Removal of sialolite in Wharton’s duct by electrosurgery: case report

Removal of sialolite in Wharton’s duct by electrosurgery: case report

RODRIGO SOUZA CAPATTI 1 | LUCAS RODARTE ABREU ARAÚJO 1 | MARCELA SILVA BARBOZA 1

ABSTRACT

Sialolithiasis accounts for 30% of salivary gland morbidity. Characterized by the interruption of normal salivary flow due to the formation of calcified structures along the duct or in the glandular parenchyma, this condition, often underdiagnosed, can lead to pain, edema and infection of the affected region. The treatment methods cited in the literature are based on the characteristics of the lesion and vary between surgical and conservative. The present study presents a case report of the use of electrosurgery for the treatment of sialolithiasis in submandibular gland with immediate elimination of signs and symptoms reported by the patient, and absence of postoperative complications. Postoperative surgery and healing were satisfactory; there were no complaints on the part of the patient, which evolved without symptomatology during the follow-up period. The removal of intra-oral sialoliths using electrosurgery showed control of trans and postoperative hemorrhage and low morbidity.

Keywords: Oral surgical procedures. Maxillofacial abnormalities. Salivary duct calculi.

1 Pontifícia Universidade Católica de Minas Gerais, Departamento de Odontologia (Belo Horizonte/MG, Brazil).

How to cite: Capatti RS, Araújo LRA, Barboza MS. Removal of sialolite in Wharton’s duct by electrosurgery: case report. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):40-4. DOI: https://doi.org/10.14436/2358-2782.5.3.040-044.oar

Submitted: March 06, 2018 - Revised and accepted: August 06, 2018

» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.

» Patients displayed in this article previously approved the use of their facial and intraoral photo graphs.

Contact address: Lucas Rodarte Abreu Araújo Rua Lassance Cunha, 260, sala 04, Centro – Sete Lagoas/MG CEP: 35.700-006 – E-mail: lucasrodarte@hotmail.com

INTRODUCTION

The sialolithiasis is the most common disease of salivary glands in adults, 1 being characterized by the formation of calcified structures inside the duct of glands or in the parenchyma, called salivary stones or sialoliths. Among the diseases that affect the salivary glands, sialolithiasis accounts for 30% of cases. 2

The etiology of sialolith may be divided into two major groups: salivary retention due to the morphological configuration of glandular ducts; and the saliva composition itself, such as pH and increased calcium concentration. 3-5 It occurs at a frequency of 12 in every 1,000 individuals, mainly adults (rarely occurring in children), there is no ethnic predilection and is more common in males. 6

In general, sialoliths measure 5 to 10 mm in their largest diameter. However, several studies report larger stones, with up to 56 mm 7 . When they are larger than 10 mm, they are considered rare and classified as giant calculi. 8

Among the most common locations of sialolith, the submandibular gland accounts for 83% to 94% of cases, followed by the parotid (4% to 10%) and sublingual (1% to 7%), rarely reaching minor salivary glands. 9,10 The frequencies of these locations are explained by some authors because of the anatomical characteristics of the submandibular gland: tortuous, long and ascending duct, 11 and its positioning in relation to the excretory canal, besides the viscosity of saliva produced. 12

Calculi are rigid bodies, of varying shape, yellow color and usually solitary in the affected region. 6 The symptoms may be reported as swelling and pain in the affected gland region; however, sialolithiasis may remain asymptomatic in many cases, diagnosed during routine examination. 10 In cases of total obstruction of salivary flow, the patient can report constant pain and eventual purulent drainage in the region. 13

The diagnosis is often defined by imaging studies such as panoramic and occlusal radiographs – the most commonly used exams – in which the sialolith appears as a radiopaque image in the areas of affected glands. 6

The appropriate treatment depends on the affected gland, location, and calculus size, and can vary from conservative approaches - such as hydration of the patient, and gland massage and drops of acidic fruit (lime) – to surgical procedures, for larger calculi located in the glandular parenchyma. 14,15

Moreover, electrosurgery is an effective alternative compared to other incision methods, in relation to hemostasis and morbidity of the surgical procedure. 17

This study reports a case of sialolithiasis in submandibular gland removed by conservative electrosurgery, besides discussing the literature on the subject.

CASE REPORT

A female patient, of mixed Caucasoid-African descent, aged 25 years, attended a private clinic complaining of “swelling under the tongue and pain on swallowing”. In anamnesis, she did not report any systemic change nor any harmful habit. On clinical examination, edema was observed on the right sublingual region (Fig 1A), also noticed by extraoral observation. During palpation, a rigid consistency was noted, with interruption of salivary flow and painful symptoms. The patient reported pulpotomy in tooth 47 about 5 years earlier (she did not know the exact time) and therefore endodontic complications were suspected. Pulp sensitivity test was performed, which did not reveal changes, thus endodontic disorder was ruled out. No other clinical changes that could be associated were observed. In the first visit the patient brought a panoramic radiograph, which confirmed the absence of other changes and the presence of radiopaque area in teeth 42 to 44 (Fig 1B). An occlusal mandibular radiograph was requested, which evidenced the presence of a radiopaque body in the duct area, allowing a conclusive diagnosis of sialolithiasis of Wharton’s duct (Fig 1C).

