- Email: [email protected]
Surgical removal of a large sialolith within the submaxillary gland
SURGICAL
REMOVAL OF A LARGE SUBMAXILLARY
SIALOLITH GLAND
WITHIN
THE
Report of a Case ROBERT W. CHRISTENSEN, 1_).1).S.,* PASADENA, CALIF.
calculi may form SALIVAIZY gland proper. Approximately
in the duct of a salivary gland or in the 90 per cent of the salivary calculi form in the submaxillary gland or its duct. The sublingual gland has the next largest incidence, and the parotid gland is rarely affected. There are several factors which probably explain the higher incidence of sialolithiasis of the submaxillary gland and duct over the other salivary glands. The anatomic position of the gland being below the level of the duct orifice, the large size of the gland and duct, the great length of the submaxillary duct, and the vulnerability of this duct to trauma and direct invasion of infection are some of the more evident factors in infection and sialolithiasis of this particular gland. The treatment of sialolithiasis and the subsequent infection of the gland, duct, and adnexa involves antibiotic therapy and surgical removal of the sialolith. Sometimes it is necessary to remove the gland itself, but most sialoliths can be removed via the intraoral approach, with conservation of the gland. The greatest percentage of sialoliths form within the duct. The case to be present4 is one in which a large sialolith was in the anterior portion of t,he gland and in which there had been considerable infection and fibrosis of gland tissue adjacent to the sialolith. It was deemed advisable to excise the gland and sialolith in one extraoral operation. Case Report On March 1, 1955, C. S., a %-year-old Caucasian man, was referred to me by his physician for diagnosis and treatment of an acute infection of the right submaxillary space.
Past Medical History.-The patient’s past history disclosed that he had been a known diabetic for the past ten years. This condition was controlled by insulin therapy for the first three years and had been partly controlled by diet since that time. He had developed gangrene of the right leg seven years before and a toe had been amputated at that time. He gave a history of a rash type allergic reaction to penicillin therapy three years ago which was controlled by antihistamine therapy. History patient
of Present Illness.-Over
was conscious
of a slight
*Member of the oral Pasadena, California.
surgery
a period of one and one-half to two years, the swelling in the right submaxillary gland area. At no
staff,
Huntington
808
Memorial
Hospital
and
St. Luke
Hospital,
SURGICAL
REMOVAL
OF LARGE
STALOT,lTTl
SO!1
time did this swelling become acute or produce other general or local symptoms. Sinc‘r there were no acute symptoms, he had not sought professional consultation regarding thi+ ranlargemrnt. On Feb. 25, 1955, the patient became aware of a sudden increase in sizt) ot anti xllilit! t(# this area, which continued to enlarge and produce pain, loss of appetite sleep, clif%cultv in breathing and swallowing, and an incarease in 1~11ly teulperaturcb.
I?&. X.--Photograph
showing
Fig. X-Radiograph
chronic
enlargement of submaxillary cellulitis has subsided.
showing
sialolith
salivary
in area of submaxillary
nland
aftw
arut<
glnn11
Head and Neck Examination.--Examination revealed a cellulitis of the right face an11 neck with an indurated, oval-shaped mass in the center of the generalized swelling (Fig. the greatly enlarged submaxillary salivary gland. Digit;11 1). The firm mass represented pressure elicited a sharp, lancinating pain, The overlying skin was taut and markedly inflamed in appearance. lymph nodes were somewhat obscured due to the cellulitis, but the anterior cervical chain of lymph nodes was enlarged to palpation. The patient,
The regional and posteri(*r who was in
Or.,1 Surg., Ord Med., 8i Oral Path. August, 1956
CHKTSTENSRN
81.0
apparent pain, was nauseat,ed and febrile. His temperature, orally, was 103.0” F. The oral examination disclosed severe edema of the floor of the mouth on the right side, with an ectatic right 1Vharton’s duct,.
Roentgen Examination.-A lateral roentgenogram of t,hc right mandible showed a large, round, ratliopaclue mass, measuring 1.5 cm. in diameter, lying at the inferior border of the mandible approximately 1.0 cm. anterior to the posterior border of the ramus of the mandible (Fig. 2). In post,eroanterior views of the mandible, this mass is seen lying just lingual to the mandible at its inferior border. Occlusal films, taken in a routine manner, fail to show this mass. The mass is the density of boue and is believetl to represent a large sialolith in the anterior lobe of the right submaxillary salivary gland. Impression: Sialolithiasis of the anterior lobe of the right submaxillary salivary gland On March 7, 1955, the patient was admittetl to St. Luke Hospital. mg. in 1000 cc. of normal saline, was given intravenously on admission. then started on Terramycin, 250 mg. every four hours, orally thereafter.
