Salivary calculi

SALIVARY CASE

DURHAM,

C

ALCULI

and

may

glands

and

systems

bibary

salivary frequent stones,

of the

than

that

caIcuIi

is roughly

caIcuIi

in these

clinical tion,

sequence and then

as the

The of

urinary

cIinica1

course

comparable other

is pain

CASE

of

much or

less

biliary

of sahvary to

systems. or coIic,

suppuration

urinary

occurrence is

that

The

M.D.*

NORTH CAROLINA

in the salivary

however,

the

TESKE,

as we11 as in other

body

systems.

caIcuIi, but

develop

ducts

REPORT

M.

JACOB

CALCULI

of

usua1

obstruc-

due to stasis.

REPORT

The patient, a white maIe, married, aged forty-seven, was admitted to Watts HospitaI on January 5, 1943, on the surgicat service of Dr. N. D. Bitting. He first began to have pain in the right submaxiIIary region about ten years ago. This pain was present onIy during meals, however, sometimes the pain was present when he merely smeIIed food. At that time he aIso noticed a smaI1 nodule about I cm. in diameter which appeared in the right submaxillary region during meaIs or when he smeIIed food and then disappeared again between meals. He passed a smaI1 caIcuIus through the right submaxiIIary duct a few weeks after the pain first began in this region. He first feIt the stone with his tongue beneath the mucous membrane of the floor of the mouth and a few days Iater he passed the calculus. Since then he passed two other stones. Occasionahy, he got a thick, stringy substance in his mouth which had the appearance of pus. No bleeding was present. The pain and sweIIing in the right submaxiIIary gland continued intermittentIy unti1 about three weeks before he entered the hospita1 when the pain began to be continuous and more severe. The swelling began to increase in size and did not disappear or diminish between attacks as it did before. At that time the

sw-elling aIso became moderateIy tender while previously it was not tender. There was no trauma to his right submaxilIary region at any time. He did not have any chiIIs, but feIt as if he had a fever the day before he entered the hospital. The only treatment he had prior to entry into the hospital was the passage of a sound or catheter into the duct. This failed to relieve the obstruction or improve the condition. There were no abnormal findings on examination except in the right submaxiIIary region there was a firm hard tumor about 5 cm. in diameter situated at the angIe of the mandibIe. This tumor was freely movable on the deep structures and was not adherent to the overIying skin. It was moderateIy tender on paIpation. His temperature was IOO.Z$‘F., pulse 82, and respirations were 20. The systolic blood pressure was 140 and the diastoIic was 70. The red blood count was s,ooo,ooo, the hemogIobin was 97 per cent, and the white blood count was 13,200 with 85 per cent neutrophiles. Examination of the urine showed no abnorma1 findings except a smaI1 trace of albumin. The Wassermann and Kahn tests of the blood gave a negative reaction. A rather large irregular caIcuIus just anterior to the angle of the mandible was visuaIized on the roentgenogram. It appeared to be Iocated in the submaxiIIary gIand or in the posterior part of Wharton’s duct. (Fig. I .) The diagnosis of a caIcuIus in the right submaxillary duct with the presence of a pyogenic infection of the submaxillary gland was made, and on January 7th, the right submaxillary gland was removed by Dr. N. D. Bitting under a genera1 anesthetic. The submaxillary gIand with its capsuIe intact was excised and the wound drained with a smaI1 Penrose drain. On section of the gland a large amount of thick, whitish material which resembIed pus escaped from the gIand, and one large and a

Passed Assistant Surgeon, U. S. Public HeaIth Service (Reserve). 254

On active duty with the U. S. Coast Guard.

Teske-SaIivary

NEwSERIESVOL.LXVIII,NO.~

number of smaller calculi were found in the substance of the gland. (Figs. 2 and 3.1 The histological examination sh&ed the

FIG.

I. Roentgenogram calculi

CaIcuIi

American

Salivary caIcuIi life and are more

females

about

showing an irregular shadow in the right submaxilIary gland.

presence of a suppurative sialadenitis. There were only small remnants of glandular tissue left while numerous small ducts were surrounded by large numbers of Iymphocytes. There was an increased amount of fibrous tissue present. His postoperative course in the hospita1 was smooth. The highest temperature he had folIowing operation was 100’F. He was dis-

charged from the hospital on January 18th, eIeven days foIIowing operation with complete heaIing of the wound. The etiology of salivary calculi is not clear. Inffammation no doubt pIays an important part. The deposition of calcium saIts being initiated by a bacteria1 nucIeus or by inAammatory epitheIia1 debris. A few cases were reported in which a foreign body formed the nucIeus upon which caIcmm salts were deposited. Pilcher reported a case in which a caIcuIus formed around a piece of grass which was Iodged in the duct. Many authors consider actinomyces as an etioIogica1 factor in the formation of salivary caIculi.

