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Transoral Removal of Submandibular Stones
Johannes Zenk, MD;
Jannis Constantinidis, MD;
Basel Al-Kadah, MD;
Heinrich Iro, MD
Arch Otolaryngol Head Neck Surg. 2001;127:432-436.
ABSTRACT
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Objective To assess transoral treatment of submandibular lithiasis.
Design Study of a series of patients with submandibular stones undergoing transoral
removal of the sialoliths. Duration of follow-up: 6 months to 7 years.
Setting Department of Otorhinolaryngology, Head and Neck Surgery, University
of Erlangen-Nuremberg, Erlangen, Germany, center for treatment of salivary
stones.
Patients Two hundred thirty-one patients (127 females, 104 males) suffering from
submandibular lithiasis had a mean age of 41.7 years (age range, 12-86 years).
Stone location was distal to the edge of the mylohyoid muscle in 115 patients
and proximal to the gland in 102 patients (mean size of sialoliths, 6.3 mm
[range, 2-30 mm]). Fourteen other patients had 2 separate stones, one within
the hilum and a smaller more proximal one within the gland.
Interventions Transoral removal of the stones under local anesthesia and preservation
of the submandibular gland.
Main Outcome Measures Complete removal of the stones, complications, and recurrence of the
stones.
Results All 115 patients with distal stone location, 93 (91%) of 102 patients
with stones of the perihilar region, and 9 (64%) of the 14 patients with 2
separate stones in the hilum and parenchyma were free of stones. Submandibulectomy
had to be carried out in 4 patients (1.7%). Recurrence of lithiasis and damage
to the lingual nerve remained below 1%.
Conclusions Transoral removal should be the treatment of choice in patients with
submandibular stones that can be palpated bimanually and localized by ultrasound
within the perihilar region of the gland.
INTRODUCTION
SIALOLITHIASIS accounts for more than 50% of the diseases of the large
salivary glands in the head and neck. With a prevalence in central Europe
of about 1.2%, sialolithiasis is thus the most common cause of acute and chronic
infections.1 More than 80% of all sialoliths
are localized within the duct system of the submandibular gland and only 20%
within the parotid gland.2, 3, 4
Approximately 90% of submandibular stones are situated in the distal portion
of the Wharton duct or at the hilum.5
Over the last 10 years several new minimally invasive techniques were
introduced in the treatment of sialolithiasis. Extracorporeal sonographically
and intracorporeal endoscopically controlled lithotripsy seemed to change
therapeutic methods completely.5, 6
In the case of parotid duct stones, the long-term outcome for extracorporeal
lithotripsy—with 50% of all patients being free of stones and 80% being
free of symptoms—is very satisfying.7
In comparison, patients suffering from sialolithiasis of the submandibular
gland receiving lithotripsy treatment are free of stones in less than 30%
of all cases.6, 8, 9, 10
The benefits of minimally invasive techniques and their comparison with other
moderately invasive surgical and gland-preserving techniques must be considered
for these patients.
Transoral removal of the stones within the distal part of the Wharton
duct in the floor of the mouth is not a major surgical problem, whereas sialolithectomy
within the duct posterior to the first molar or even more proximally in the
so-called comma area (where the duct turns inferiorly at the posterior border
of the mylohyoid muscle) is difficult and may be hazardous to the lingual
nerve.2 Nevertheless, in the literature, expanded
incision of the duct has been continually favored as a gland-preserving therapy.3, 11, 12, 13, 14
PATIENTS, MATERIALS, AND METHODS
DIAGNOSTIC MEASURES
Subsequent to taking the patient's medical history and performing a
clinical examination, an ultrasound of the affected gland was performed (Sonoline
SI 450 and Sonoline Elegra; Siemens Co, Erlangen, Germany) to confirm the
diagnosis. The presence of 1 or more concrements lodged within the duct system
of the gland and their precise pretherapeutic localization (ie, intraparenchymal
duct system, hilar region with its relation to the mylohyoid muscle, or distal
duct system) could be reliably established using sonography (Figure 1). Additional diagnostic imaging techniques were not required
in any of the patients.
