“Sialolithiasis” is the formation of calcific concretions within the
ductal system of major or minor salivary glands.
Here we present 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
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
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.
Occlusal mandibular roentgenogram showing bilateral ductal calculi
Elevated, erythematus oral floor
Stay suture placed circumductally posterior to the stone
Submandibular duct exposed by a combination of blunt & sharp dissection
Longitudinal incision over the duct exposing calculus into view
Removal of calculus
Duct after calculus removal
Right ductal calculus
Left ductal calculus