Two Cases of Unusual Size Sialolith in
Wharton’s Duct With Review of Literature
Kalim Ansari*, Syed S Ahmed, Hashmi GS, Tabishur Rahman and Mohd Aqib Ansari
Department of oral and maxillofacial surgery, Aligarh Muslim University, India
Submission: December 27, 2016; Published: March 14, 2017
*Corresponding author: Kalim Ansari MD, Department of oral and maxillofacial surgery, Aligarh Muslim University, India, Tel:8439441242 ; Email:firstname.lastname@example.org
How to cite this article: Kalim A, Syed S A, Hashmi G, Tabishur R, Mohd A A. Two Cases of Unusual Size Sialolith in Wharton’s Duct With Review of Literature. Adv Dent & Oral Health. 2017; 4(2): 555633. DOI: 10.19080/ADOH.2017.04.555633
Sialolithiasis is one of the commonest disease of major salivary gland especially submandibular salivary gland. It occurs most commonly in 3rd and 4th decades of life and rarely seen in children. Patients usually present with pain and swelling due to obstruction of salivary duct classically at meal time. The diagnosis can be made by history, physical examination and using Ultrasonography, sialography or CT scan. Treatment is mainly surgical and it depends weather the stone is intraglandular or in the salivary duct. Here we report two cases of large stone in Wharton’s duct which was removed trans- orally without any complication. We have also reviewed the related previous article
Keywords: Sialolith; Calculus; Salivary gland; Sub mandibular duct; Wharton’s duct
Sialolithiasis is the occurrence of calcareous concretions in the salivary ducts or glands. It is the most common pathological condition affecting the major salivary gland. It has an incidence of 0.012% in the adult population . Males are more commonly affected than females with a peak incidence in 4th to 6th decades of life . Most salivary calculi occur in submandibular gland (80-90%) followed by parotid gland (5-20%) and sublingual and minor salivary glands (1-2%) . The reasons for commonest involvement of submandibular gland and its ducts are, tenacity of sub mandibular saliva, which because of its high mucin contents adheres to any foreign particles and duct of this gland is long, tortuous, & upward in its course. Also it is important to note that sialolith in the submandibular gland is more common in the duct compared to glandular parenchyma. The shape of sialolith may be round, ovoid or elongated and its size may range from few millimeters to 2cm or more. Stones over 10mm are reported as unusual in size. The involved duct may contain one or more stones. They are usually yellow. Calculi generally consist of mixture of calcium phosphates, calcium carbonates together with an organic matrix .
Patients usually present with pain and swelling due to obstruction of salivary duct classically at meal time. The diagnosis can be made by history, physical examination and using Ultrasonography, Xrays (most commonly occlusal radiographs or OPG), Sialography or CT scan. Treatment for salivary gland calculi depends upon the size &postion of stones and ranges
from application of moist warm heat with gland massage, use of sialogogue, and tranoral removal to complete gland removal (sialoadenectomy)  . Other methods of treatment include shock wave lithotripsy, sialoendoscopy, interventional radiology, laser fragmentation and endoscopically assisted transoral removal . Here we report two cases of sialolith in Wharton’s duct and also reviewed the related literatures.
A 55 years old male reported to department of oral and maxillofacial surgery, with a chief complaint of pain and swelling in left side floor of mouth since 3 months. According to patient it started as a small swelling which used to be painful before meals five months back. The swelling gradually increased in size and then it burst leaving a yellowish hard mass in left side floor of mouth. Patient experienced pain and thick discharge from that region.
Extraoral examination revealed mild swelling in left submandibular region with no other significant findings. Upon intraoral examination a well-defined swelling with exposed hard yellowish mass of approximately 1.5x 1.0cm was found in left canine premolar region of floor of mouth. Overlying mucosa was normal in color except in the anterior most part of swelling where there was an opening with exposed yellowish mass. It was hard in consistency and slight tender on palpation (Figure 1). His left mandibular second premolar and first molar was missing.A provisional diagnosis of left Wharton’s duct sialolith was made. Mandibular occlusal radiograph was advised which showed a radiopaque mass extending back beyond the lower left first permanent molar located within the Wharton’s duct (Figure 2). A final diagnosis of left Wharton’s duct sialolith was made (Table 1).
Under local anesthesia a transorallongitudinal incision was
given over the duct including the preexisting sialo oral fistula.
Blunt dissection was done and sialolith was removed taking care
not to injure the lingual nerve. After removal of the stone thick
salivary discharge came from the incised duct which was flushed
and area irrigated with saline. Primary closure of only mucosa was
done. Postoperative healing was uneventful (Figure 3).
A 45 years old male reported to department of oral and
maxillofacial surgery, with a chief complaint of pain and swelling
while eating, in right side of floor of mouth since 1 year. There
was no history of any systemic disease and patient was in good
health. Extraoral examination revealed mild swelling in right
submandibular region and a small fluctuant swelling in right side
of chin. On intra oral examination a large, firm, nontender swelling
in right floor of mouth in the region of submandibular duct was
noted. Overlying mucosa was normal in color with no discharge.