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Figure 1. Sonogram of multiple submandibular
stones (the reflexes with high echogenity and distal shadowing are clearly
detectable between the white crosses in the figure, 1 in the hilum [left side],
11.2 mm, and 2 within the intraglandular duct system [right side]) of a 25-year-old
woman, prior to therapy. Two longitudinal planes of the right submandibular
gland. GSM indicates submandibular gland; T, tongue; and MM, mylohyoid muscle.
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PATIENTS
Between July 1, 1989, and December 31, 1998, two hundred thirty-one
patients suffering from sialolithiasis of the submandibular ducts were treated
by transoral incision and marsupialization of the duct and gland (ie, sialodochotomy
and submandibulotomy).
The patient population comprised 127 (55%) females and 104 (45%) males
with a mean age of 41.7 years (age range, 12-86 years). The duration of symptoms
was 25 months on average (range, 1 month to 25 years). The mean maximum stone
diameter (as determined by sonography) was 6.8 mm (stone diameter range, 2-30
mm). A total of 335 sialoliths were removed transorally from 231 patients.
STONE LOCATION
In 13.7% cases more than one concrement was identified in the course
of the duct—generally in direct anatomical proximity to the largest
concrement detected (Table 1).
One hundred fifteen patients (50%) exhibited 1 or more sonographically imageable
stones located above the mylohyoid muscle and more than 1.5 cm distant from
its dorsal end in the distal portion of the Wharton duct (mean diameter, 6.3
mm). In 102 patients multiple concrements were detected sonographically adjacent
to one another in more proximal areas extending as far as the hilar region
or within the glandular parenchyma. Another 14 patients (6%) had one concrement
in the intraparenchymatous part or in the hilum of the duct system and a second,
smaller concrement at a distinctly proximal site (Figure 1).
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Location and Results of Transoral Removal of Submandibular Stones in
231 Patients*
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INDICATIONS AND CONTRAINDICATIONS
Incision of the duct was performed in the event that stones were sonographically
localized above the mylohyoid muscle in the anterior two thirds of the floor
of the mouth, irrelevant of their palpability. Furthermore, the indication
for incision of the duct was extended to transoral submandibulotomy when concrements
were identified by palpation and sonography and localized in the posterior
part of the floor of the mouth.
If 2 concrements were encountered—the first and larger of the
detected stones located in the hilar region and the second and smaller stone
more proximally in the obstructed duct system—incision of the duct was
performed to remove the larger (preceding) stone with the additional intention
of achieving spontaneous discharge of the smaller concrement. Incision of
the duct was contraindicated in the acute inflammatory stage.
SURGICAL PROCEDURE
Surgery was carried out under general anesthesia in only 5 patients
(2%). All other interventions (98%) were performed with local anaesthesia
(4% lidocaine hydrochloride, 8-10 mL with epinephrine1:200 000) (Figure 2). The duct, together with the oral
mucosa, was incised from the ostium until the stone was visible. Following
the incision of the oral mucosa, the course of the lingual nerve could be
dissected from a lateral upper position below the duct to medially into the
lateral lower portions of the tongue.
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Figure 2. Intraoperative site of an transoral
removal of a stone (arrow) within the hilum at a right submandibular gland.
T indicates tongue.
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When sialoliths were located at very proximal sites or within parenchymatous
regions, transoral dissection was enabled by cranial displacement of the uncinate
process of the gland in the direction of the floor of the mouth. If the duct
was incised up to the hilar region and the stone was palpable still further
in the adjacent parenchyma, the glandular parenchyma was incised with a scalpel
as far as the stone bed (submandibulotomy) under direct visual control. The
duct or the incised parenchyma of the submandibular gland was subsequently
sutured using 4-0 polyglactin (Vicryl) to the oral epithelium creating a neo-ostium.
FOLLOW-UP MEASURES
Postincisional therapy included regular oral rinses with a mixture of
sage, eucalyptus, peppermint, cinnamon, cloves, fennel, and anisole, levomenthol,
and thymol (Salviathymol; Galenika Fr, Fuerth, Germany), detumescent medication,
and gland massage to maintain a continuous salivary flow. In the event of
conglutination and narrowing of the neo-ostium, repeated bougienage was performed.
