Case Study 1 - The Combined Approach

T.M. is a 57-year-old female with a several year history of recurrent swelling and pain with eating on the left side of her neck in the region of the left submandibular gland (SMG). She had previously seen an ENT who performed a CT scan which revealed several stones in the left proximal SMG duct near the gland. She underwent attempted trans-oral removal and apparently a part of the stone was able to be removed but the more proximal part was not. She had lingual nerve hypoesthesia (numbness) that lasted several months after the procedure and continued to be symptomatic with eating. We saw her in consultation a year after her initial surgery. On examination, the stone was palpable in the left posterior floor of mouth. We recommended sialendoscopy and probable trans-oral removal of the stone using a combined approach.

Under general anesthesia, the sialendoscope was used to identify and verify the stone location. A mucosal incision was made along the left posterior floor of mouth and dissection carried down to the submandibular duct, which was identified easily using trans-illumination from the sialendoscope. The lingual nerve was also identified just below the duct. Once the stone was visualized through the duct wall, an incision was made in the wall and the stone easily removed. The mucosal incision was repaired. At the two-week follow-up appointment, she was eating without any symptoms and had no lingual nerve hypoesthesia.

The so-called “combined” approach to salivary gland stones can be useful for large stones that cannot be removed using a sialendoscope and basket or laser lithotripsy. In theory, any stone could be managed using laser lithotripsy, but very large stones are both difficult to break up without damaging the duct wall and also are prohibitively time consuming. Submandibular stones that can be manually palpated can typically be removed trans-orally as in this case. The sialendoscope is helpful to trans-illuminate the duct and identify the exact location of the stone. For parotid stones, an external skin incision is required to use this approach.