Mandibular occlusal radiograph was advised which showed a
large radiopaque stone in right Wharton’s duct (Figures 4 & 5).
Under local anesthesia a transorallongitudinal incision was
made over the duct (Figure 6). Sharp dissection was done and
sialolith was removed taking care not to injure the lingual nerve.
The exposed stone was grasped with the sinus forceps and gently
teased but it was broken and so removed in 3 small pieces (Figure
7). After removal of the stone thick salivary discharge came from
the incised duct which was flushed and area irrigated with saline.
Primary closure of only mucosa was done (Figure 8). Postoperative
healing was uneventful.
At a follow up period of 6 months both patients were fine.
The submandibular gland is the site for majority of salivary
calculi and this may be due to the direction of salivary flow
(against gravity), long tortuous duct course, more alkaline pH and high calcium and mucin content, but the exact etiology and
pathogenesis are unknown. The age in the cases reviewed ranged
from 21 to 75 years with average 51.4 years. Majority of duct
stone occurred in 4th to 5th decades of life which is consistent with
previous literature on sialoloith. Among the 34 cases reviewed
in this article the incidence is higher in male (n=28) compared
to females (n=6) with male to female ratio of 4.7:1. Size of stone
in the reported cases ranged from 15mm to 72mm. Stones over
10 mm are reported as unusual in size. The two cases reported
here are more than 20mm in size. The largest stone reported has
been presented by Rai and colleague  which was 72mm in size.
The ability of a calculus to become giant depends mainly on the
reaction of the affected duct. If the duct adjacent to the sialolith is
able to dilate allowing nearly normal salivary flow, it might remain
asymptomatic for a long period; thus eventually creating a giant
calculus . Out of 34 cases reviewed, 19 cases involved left side
of duct and 11 cases involved right side duct and in 4 cases side
was not mentioned. So from above data it can be predicted that
sialolith of unusual size mainly occurs in left Wharton’s duct. In
our cases 1 patient had sialolith in left and 1 patient had right.
In the above reviewed cases pain and swelling was the most
common symptoms for which patient visited to their physician.
Cause of pain and swelling of the involved salivary gland is due to
obstruction of salivary flow during the food related surge . The
severity of symptoms depends on the degree of obstruction. In few
cases patients were asymptomatic.
The diagnosis can be made by history, physical examination
and using Ultrasonography, Xrays (most commonly occlusal
radiographs or OPG), Sialography or CT scan. Small stones
especially which are radiolucent can be diagnosed by investigations
like Computed tomography, sialography or ultrasonography.
Sialoendoscopy is a new, minimally invasive technique developed
for direct visualization of intra‑ductal stones [8,9]. In our cases
the stone was radiopaque , large size and was clearly visible on
occlusal radiographs so no further investigations were needed.
Large calculi especially when present in anterior part of duct
may result in floor of mouth perforation and sialo oral fistula
formation. In one of our cases, calculus has extruded in floor of
mouth causing sialo oral fistula formation. Similar findings was
reported by El Gehani, Akimoto, Patil, Huber, Shetty; whereas Paul
and Chauhan reported sialo‑oral as well as sialo-cutaneous fistula
caused by sialolith [10-15].
Treatment objective for salivary duct stone is to remove the
stone and restore the normal salivary flow. Numerous treatment
methods has been described depending upon the size & postion of
stones and ranges from application of moist warm heat with gland
massage, use of sialogogue, and tranoral removal to complete
gland removal (sialoadenectomy) . Other methods of treatment
include shock wave lithotripsy, sialoendoscopy, interventional
radiology, laser fragmentation and endoscopically assisted
transoral removal5.Transoral removal of stone is a versatile
technique and is recommended whenever stones can be palpated intraorally. This approach is without complication however
care must be given no to injure lingual nerve. We successfully
treated both the cases by tranoral incision. At a follow up period
of 6 months both pateints were fine with normal salivary flow. A
protein rich diet with lots of liquid and acid food and drinks were
advised in order to prevent recurrence. The patient should be
encouraged to seek early treatment for salivary calculi because
long term obstruction in the absence of infection can lead to
atrophy of the gland with resultant lack of secretory function and
ultimately fibrosis. However, after elimination of the obstruction,
the apparent resiliency of the submandibular gland results in no
Consuegra reported two cases of giant sialolithiasis within
the Wharton’s duct causing unilateral absence of submandibular
gland due to complete acinar atrophy.
Early diagnosis and treatment should be done to prevent
large submandibular stone formation which if left untreated
for long period may lead to complete salivary gland fibrosis
and dysfunction. The ultimate surgical removal of gland due to
chronic obstruction can be avoided by educating patients about
the importance of hydration and oral hygiene and prompt removal