Sialolithiasis - PDF Document

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  1. Sialolithiasis Cornell David I. Blaustein, in an 8-year-old child: case report McCullom III, DDS Cameron Y.S. Lee, DDS, PhD DMD Abstract Sialolithiasis rarely occurs in children; it is observed more commonly in adults. Various treatment modalities for sialolithiasis have been reported in the world dental and medical literature; most rely upon surgical intervention. This case report demonstrates that surgical intervention is not always indicated. We describe an 8-year-old child with a sialolith in the posterior third of Wharton’s duct which spontaneously passed from the duct. Clinical findings, etiology and treatment of sialolithiasis are reviewed. (Pediatr Dent 13:231-33, 1991) Introduction Sialoliths found in the ducts of the major or minor salivary glands or within the glands themselves. They are thought to form by deposition of calcium salts around a central nidus which may consist of desquamated epithelial cells, bacteria, products of bacterial decomposition, or foreign bodies (Shafer 1983). The disease entity is known as sialolithiasis and is a rare occurrence in children (Doku and Berkman 1967). The condition is found more commonly in middle-aged adults. most commonly affected is the submandibular gland (Blatt 1962). are calcareous concretions that may be Case Report An 8-year-old black female presented to the oral and maxillofacial surgery clinic at the University of Illinois College of Dentistry with the chief complaint of pain and swelling in the right submandibular region for three days. The mother stated that the child had a decreased appetite during this period and that the dis- comfort was exacerbated at meal time. The patient had no previous history of facial trauma, carious teeth, ab- normal eating habits, or sialoliths. The patient’s past medical history was unremarkable. There was no report of any allergy to medication or food. (At presentation, the child was not taking any medication). On general examination, height and weight for her age. She was in no acute distress, but minor dysphagia was noted. Her oral tem- perature was 100.2~F, pulse was 100 beats per min, and blood pressure 102/74 mm Hg. Clinical examination revealed mild right subman- dibular swelling with no visually distinct localized mass. On bidigital palpation, the right submandibular gland was tender. Lymph nodes were palpable in the right submandibular region, but absent in the cervical por- tion of the neck. Trismus was not noted but when the patient responded verbally to questions, she spoke in a manner to limit lip movement. The remaining extraoral examination was unremarkable. Intraorally, there were no grossly carious teeth. Bilat- eral Stenson’s ducts were patent with clear salivary flow produced on gentle palpation. Wharton’s duct on the__left side was patent with free salivary flow, while thgright Wharton’s duct produced minimal to no sali- vary secretion on gentle manipulation. The puncture of the right Wharton’s duct was noted to be erythematous and edematous, but nontender. The remaining intraoral examination was unremarkable as there were no other distinct masses or lesions in the oral cavity. The floor of the mouth was soft and nontender and the tongue was The salivary gland Literature Review In surveying the dental literature 1966, Doku and Berkman (1967) found 11 cases submandibular sialoliths years and described one case of their own. Reuther and Hausamen’s survey (1976) of the dental literature tween 1898 and 1973 documented 21 pediatric Additional cases were described by Feldman (1970, Canada) and by Longhurst (1973~ England). Timosca al. (1976) from France reviewed 267 reports sialolithiasis through 1976, of which five cases were in the 5-15 year old range. Over a period of 30 years, Kaban studied patients treated for sialadenitis (Kaban et al. 1978) and docu- mented seven cases of pediatric sialolithiasis. recently, Volkova (1978, Russia) described nine cases and Bullock (1980, England) reported another case. Bodner and Azaz (1982, Israel) reported nine cases pediatric sialolithiasis while Tepan and Rohiwal (1985, India) and Grunebaum and Mankuta (1985) each ported a case of their own in 1985. Since the majority of the reported cases of sialolithiasis in children were treated by surgical means, this case report is presented to illustrate that conservative treat- ment may be successful and should be instituted surgical intervention. between 1916 and the patient was normal in children younger than 15 be- cases. More before PEDIATRIC DENTISTRY: JULY/AuGuST, 1991 ~ VOLUME 13, NUMBER 4 231

