A case of submandibular swelling
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This case report describes a 22-year-old male presenting with a painful swelling in the right submandibular region for 7 days that was aggravated by eating. Clinical examination revealed a sublingual hard mass that was mobile with an irregular surface. Ultrasound showed a sialolithiasis measuring 20 x 8 mm in the right Wharton's duct with secondary sialadenitis of the right submandibular gland. The patient underwent transoral excision of the sialolithiasis and was discharged after recovery with no complications.
A case of submandibular swelling
- 1. A Case of Submandibular Swelling Arun S Nair
- 2. 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
- 3. No H/o • Fever • Trauma • Significant wt loss • Purulent discharge • Tooth Caries
- 4. Past h/o • Similar complaints in the past during school/colleg days • Relieved by massaging over the area
- 5. Clinical examination • Pulse : 86/min • BP : 110/76mmHg • Temp : afebrile • RR : 16/min • No Pallor
- 6. • Local examination • Swelling + • Tenderness • Bimanual palpation Sublingual hard mass • Mobile • Irregular surface • Systemic examination .. NAD
- 7. • Blood • Hb 16.2 • TLC 6400 • DLC N56 L34 M07 E08 • Plt 185000
- 8. USG • S/O sialolithiasis (20 × 8 mm) R Wharton’s Duct with sialoadenitis R SM gland
- 9. Diagnosis Sialolithiasis with secondary Sialadenitis R SM Gland
- 10. Treatment • Adequate analgesics • Transoral excision ↓ LA on 23 Jan 2014 • Post OP • DOD 31 Jan 2014
- 14. 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
- 15. 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 • Physiological 1.High mucin content 2.Alkaline pH 3.High phosphate & calcium
- 16. 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
- 17. Stasis of saliva Duct obstruction Reduce salivary secretion Stricture Stone Trauma Oral infection Cystic fibrosis Dehydration Anticholinergic drug Lack of oral intake
- 18. • 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
- 19. 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
- 20. 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
- 21. 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
- 22. 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
- 23. Extracorporeal Shockwave lithotripsy Effective for stones that are intraductal and less than 7 mm & identifiable by USG
- 24. Interventional Radiology • Wire basket retrieval under fluoroscopic guidance • Best for extraglandular & Mobile stones
- 25. Complications • Sialadenitis • Abscess • Gland Atrophy • Reccurance
- 26. 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.
- 27. 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) .
- 28. 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
- 29. 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 lymphoepithelial cysts, 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 intraglandular ducts
- 30. 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
- 31. 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