A Case of Submandibular Swelling

Arun S Nair

Presinting Complaints

• 22/M

• Non smoker / doesn’t consume alcohol admitted on 20 Jan 2014

• Painful swelling sub mandibular region R

• last 7 days

• aggravated by eating

No H/o

• Fever

• Trauma

• Significant wt loss

• Purulent discharge

• Tooth Caries

Past h/o

• Similar complaints in the past during school/colleg days

• Relieved by massaging over the area

Clinical examination

• Pulse : 86/min

• BP : 110/76mmHg

• Temp : afebrile

• RR : 16/min

• No Pallor

• Local examination

• Swelling +

• Tenderness

• Bimanual palpation Sublingual hard mass

• Mobile

• Irregular surface

• Systemic examination .. NAD

• Blood

• Hb 16.2

• TLC 6400

• DLC N56 L34 M07 E08

• Plt 185000

USG

• S/O sialolithiasis (20 × 8 mm) R Wharton’s Duct with sialoadenitis R SM gland

Diagnosis

Sialolithiasis with secondary Sialadenitis R SM Gland

Treatment

• Adequate analgesics

• Transoral excision ↓ LA on 23 Jan 2014

• Post OP

• DOD 31 Jan 2014

TOPIC DISCUSSION

Sialolithiasis

Sialolithiasis (salivary calculi) the presence of stones in the salivary glands or ducts

• Cacium , phosphate and carbonate , combined with other salts (Mg,Zn,NH3) and

organic material

• 80 to 92 % submandibular

• 6 to 20 % parotid

• 1 to 2 % sublingual as well as minor

• 1 percent incidence is noted in autopsy studies

• M:F = 2:1

• 75 % single

• 3 % bilateral

Factor predisposing to Submandibular Sialolithiasis

• Anatomy

1.Lengthy and irregular course of Wharton’s duct

2.Position of ductal orifice

3.Size of orifice smaller than duct lumen

• Physiological1.High mucin content2.Alkaline pH3.High phosphate & calcium

Etiology

•Relative stagnation & Concentration of saliva•Dehydration

• Concentration of saliva

• Fasting or Anorexia• Stasis of saliva

•Drugs- Anti-histamines, Anti-cholinergics.• Decrease production of saliva

• Stone can cause stasis of saliva and subsequent bacterial ascent into the gland.• Most commonly S. aureus or Strep Viridans.

• Trauma / Stricture

Stasis of saliva

Duct obstruction

Reduce salivary secretion

Stricture

Stone

Trauma

Oral infection

Cystic fibrosis

Dehydration

Anticholinergic drug

Lack of oral intake

• Symptoms

• colicky postprandial pain and swelling

• Local swelling & tenderness at ductal opening if the stone is superficially

• Secondary infection ---> duct stricture

• Diagnosis

• History and Bimanual palpation of duct

• Diagnostic imaging

Imaging studies

• Plain films

• Submandibular calculi radiopaque in 80 to 95 % of cases.

• Parotid calculi are radiopaque in 60 % of cases

• Sialography

• Duct is cannulated and radiopaque dye is injected, followed by plain films.

• Invasive & technically demanding

• Contraindicated in patients with acute sialadenitis or contrast allergy.

• May help facilitate a diagnosis other than sialolithiasis such as stricture, sialectasis, and

cystic degeneration of the duct and gland

Imaging studies

• Ultrasound

• Stones of 2 mm in diameter or larger

• Better assessment of periglandular structures

• Advantage; Radiolucent stones or radiopaque stones that are superimposed on bone

