Abstract
Salivary stones larger than 15 mm are classified as giant sialoliths. They are uncommon in the practice of otolaryngology, and their management has always been a therapeutic challenge. Traditionally, when they cannot be retrieved by marsupialization, removal of the salivary gland has been advocated. Sialendoscopy and the recent development of combined endoscopic and external approaches for extraction of large stones with preservation of the major salivary glands are promising. We present the first case of simultaneous bilateral giant sialoliths, and the first report that associates giant sialoliths and the use of salivary endoscopy. In this case, both giant stones were removed with the assistance of a salivary endoscope and without removing the submandibular glands.
1
Introduction
Sialolithiasis is the most common disease of the salivary glands, with an incidence of approximately 1.2% in the adult population . The average stone size is 3.2 mm for the parotid gland and 4.9 mm for the submandibular gland . Sialoliths that exceed 15 mm in any one dimension or 1 g in weight have been classified as giant . In the normal gland, the diameter of the Wharton and Stensen ducts is approximately 3 and 4 mm, respectively .
Some authors have analyzed the characteristics of different giant sialoliths reported in the literature . Bodner found only 14 well-described cases in his review published in 2002. We found that all giant sialoliths documented in the English language have been unilateral and present the first case, to the best of our knowledge, of simultaneous bilateral giant sialoliths. Both giant stones were removed with the assistance of a salivary endoscope and without removing the glands. This is also the first report that associates giant sialoliths and the use of salivary endoscopy.
2
Case report
A 69-year-old man presented to our office complaining of chronic unrelenting purulent discharge from bilateral submandibular ducts despite appropriate medical therapy. A computed tomographic scan revealed large bilateral radiopaque masses at the hilum of each submandibular gland, consistent with salivary stones ( Fig. 1 ). The masses were palpable intraorally. A staged transoral sialolithotomy approach was planned and performed bilaterally. After the stones were removed, a salivary endoscope was used to explore the main duct, the stone cavity, and the distal ductal system. Exploration was made through the main duct via a transpapillary approach and also through the intraoral sialolithotomy opening. Small pieces of the larger stones and/or smaller stones were found lodged in the intraglandular ducts immediately distal to the cavity, which were removed under direct visualization. Once the calculi were removed, the salivary duct and soft tissues were closed in layers at the end of each procedure. The patient tolerated both outpatient operations without complications and is currently asymptomatic 1 year after his last intervention. The right and left stone measured 2 × 1.5 × 1.5 and 2.3 × 1.6 × 1.3 mm, respectively ( Fig. 2 ).
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