewer than 3% ofcases of sialolithiasis (Sunder, et al. 2014). Thisnotwithstanding, surgeons must be vigilant interms of investigating for the possibility of multiplegland involvement when preparing a patient forsurgery related to a diagnosis of sialolithiasis. Areview of the literature indicates that when multi-ple sialoliths occur, they occur in a bilateral samegland fashion rather than involving two differentsalivary glands.

Differential Diagnosis andDiagnosis of Sialolithiasis

Patients with sialolithiasis most commonly presentwith clinical and historical evidence of salivarycalculi. A history of submandibular swelling,prandial pain, and bouts of sialadenitis are highlysuggestive of a diagnosis of sialolithiasis. Thisnotwithstanding, many patients are asymptomaticsuch that only a panoramic radiograph may allowfor the diagnosis of submandibular sialolithi-asis as it may reveal calcifications within thesubmandibular triangle. It has been observedthat submandibular stones located anteriorly aremore often symptomatic than those lodged in theintraglandular portion of the duct (Karas 1998).While such calcifications may lead to a diagnosis ofsubmandibular sialolithiasis, it is important for theclinician to consider other diagnoses that presentwith submandibular calcifications, particularlywhen pain is absent. Amongst these are calcifiedlymph nodes associated with mycobacterial adeni-tis (scrofula) (Figure 5.7), phleboliths associatedwith oral/facial hemangiomas (Figure 5.8), and amandibular osteoma as might occur in Gardnersyndrome (Figure 5.9). All of these calcificationsmay, at first glance, appear similar to submandibu-lar sialolithiasis. Close examination of panoramicradiographs may, however, allow for the clinicianto establish a radiographic diagnosis other thansubmandibular sialolithiasis (Mandel 2006). Mostsubmandibular calculi contain smooth borderswhen they exist within the gland. Calcified lymphnodes generally show irregular borders, and osteo-mas of the mandible are larger than most salivary

gland stones, and are intimately associated withthe mandible. Phleboliths are commonly multiplein number and also exist within the neck outside ofthe submandibular triangle. They are scattered andhave a classic lamellated appearance with a lucentcore. Finally, phleboliths are smaller than sialolithsand demonstrate an oval shape, compared to thesialolith whose elliptical shape has been createdby a salivary duct (Mandel and Surattanont 2004).One further entity worthy of mention is calcifiedatheromas of the carotid artery which is sufficientlydistant from the submandibular triangle so as tonot be confused with a submandibular sialolith.These are most commonly located inferior andposterior to the mandibular angle adjacent to theintervertebral space between cervical vertebrae 3and 4 (Friedlander and Freymiller 2003).

While the diagnosis of sialolithiasis is fre-quently confirmed radiographically, it is importantfor the clinician to not obtain radiographs prior toperforming a physical examination. Bimanual pal-pation of the floor of mouth may reveal evidenceof a stone in a large number of patients. Similarpalpation of the gland may also permit detectionof a stone as well as the degree of fibrosis presentwithin the gland. Examining the opening of theWharton duct for the flow of saliva or pus is animportant aspect of the evaluation. It has beenestimated that approximately one quarter of symp-tomatic submandibular glands that harbor stonesare non-functional or hypofunctional. Radiographsshould be obtained, and may reveal the pres-ence of a stone. It has been reported that 80%of submandibular stones are radio-opaque, 40%of parotid stones are radio-opaque, and 20% ofsublingual gland stones are radio-opaque (Miloro1998).

Treatment of Sialolithiasis

General principles of management of patients withsialolithiasis include conservative measures such aseffective hydration, the use of heat, gland massage,and sialogogues that might result in flushing a smallstone out of the duct. A course of oral antibioticsmay also be beneficial. These measures may be par-ticularly appropriate since some patients may carrya clinical diagnosis of sialadenitis in case of a radi-olucent sialolith. As such, the treatment is the samein the initial management of both diagnoses.

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(a) (b)

(c)

(e)

(d)

Figure 5.7. A close-up of a panoramic radiograph obtained in a patient with a chief complaint of right submandibular pain(a). The calcifications noted on this radiograph are located in the retromandibular region as well as the submandibular glandarea. Exploration of the neck showed indurated lymph nodes present in association with the right submandibular gland,but clearly not sialoliths (b). The lymph nodes were removed (c) and bisected, showing macroscopic (d) and microscopicevidence of caseous necrosis (e). A diagnosis of tuberculous adenitis was therefore established. The patient was subjectedto a purified protein derivative (PPD) skin test that was positive.