The selected treatment was removal by electrosurgery. After local anesthesia, the sialolith position was identified by palpation and transfixation was performed with nylon suture (4-0) immediately after the foreign body, to prevent it from penetrating deeper into the duct toward the gland during the procedure. An incision was made parallel to the duct, with approximately 15 mm, near the left sublingual caruncle, using an electric scalpel with small straight knife electrode, 67 mm (BP-100 Plus Transmai, São Paulo, Brazil) (Fig 2A). After slight tissue divulsion using 2.1 mm ball type electrode coupled to the electric scalpel, the sialolith was located and removed,

measuring approximately 12 x 5 mm (Fig 2B). The duct was flushed with saline and then a simple suture was performed joining the epithelial edges without collapsing the duct and keeping the orifice clear (Fig. 3A). The drug protocol used included antibiotic (amoxicillin 1g), analgesics (sodium dipyrone 500mg) and rinse with 0.12% chlorhexidine digluconate. The suture was removed after 10 days, with good local healing and normalization of salivary flow (Fig 3B).

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B

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Figure 1: A) Initial clinical intraoral image of the mouth floor, showing the preoperative aspect of the mucosa. B) Panoramic radiograph showing radiopaque image close to the region of teeth 43 and 44, suggesting sialolith. C) Occlusal radiograph showing radiopaque image lingual to teeth 44 and 45, suggesting sialolith.

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Figure 2: A) Intraoral clinic image of the mouth floor, showing the appearance of the mucosa and sialolith after incision and divulsion of tissues with electric scalpel. B) Sialolith image after removal, showing its dimensions.

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Figure 3: A) Intraoral clinical image of the mouth floor, showing the appearance of mucosa in the immediate postoperative period. B) Final intraoral clinical image of the mouth floor, showing the appearance of mucosa at 10 days postoperatively.

DISCUSSION

Among the diseases of salivary glands, sialolithiasis accounts for 30% of cases. 2 The frequency of 12 in every 1000 individuals 6 suggests that this morbidity is present in the daily clinic of the dentist, often undiagnosed by the professional. Most sialoliths are diagnosed in adult men; however, the present case was observed in a female patient. This gender predilection is not as significant as the patient age, and it rarely occurs in children. 1

According to Arunkumar et al, 8 sialoliths greater than 10 mm are considered giant, but they may range from 5 to 56 mm 7 . Symptoms as swelling and pain of the affected region in the gland may be related to the lesion size and its ability to block salivary flow in the region, while smaller calculi can remain asymptomatic for long periods and are only diagnosed in routine tests. 10 The patient had complaints of slight increase in volume and pain in the sublingual region, which justified the complementary tests to define the diagnosis.

Although the best method for precise location of sialoliths is cone beam computed tomography, images of the most commonly used tests to diagnose this type of change are the occlusal and panoramic radiographs. 6 The intention to request both exams is justified by the need of clinical treatment and general evaluation of the jaws (panoramic radiograph), besides the diagnosis of possible change in the sublingual or submandibular gland regions (occlusal radiography).

The submandibular gland is affected in 83-94% of cases of sialolithiasis, 9-11 which agrees with the present report.

Definition of the best treatment for sialolithiasis depends on the lesion characteristics: size, location (glandular parenchyma or duct) and affected gland. Conservative treatments as gland massage, hydration, and use of moist heat secretagogues are reserved for smaller sialoliths, resulting in spontaneous expulsion of the calculus. 9 According to the present case, care related to duct dissection and sutures is essential to prevent postoperative complications, such as stenosis and fibrosis in the duct area, besides formation of saliva retention regions. 16

The proposed surgical treatment is justified by the lesion size and increase in volume during clinical examination, 14,15 as well as preventive antibiotic therapy, which was given due to the presence of purulent exudate at the examination. 13

The use of electric scalpel, compared to other sectioning methods, has better performance in relation to hemostasis at the operated region, 17 which improves the field visualization and consequently access to the surgical area.

Since 1914, the medicine uses this method to incise or promote tissue hemostasis tissue; also, the patients experience minimal or no postoperative morbidity. 18 Electrosurgery has applications in several techniques in dentistry, even though it is rarely used. Regular users know from experience that, when applied in accordance with the principles, it is possible to obtain satisfactory and predictable wound healing. 19

FINAL CONSIDERATIONS

As described in the literature, there are several proposed methods for the treatment of this type of injury. Surgical removal by electrosurgery is an effective alternative, whose results are elimination of the signs and symptoms and restoration of normal function of the affected gland.

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