• Magnetic resonance imaging

• Standard MRI will not visualize stones

• Visualize ducts as an alternative to conventional sialography

• No intraductal contrast is required for MR sialography

• Superior sensitivity compared with ultrasound

TREATMENT•Conservative• < 2mm often pass on their own

• Hydration

• Moist heat

• Massage the gland & milk the duct

• Sialogogues• Lemon drops

• Bitter/tart hard candies

• d/c Anti-cholinergics / Anti-histamines

• Antibiotics & Analgesics

Surgery• Excision

• Transoral

• Transcervical

• Sialadenectomy• Recurrent cases only

• chance of facial nerve injury• Parotidectomy ; 29%

• Submandibular; 12%

• Sialoendoscopy• Laser lithotripsy via endoscope

• Can reach even small stones not accessible by transoral approach

• < 3mm in the parotid

• < 4mm in the submandibular gland

Extracorporeal Shockwave lithotripsy

Effective for stones that are intraductaland less than 7 mm & identifiable by USG

Interventional Radiology

• Wire basket retrieval under fluoroscopic guidance

• Best for extraglandular & Mobile stones

Complications

• Sialadenitis

• Abscess

• Gland Atrophy

• Reccurance

D/D

• Viral sialadenitis — Viral parotitis due to mumps virus is characterized by acute pain and

swelling of one or both parotid glands.

• Most common cause of parotid gland swelling.

• Infection is accompanied by a nonspecific prodrome consisting of low grade fever,

malaise, headache, myalgias, and anorexia. These symptoms are generally followed

within 48 hours by the development of parotitis.

• Less common - Coxsackie viruses A and B, Echovirus, Parainfluenzavirus, Influenza A,

and Epstein-Barr virus.

D/D

• Acute bacterial sialadenitis — Suppurative sialadenitis commonly affects elderly, malnourished,

or postoperative patients.

• The parotid gland is most commonly involved.

• Sudden onset of a very firm and tender swelling.

• Fever and chills are usually present, generally with fairly marked systemic toxicity.

• Purulent drainage can often be expressed from the effected duct orifice.

• (Staphylococcus aureus {common} ,Streptococcus pneumonia, Streptococcus viridans,

Haemophilus influenzae, and Bacteroides) .

D/D

• Chronic bacterial sialadenitis is a low grade chronic infection.

• Can eventually lead to destruction of the salivary gland.

• It may occur more commonly in patients with decreased salivary secretion and

increased mucus content in their saliva.

• Predisposing factors include stones, strictures, and trauma.

• Generally have intermittent exacerbations of acute sialadenitis

D/D• Human immunodeficiency virus — Prone to the development of lymphoepithelial

cysts within the gland.

• These may become superinfected.

• Parotid swelling in HIV infection is typically diffuse and symmetric.

• Cystic lesions on imaging are consistent with the diagnosis of lymphoepithelialcysts, but solid lesions are concerning for lymphoma or other parotid malignancy.

• Sjögren's syndrome — Chronic inflammatory disorder

• Diminished lacrimal and salivary gland secretions resulting in symptoms of dry eyes and dry mouth, sicca complex

• Gradual swelling of the parotid or submandibular glands, typically bilaterally.

• Eventually causes parenchymal destruction and dilation of the intraglandularducts

D/D

•Sarcoidosis — Extrapulmonary sarcoidosis affects the parotid glands in 1 to 6

percent of cases and may be associated with uveitis and facial paralysis

(Heerfordt's syndrome).

• Bilateral painless parotid enlargement due to granulomatous infiltration.

• Radiation sialadenitis — Low-dose radiation to a salivary gland causes acute,

tender, painful swelling.

• C/O of burning, dry mouth with diminished ability to taste

D/D•Malnutrition — Sialadenosis, which is a noninflammatory, non-neoplastic

enlargement of a salivary gland, typically the parotid.

• Associated conditions include anorexia nervosa, bulimia, beriberi, pellagra, diabetes, and alcoholic cirrhosis.

• Histologic evaluation reveals acinar hypertrophy without an inflammatory infiltrate.

•Salivary gland tumors – swelling with a significant degree of

asymmetry with diffuse parotid enlargement or any focal parotid mass, raises a concern for neoplasm