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Sialolithiasis 123

(a) (b)

Figure 5.8. A panoramic radiograph demonstrating calcifications within the left submandibular region (a). At first glanceof the radiograph, submandibular sialolithiasis is a reasonable consideration. Close examination of the radiograph revealsmulticentric lamellated calcifications in the submandibular and preauricular regions, as well as a calcification superimposedon the left mandibular second molar roots. A complete physical examination revealed signs consistent with a hemangiomaassociated with the left mandibular gingiva (b). As such, the calcifications are presumed to represent phleboliths, and arenot removed. It is important, therefore, to diagnose sialolithiasis based on a review of a radiograph as well as a physicalexamination.

SUBMANDIBULAR SIALOLITHIASIS

The treatment of salivary calculi of the sub-mandibular gland is a function of the location andsize of the sialolith (Figure 5.10). For example,sialoliths present within the duct may often beretrieved with a transoral sialolithotomy pro-cedure and sialodochoplasty. In general terms,if the stone can be palpated transorally, it canprobably be removed transorally. A review of 172patients who underwent intraoral sialolithotomyof a submandibular stone assessed results asto complete removal, partial removal, and fail-ure (Park, et al. 2006). The effect of location,size, presence of infection, and palpability of thecalculi on the results was assessed. Univariateanalysis showed that palpability and the presenceof infection were statistically significant factorsaffecting transoral sialolithotomy. Palpabilitywas the only significant factor after multivariateanalysis. This study provides scientific evidencesupporting intraoral removal of extraglandularsubmandibular gland stones regardless of loca-tion, size, presence of infection, or recurrence ofcalculi as long as the calculi are palpable. Thisprocedure involves excising the Wharton ductoverlying the stone thereby permitting its retrieval(Figure 5.11). Reconstruction of the duct in theform of a sialodochoplasty permits shorteningof the duct and enlargement of salivary outflow

thereby preventing recurrence and allowing forhealing of the gland (Rontal and Rontal 1987).A properly performed sialodochoplasty ensureseffective flow of saliva from the gland in hopesof maintaining the health of the salivary gland.This procedure involves suturing the edges ofthe duct’s mucosa to the surrounding oral mucosa(Figure 5.11). The number of sutures placed is arbi-trary; however, a sufficient number of sutures isrequired so as to stabilize the reconstructed duct tothe floor of mouth. Proper postoperative hydrationof the patient with free flowing saliva maintainspatency of the sialodochoplasty, thereby enhanc-ing the potential for reversal or stabilization of theunderlying sialadenitis. Chronic submandibularobstructive sialolithiasis clearly leads to chronicsialadenitis with presumed parenchymal destruc-tion. After removal of the sialolith, however, theapparent resiliency of the submandibular glandusually results in no adverse symptoms (Baurmash2004). As such, the ability to effectively retrieve asialolith usually refutes the need to also remove theaffected salivary gland. Sialoliths located withinthe submandibular gland or its hilum are mostcommonly managed with submandibular glandexcision (Figure 5.12). This controversial statementis made based on the relative difficulty to retrievestones from this anatomic region of the gland,rather than based on the assumption that prox-imal stones cause permanent structural damage

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124 Chapter 5

(a) (b)

(c) (d)

Figure 5.9. This panoramic radiographic close-up shows an irregular mass associated with the left submandibular region(a). Computerized tomograms were not obtained preoperatively, and a differential diagnosis of submandibular sialolithiasiswas established. The calcification, however, does not show typical radiographic signs of a sialolith, including its irregularborders. The patient underwent exploration of the left submandibular region, whereupon the calcified mass was identified asa distinct entity from the left submandibular gland (b). The mass was removed (c) and the left submandibular gland remainedin the tissue bed (d). A histopathologic diagnosis of osteoma was made. A subsequent diagnosis of Gardner syndrome wasmade, and the patient underwent colectomy when a diagnosis of adenocarcinoma of the colon was established.

to the gland that results in the need for removalof the gland. To this end, a study examined aseries of 55 consecutive patients who underwenttransoral removal of stones from the hilum ofthe submandibular gland (McGurk, et al. 2004b).Stones were able to be retrieved in 54 patients(98%), but four glands (8%) required subsequentremoval due to recurrent obstruction. The authorsemphasized that it was necessary for the stoneto be palpable and no limitation of oral opening

should exist in order for patients to undergo theirtechnique. They reported an acceptable incidenceof complications associated with their technique,although they lamented that it remained to be seenif the asymptomatic nature of their patients wouldbe maintained over time.

