Transoral Removal of Submandibular Stone

Salivary Stones or Sialoliths of The Wharton's Duct

Video Description: At the mouth of the left submandibular gland duct (Wharton's Duct), oval shaped salivary glands were observed with a size of about 3x6 mm and the duct was exposed under local anesthesia After being expanded with a scalpel, simultaneous in-mouth and under-jaw massage was performed to allow the stone to move into the mouth.

Transoral Removal of Submandibular Stone - Removal of Salivary Gland Stone - Intraoral Removal of Stone in The Proximal Submandibular Duct - Removing A Stone From A Salivary Duct - Wharton's Duct Sialolith Removal

It is rarely necessary today to remove saliva stones by making a small incision in the mouth. In the above video, a painful left jaw six salivary gland bulge and a jaw-bottom salivary gland can be seen from inside the mouth. In order to fall into the mouth, the mouth of the canal is cut with a few mm bisturion on the stone, has been observed.

Sialolithiasis of the Submandibular Gland

Salivary gland stones are called “sialolithiasis” or “salivary calculi” and are most commonly seen in the sumandibular gland. Salivary gland stones are most common in the submandibular gland. This is because the ostium of the submandibular salivary gland is slightly narrower than its duct (Wharton Duct), the duct is longer and more curved than the other gland ducts, the duct mouth is upward and its drainage is in the opposite direction of gravity, the submandibular It can be summarized as the fact that the calcium and phosphate that play a role in the formation of stones in the gland secretion are intense, and the secretion is intense and alkaline. The submandibular gland produces most of the daily saliva. When this gland duct is blocked by a stone, swelling under the chin usually occurs suddenly and painfully.

Submandibular Gland Stone Causes

The reasons that facilitate stone formation in the submandibular gland can be listed as follows:

- Dietary changes (insufficient fluid intake), medications, or the presence of diseases that may cause a decrease in saliva production
- Narrower than normal salivary gland duct
- Use of drugs that can accelerate stone formation
- Presence of salivary gland infections that may facilitate stone formation in the canal

Submandibular Gland Stone Symptoms

When the salivary gland stone is small and does not completely block the duct, it may not give any symptoms. The following symptoms may occur as the stone increases in size and begins to block the canal:

- Painful swelling under the chin, especially while eating (may occur faster when sour and acidic foods that increase saliva secretion are eaten)
- Pain and temperature increase under the chin (indicates that salivary gland inflammation accompanies.)
- Swelling in the subjacent lymph nodes adjacent to the submandibular gland
- If the salivary gland stone is small and partially obstructs the duct, swelling may disappear in the hours after eating and swelling may occur again during eating afterwards
- From time to time, redness and inflammatory secretion flow in the mouth, in the canal opening holes, and sometimes the stone is felt in the mouth just behind the canal

Patient Examination For Submandibular Gland Sialolithiasis 

In patients with submandibular gland stones, it can be evaluated whether it is seen in the mouth of the canal in the mouth after bilateral examination and evaluation of the canal openings, palpation of the submandibular gland, feeling the stone in the mouth or massaging the submandibular gland. In patients with submandibular gland stones, submaxillary USG, Tomography or MRI imaging techniques can be used. Magnetic resonance imaging may also be useful in excluding a lesion that presents with slow growth, such as a tumor. When the salivary gland stone is small, it may not be seen on ultrasound and other imaging techniques. Sialography is another useful diagnostic tool.

How is Submandibular Salivary Gland Stone Diagnosed?

Salivary gland stones can be detected at a rate of 80-90% with standard x-ray films called direct graphy. When submandibular gland stones enlarge and cause obstruction of Wharton's Canal, it is a painful under-chin swelling that occurs when the patient has a history of eating and salivation. Generally, as the saliva secretion decreases or if the saliva is partially emptied into the mouth, complaints are relieved. In salivary gland tumors, the complaints are more chronic and there is a growing, slower gland growth than the salivary gland stone growth. In patients with submandibular gland stones, patient symptoms that are helpful without diagnosis:

- acute increase of salivary gland swelling with eating
- frequent inflammation of the submandibular salivary glands with stones and coming out of the duct mouth
- fever, pain, change in sense of taste with inflammation
- Findings such as increased skin temperature and redness on the salivary gland under the chin, and lymph node enlargement in the neck.

Apart from these, when imaging methods are used, the probability of being diagnosed increases.

Submandibular Salivary Gland Stone Treatment

With the developing technology, sialendoscopy techniques can be used in salivary gland stones when medical treatment and follow-up are not beneficial. Before any intervention is performed on the patient, imaging methods (ultrasonography, computed tomography and magnetic resonance imaging studies) may be preferred for a more detailed evaluation of the size, number, location of the salivary gland stones, as well as the state of the salivary gland tissue and salivary ducts.

Classical and non-surgical treatment method for small submandibular gland stones is "drinking plenty of water and salivary gland massage"

As a classical information, in order to move the movable and small-sized salivary gland stones to the mouth of the canal or to get them out of the canal, at the same time, in order to make the salivary secretions more liquid, patients should drink more water than normal and circular - two fingers under the chin saliva. We recommend regular salivary gland massage. In this way, the movement of small stones that can move into the canal mouth as much as possible and the possibility of their spontaneous coming out can be increased. As above, in order to remove the palpable and visible submandibular gland in the mouth of the canal, after the application of local anesthetic, a simple incision can be made and the submandibular gland can be massaged at the same time, allowing the stone to fall into the mouth. In large and non-moving salivary gland stones, it can be planned to break up the stone by endoscopic method and remove it in that way. In stones associated with chronic sialadenitis, submancibular gland excision can be performed with a longitudinal external incision. This procedure is a much larger surgical procedure and there is a risk of injury to the marginal mandibular branch of the facial nerve and incision scarring that can be seen in the neck. It may be preferred when other treatments are ineffective and there is recurrent chronic infection - abscess development in the submandibular gland. The treatment approach of surgical removal of the submandibular salivary gland in stone patients has decreased considerably, thanks to the introduction of techniques that allow sialendoscopy to break large stones in the submandibular gland canal into smaller pieces.

Submandibular Gland Stone and Medical Treatment in Acute Infection

In patients with chronic canal obstruction due to stones and infection in the submandibulargland, we recommend that patients drink plenty of water, and the following drugs can be used in acute infection:

- Massages that promote saliva flow, such as expectorant medications
- Antibiotic treatments to prevent infection
- Muscle relaxants that can make the canal relax more easily
- Cortisone-containing drugs to prevent canal narrowing
- Drugs that increase salivation
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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