Terramycin, The patient
500 was
S1 l!l55, the laboratory findings were essentially Laboratory Findings.-On March The red blood count was 5,500,000, and the white hlootl count was 7,950, with negative. 3 stabs, lymphocytes 68 per cent polymorpl~onuclear, 2s per relit, and monocytes 1 per Fasting I,lood sugar was 155 uig. per cent. cent. Serology was negative.
Fig.
Operation.-On larged,
3.-Photograph
showing
the sialolith
visible
March 9, 1955, the right submaxillary but the surrounding cellulitis had subside(1.
durinfi gland
suraery. was
still
greatly
en
The patient was given routine preoperative medication and was anesthetized with intravenous Pentothal sodium and nasoendotracheal nitrous oxide-oxygen. The operative area was prepared and draped in a normal manner. A skin incision was made, with a scalpel, parallel to and 3 cm. below the inferior border of the right mandible. The incision was 7 cm. in length and centeretl over the submaxillary gland. It was carried through the skin, superficial fascia, platysma, aud deep cervical fascia. By sharp and blunt dissection, the gland was carefully freed from its surrounding fascial curelope. The gland was found to be adherent in its anterior surface to the posterior surface of the mylohyoid muscle. The anterior portion, near its junction with Rhart,on’s duct, was enlarged and firm to palpation.
area uf thr attachment attachment forceps and
glalltl more accessil)le. \Yhen this portion of the gland was tlissected frc’e, tIltI to \\-harton’s duct became visible and u-as severed by scissors 1 cm. from it>. to the g-land. The portion of the duet which remained was held by a Iioll~ tied with a 000 catgut suture,
CHRISTENSEN
812
Oral
kg.,
Oral Med.,
& Oral August,
Path. 1956
At this point, the cavity which remained was inspected for bleeding points, which were grasped with hemostats and electrocoagulated. A continuous suture of plain 000 catgut was used to close the deep fascia. A one-quarter inch Penrose drain was inserted deep into the wound and allowed to project from the wound. The superficial fascia and platysma were closed with interrupted 000 catgut sutures; approximately eight 0000 Dermalon interrupted mattress sutures were used to evulse and close the skin incision. The wound was pressed firmly to express fluid and air from the wound cavity. The Penrose drain was sutured to the skin. A petrolatum gauze strip was placed over the wound and a pressure pack was applied over this. The blood sugar immediately before surgery was 158 mg. per cent and immediately following surgery it was 157 mg. per cent. At the end of surgery Terramycin, 500 mg. in 1 liter of normal saline, was given intravenously.
Pathology Report.Gross: The specimen consisted of (1) a nodular, roughly oval gland measuring 4.0 by 2.5 by 2.0 cm., (2) a second, smaller section of the gland, which appeared more fragmented, fibrous, and hemorrhagic, measuring 0.8 by 1.0 em., and (3) a roughly spherical grayish yellow concretion having a diameter of 1.5 cm. (Figs. 4 and 5). The gland’s capsule appeared intact, with the exception of one end which appeared to have been dissected. The smaller fragment had the proximal portion of Wharton’s duct emerging from it. Microscopic: The sections of submaxillary salivary gland tissue showed several irregular lobules of parenchyma within a fibrofatty stroma. There was an intense interstitial roundcell inflammatory exudate consisting mainly of plasma cells and lymphocytes, with some polymorphonuclear leukocytes. There also were considerable interstitial fibrosis and edema. In some areas the cellular exudate was organized into small lymphoid follicles. Many of the secondary duct branches were distended with reticulated mucoid material in which there were scattered epithelial cells and blood cells. There was no evidence of malignant change. The areas of fibrous and fatty tissue showed an intense chronic inflammatory reaction which was largely perivascular and accompanied by dense fibrous connective tissue proliferation. No major duet was identified. However, the concentric laminations of fibrous and inflammatory tissue in one area suggest the outline of a duct which is completely stenotic. In another field a small, incompletely epithelial-lined channel adjacent to a mass of calcareous material was compatible with a small tributary duct and sialolith. Diagnosis
:
1. Sialolith, right submaxillary salivary gland. 2. Sialitis, chronic, right submaxillary salivary
gland.
Summary A case of sialolithiasis of the submaxillary salivary Because of the size and anatomic location of the sialolith, fection present, the history of chronic infection and gland, and the patient’s general condition, it was deemed the entire gland and sialolith in one extraoral operation. excision, healing was uneventful.
gland is presented. the amount of inenlargement of the advisable to remove Following surgical
References 1. Thoma, Kurt H. : Oral Pathology, St. Louis, 1954, The C. V. Mosby Company. Oral Surgery, St. Louis, 1952, The G. V. Mosby Company. 2. Thoma, Kurt H.: 3. Mead, Sterling V.: Oral Surgery, St. Louis, 1954, The C. V. Mosby Company. 90 NORTH OAKLAND AVE.
