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Large calcified mass in the submaxillary gland
Large calcified mass in the submaxillary gland G. S. Hoggins, B.D.S., P.D.S.R.C.X. Birmingham, England SELLY
OAK
(Eng.),
L.D.S.R.C.X.
(Eng.),
HOSPITAL
A
52.year-old man reported to the hospital with a massive inflammatory swelling in the right submaxillary region. Because his condition was very toxic, with pyrexia and great pain, immediate admission to the hospital was advised. The previous history showed that the swelling had occurred 20 years previously, necesbut there had been no x-ray investigation or operative sitating inpatient hospital treatment, intervention. A further episode of swelling had occurred 10 years later, but it had resolved without special treatment. There had been no other serious episodes of swelling since that time, until the present admission. The past medical history showed no previous operations. The patient had had pneumonia at the age of 21 years but had been otherwise free of major illness. He was a fairly heavy smoker, with a tendency to bronchitis and cough. On admission to the hospital on April 22, 1966, he was x-rayed fully, and the films demonstrated the presence of a huge calcified mass in the right submaxillary region (Figs. 1 and 2). Clinical examination confirmed a gross smelling of the right submaxillary region, fluctuant in one area but vrry hard otherwise. The patient had difficulty in opening the jaw because of trismus. The hard mass was palpable in the right floor of the mouth, displacing the tongue to the left side and causing difficulties with speech, mastication, anil swallowing. Extension of the swelling behind the right faucial area was also noted. The jaws were edentulous. Emergency treatment to drain a col)ious amount of pus from the swelling was followed 11~ rapid improvement in the pat,ient’s general condition. (An alpha hemolytic streptococcus, which q as scnsitircs to penicillin, n-as grown on culture.1 The patient was discharged on May 1, 19M.
The patient \vas maintaincif on pomillin therapy for a long period unl-il his readmission s:: .ll&j 7, 19%it \VI!S~IIth5> infwtlon \sas controllrd ant\ the area ;*ias saitable for an operation tn t~~~~lorr
and
fymov~
thr
c:alcififd
mass.
An operation was performed, with the patient nntlcr general aneatllesia, on July 8, 1966. PousLlerable di%culty was experienced in passing the endotracheal tube, particularly in produced by the massive s\velling. A long submandibular view oE the abnormal conditions incision was made, and dissection was carried out to a deep level into the submaxillary spm:e until the hard mwss was lo44 and exposed. PITo submaxillary salivary gland was founcl, and only a few isolated lymph nodes were seen. The mass appeared to be contained in a capsule and n-as eventually delivered after great difficulty had been experienced, entirely because of its Iarge size (Fig. 3). The wound was closed in layers with catgut, and silk sutures were used for closure of the skin wound. A corrugated drain was sewed into the large
679
Fig.
Figs . 1 and 2’. X-ray
Fig. 3. Calcified
views of large
mass removed
from
calcified
mass responsible
submandibular
space.
for
submandibular
Eiwelli ag.
Volume ‘5 Number-k
If’i!/. 4. POb;topc ‘Pa ttive
view showing
healed
b-if/. 5. l’ostopcrative
view showing
deviation
insn&bu?lar
of tongue
sear.
to right
side.
tlratl space rvlriCl1 had coutained the calcified mass. Recovc~ry \vas unercwtful, and heahg \vas sat,isfac+orp aftc7 removal of the drain. Follow-up rrvi1.w showed complete resolution of symptoms except for partial atrophy of the right side of the tongue muscuIat,ure, probably associated with damage to the hypoglossal uerve tluriug delivrry of th(, mass (F’igs. 4 am1 5 ). Recent follo\v-up examination (‘0~ tirma that musc~lc activity in ttrc right *idr of tllc, tongue is rc*turning aud it is l~optd that full rcc:ovt~ry will uow o~ur. ChtWli(*al analysir of thr Gone shored it to 1~ cWrnp0sc~i maini: ,if I~alrilltll ~‘l!“~l’llilci’,
DISCUSSION
This unusual c~nlcificd mass appears to have Iwn c~~nscd hy the axur~e~we of excessive aalcificat~ion within the right submaxillary gland, as this structure was not lowff31 at operation. 370 special history of salivary gland symptoms was I’+ ported by the patient, aside from the two episodcn of swelling during the ZOyear period prior to the operation. The assistance graphs is gratefully
of Mr. Cr. IIolland, acknowledged.
