CC
A 41-year-old male reports to your office with pain and swelling within the left submandibular region.
HPI
The patient reports eight episodes of periprandial pain reaching a maximum severity of 4 out of 10 and visible extraoral swelling within the left submandibular region over the past 12 months. The patient’s pain is controlled with the use of acetaminophen and ibuprofen. The submandibular swelling resolves spontaneously within hours to days after the initiation of each episode without intervention and is occasionally associated with either a foul or salty taste. The patient denies fever, chills, dysphagia, odynophagia, dysphonia, and dysarthria during the aforementioned episodes. The current episode, which has nearly resolved, began three days before their presentation and they have not previously sought investigation or treatment for these symptoms.
PMHX/PSHX/medications/allergies/SH/FH
The patient’s past medical history is significant for well-controlled hypertension, hypercholesterolemia, type 2 diabetes mellitus, and major depressive disorder. Previous surgical procedures include a tonsillectomy and adenoidectomy as well as laparoscopic cholecystectomy. Current medications include amlodipine, metformin, atorvastatin, and amitriptyline. The patient has no known allergies. The patient’s social history is significant for a past smoking history of 15 pack-years, social alcohol consumption of approximately one to two drinks per week, and smoking of approximately 1 g of cannabis per month. His family history is significant for paternal coronary artery disease.
Examination
General. The patient is a well-developed and well-nourished male who appears younger than his stated age. He is alert and oriented, overweight, and in no acute distress.
Vital signs. Blood pressure is 125/84 mm Hg, heart rate is 94 bpm, and respiratory rate is 16 breaths per minute. The patient is afebrile with a temperature of 99.3°F.
Head and neck. There is no palpable cervical lymphadenopathy. Minimal residual swelling within the left submandibular region is appreciated, which is soft and tender to palpation. There are no cutaneous abnormalities within the left submandibular region. No intraoral mucosal abnormalities are identified. The patient is fully dentated with no gross evidence of odontogenic infection. Temporomandibular joint range of motion is within functional limits. Mucous membranes appear well lubricated. The oropharynx is patent and symmetric with no evidence of oropharyngeal effacement or displacement of the uvula from the midline. Bimanual palpation between the left floor of mouth and left submandibular region reveals a firm and tender mass measuring approximately 3 cm in its greatest dimension. Salivary flow from the left submandibular gland duct is decreased relative to the contralateral side. The quality of the saliva is relatively viscous with no expression of purulent material. The parotid ducts expressed saliva in both normal quantities and quality.
Imaging
In view of the aforementioned physical examination findings, a computed tomography (CT) study with contrast was ordered as the initial radiographic investigation ( Fig. 43.1 ). CT imaging demonstrated a 1.4 cm × 1.6 cm × 2.4 cm (transverse × anteroposterior × craniocaudal) calcified mass within the hilum of the left submandibular gland consistent with a sialolith resulting in postobstructive parenchymal hyperenhancement and sialectasis suggestive of sialadenitis. No abscesses or reactive lymph nodes were appreciated.
Labs
Recent complete blood count, serum electrolytes, liver function tests, lipid profile, creatinine, glomerular filtration rate, and glycosylated hemoglobin values were within the range of normal. Laboratory studies were not ordered at the time of examination and are generally not indicated in the setting of suspected sialolithiasis unless required for pertinent conditions discovered during the review of the patient’s medical history or on the discovery of concerning findings during the physical examination such as evidence of infection or sepsis.
Assessment
Sialolithiasis involving the left proximal Wharton’s duct and submandibular gland hilum with associated chronic sialadenitis.
Treatment
In the present case of chronic sialadenitis and the presence of a large sialolith, informed consent was rendered for the transcutaneous excision of the left submandibular gland with the accompanying sialolith. After the induction of general anesthesia via intravenous access, oral endotracheal intubation was facilitated with the use of succinylcholine to allow for accurate nerve testing during the following approach. A cutaneous incision was made approximately 3 cm below the inferior border of the mandible with a #10 scalpel blade centered over the submandibular gland parallel to the cervical rhytids ( Fig. 43.2 ). Subcutaneous tissue and the platysma muscle were divided with monopolar electrocautery, and subplatysmal flaps were developed to facilitate wound closure. The investing layer of deep cervical fascia was elevated superiorly from an incision originating at the most inferior extent of the submandibular gland to protect the marginal mandibular branch of the facial nerve, which lies within this layer, from inadvertent trauma ( Fig. 43.3 ). The marginal mandibular nerve, in this case, was visualized following the elevation of the superior subplatysmal flap, and its identity was confirmed with a nerve stimulator. The superior dissection was aided by the inferior retraction of the submandibular gland with Allis forceps. The facial artery and vein were identified, ligated, and divided. The mylohyoid muscle was then exposed and retracted superiorly and anteriorly to facilitate visualization of the lingual nerve. The submandibular ganglion and its associated vein were identified, ligated, and divided. The submandibular duct was identified inferior to the lingual nerve and was ligated and divided as far distally as was achievable. The left submandibular gland was subsequently delivered from the neck and submitted in 10% formalin for histopathologic analysis ( Fig. 43.4 ). The wound was closed in a layered fashion. The placement of a drain can be considered when there is a concern for a large dead space from the extirpated gland. Histopathology revealed the presence of a large submandibular sialolith within the hilum and gland parenchyma as well as findings consistent with sialadenitis, including the presence of a patchy lymphocytic and plasma cell infiltrate, acinar atrophy, ductal dilatation, and fibrosis of glandular parenchyma.
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