REMOVAL OF A LARGE SUBMAXILLARY
SIALOLITH GLAND
WITHIN
THE
Report of a Case ROBERT W. CHRISTENSEN, 1_).1).S.,* PASADENA, CALIF.
calculi may form SALIVAIZY gland proper. Approximately
in the duct of a salivary gland or in the 90 per cent of the salivary calculi form in the submaxillary gland or its duct. The sublingual gland has the next largest incidence, and the parotid gland is rarely affected. There are several factors which probably explain the higher incidence of sialolithiasis of the submaxillary gland and duct over the other salivary glands. The anatomic position of the gland being below the level of the duct orifice, the large size of the gland and duct, the great length of the submaxillary duct, and the vulnerability of this duct to trauma and direct invasion of infection are some of the more evident factors in infection and sialolithiasis of this particular gland. The treatment of sialolithiasis and the subsequent infection of the gland, duct, and adnexa involves antibiotic therapy and surgical removal of the sialolith. Sometimes it is necessary to remove the gland itself, but most sialoliths can be removed via the intraoral approach, with conservation of the gland. The greatest percentage of sialoliths form within the duct. The case to be present4 is one in which a large sialolith was in the anterior portion of t,he gland and in which there had been considerable infection and fibrosis of gland tissue adjacent to the sialolith. It was deemed advisable to excise the gland and sialolith in one extraoral operation. Case Report On March 1, 1955, C. S., a %-year-old Caucasian man, was referred to me by his physician for diagnosis and treatment of an acute infection of the right submaxillary space.
Past Medical History.-The patient’s past history disclosed that he had been a known diabetic for the past ten years. This condition was controlled by insulin therapy for the first three years and had been partly controlled by diet since that time. He had developed gangrene of the right leg seven years before and a toe had been amputated at that time. He gave a history of a rash type allergic reaction to penicillin therapy three years ago which was controlled by antihistamine therapy. History patient
of Present Illness.-Over
was conscious
of a slight
*Member of the oral Pasadena, California.
surgery
a period of one and one-half to two years, the swelling in the right submaxillary gland area. At no
staff,
Huntington
808
Memorial
Hospital
and
St. Luke
Hospital,
SURGICAL
REMOVAL
OF LARGE
STALOT,lTTl
SO!1
time did this swelling become acute or produce other general or local symptoms. Sinc‘r there were no acute symptoms, he had not sought professional consultation regarding thi+ ranlargemrnt. On Feb. 25, 1955, the patient became aware of a sudden increase in sizt) ot anti xllilit! t(# this area, which continued to enlarge and produce pain, loss of appetite sleep, clif%cultv in breathing and swallowing, and an incarease in 1~11ly teulperaturcb.
I?&. X.--Photograph
showing
Fig. X-Radiograph
chronic
enlargement of submaxillary cellulitis has subsided.
showing
sialolith
salivary
in area of submaxillary
nland
aftw
arut<
glnn11
Head and Neck Examination.--Examination revealed a cellulitis of the right face an11 neck with an indurated, oval-shaped mass in the center of the generalized swelling (Fig. the greatly enlarged submaxillary salivary gland. Digit;11 1). The firm mass represented pressure elicited a sharp, lancinating pain, The overlying skin was taut and markedly inflamed in appearance. lymph nodes were somewhat obscured due to the cellulitis, but the anterior cervical chain of lymph nodes was enlarged to palpation. The patient,
The regional and posteri(*r who was in
Or.,1 Surg., Ord Med., 8i Oral Path. August, 1956
CHKTSTENSRN
81.0
apparent pain, was nauseat,ed and febrile. His temperature, orally, was 103.0” F. The oral examination disclosed severe edema of the floor of the mouth on the right side, with an ectatic right 1Vharton’s duct,.
Roentgen Examination.-A lateral roentgenogram of t,hc right mandible showed a large, round, ratliopaclue mass, measuring 1.5 cm. in diameter, lying at the inferior border of the mandible approximately 1.0 cm. anterior to the posterior border of the ramus of the mandible (Fig. 2). In post,eroanterior views of the mandible, this mass is seen lying just lingual to the mandible at its inferior border. Occlusal films, taken in a routine manner, fail to show this mass. The mass is the density of boue and is believetl to represent a large sialolith in the anterior lobe of the right submaxillary salivary gland. Impression: Sialolithiasis of the anterior lobe of the right submaxillary salivary gland On March 7, 1955, the patient was admittetl to St. Luke Hospital. mg. in 1000 cc. of normal saline, was given intravenously on admission. then started on Terramycin, 250 mg. every four hours, orally thereafter.