Shock wave lithotripsy has been reported asa primary form of treatment for submandibularsalivary gland stones. Salivary stone lithotripsyrequires a gland to be functional by virtue of

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Sialolithiasis 125

Submandibular sialolithiasis

Location

Intraglandular ductHilum

Extraglandular duct

Transoral sialolithotomy with sialodochoplastyConsider sialoendoscopy with sialolithotomy,

possible papillotomy

Resolved?

Monitor Submandibular glandexcision

Size

> 7 mm < 7 mm

Considerlithotripsy

Resolved?

Yes YesNo

Monitor Submandibulargland excision

Lithotripsy

No

Yes No

Resolved?

Monitor Consider sialoendoscopywith sialolithotomy possible

papillotomy

Resolved

Monitor

Yes No

Submandibular gland excision

Figure 5.10. Algorithm for submandibular sialolithiasis.

production of saliva in order for the stone frag-ments to be eliminated from the duct. Someauthors have implemented a sour gum test priorto performing extracorporeal lithotripsy (Williams1999). This test involves the patient chewing sourgum whereby the clinician looks for swelling of thegland. The development of swelling indicates thatthe gland is functional such that extracorporeallithotripsy may be attempted. In the absence ofswelling, extracorporeal lithotripsy is contraindi-cated, and the gland is planned for removal.Two techniques of salivary lithotripsy have beendeveloped, including extracorporeal, sonograph-ically controlled lithotripsy, and intracorporealendoscopically guided lithotripsy (Escudier 1998).

Extracorporeal shockwave lithotripsy was firstused to treat renal stones in the early 1980s. Theshockwaves can be generated by electromagnetic,piezoelectric, and electrohydraulic mechanismsand the resultant waves are brought to a focusthrough acoustic lenses. They then pass througha water-filled cushion to the stone where stressand cavitation act to fracture the stone. At thesialolith-water interface a compressive wave ispropagated through the stone thereby subject-ing it to stress. Cavitation occurs when reflectedenergy at the sialolith-water interface results ina rebounding tensile or expansion wave whichinduces bubbles. When these bubbles collapse ajet of water is projected through the bubble onto

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126 Chapter 5

(a) (b)

(c) (d)

Figure 5.11. A sialolith is noted at the opening of the right Wharton duct (a). Since this stone was able to be palpatedon oral examination, it was removed transorally without necessitating the removal of the right submandibular gland. Themain stone was removed (b), after which time exploration of the proximal duct revealed two additional stones that werealso removed (c). A sialodochoplasty was performed to widen and shorten the right Wharton duct (d). A sialodochoplastyperformed near the papilla of the Wharton duct is termed a papillotomy.

the stone’s surface. This force is sufficient to pitthe stone and break it. Extracorporeal lithotripsyfor submandibular gland stones is somewhat lesssuccessful than that of parotid stones (Williams1999). Ottaviani and his group evaluated theresults of 52 patients treated with electromag-netic extracorporeal lithotripsy for calculi of the

submandibular gland (n = 36 patients) and parotidgland (n = 16 patients) (Ottaviani, et al. 1996).Complete disintegration was achieved in 46.1%of patients, including 15 with submandibularsialolithiasis and 9 with parotid sialolithiasis.Elimination of the stones was confirmed by sono-gram. Residual concrements were detected by

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Sialolithiasis 127

ultrasound in 30.8% of patients, including 9 withsubmandibular stones, and 7 with parotid stones.Four patients with residual submandibular stonesrequired surgical retrieval. The authors concludedby indicating that if hilar and intraglandular ductstones are smaller than 7 mm in size, they maybe successfully treated with lithotripsy (Williams1999). The surgeon should proceed with sub-mandibular gland excision if this trial of lithotripsyis not successful, or if stones larger than 7 mm areidentified.

Intracorporeal lithotripsy techniques are nowused in which a miniature endoscope is utilized tomanipulate the stone under direct vision. In thistechnique, shockwaves are applied directly to the

surface of the stone under endoscopic guidance.The shockwave may be derived from an electrohy-draulic source, a pneumoballistic source, or from alaser. Pneumoballistic energy has been shown toproduce calculus fragmentation with greater effi-ciency than lasertripsy (Arzoz, et al. 1996). Thedisadvantage of these techniques is that the size ofthe endoscope and probe requires that the duct beincised so as to facilitate entry.