Antibiotic prophylaxis with roxithromycin was administered over a 3-day period
in the event of a purulent salivary secretion and in cases of extensive expanded
duct incision up to and beyond the hilar region.
Sonographic controls were conducted on the first day postoperatively
and 4 weeks after incision of the duct. Regular clinical and sonographically
controlled examinations followed.
RESULTS
All 115 patients with distal stones were stone free and symptom free
following the duct-incision intervention (Table 1). Concrements in the region of the hilum of the gland or
in the adjacent glandular parenchyma were treated 102 times (44%); stone clearance
and freedom of symptoms was achieved in 93 patients (91%). In 6 patients intraoperative
crushing of the concrement occurred, causing residual fragments to remain
in the gland; residual concrements remained sonographically detectable despite
freedom of symptoms. The concrement was inaccessible by the transoral approach
in 3 patients, thus necessitating removal of the gland.
In 14 patients (6%) the indication for expanded incision of the duct
was established when 1 stone was found in intraparenchymal parts in the hilum
of the duct system and a second smaller stone was found at a more proximal
site. The distally localized concrement could be removed in 13 patients. Complete
stone clearance was achieved in 9 patients (64%) due to the additional secondary
discharge of the smaller proximal concrement (Figure 3). Four patients (29%) were symptom free during follow-up
despite the remaining smaller residual concrement. Stone removal was not possible
in 1 case, requiring secondary submandibulectomy to be performed (Table 1).
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Figure 3. Sonogram 6 months after transoral
removal with a normal echogenity of the submandibular gland and free of stones
(same patient as shown in Figure 1). Logitudinal plane of the right submandibular
gland. GSM indicates submandibular gland; MM, mylohyoid muscle; and T, tongue.
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Swelling of the floor of the mouth and the affected submandibular gland
accompanied by disturbed swallowing was noted in all patients on the first
postoperative day. At this time 95% of all patients were able to resume oral
intake of food and to leave the clinic.
In 11 patients (5%), including 7 who had been subjected to expanded
incision of the duct, pronounced swelling of the tongue and the pharynx occurred.
In 1 patient the swelling spread as far as the larynx, causing moderate shortness
of breath and hoarseness. All patients recovered from these effects following
detumescent therapy (as described in the "Follow-up Measures" subsection of
the "Patients, Materials, and Methods" section) and intravenous antibiosis
(ampicillin sodium-sulbactam sodium, 2 g 3 times daily), albeit during a prolonged
stay at the clinic.
Stenosis of the neo-ostium that developed in 5 patients (2%) was reopened
by renewed incision. A lesion of the lingual nerve causing paresthesia and
anesthesia in the area of the tongue and the inside of the lip was observed
in 2 patients (1%). One patient recovered fully; in the other patient (0.4%)
the lesion remained permanently. Follow-up in 2 patients demonstrated a ranula
in the region of the sublingual gland that was treated by incision and marsupalization.
A recurrent stone was detected 1 year later in 1 patient where stone clearance
following incision of the duct had been sonographically demonstrated.
COMMENT
Preservation of gland function in conjunction with low-level risk and
discomfort for the patient should be the primary objective in the treatment
of sialolithiasis. Apart from problems such as scar formation, disturbances
of skin sensation, and injury to the gustatory nerves, it is above all transient
functional disturbances of the marginal branch of the facial nerve that are
encountered in up to 12.5% of open gland excisions. Permanent lesions are
reported in as many as 7% of the cases.15, 16
Moreover, unilateral excision of the submandibular gland also leads to a substantial
reduction in the nonstimulated flow of saliva, which may have an important
influence on oral hygiene, risk of caries, and the development of xerostomia.17
Preservation of the submandibular gland has always been attempted in
the treatment of sialolithiasis by transoral resection of the salivary stone.3 The transoral approach for the removal of salivary
concrements in the first 2 distal anatomical sections of the duct (in approximately
30%-50% of the patients) is unproblematic. However, sialoliths lodged in the
posterior third of the duct system, in the hilum, or still further within
the glandular parenchyma present a problem.
