Here is an unusual case wherein a 52 year old male patient presented with sialoliths bilaterally in his submandibular ducts.
This patient, a long standing reasonably well controlled diabetic, arrived in our department with a grossly swollen lower face since the past one week. He was put on empirical antibiotics and anti inflamatory drugs from a nearby clinic. On initial assessment he was found to be febrile, debilitated due to poor intake since the past few days due to odynophagia( pain during swallowing ), foul breath (fetor oris) and a poor oral hygiene. His lower face was grossly swollen, oral floor appeared elevated which accounted for his dysphagia. No dental caries was detected clinically.
A brief history revealed that the swelling increased in size with accompanying pain briefly during meals which subsided slowly in the subsequent hours. On palpation of the oral floor, bilateral firm to hard calculi were detected in the course of the submandibular ducts. An occlusal mandibular roentgenogram revealed two large salivary calculi bilaterally in the ducts anterior to the first molars (anterior calculi).
He was put on a course of broad spectrum antibiotics and anti inflammatory drugs to curb the acute phase of infection and a surgery was planned for the removal of the stones subsequently after a course of 5 days. In the meantime medical opinion was obtained for adequate control of his blood sugar.
The surgical procedure was planned under local anesthesia after obtaining a verbal consent. A preoperative sialogram was not taken since force of injection of the contrast medium may dislodge the calculus to the posterior portion of the duct.
Initially a stay suture was passed into the oral floor encircling the duct posterior to the stone to prevent further posterior displacement during manipulation. The suture was then secured to a hemostat & placed over the adjacent teeth so as to kink the duct. A second suture was then placed between the duct papilla & the sublingual frenum. Gentle traction of these sutures will make the tissues taut for easy placement of incision on the oral floor. Then an incision is made along the line of the duct over the stone (along a line that bisects the angle between the sublingual plica & the root of the tongue). The duct was then identified by a combination of blunt & sharp dissection & the sialoliths released by a longitudinal incision over the duct. During closure of the incision, a few interrupted sutures are all that is required on the oral floor; the ductal incision is not sutured to prevent stricture formation. Postoperatively the patient was advised to drink copious amount of fluids & use sugarless lemon drops to encourage salivary flow & hence maintain duct patency during the healing period.
Initially he was reviewed every alternate day to monitor his oral hygiene in the immediate postoperative period & to provide appropriate oral care. His sutures were removed on the seventh day following which he was put on a weekly review to make sure that he had an uneventful healing phase.
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