Finally, interventional sialoendoscopy hasbeen developed that may permit the use of afine sialoendoscope to retrieve salivary stones(Nakayama, et al. 2003), (Figure 5.13). The size ofsome sialoliths, however, is such that an incision

(a)

(b)

(c)

Figure 5.12. The clinical appearance of a man with pain and left submandibular swelling (a). His panoramic radiographic (b)shows a sialolith in the left submandibular gland. A standard transcutaneous approach was followed to submandibular glandexcision (c). A subfascial dissection of the gland was performed. Inferior retraction on the gland allowed for preservation ofthe marginal mandibular branch of the facial nerve (d). Superior and anterior retraction of the gland allowed for identificationof the sialolith that was located at the hilum of the gland (e). The excised gland (f) was bisected (g) and demonstratedsignificant scar tissue formation.

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128 Chapter 5

(e) (g)

(f)(d)

Figure 5.12. (Continued).

of the papilla may be necessary for their deliv-ery. Interventional sialoendoscopy may be usedwith lithotripsy to fragment large stones so asto achieve a completely noninvasive therapeuticsialoendoscopy.

McGurk, et al. (2004a) assessed the efficacyof extracorporeal shock wave lithotripsy, basketretrieval as part of interventional sialoendoscopy,and intraoral surgical removal of salivary calculi.Three hundred and twenty-three patients with sub-mandibular calculi were managed. Extracorporealshock wave lithotripsy was successful in 43 of 131(32.8%) patients, basket retrieval was successfulin 80 of 109 (73.4%) patients and surgical removal

was successful in 137 of 143 (95.8%) patients withsubmandibular stones.

PAROTID SIALOLITHIASIS

Sialoliths of the parotid gland are divided anatom-ically into those that are located within theintraglandular duct and the extraglandular duct(Figure 5.14). Extraglandular duct sialoliths may beremoved surgically through and intraoral approach(Figure 5.15). In this procedure, a C-shaped inci-sion is made anterior to the Stensen papilla.Dissection is performed deep (lateral) to the ductsuch that it is included in the mucosal flap suchthat the duct is separated from the more lateral soft

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Sialolithiasis 129

(a) (b)

(e)

(c) (d)

Figure 5.13. Interventional sialoendoscopic instrumentation for retrieval of salivary calculus, including the operating sheaths(a) that accept the miniature endoscope in the telescope channel (b). The grasping forceps (c), are placed within the workingchannel of the operating sheaths (d), and are able to retrieve stones that may be identified on diagnostic sialoendoscopy(e). Figure 5.13(e) Source: Maria Troulis, Boston, Massachusetts.

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Parotid sialolithiasis

Location

Intraglandular duct Extraglandular duct

Consider lithotripsy

Monitor Consider extraoralsialolithotomyConsidersialoendoscopy

Considersialoendoscopywith sialolithotomyPossible papillotomy

Transoralsialolithotomy

Resolved?

Yes

Monitor

No

Superficialparotidectomy

Resolved?

Yes NoResolved?

Yes

Monitor

No

Superficialparotidectomy

Resolved?

Yes

Monitor

No

Superficialparotidectomy

Figure 5.14. Algorithm for parotid sialolithiasis.

tissues. A retraction suture may be placed at theanterior aspect of the mucosal aspect of the flap.The duct is dissected from anterior to posterior soas to identify the stone within the duct. Once thestone is located, the duct is incised longitudinallythereby allowing for retrieval of the sialolith. Themucosal flap is reapproximated; however, the inci-sion in the duct is not sutured. These longitudinalincisions placed in the duct do not appear to resultin the formation of strictures, although transverseincisions in the duct may result in stricture forma-tion (Seward 1968; Berry 1995). Strictures in theparotid duct will respond favorable to intermittentdilation; however, submandibular duct stricturesusually require surgical intervention.

Parotid sialoliths located within the intraglan-dular portion of the ductal system may be

addressed through an extraoral approach. Twooptions exist, one involving a traditional parotidec-tomy approach (without performing a parotidec-tomy) with a curvilinear skin incision in thepreauricular and upper neck regions (Berry 1995),and the other involving a horizontal incisionover the duct in the cheek region (Baurmash andDechiara 1991). In the former approach, the skinflap is elevated superficial to the parotid fascia,and the duct is identified at the point where itexits the anterior border of the gland. The place-ment of a lacrimal probe within the Stenson ductmay permit accurate identification of the duct.Once the duct is located, it is dissected posteri-orly into the gland and the stone is identified. Alongitudinal incision is made over the duct andthe stone is retrieved (Figure 5.16). As in the

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Sialolithiasis 131

case of a transoral sialolithotomy, the incision inthe Stenson duct is not closed at the conclusionof the surgery. Sialolithotomy performed witha transcutaneous approach in the cheek mayalso be accomplished for a diagnosis of parotidsialolithiasis (Figure 5.17).

