Sialolithiasis and its management in oral and maxillofacial surgery
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Transcript of Sialolithiasis and its management in oral and maxillofacial surgery
SIALOLITHIASIS Dr ARJUN SHENOYPG STUDENT DEPT OF OMFS
INTRODUCTION
Sialoliths are calcified structures that develop within the salivary gland or the ductal system.
Men > women
Rare in children
75% - single
3% - bilateral
1.2% -autopsy
GLAND WISE DISTRIBUTION
80-92% - submandibular gland.
6-20% - parotid.
1-2% - sublingual and the minor salivary
glands.
Submanibular – larger & intraductal
Parotid – multiple, within the gland
SUBMANDIBULAR GLAND OCCURENCE
Abundant calcium concentration Alkaline Ph
Anatomic factors
Wharton’s duct - longest - two sharp curves - small punctum
Composition
Organic substances
organic Inorganic
MUCOPOLYSACCHARIDES
GLYCOPROTEINS
CELLULAR DEBRIS
INORGANIC
CALCIUM PHOSPHATE
Fe
Cu
Mn
CALCIUM CARBONAT
E
CHEMICAL COMPOSITION
Chemical composition Microcrystalline apatite (Ca5[PO4]3OH) or Whitlockite (Ca3[PO4]) Brushite and weddellite
BRUSHITE
WEDDELLITE
RECENT DISCOVERIES Scanning electron microscopy has demonstrated oval,
elongated shapes, suggesting the presence of bacilli in sialoliths.
A recent polymerase chain reaction study found bacterial DNA, mainly belonging to the Streptococcus genus
ARCH OTOLARYNGOL HEAD NECK SURG/VOL 129, SEP 2003
PATHOGENESIS
Multifactorial event
Secretory disturbances & precipitation – inflammatory process
Specific changes in structure of organic molecules – supportive frame formation
Metabolic disturbances – alkalinity & precipitation
MICROLITHS
Concrements detectable only microscopically
Contain – calcium and phosphorus
hydroxyl apatite organic secretory material necrotic cellular residues
Generated - autophagocytosis of organelles that are rich in calcium.
Dyschylia - Disturbed salivary secretion & change in the
composition
Accumulation of organic substances & mineralisation of organic matrix
Accumulation of calcium Increase in pH
Decreases the solubility of calcium phosphates
PROGRESSION
Secretory disturbances viscous secretions Microlith formation ductal obstruction
Coaction of factors + participation of bacteria sialoliths
Dyschylia & increasing microlith formation ascent of bacteria lead to a focal obstructive atrophy of the acinar cells secretory disturbances
Journal of Oral Science, Vol. 45, No. 4, , 2003
OTHER FACTORS
Infection Salivary dysfunction Ductal anamolies Foreign bodies Ductal epithelium metaplasia
SYMPTOMS
Pain, swelling & discomfort Pain - meal time – severe with sour or acidic food Unusual taste Associated with infection – fever , purulent discharge &
lymphadenopathy
CHARACTERISTICS
The annual growth rate - 1 mm per year
Shape - round or irregular
Size - 2 mm to 2 cm
GIANT SIALOLITH
72 mm in length and weighing 45.8 g
The ability of a calculus to grow and become a giant sialolith depends mainly on the reaction of the affected duct.
Rai and Burman. Giant Submandibular Sialolith. J Oral Maxillofac Surg 2009.
TREATMENT MODALITIES
Newer treatment modalities - extracorporeal short-wave lithotripsy and sialoendoscopy are effective alternatives to conventional surgical excision for smaller sialoliths.
However, for giant sialoliths, transoral sialolithotomy with sialodochoplasty or sialadenectomy remains the mainstay of management.
HISTOLOGIC FEATURES
Stratified & mineralized with metaplastic excretory duct cells
Concentric laminated structures Acini infiltrated by lymphocytes Dialatation of duct Epithelium exfoliation
DIAGNOSIS
History
Clinical examination Bi-manual palpation
Imaging
BIMANUAL
IMAGING
Conventional radiography
Sialography
Ultrasonography
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Sialoendoscopy
Imaging
Conventional radiography
Intra oral radiographs IOPA , Occlusal radiographs Extra oral radiographs Panaromic , PA skull projection Intraglandular and small stones can be missed. 20% of sialoliths are radiolucent
Sialography
"Gold Standard”
Retrograde infusion of oil or water based contrast & the architecture of the salivary duct system is visualized radio graphically .
LIMITATIONS
Advantagedetects
radiolucent stones
Therapeutic
Disadvantage
• invasive• bleeding &
perforations
contraindicated• acute infections
• allergic to contrast
Ultrasonography
Non invasive, alternative method
Stones > 2mm detected as echo-dense spots with a characteristic acoustic shadow.
MR Sialography
Non invasive Acute infections Canulation not possible
COMPUTED TOMOGRAPHY
Posterior of the duct Hilum of the gland Substance of the gland
Radiation exposure Non invasive & do not require contrast media
SIALOENDOSCOPY
Minimally invasive
Diagnostic & therapeutic
Small endoscope – light at end of flexible cannula
Differential diagnosis
Phleboliths – radiolucent center
Dystrophic calcification of lymph nodes – Cauliflower shaped
Palatine tonsiliths- multiple & punctate
Haemangiomas with calcifications
TREATMENT
Symptomatic Surgical
• Opening of wharton’s ductTrans oral
Ductotomy ( sialolithotomy)
• Deep intra glandular• Multiple stones• Prevent recurrence
Sialoadenectomy
Sialoendoscopy
Small endoscope – optical fibres - irrigation or working ports
Special devices – guide wire - balloon catheters - metal baskets - laser fibres
Ductal dialation – lacrimal probe - balloon dialator
Sialoendoscopy – assisted Sialolithectomy
Large sialolith
Lithotripsy Fragmentation
Types – intracorporeal - extracorporeal
Intracorporeal techniques
Mechanical fragmentation
Intracorpreal laser lithotripsy - Er: YAG - Ho: YAG
Pneumatic lithotripsy
ARCH OTOLARYNGOL HEAD NECK SURG/VOL
129, SEP 2003
Extracorporeal Lithotripsy
Shock waves – focused, multiple high intensity acoustic pulses
Kinetic energy – compressive & tensile forces
Complications
-Inability to remove fragment
-Postoperative infections
-Neural damage -Intraductal
adhesion
-Subglossal scar band formation
-Sialocele & Ranula formation
paediatric patients
Relatively small and distal
Bimanual careful palpation is mandatory to diagnostic approach for children suspicious of sialolithiasis.
These findings also suggest that intra-oral approach is effective
treatment procedure for most of sialolithiasis in children.
Int J Pediatr Otorhinolaryngol 2007 May;71(5)
MIGRATING SALIVARY STONES
Conclusion
Sialolithiasis is the main cause of unilateral diffuse parotid or submandibular gland swelling.
Mechanical obstruction of the salivary duct, causing repetitive swelling during meals, & often complicated by bacterial infections.
Common in submandibular gland , 10 – 20% are radiolucent
Newer minimally invasive diagnostic & therapeutic modalities
References
Contemporary OMFS – Perterson
Oral Radiology – principles & interpretation – White & Pharoah
Sialoendoscopy & salivary gland sparing surgery - Oral Maxillofaccial Surg Clin N Am 21 (2009)
Pathogenesis & diverse histologic findings of sialolithiasis – J Oral Maxillofac Surg 68: 2010
Imaging the major salivary glands – British Journal of Oral & Maxillofacial Surgery 49 (2011)
Oral & maxillofacial pathology – Neville
Text book of OMFS – Neelima Mallik