Various techniques of sialodochotomy have been described in the literature
whereby a major point of concern has always been the risk of injury to the
lingual nerve which courses in close proximity to the Wharton duct.12, 13, 14, 18, 19
Surgical excision of the gland is recommended in cases of extreme proximal
stone localization13, 20 due to
the anatomical circumstances and the assumption that the submandibular salivary
gland has no tendency for recovery after years of obstruction and recurrent
inflammation. Nevertheless, van den Akker et al21
were able to show by salivary gland scintigraphy that complete recovery of
glandular function, in fact, can be achieved after stone removal.
While, in the literature, the indication for incising the duct has mostly
been based on clinical examination in combination with plain radiography or
sialography,14 diagnostic ultrasound (7.5 MHz)
can furnish the surgeon with much more detailed information on the exact stone
localization, the number of stones, and the functional status of the glandular
parenchyma.22 However, the palpation of concrements
localized within the parenchyma remains important in the preoperative assessment
of the accessibility of the stone by expanded incision of the duct.
In contrast to the surgical techniques described in the literature,
where the incision is performed directly over the palpated stone without dissecting
the duct19 or where the Wharton duct is identified
at a distant proximal point and opened above the stone,12
incision of the duct by proceeding from the ostium was used in this series.
The duct thus provides the surgeon with an anatomical landmark as a guide.
The lingual nerve that crosses below the duct from lateral to medial can be
dissected without problem in a well-defined surgical field of view.
It is a problem when the stone location is directly below the course
of the nerve and recurrent inflammation has led to scar formation in this
area, a problem known also from the external approach. In 2 patients nerve
dissection in this situation led to lingual nerve injury and paresthesia.
The risk of lingual nerve damage of 1% of the patients in this study is equal
to that for the external approach. Ichimura et al23
reported a total incidence of 2.4% of paresthesia of the lingual nerve and
of 1.6% in the case of inflammatory disorders following surgery in the submandibular
angle.
The high rate of stone-free and symptom-free patients (91%), who had
extremely proximal stones or multiple stones in the hilar and parenchymal
regions (64%), and the low rate of lesions of the lingual nerve underscore
the importance of transoral stone removal that can be performed under local
anesthesia in as many as 98% of the patients. A submandibulectomy with the
risk of injury to the marginal branch of the facial nerve thus can be avoided.
In the literature the rate of recurrent stones is reported as being
low (<10%).3 In our series 1 recurrent stone
has been observed to date. This low recurrence rate may be attributed to 2
factors.
First, the examination was not conducted with plain radiography or sialography
to confirm the diagnosis as in earlier reports, but rather with high-resolution
ultrasonography. It is likely that this led to the diagnosis and treatment
of a greater number of secondary concrements that had previously escaped reliable
detection. Second, the status of stone clearance following treatment can be
better defined by ultrasonography.
Moreover, patients were advised to carry out gland massages regularly,
even 4 weeks after surgery, and to take sialagogue. This represented a further
prophylactic measure. The results of our series show that transoral incision
of the duct should be the therapy of choice in most cases of sialolithiasis
of the submandibular gland.
The indication for this therapy includes all sialoliths localized distally
in the floor of the mouth and all more proximally localized concrements that
can be demonstrated by sonography and palpation. According to investigations
on stone localization, this encompasses almost 90% of all sialoliths of the
submandibular glands.5
The significance of extracorporeal and intracorporeal lithotripsy as
an organ-preserving technique is reduced by the technique of expanded incision
of the Wharton duct; nevertheless, extracorporeal lithotripsy, in particular,
remains indicated for impalpable small stones located in the hilum and the
parenchymal region. The use of intracorporeal lithotripsy24, 25
and other techniques for stone removal26 will
remain limited in the cases of submandibular duct stones.
AUTHOR INFORMATION
Accepted for publication June 16, 2000.
We thank Maria Klohmann for revising the translation of the manuscript.
From the Department of Otorhinolaryngology, Head and Neck Surgery,
University of Erlangen-Nuremberg, Erlangen, Germany.
Corresponding author: Johannes Zenk, MD, Department of Otorhinolaryngology,
Head and Neck Surgery, University of Erlangen-Nuremberg, Waldstrße 1
D-91054, Erlangen, Germany (e-mail: johannes.zenk{at}hno.imed.uni-erlangen.de).
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ABSTRACT
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