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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 4  |  Page : 966-968

Submandibular sialolithiasis USG diagnosis

Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India

Date of Submission22-Feb-2021
Date of Decision10-Jan-2022
Date of Acceptance22-Mar-2022
Date of Web Publication10-Feb-2023

Correspondence Address:
Dr. Suresh Vasant Phatak
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_84_21

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Submandibular sialolithiasis is an uncommon pathology characterized by the presence of calculi in the salivary ducts. Ultrasonography is highly sensitive and specific for its diagnosis and helps in patient management.

Keywords: Salivary gland pathology, sialolith, submandibular gland, ultrasonography

How to cite this article:
Phatak SV, Madurwar KA, Harshith Gowda K B, Nagendra V. Submandibular sialolithiasis USG diagnosis. J Datta Meghe Inst Med Sci Univ 2022;17:966-8

How to cite this URL:
Phatak SV, Madurwar KA, Harshith Gowda K B, Nagendra V. Submandibular sialolithiasis USG diagnosis. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Apr 1];17:966-8. Available from: http://www.journaldmims.com/text.asp?2022/17/4/966/369520

  Introduction Top

Sialolithiasis is a salivary gland disorder characterized by the presence of calculus within the salivary gland or its excretory system leading to obstruction.[1] Bilateral involvement is rarely observed but may occur and is predominately seen in the submandibular glands. Size of calculi is variable, from a few millimeters to several centimeters. Giant sialolithiasis is a condition where calculi dimension exceeds 1.5 cm.[2] They are usually seen in males over 30 years of age. All glands can be involved in the disease process. However, they mainly involved are the submandibular glands with a frequency of 80%. This could be explained by its different salivary composition.[1] Salivary calculi are composed of an organic component (bacteria or desquamated cells) around which mineral salts are precipitated. Sialoliths are primarily composed of inorganic material.[3] They usually contain calcium phosphates, either as carbonate apatite or hydroxyapatite, whitlockite, and brushite.[4] Precipitation of calcium is usually caused by salivary stasis or decreased salivary flow.[5] Other inorganic components such as silicon, ferrum, brimstone, potassium, and chloride can also be found but only in traces.[6] On the other hand, the organic material includes neutral and acid glycoproteins, lipids, collagen, other proteins, and carbohydrates such as mannose and glucose.[7]

  Case Report Top

A 43-year-old woman presented to the radiodiagnosis department for neck sonography examination with complaints of recurrent episodes of pain, difficulty in swallowing, and swelling in the left side of neck. Local examination revealed a diffuse swelling over the left submandibular region. On bimanual palpation, left submandibular gland was firm and tender with palpable left submandibular lymph nodes. Ultrasonography (USG) revealed an enlarged, hypoechoic, hypervascular left submandibular gland [Figure 1], dilated ductal system [Figure 2], 1.7 mm small nonshadowing calculus in duct [Figure 3], and left submandibular reactive lymphadenopathy [Figure 4]. Based on these findings, diagnosis of submandibular sialolithiasis was given which was confirmed later and calculus was removed.
Figure 1: Ultrasonography showing hypoechoic enlarged left submandibular gland with globular margins and hypervascularity

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Figure 2: Ultrasonography of left submandibular gland showing dilated ductal system

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Figure 3: Ultrasonography left submandibular gland showing echogenic, nonshadowing 1.7 mm size calculus in duct with proximal dilatation of ductal system confirming the diagnosis of calculus

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Figure 4: Ultrasonography showing multiple small left submandibular reactive lymph nodes

