Mealtime swelling of the submandibular gland

§Chief complaint

Painful swelling under the jaw that appears at mealtimes and settles after an hour

§Medical & dental history

• 01Well; no xerostomic medication
• 02Poor fluid intake
• 03No dental pain; calculus deposits in the lower anterior region

§Clinical examination

• 01Tender, enlarged left submandibular gland, fluctuating with meals
• 02Hard palpable stone in the floor of mouth along Wharton duct
• 03Scanty, cloudy saliva expressed from the left duct orifice
• 04No skin erythema or systemic upset; bimanual palpation confirms a mobile gland

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§Differential diagnosis

§Final diagnosis

Obstructive sialadenitis of the left submandibular gland due to a distal Wharton duct calculus

Classic mealtime syndrome with a palpable radio-opaque stone in the distal duct and a gland that is enlarged but not chronically fibrotic indicates gland-preserving stone removal rather than excision.

§Investigations

• 01Lower true occlusal radiograph — radio-opaque calculus visible
• 02Ultrasound to size the stone and assess the gland parenchyma
• 03Sialendoscopy for diagnosis and treatment if the stone is proximal

§Radiology

• 01Occlusal radiograph — 8 mm radio-opaque calculus in the distal left Wharton duct
• 02Ultrasound — dilated duct proximal to the stone, gland parenchyma preserved without abscess

§Treatment plan

• 01Conservative measures: hydration, sialogogues, gland massage, moist heat
• 02Transoral removal of the distal stone under local anaesthesia
• 03Antibiotics only if there is active bacterial sialadenitis
• 04Gland excision reserved for irreversible parenchymal damage

§Surgical procedure

• 01Suture placed behind the stone to prevent retro-displacement
• 02Longitudinal incision over the duct through the floor of mouth mucosa, stone delivered, duct marsupialised rather than closed
• 03Lingual nerve identified and protected

§Follow-up & outcome

• 011 week — swelling resolved, clear saliva flowing, tongue sensation normal
• 023 months — no recurrence of mealtime symptoms
• 0312 months — gland function preserved on ultrasound

Outcome: Symptom-free with a preserved functioning gland.

§Discussion

• 01About 80% of salivary calculi occur in the submandibular gland because of the long, upward-running duct and viscous mucinous saliva.
• 02Minimally invasive options — sialendoscopy, basket retrieval, lithotripsy — have greatly reduced gland excision rates.
• 03Proximal hilar stones and a fibrotic gland are the usual indications for gland removal.

§Clinical pearls / learning points

• 01Place a stay suture behind the stone before incising, or it will slip backwards.
• 02Marsupialise the duct to avoid stricture.
• 03The lingual nerve crosses the duct — protect it.

§Viva questions

§MCQs

§Related diseases

§Similar cases