.i.I.I.I’.,
in tllc> pr~~paration
of the s-rays
and photo-
OAK
(Eng.),
L.D.S.R.C.X.
(Eng.),
HOSPITAL
A
52.year-old man reported to the hospital with a massive inflammatory swelling in the right submaxillary region. Because his condition was very toxic, with pyrexia and great pain, immediate admission to the hospital was advised. The previous history showed that the swelling had occurred 20 years previously, necesbut there had been no x-ray investigation or operative sitating inpatient hospital treatment, intervention. A further episode of swelling had occurred 10 years later, but it had resolved without special treatment. There had been no other serious episodes of swelling since that time, until the present admission. The past medical history showed no previous operations. The patient had had pneumonia at the age of 21 years but had been otherwise free of major illness. He was a fairly heavy smoker, with a tendency to bronchitis and cough. On admission to the hospital on April 22, 1966, he was x-rayed fully, and the films demonstrated the presence of a huge calcified mass in the right submaxillary region (Figs. 1 and 2). Clinical examination confirmed a gross smelling of the right submaxillary region, fluctuant in one area but vrry hard otherwise. The patient had difficulty in opening the jaw because of trismus. The hard mass was palpable in the right floor of the mouth, displacing the tongue to the left side and causing difficulties with speech, mastication, anil swallowing. Extension of the swelling behind the right faucial area was also noted. The jaws were edentulous. Emergency treatment to drain a col)ious amount of pus from the swelling was followed 11~ rapid improvement in the pat,ient’s general condition. (An alpha hemolytic streptococcus, which q as scnsitircs to penicillin, n-as grown on culture.1 The patient was discharged on May 1, 19M.
The patient \vas maintaincif on pomillin therapy for a long period unl-il his readmission s:: .ll&j 7, 19%it \VI!S~IIth5> infwtlon \sas controllrd ant\ the area ;*ias saitable for an operation tn t~~~~lorr
and
fymov~
thr
c:alcififd
mass.
An operation was performed, with the patient nntlcr general aneatllesia, on July 8, 1966. PousLlerable di%culty was experienced in passing the endotracheal tube, particularly in produced by the massive s\velling. A long submandibular view oE the abnormal conditions incision was made, and dissection was carried out to a deep level into the submaxillary spm:e until the hard mwss was lo44 and exposed. PITo submaxillary salivary gland was founcl, and only a few isolated lymph nodes were seen. The mass appeared to be contained in a capsule and n-as eventually delivered after great difficulty had been experienced, entirely because of its Iarge size (Fig. 3). The wound was closed in layers with catgut, and silk sutures were used for closure of the skin wound. A corrugated drain was sewed into the large
679
Fig.
Figs . 1 and 2’. X-ray
Fig. 3. Calcified
views of large
mass removed
from
calcified
mass responsible
submandibular
space.
for
submandibular
Eiwelli ag.
Volume ‘5 Number-k
If’i!/. 4. POb;topc ‘Pa ttive
view showing
healed
b-if/. 5. l’ostopcrative
view showing
deviation
insn&bu?lar
of tongue
sear.
to right
side.
tlratl space rvlriCl1 had coutained the calcified mass. Recovc~ry \vas unercwtful, and heahg \vas sat,isfac+orp aftc7 removal of the drain. Follow-up rrvi1.w showed complete resolution of symptoms except for partial atrophy of the right side of the tongue muscuIat,ure, probably associated with damage to the hypoglossal uerve tluriug delivrry of th(, mass (F’igs. 4 am1 5 ). Recent follo\v-up examination (‘0~ tirma that musc~lc activity in ttrc right *idr of tllc, tongue is rc*turning aud it is l~optd that full rcc:ovt~ry will uow o~ur. ChtWli(*al analysir of thr Gone shored it to 1~ cWrnp0sc~i maini: ,if I~alrilltll ~‘l!“~l’llilci’,
DISCUSSION
This unusual c~nlcificd mass appears to have Iwn c~~nscd hy the axur~e~we of excessive aalcificat~ion within the right submaxillary gland, as this structure was not lowff31 at operation. 370 special history of salivary gland symptoms was I’+ ported by the patient, aside from the two episodcn of swelling during the ZOyear period prior to the operation. The assistance graphs is gratefully
of Mr. Cr. IIolland, acknowledged.
.i.I.I.I’.,
in tllc> pr~~paration
of the s-rays
and photo-