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  Discussion Top

In more than 80% of salivary concretions are seen in the submandibular gland or in Wharton's duct. Approximately 15% of cases of sialolithiasis occur in the parotid gland. Salivary calculi usually are symptomatic only if it leads to obstruction of the ductal system.[8] From the therapeutic point of view, it is necessary to differentiate lithiasis of the main duct from those of the intraglandular ducts.[9] Typical sites for lithiasis are at the anterior bend of Wharton's duct and at the confluence of the intraglandular ducts. Intraoral transducers are at times used to localize submandibular stones.[10] On sonography, typical imaging findings are a bright curvilinear echo complex accompanied by posterior acoustic shadowing.[11] When lesions are smaller than 2 mm, shadow may be missing. In symptomatic cases of sialolithiasis, dilated ductal system or inflammation is frequently present. Intraglandular dilated ducts are imaged as multiple tubular hypoechoic structures, whereas the dilated main duct is often located in a extraglandular position and has a more linear shape. Inflammatory changes make the gland diffusely hypoechoic and with more rounded, globular margins. Color Doppler shows hypervascularization.[12] The accuracy of ultrasound (US) in the assessment of sialolithiasis is approximately 90%.[13] Differentiation from calcified lymph nodes and phleboliths in facial veins from sialolithiasis can be done accurately. Approximately 20%–40% of the salivary lithiasis are not opaque on radiography, but most of these calculi can be visible on the US. Salivary stimulation (lemon juice or Vitamin C) can demonstrate prominent intraglandular ducts. This will help the identification of small lithiasis and the echogenic lithiasis by improving contrast. In experienced hands, US is the primary method for detecting salivary calculi[12] magnetic resonance imaging or sialography is the investigation of choice for those patients with inconclusive sonographic results or for patients with negative sonographic results but a typical clinical presentation of ductal obstruction.[14] High-resolution US can differentiate various salivary gland lesions. Addition of color Doppler US can increase its diagnostic accuracy. High-resolution US with color Doppler sonography should be the first line of imaging modality in suspected cases of salivary gland lesions.[15]

  Conclusion Top

USG has high sensitivity and specificity in early diagnosis of sialolithiasis and hence helps in better management of patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kraaij S, Karagozoglu KH, Forouzanfar T, Veerman EC, Brand HS. Salivary stones: Symptoms, aetiology, biochemical composition and treatment. Br Dent J 2014;217:E23.  Back to cited text no. 1
Gupta A, Rattan D, Gupta R. Giant sialoliths of submandibular gland duct: Report of two cases with unusual shape. Contemp Clin Dent 2013;4:78-80.  Back to cited text no. 2
[PUBMED]  [Full text]  
Harrill JA, King JS Jr., Boyce WH. Structure and composition of salivary calculi. Laryngoscope 1959;69:481-92.  Back to cited text no. 3
Huoh KC, Eisele DW. Etiologic factors in sialolithiasis. Otolaryngol Head Neck Surg 2011;145:935-9.  Back to cited text no. 4
Marchal F, Kurt AM, Dulguerov P, Lehmann W. Retrograde theory in sialolithiasis formation. Arch Otolaryngol Head Neck Surg 2001;127:66-8.  Back to cited text no. 5
Su YX, Zhang K, Ke ZF, Zheng GS, Chu M, Liao GQ. Increased calcium and decreased magnesium and citrate concentrations of submandibular/sublingual saliva in sialolithiasis. Arch Oral Biol 2010;55:15-20.  Back to cited text no. 6
Jayasree RS, Gupta AK, Vivek V, Nayar VU. Spectroscopic and thermal analysis of a submandibular sialolith of Wharton's duct resected using Nd: YAG laser. Lasers Med Sci 2008;23:125-31.  Back to cited text no. 7
Zenk J, Constantinidis J, Kydles S, Hornung J, Iro H. Clinical and diagnostic findings of sialolithiasis. HNO 1999;47:963-9.  Back to cited text no. 8
Yoshimura Y, Inoue Y, Odagawa T. Sonographic examination of sialolithiasis. J Oral Maxillofac Surg 1989;47:907-12.  Back to cited text no. 9
Brown JE, Escudier MP, Whaites EJ, Drage NA, Ng SY. Intra-oral ultrasound imaging of a submandibular duct calculus. Dentomaxillofac Radiol 1997;26:252-5.  Back to cited text no. 10
Gritzmann N. Sonography of the salivary glands. AJR Am J Roentgenol 1989;153:161-6.  Back to cited text no. 11
Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands. Otolaryngol Clin North Am 2009;42:973-1000.  Back to cited text no. 12
Bartlett LJ, Pon M. High-resolution real-time ultrasonography of the submandibular salivary gland. J Ultrasound Med 1984;3:433-7.  Back to cited text no. 13
Becker M, Marchal F, Becker CD, Dulguerov P, Georgakopoulos G, Lehmann W, et al. Sialolithiasis and salivary ductal stenosis: Diagnostic accuracy of MR sialography with a three-dimensional extended-phase conjugate-symmetry rapid spin-echo sequence. Radiology 2000;217:347-58.  Back to cited text no. 14
Patange NA, Phatak SV. Ultrasound and Doppler evaluation of salivary gland pathology. Int J Res Med Sci 2017;5:79-82.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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