Extracorporeal lithotripsy seems to be quiteeffective for the treatment of intraparotid stones.With three outpatient treatments, 50% of patientshave been reported to be rendered free of cal-culus (Williams 1999). Half of the remainingpatients may be rendered free of symptoms, but

(a) (b)

(c) (d)

Figure 5.15. Management of an extraglandular parotid duct sialolith. The panoramic radiograph demonstrates a smallsialolith in the right Stensen duct (a). The approach for this transoral sialolithotomy involved a mucosal incision anterior to theStensen papilla (b). A mucosal flap was developed that included the Stensen duct such that the dissection occurred lateralto the duct (c). Continued dissection allowed for palpation of the sialolith within the duct. The duct was longitudinally incisedover the sialolith (d), such that the stone was able to be removed (e). The mucosal flap was sutured without reapproximatingthe incision in the Stensen duct (f). Patent salivary flow was re-established as noted two months postoperatively (g). Nofurther treatment of the gland was required.

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132 Chapter 5

(e) (f)

(g)

Figure 5.15. (Continued).

having small fragments left in the ductal system.In Ottaviani’s cohort of 16 patients with parotidstones, all were relieved of their symptoms withextracorporeal lithotripsy (Ottaviani, et al. 1996).Nine of their 16 patients experienced complete dis-integration and elimination of stones and 7 patientsshowed residual stone fragments that were ableto be flushed out spontaneously or with salivationinduced by citric acid (Ottaviani, et al. 1996).

McGurk, et al. (2004a) found extracorporealshock wave lithotripsy to be successful in 44 of90 (48.9%) patients with parotid sialoliths, and

basket retrieval was successful in 44 of 57 (77.2%)of patients with parotid sialoliths. Interestingly, nopatients with parotid stones underwent transoralsurgical removal.

TREATMENT OF MULTIPLE SIALOLITHSAND BILATERAL (MULTIPLE GLAND)SIALOLITHS

While rare, the incidence of multiple sialolithswithin one salivary gland and synchronous mul-tiple gland sialoliths requires that all patients

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Sialolithiasis 133

(a) (b)

Figure 5.16. Axial CT scan demonstrating a parotid sialolith at the hilum with proximal dilatation of the duct due to obstruc-tion of salivary flow (a). A parotidectomy approach to stone retrieval was performed without parotidectomy (b).

(a) (b)

Figure 5.17. A lateral oblique plain film demonstrating two sialoliths of the Stenson duct (a). An incision through skinwas placed in a resting tension line of the cheek (b). A finger was inserted in the oral cavity to created better accessto the duct, thereby permitting stone retrieval (c). A primary closure was obtained (d). Source: Ord RA: Salivary glanddisease. In: Fonseca R (ed.), Oral and Maxillofacial Surgery, Volume 5, Surgical Pathology. Philadelphia, W.B. Saunders Co.,pp. 273–293. Reproduced with permission of Elsevier.

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134 Chapter 5

(c) (d)

Figure 5.17. (Continued).

undergo CT imaging when a diagnosis of sialolithi-asis has been made (Figure 5.18). In so doing, areview of these CT scans should rule out multiplegland involvement and the presence of multiplesialoliths. When the review of the CT scan revealsmultiple sialoliths in a single gland system, thecount must be verified at the time of surgery.When multiple salivary glands are involved withthe sialolithiasis, the surgeon should treat eachgland according to standard, single gland protocolsdiscussed in this chapter.

Miscellaneous Sialolithiasis

The incidence of sialolithiasis of the sublingualgland and the minor salivary glands is very rare.In McGurk, et al.’s (2004a) study of 455 casesof salivary calculi, no cases were present in thesublingual gland or minor salivary glands. As

such, swellings of these glands are most likely toengender a clinical diagnosis of neoplastic disease,with the diagnosis of sialolithiasis made only afterfinal histopathologic analysis of the gland occurs(Figure 5.19). One report examining sialolithia-sis of the minor salivary glands found that only20% of cases were correctly clinically diagnosedas sialolithiasis (Anneroth and Hansen 1983).The paucity of accurate diagnosis may also stemfrom the frequent spontaneous resolution of theproblem due to ejection of the calculus (Lagha,et al, 2005). Two stages of minor salivary glandsialolithiasis have been described including anacute stage characterized by inflamed overlyingsoft tissue whereby the most common clinicaldiagnosis is cellulitis of the soft tissue. The chronicstage follows and calls to mind a differential diag-nosis of neoplasm, irritation fibroma, or foreignbody. An anatomic distribution of 126 cases ofsialolithiasis of the minor salivary glands identifieda significant majority occurring in either the upper