  2. not elevated, since the sublingual space was not in- volved. Radiographic examination (Fig 1) revealed a curved, elliptical, radiopaque mass about 10 mm long and 3-4 mm in diameter. The mass was located between the apical portion of unerupted tooth #31 and the inferior border of the right mandible. mass proved to be a sialolith, 10 mm long and 4 mm in diameter. The yellowish-white granular sialolith had a curved, elliptical shape that corresponded to its radio- graphic appearance (Fig 2). Clinically, the right submandibular swelling had re- solved, and was nontender. Intraoral examination dem- onstrated that the right Wharton's duct was patent and nonedematous, with free-flowing saliva. Home care instructions included hydration, mas- sage to the submandibular gland and use of lemon drop candy. On follow-up examination 22 months later, the patient remained asymptomatic without recurrence of sialoliths. Discussion Acute sialadenitis of the submandibular gland is the most common form of inflammation to the major sali- vary glands. Obstruction of the salivary duct due to sialolithiasis is the most frequent etiology (Kaban 1990). Children who present to the clinician's office are usually healthy, without systemic illness. Their chief complaint is intermittent, unilateral pain and swelling in the submandibular region associated with eating. Patients characteristically report that the swelling sub- sides between meals, only to recur with their next meal. The child also may complain of malaise and fever (Kaban 1990). In the early stages of an obstructed submandibular gland, the gland is usually soft and nontender to palpa- tion. At some point after the onset of obstructive symp- toms, secondary infection of the gland occurs. Infection produces a gland that is enlarged and tender to palpa- tion, with the overlying skin often erythematous. Intraorally, the submandibular duct is edematous, 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. Deter- mination of the amount and character of saliva should be noted. In most instances of an obstructed salivary duct, there is decreased or absent salivary flow. Puru- lence in the saliva commonly is observed, indicating a bacterial infection (Hall 1969). Panoramic and mandibular occlusal radiographs of- ten will reveal the radiopaque salivary calculus. How- ever, 20% of salivary calculi are radiolucent and can be detected only by sialography. Visualization of the sialolith in relation to the submandibular gland and its duct utilizing sialography is a more accurate method of diagnosis, compared to routine radiography, but should be performed only after the acute infection has resolved (Blatt, 1962). The treatment of submandibular sialolithiasis is sur- gical removal of the calculus or complete excision of the submandibular gland. However, initial management Fig 1. Panoramic projection of 8-year-old patient demonstrating a sialolith in the right posterior portion of the submandibular duct. Following clinical and radiographic examination, a diagnosis of right submandibular sialadenitis as a re- sult of sialolithiasis was made. The patient was placed on penicillin (250 mg) and aspirin (325 mg) ad lib. The patient was instructed to use lemon or orange drop candy to stimulate salivary flow, drink fluids, and ap- ply moist heat to the right submandibular region. A follow-up appointment was given for five days. Fig 2. A 1.0 cm sialolith of 8-year-old patient that had spontaneously migrated out of the right submandibular duct (each increment equals one millimeter). On the third day after clinical examination, the mother was called to inquire about her daughter's progress. She stated that the previous night her daughter felt a hard mass in her mouth, and an immediate discomfort. The mother was instructed to bring the mass to the oral and maxillofacial surgery clinic for examination. The 232 PEDIATRIC DENTISTRY: JULY/AUGUST, 1991 ~ VOLUME 13, NUMBER 4

  3. C(~nclusion consists of antibiotic acute infection. 500 mg orally, penicillin, clindamycin, 150 mg-300 mg every 6 hr is the alternate drug. The child is also instructed or orange candy to stimulate salivary Kaban 1990). Review of the dental Hausamen 1976) revealed two consistent the majority of salivary calculi found were in the middle or posterior portion of the duct; and 2) the majority of cases were treated surgically (removal of the salivary sialoadenectomy (excision of the salivary Specific surgical management depends on the loca- tion of the sialolith in relation to the salivary gland and its duct. If it is located in the anterior third or middle portion of the duct, dilation sialolithotomy is usually (Timosca et al. 1976). If the calculus is located in the posterior third of the duct or in the gland, treatment consists of