Terramycin, The patient
500 was
S1 l!l55, the laboratory findings were essentially Laboratory Findings.-On March The red blood count was 5,500,000, and the white hlootl count was 7,950, with negative. 3 stabs, lymphocytes 68 per cent polymorpl~onuclear, 2s per relit, and monocytes 1 per Fasting I,lood sugar was 155 uig. per cent. cent. Serology was negative.
Fig.
Operation.-On larged,
3.-Photograph
showing
the sialolith
visible
March 9, 1955, the right submaxillary but the surrounding cellulitis had subside(1.
durinfi gland
suraery. was
still
greatly
en
The patient was given routine preoperative medication and was anesthetized with intravenous Pentothal sodium and nasoendotracheal nitrous oxide-oxygen. The operative area was prepared and draped in a normal manner. A skin incision was made, with a scalpel, parallel to and 3 cm. below the inferior border of the right mandible. The incision was 7 cm. in length and centeretl over the submaxillary gland. It was carried through the skin, superficial fascia, platysma, aud deep cervical fascia. By sharp and blunt dissection, the gland was carefully freed from its surrounding fascial curelope. The gland was found to be adherent in its anterior surface to the posterior surface of the mylohyoid muscle. The anterior portion, near its junction with Rhart,on’s duct, was enlarged and firm to palpation.
area uf thr attachment attachment forceps and
glalltl more accessil)le. \Yhen this portion of the gland was tlissected frc’e, tIltI to \\-harton’s duct became visible and u-as severed by scissors 1 cm. from it>. to the g-land. The portion of the duet which remained was held by a Iioll~ tied with a 000 catgut suture,
CHRISTENSEN
812
Oral
kg.,
Oral Med.,
& Oral August,
Path. 1956
At this point, the cavity which remained was inspected for bleeding points, which were grasped with hemostats and electrocoagulated. A continuous suture of plain 000 catgut was used to close the deep fascia. A one-quarter inch Penrose drain was inserted deep into the wound and allowed to project from the wound. The superficial fascia and platysma were closed with interrupted 000 catgut sutures; approximately eight 0000 Dermalon interrupted mattress sutures were used to evulse and close the skin incision. The wound was pressed firmly to express fluid and air from the wound cavity. The Penrose drain was sutured to the skin. A petrolatum gauze strip was placed over the wound and a pressure pack was applied over this. The blood sugar immediately before surgery was 158 mg. per cent and immediately following surgery it was 157 mg. per cent. At the end of surgery Terramycin, 500 mg. in 1 liter of normal saline, was given intravenously.
Pathology Report.Gross: The specimen consisted of (1) a nodular, roughly oval gland measuring 4.0 by 2.5 by 2.0 cm., (2) a second, smaller section of the gland, which appeared more fragmented, fibrous, and hemorrhagic, measuring 0.8 by 1.0 em., and (3) a roughly spherical grayish yellow concretion having a diameter of 1.5 cm. (Figs. 4 and 5). The gland’s capsule appeared intact, with the exception of one end which appeared to have been dissected. The smaller fragment had the proximal portion of Wharton’s duct emerging from it. Microscopic: The sections of submaxillary salivary gland tissue showed several irregular lobules of parenchyma within a fibrofatty stroma. There was an intense interstitial roundcell inflammatory exudate consisting mainly of plasma cells and lymphocytes, with some polymorphonuclear leukocytes. There also were considerable interstitial fibrosis and edema. In some areas the cellular exudate was organized into small lymphoid follicles. Many of the secondary duct branches were distended with reticulated mucoid material in which there were scattered epithelial cells and blood cells. There was no evidence of malignant change. The areas of fibrous and fatty tissue showed an intense chronic inflammatory reaction which was largely perivascular and accompanied by dense fibrous connective tissue proliferation. No major duet was identified. However, the concentric laminations of fibrous and inflammatory tissue in one area suggest the outline of a duct which is completely stenotic. In another field a small, incompletely epithelial-lined channel adjacent to a mass of calcareous material was compatible with a small tributary duct and sialolith. Diagnosis
:
1. Sialolith, right submaxillary salivary gland. 2. Sialitis, chronic, right submaxillary salivary
gland.
Summary A case of sialolithiasis of the submaxillary salivary Because of the size and anatomic location of the sialolith, fection present, the history of chronic infection and gland, and the patient’s general condition, it was deemed the entire gland and sialolith in one extraoral operation. excision, healing was uneventful.
gland is presented. the amount of inenlargement of the advisable to remove Following surgical
References 1. Thoma, Kurt H. : Oral Pathology, St. Louis, 1954, The C. V. Mosby Company. Oral Surgery, St. Louis, 1952, The G. V. Mosby Company. 2. Thoma, Kurt H.: 3. Mead, Sterling V.: Oral Surgery, St. Louis, 1954, The C. V. Mosby Company. 90 NORTH OAKLAND AVE.