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Sialolithiasis 135

(a) (b)

(c) (d)

Figure 5.18. A 72-year-old man with pain and swelling of one month’s duration in the right submandibular gland (a).Physical examination was significant for a tender right submandibular gland but no symptoms associated with the left sub-mandibular gland (b). The patient underwent CT scanning that demonstrated an enlarged right submandibular gland withthe presence of a single intraglandular sialolith (c and d). Thorough evaluation of the CT scans also identified five extraglan-dular right submandibular stones and two extraglandular left submandibular stones (e, and f). The patient underwent rightsubmandibular gland excision in a standard fashion (g and h) with exploration of bilateral Wharton ducts so as to removefive right extraglandular stones and two left extraglandular stones (i). A left Wharton sialodochoplasty was performed.

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(g) (h)

(i)

(e) (f)

Figure 5.18. (Continued).

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Sialolithiasis 137

(a) (b)

(c) (d)

Figure 5.19. Floor of mouth swelling present in a 55-year-old woman (a). A diffuse mass is noted beneath the surfacemucosa that is smooth and of normal color. A presumptive diagnosis of ranula versus neoplasm was established. A leftsublingual gland excision was performed in the standard fashion (b). The specimen (c) exhibited mild induration withoutsigns of ranula, such that a neoplastic process was favored while the possibility of a mucous escape reaction was discarded.Final histopathology showed a sialolith (d) in the background of sialadenitis (e). The tissue bed is noted (f), particularly thelingual nerve (retracted with the vessel loop) and the Wharton duct. A 6-month postoperative evaluation showed acceptablehealing (g).

lip or the buccal mucosa. As such, sialolithiasisshould be included on the differential diagnosis ofan indurated submucosal nodule of the upper lipor buccal mucosa, and surgical excision should beperformed.

Summary

• Sialoliths are calcium phosphate stones thatdevelop within the ductal system of salivaryglands.

• Sialolithiasis is thought to affect approxi-mately 1% of the population based on autopsystudies.

• Sialolithiasis has been estimated to representmore than 50% of major salivary gland diseaseand is the most common cause of acute andchronic salivary gland infections.

• Approximately 85% of sialolithiasis occurs inthe submandibular gland, 10% in the parotidgland, 5% in the sublingual gland, and theincidence of this pathology is rare in thesublingual gland and minor salivary glands.

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138 Chapter 5

(e) (f)

(g)

Figure 5.19. (Continued).

• 80% of submandibular sialoliths are radio-opaque, while 40% of sialoliths of the parotidgland are radio-opaque.

• Approximately 7% of sialoliths are bilateral.• Approximately 3% of cases of sialolithiasis

occur simultaneously in multiple glands.• Systemic disorders of calcium metabolism do

not seem to represent predisposing factors tosialolithiasis. The one exception to this ruleis gout where a higher incidence of uric acidstones has been observed.

• 75–85% of submandibular stones are locatedin the duct, while parotid stones are located inthe hilum or gland parenchyma in at least halfof cases.

• Several “great imitators” of submandibularsialolithiasis exist, including scrofula, phle-boliths, osteomas, and occasionally, carotidplaques.

• Numerous techniques are available to treatsialolithiasis including surgical sialolitho-tomy with or without sialodochoplasty,sialoendoscopy with sialolithotomy, intracor-poreal or extracorporeal lithotripsy, or glandremoval.

References

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Ardekian L, Klein HH, Araydy S, Marchal F. 2014. The useof sialoendoscopy for the treatment of multiple salivarygland stones. J Oral Maxillofac Surg 72:89–95.

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Kasaboglu O, Er N, Tumer C, Akkocaoglu M. 2004. Micro-morphology of sialoliths in submandibular salivary gland:A scanning electron microscope and X-ray diffractionanalysis. J Oral Maxillofac Surg 62:1253–1258.

Kim DH, Song WS, Kim YJ, Kim WD. 2013. Parotid sialolithi-asis in a two-year old boy. Korean J Pediatr 56:451–455.

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