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return to: Sialendoscopy; Sialogram Technique; Anatomy of submandibular gland and duct

see also: Salivary Stone Removal with Ductoplasty from Submandibular Gland

Left Wharton's ductoplasty after superficial cancer resection left floor of mouth

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Salivary Stones

1. Epidemiology (Bailey)
   1. 80% of salivary stones occur in the Submandibular Gland (SMG)
   2. 90% of SMG stones are radiopaque; 90% of parotid gland stones are radiolucent
2. Risks (Bailey)
   1. Nidus of material allowing precipitation of salts coupled with salivary stasis
   2. SMG has more alkaline saliva and higher concentrations of calcium and phosphate
   3. Gout is the only systemic disease known to cause salivary gland calculi (Uric acid stones)
3. Indications
   1. Palpable or hilar stone seen on CT or Ultrasound
   2. Recurrent obstructive symptoms
4. Contraindications
   1. Poor mouth opening
5. Stone removal; Efforts should be made to save glands that are obstructed by stones
   1. Functional recovery of glands following surgery tested by scintigraphic studies indicate return of function (Makdissi J 2004) 
   2. Large stones (>10 mm) located proximally in the hilum have successfully been removed through transoral approach (Zhang 2010)

OPERATIVE PROCEDURE

1. Two techniques for intraoral removal of stones
   1. Duct incision from papilla to stone with marsupialisation (Zenk 2004)
      1. Inject floor of mouth with Lidocaine with epinephrine
      2. Duct and overlying mucosa incised from papilla to stone.
      3. Identify lingual nerve as needed
      4. Creation of neo-ostium: suture duct to the oral epithelium using 4-0 vicryl
      5. No stents placed
      6. 231 patients (115 with distal stones; 102 with hilum stones; 14 with more than 1 stone)
      7. Neo-ostium stenosis in 5 patients (2% rate)
   2. Preservation of duct with ductal incision over the stone with closure of duct (McGurk 2004)
      1. Oblique incision from punctum of SMG along FOM towards 3rd molar tooth leaving a cuff 1.5 cm wide of normal lingual mucosa to facilitate closure
      2. Dissection down to duct and stone
      3. Identify lingual nerve
      4. palpate stone;  incise duct over stone
      5. Closure of duct with 6-0 vicryl
      6. No stents placed
      7. 54 patients
      8. Stricture formation: 3/55 patients (5% rate)
2. Sialodochoplasty of SMG duct (Rontal 1987) 
   1. 27 patients treated
   2. Probe duct with lacrimal probe
   3. Sharply open the duct posteriorly
   4. For each 1 cm opened, suture with 5-0 chromic the duct to the oral mucosa ("suture as you go")
   5. This is performed back until the stone is encountered
   6. No stent placed
   7. Patient treated with 10 days of antibiotics
   8. Only 1 patient had restenosis b/c the posterior portion of the duct was not completely sutured

REFERENCES

McGurk M, Makdissi J, Brown JE. Intra-oral removal of stones from the hilum of the submandibular glan: report of technique and morbidity. Int J Oral Maxillofac Surg 2004; 33:683-6

Zenk J, Constantinidis J, Al-Kadah B, Iro H. Transoral removal of submandibular stone. Arch Otolaryngol Head Neck Surg 2001; 127: 432-6

Rontal, M, Rontal E, The use of Sialodochoplasty in the treatment of benign inflammatory obstructive submandibular gland disease. Laryngoscope 1987; 97: 1417-21

Zhang Lei et al. Long-term outcome after intraoral removal of large submandibular gland calculi. Laryngoscope; 120: 964-6

Makdissi J, Escudier MP, Brown JE, Osailan S, Drage N, McGurk M. Glandular function after intraoral removal of salivary calculi from teh hilum of the submandibular gland. Br J Oral Maxillofac Surg 2004: 42:538-541

Bailey, Byron & Johnson Jonas; Head and Neck Surgery--Otolaryngology 4th ed. 2006