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OMFS-0118Salivary GlandbeginnerSubmandibular gland

Mealtime swelling of the submandibular gland

41-year-old male

Draft — educational study aid, pending faculty review.

§Chief complaint

Painful swelling under the jaw whenever I eat, for 6 months

§Medical & dental history

  • 01Dehydration-prone occupation (outdoor labourer)
  • 02No diuretics
  • 03Nil relevant

§Clinical examination

  • 01Tender, enlarged right submandibular gland that swells within minutes of eating and subsides after an hour
  • 02Hard palpable body in the floor of mouth along the course of Wharton duct
  • 03Scanty saliva expressed from the right duct orifice on bimanual massage
  • 04No pus, no facial nerve or lingual nerve deficit

§ figuresFigures (4)

Fig. 1Salivary gland stone (Sialolithiasis) and the operation marks

“Salivary gland stone removed” · Peternickson · CC0 · Wikimedia Commons

Fig. 2Sialolithiasis, Salivary stones

“Sialolithiasis IMG 2368” · Milorad Dimic MD · CC BY 4.0 · Wikimedia Commons

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Sialolithiasis figures pending faculty review.

§Differential diagnosis

Submandibular sialolithiasisClassic mealtime syndrome, palpable stone
Sialadenitis without a stoneConstant swelling, purulent discharge
Sjogren syndromeBilateral, dry eyes and mouth, autoantibodies
Submandibular neoplasmProgressive painless enlargement, not meal-related

§Final diagnosis

Obstructive sialolithiasis of the right Wharton duct

Mealtime syndrome — swelling that reliably appears with salivary stimulation and settles afterwards — is pathognomonic of obstruction. A palpable stone in the floor of the mouth localises it to the distal duct, which is amenable to intraoral removal.

§Investigations

  • 01Lower true occlusal radiograph — radiopaque calculus 8 mm in the distal duct
  • 02Ultrasound — dilated duct proximal to the stone, gland not atrophic
  • 03Sialendoscopy where available

§Treatment plan

  • 01Conservative measures first: hydration, sialogogues, gland massage, warm compresses
  • 02Intraoral surgical removal of the distal duct stone
  • 03Antibiotics only if acute infection supervenes
  • 04Gland preservation — sialadenectomy reserved for a chronically damaged gland

§Surgical procedure

  • 01Suture placed behind the stone to prevent retropulsion
  • 02Longitudinal incision over the duct with lingual nerve identification and protection
  • 03Stone delivered; duct marsupialised rather than sutured closed

§Follow-up & outcome

  • 01Symptoms resolved immediately
  • 02Normal salivary flow at 6 weeks; gland preserved
  • 03Advised on hydration and regular sialogogues

§Clinical pearls / learning points

  • 01Eighty percent of salivary calculi are submandibular because of viscous mucous saliva and an uphill duct course.
  • 02Always secure the stone with a stay suture before incising the duct.
  • 03Marsupialise the duct — primary closure risks stricture.

§References

  • Marchal F, Dulguerov P. Sialolithiasis management: the state of the art.

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