sialolithotomy and Hausamen 1976; Timosca et al. 1976). Attempts to remove a salivary stone located this posterior duct or in the hilus of the gland may be difficult cause damage to the gland. Damage to the gland could result in a progressive obstructive disorder of the gland. Once the gland undergoes irreversible tion is impaired and sialoadenectomy is indicated. This case illustrates all the classic signs and symp- toms of salivary gland or duct obstruction as a result of a salivary calculus and its management. The salivary stone was located posterior, mandibular gland. In most instances, anatomically located this far posterior able to course along the entire pass spontaneously from the duct. With no progress of anterior migration of the sialolith, mandibular gland is indicated, and salivary stasis become chronic. In addition, mandibular space infection following initial clinical there was spontaneous passage of the sialolith, immediate relief of discomfort. reported pediatric cases of sialolithiasis posterior one-third of the submandibular duct, surgery (excision of the gland) was not elected as the treatment of choice. Instead, the patient was observed and treated conservatively, enabling the sialolith pass out of the submandibular duct. therapy to reduce or eliminate the The drug of choice is penicillin every 6 hr). For children erythromycin, 250 mg-500 mg, or (250 mg- Sialolithiasis but should be considered in the differential patients who present pain. Establishing a diagnosis of sialolithiasis thorough history and physical routine radiographs. sialolithiasis is surgical intervention, the sialolith or complete excision of the gland. This case report demonstrates that nonsurgical treat- ment in resolution of the obstruction recovery and normal function This spares the child an unnecessary surgical which requires several days of hospitalization. is not commonly observed in children, allergic to diagnosis in swelling requires a along with treatment either removal of with submandibular and to suck on sour lemon flow (Blatt 1962; examination The accepted of literature (Reuther findings: and 1) may lead to full of the salivary gland. procedure either stone from the duct) by sialolithotomy gland). Dr. McCullom maxillofacial surgery and Dr. Blaustein is associate professor and director of research, in the Department of Oral and Maxillofacial Surgery, College of Dentistry, University of Illinois, Chicago, IL. Reprint requests should be sent to Dr. Cornell McCullom, sity of Illinois, Department of Oral and Maxillofacial Surgery, College of Dentistry, 801 South Paulina, Chicago, IL 60612. is assistant professor, Dr. Lee is chief resident, oral and of the duct and/or the treatment llI, Univer- of choice Blatt IM: Studies in sialolithiasis. III. Pathogenesis, diagnosis and treatment. South Med J 57:723-29, 1962. Bodner L, Azaz B: Submandibular sialolithiasis in children. J Oral Maxillofac Surg 40:551-54, 1982. Bullock KN: Salivary duct calculi presenting as trismus in a child. Br Med J 280:1357-58,1980. Doku HC, Berkman M: Submaxillary salivary calculus in children. Am J Dis Child 114:671-73, 1967. Feldman W: Submaxillary salivary calculus in a child. Can Med J 102:1310-11, 1970. Hall HD: Diagnosis of diseases of the salivary glands. J Oral Surg 27:16-25,1969. Grunebaum M, Mankuta DJ: Submaxillary sialadenitis with a calcu- lus in infancy diagnosed by ultrasonography. Pediatr Radiol 15:191-92, 1985. Kaban LB, Mulliken JB, Murray JE: Sialadenitis in childhood. J Surg 135:570-76,1978. Kaban LB: Salivary gland disease, in Pediatric Oral and MaxiIlofacial Surgery. Philadelphia: WB Saunders, 1990, pp 189-200. Longhurst P: Submandibular sialolithiasis in a child. Br DentJ 135:291- 92, 1973. Reuther J, Hausamen JE: Sialothisis der glandula submandibularis in kinoesalter. Klin Padiatr 188:285-88, 1976. Shafer WG, Hine MK, Levy BM: Physical and chemical injuries of the oral cavity, in A Textbook of Oral Pathology. 4th ed. Philadelphia: WB Saunders Co, 1983, p 561. Tepan MG, Rohiwal RL: Multiple salivary calculi in Wharton’s duct. J Laryngol Otol 99:1313-14, 1985. Timosca G, Gavrilita L, Barna M: La lithiase salivaire chez les enfants, consid6rations concernant 12 cas. Rev Stomatol Chir Maxillofac 77:341-46, 1976. Volkova M: Sialolithiasis in children. Stomatologia (Mosk) 57:86-7, 1978 (In Russian). or sialoadenectomy (Reuther in the and changes, its func- near the hilus of the sub- a salivary stone would not be length of the duct and excision of the sub- since swelling, pain, a sub- may develop. examination and diagnosis, Three days with Unlike the majority of located in the to spontaneously PEDIATRIC JULY/AuGuST, "[ 991 -- VOLUME 1 3, NUMBER 4 233 DENTISTRY: