Went in Search of a Stone But Found a Diamond: Case Report on Giant Submandibular Salivary Gland Sialolith with Acute on Chronic Sialadenitis

INTRODUCTION

Sialoliths are stone-like deposits composed primarily of calcium that form within the ducts of major or minor salivary glands. These stones typically develop as calcium salts accumulate around a central core, which includes desquamated epithelial cells, bacterial debris, or foreign material. These calculi can obstruct the flow of saliva and cause stasis and sialadenitis.^[1]

Sialadenitis is inflammation of the salivary glands, and it is more common in the parotid gland as compared to the submandibular salivary gland. Chronic sialadenitis is due to recurrent inflammation of the salivary gland. Chronic sialadenitis is caused mainly by obstruction due to calculi and stricture and usually presents with swelling without erythema.^[2]

Sialoliths commonly measure 5–10 mm in size, and stones over 10 mm have been reported as sialoliths of unusual size. Giant sialoliths are those that measure more than 35 mm.^[3]

We have reported a case of a giant sialolith measuring 38 × 20 mm managed surgically in our tertiary care hospital. This case report aims to discuss the clinical presentation, diagnostic challenges, and surgical management of a giant sialolith.

CASE REPORT

A 50-year-old gentleman presented to the General Surgery out patient department (OPD) with complaints of swelling over the upper part of the left side of his neck for the past 2 years. The patient also complained of on-and-off pain over the swelling, which had been exacerbated during meals for the last 2 months. The patient gave no history of fever or discharge from the oral cavity. The patient had no significant past medical history.

Examination of the neck revealed a solitary Swelling of size 5 × 5 cm in the left submandibular region, tender and firm in consistency. The skin over the swelling was normal. No lymph nodes were palpable in the neck.

On oral cavity examination, a bulge was noted over the floor of the mouth with a normal submandibular duct opening.

Investigations

Ultrasound (USG) Neck showed an enlarged left submandibular gland with a heterogeneous echo pattern, with multiple dilated ducts and increased vascularity within. Intraparenchymal hyperechoic foci with posterior acoustic shadowing suggestive of a sialolith measuring approximately 1.5 cm in size.

Fine needle aspiration (FNAC) showed features of acute-on-chronic sialadenitis.

X-ray of the neck revealed a large sialolith [Figure 1].

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Figure 1:

X-ray of the head and neck region in lateral view showing the sialolith.

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Based on the clinical and radiological findings, a diagnosis of acute-on-chronic sialadenitis with sialolithiasis of the left submandibular gland was made.

The patient was started on IV antibiotics for 5 days and was taken up for submandibular salivary gland excision under general anaesthesia. Intraoperative findings were as follows: a thickened capsule was noted along with adhesions over the submandibular salivary gland. The submandibular salivary gland was dissected out after retracting the mylohyoid muscle. The submandibular ganglion and hypoglossal nerve were identified and preserved. A dilated Wharton’s duct was noted with a large calculus within it, and the calculus was partly intraglandular [Figure 2]. Calculi were extracted, and the duct was doubly ligated and cut. The deep lobe was freed from its attachments and the specimen was sent for Histopathology examination (HPE). A drain was placed in the submandibular region [Figures 3a and b].

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Figure 2:

Intraoperative image showing dilated and partially ruptured Warton’s duct with a large calculus within it.

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Figure 3:

(a) Excised specimen of submandibular salivary gland with giant sialolith and (b) Excised specimen of the submandibular salivary gland with a giant sialolith.

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The patient’s postoperative course was uneventful. The drain was removed on postoperative day 4, and the patient was discharged on postoperative day 5. The patient was followed up for 3 months postoperatively.

DISCUSSION

Acute sialadenitis is the most common form of inflammation of the major salivary glands. Moreover, obstruction of the salivary duct due to sialolithiasis is the most frequent aetiology.^[4]

In the early stages of an obstructed salivary gland, the gland is usually soft and nontender to palpation. Secondary infection of the gland occurs and causes the gland to become enlarged and tender on palpation, with the overlying skin often erythematous. Intraorally, the submandibular duct is oedematous and tender to digital palpation. If the sialolith is located in the anterior third of the submandibular duct, digital palpation may reveal its exact location and size. Purulence in the saliva is commonly seen, indicating a bacterial infection. The submandibular salivary gland is the most commonly affected gland due to the nature of the secretion and the antigravity drainage.

The treatment of submandibular sialolithiasis with chronic sialadenitis is surgical removal of the calculus or complete excision of the submandibular gland. However, initial management consists of antibiotic therapy to control the acute infection.^[5]

Giant sialoliths are uncommon and can lead to significant morbidity if not treated promptly. While smaller stones may be managed conservatively or by minimally invasive techniques, larger stones often require surgical intervention.

CONCLUSION

This case highlights the effective management of a giant sialolith through surgical excision. Early diagnosis and appropriate intervention are crucial in preventing complications and ensuring a good surgical outcome for the patient.