Journal

usuaIIy

ofSurgery

occur

255 in aduIt

common in males than submaxilIary 2: I. The

of the

involved gland is much more frequentIy 174 cases reviewed than the others. In from the literature the incidence of OCcurrence in either gland or duct were as foIlows: submaxillary 150 cases or 86.2 per cent, parotid twenty cases or I 1.5 per cent, and sublingua four cases or 2.3 per cent. The symptoms of sahvary caIculi are rather typical with intermittent pain and sweIIing in the region of the involved gIand. The pain and swelling usually occur during meals or by the mere sight of food. The condition is usually chronic but may have acute exacerbations accompanied with ceIIuIitis and fever. Pus may escape from the orifice of the duct. A moderate Ieukocytosis with an increase in polymorphonucIear leukocytes is frequently present. By a combined intraoral and extraora1 palpation the hard stone can usually be felt. The orifice of the duct may be inflamed and pus can usually be expressed from it. The roentgenogram is very usefu1 in the diagnosis and shouId be done in every

256

American

Journal

of Surgery

Teske-Salivary

case for occasionally there are multipIe However not a11 stones stones present. can be demonstrated by x-ray, but about

Calculi has subsided. The passage of a catheter or sound should be avoided during this stage.

FIG. 3. CalcuIi removed from the submaxilIary gland.

2. Section of the submaxiIIary gIand shows a large stone near the beginning of Wharton’s duct and a number of smaller ones embedded in the substance of the gIand.

FIG.

80 per cent can be visuahzed. IgIauer stated that by depression of the ffoor of the mouth with the finger the submaxihary gIand and duct couId be depressed beIow the IeveI of the mandibIe and then be visualized by a IateraI x-ray. In cases in which a caIcuIus was suspected in the anterior two-thirds of the submaxiIIary duct Ivy and Curtis suggested that an x-ray fiIm be pIaced in the mouth between the upper and Iower teeth and heId in pIace by approximating the teeth. The fiIm is pIaced as far back as possibIe and the rays directed upward from beIow the chin. The treatment depends to a Iarge extent upon the amount of infection and destruction of the sahvary gIand invoIved. In the presence of an acute inflammation it is advisabIe to treat the condition conservativeIy with hot compresses and hot irrigations unti1 the acute inff ammation

If the calculus is located in the submaxihary duct, it may be removed by an incision directly over the stone in the mucous membrane of the Aoor of the mouth. If a stone is situated in the gIand proper, it is best to remove the whoIe gland through an inframandibuIar inRemovaI of the entire gIand is cision. usuaIIy necessary to cIear up the condition and to prevent a recurrence in case of a caIcuIus of Iong standing with the presence of chronic suppuration. It is apparent in the case reported here with the extensive suppuration and destruction present and aIso the presence of a few smaIIer stones in the substance of the gIand that simpIe remova of the Iarge stone would not have cIeared up the symptoms in this case. New and Harper reported a recurrence of symptoms in 16.3 per cent of the cases in which a stone was removed through the mouth from the duct or gIand without remova of the gIand. Stones in the subIingua1 gIand or duct may be removed by an incision directly over the stone and is not a difficult procedure. When the stone is embedded in the substance of the gIand, remova of the whole gIand may be necessary. Harrison advises the removal of saIivary caIcuIi whether they produce symptoms

Teske-Salivary or not for they

are a potentia1 danger may cause serious trouble later.

and

CalcuIi

American

Journal

of Surgery

up the symptoms and to prevent currence of the condition.

257

a re-

SUMMARY

REFERENCES

The case history of a man forty-nine years old who had symptoms of a submaxiIIary salivary calculus for ten years is reported. RemovaI of the calculus with the whole salivary gland gave him complete reIief of the symptoms with no recurrence. A calcuIus in the submaxiIIary gIand or duct of long standing usuaIIy requires compIete extirpation of the gIand to clear

G. R. Calculi of the salivary glands and ducts. Surg., Gynec. c~ Obst., 43 : 43 I, I 926. 2. IGLAUER, S. A simple maneuver to increase the visibility of a salivary calculus in the roentgenogram. Radiology, 2 I : 297, 1933. 3. IVY, R. H. and CURTIS, L. Salivary calculi. Ann. SUTg., 96: 979, 1932. 4. NEW, G. B. and HARPER, F. R. Chronic inflammation of the salivary glands with or without calculi. SUT&, Gynec. CY Obst., 53: 456, 1931. 5. PILCHER, J. A. Salivary calculus containing a foreign body. Arch. Otolaryngol., 26: 531, 1937.

I.

HARRISON,

THE chief indication for operation upon the parathyroid bodies is hyperparathyroidism. Transplantation of a parathyroid may rareIy be indicated when it is removed by accident during thyroidectomy. From “Operations of Genera1 Surgery” by Thomas G. Orr (W. B. Saunders Company).