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| CASE REPORT |
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| Year : 2022 | Volume
: 17
| Issue : 4 | Page : 966-968 |
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Submandibular sialolithiasis USG diagnosis
Suresh Vasant Phatak, Kaustubh A Madurwar, KB Harshith Gowda, Vadlamudi Nagendra
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra, India
| Date of Submission | 22-Feb-2021 |
| Date of Decision | 10-Jan-2022 |
| Date of Acceptance | 22-Mar-2022 |
| Date of Web Publication | 10-Feb-2023 |
Correspondence Address:
Dr. Suresh Vasant Phatak
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_84_21
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 |
| Introduction | |  |
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 | | |
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 | | |
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 | | |
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.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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