AMSER Case of the Month September 2019

61-year-old male with left submandibular fullness

Kevin Guzak, OMS IV

Lake Erie College of Osteopathic Medicine

Scott Rudkin, MD, PGY-5

Matthew Hartman, MD

Charles Q. Li, MD

Allegheny Health Network

Department of Radiology

Patient Presentation

● HPI: 61 y.o. M presents with 1 month of left submandibular pain and fullness.

Also endorses dysphagia and left ear pain. Two sialoliths recently expelled

spontaneously.

● MHx: HTN, HLD, T2DM, CVA, and right renal cell carcinoma

● SHx: Cryoablation of right renal mass, upper GI endoscopy with biopsies

● Medications: Aspirin 81mg, Xarelto 20mg, Novolog 100 units, Tresiba 100

units, Pravastatin 20mg

Physical Exam

● Neuro: AOx3 normal speech, no focal findings or movement disorder noted,

CN II through XII intact

● HEENT: ● Ear: Normal pinnae shape and position. Normal TM’s and external ear canals b/l

● Nose: Nares normal, septum midline, mucosa normal, no drainage or sinus tenderness

● Oral Cavity: normal examination of teeth, lips, gums, buccal mucosa, and tongue

● Palpable sialolith left posterior submandibular duct, no significant tenderness

● Saliva not clearly expressible from either submandibular duct

● Oropharynx: normal appearance of hard & soft palates, tongue, and tonsils/posterior pharynx

● Cardiovascular: Normal rate, regular rhythm and intact distal pulses.

● Pulmonary/Chest: Effort normal. Breath sounds normal.

● Abdominal: Soft. Bowel sounds normal. No distension. No tenderness.

Labs

● CBC ○ WBC – 8.88 k/mcL

○ Platelets - 257 k/mcL

○ Hgb – 14.0 g/dL

● Chem profile ○ Sodium- 142 mEq/L

○ Potassium- 4.4 mEq/L

○ Creatinine - 0.78 mg/dL

○ BUN- 21 mg/dL

○ Calcium - 9.1 mg/dL

ACR Appropriateness Criteria

Imaging

● Began with neck ultrasound

● Recommended follow up with CT and MRI

Findings: Unlabeled

3.6 cm heterogeneous left neck lesion, either left submandibular gland or an enlarged level 1B lymph node

(yellow arrows). Large coarse calcification with posterior acoustic shadowing (asterisk) within this structure

could represent a sialolith (blue arrows). Suggest contrast-enhanced neck CT for further evaluation.

Findings: Labeled

*

Findings:

Unlabeled

Scout

Findings:

Unlabeled

Axial CT

Findings: Unlabeled Sagittal and Coronal CT

Findings:

Labeled

Scout Calculus measuring

11 x 16 mm (blue

arrow)

Findings:

Labeled

Axial CT

Incidental lipoma present

in the musculature in the

right neck. Some

septations within this.

MRI of the neck without

and with contrast with fat

saturation technique

recommended for follow

up (orange).

Calculus (blue) at the

hilum of the

submandibular gland

measuring 11 x 16 x

14 mm.

Normal right submandibular

gland (red).

*

Blue: Sialolith

Red: Submandibular gland

Findings: Labeled Sagittal and Coronal CT

Findings: Unlabeled

MRI axial T1 fat-saturated with contrast MRI sagittal T1 fat-saturated with contrast

Findings: Labeled

Blue: Sialolith

Red: Submandibular gland

Final Diagnosis:

Left Submandibular Sialolithiasis

Patient currently being treated conservatively as he is

asymptomatic. Surgical extraction of stone with possible

excision of affected submandibular gland recommended if

symptoms return.

Sialolithiasis

● Definition: Sialolithiasis- Stone within the salivary glands or the salivary gland

ducts

Sialadenitis- Inflammation of a salivary gland

● Epidemiology: Seen in men > women usually between the ages of 30-60. 0.45%

lifetime prevalence, 1% seen incidentally on autopsy. 75% of stones are single,

3% bilateral. Stones occur equally on right and left sides.

● Pathogenesis: Unknown, stagnation of salivary flow and salivary calcium

concentration thought to be contributing factors. Stones largely composed of

calcium phosphate and hydroxyapatite with small amounts of magnesium,

potassium, and ammonium. Submandibular gland most prone due to longer duct.

Sialolithiasis

● Clinical Presentation:

○ Pain and swelling of the involved gland, exacerbated by eating or anticipation of eating

○ Painless swelling less common presentation

● Physical exam: ○ Submandibular gland- palpate course of Wharton’s duct along floor of mouth in posterior to

anterior direction

○ Parotid gland- palpate buccal mucosa near Stensen’s duct adjacent to upper second molar

○ Normal gland- spongy and elastic, compression should cause expression of saliva

○ Sialolithiasis- typically felt as small, hard/rocky masses that can be smooth or irregular. Will

usually be tender, can cause obstruction of salivary flow

● Differentials: ○ Viral/bacterial sialadenitis, Sjӧgren’s syndrome, sarcoidosis, salivary gland tumor

Sialolithiasis- Features

● Ultrasound: ○ Must be >2 mm in diameter to be visualized

○ Hyperechoic lines with distal acoustic shadowing

● CT: ○ Imaging modality of choice, sensitivity 95%, specificity 88%

○ Calcification within the ducts of salivary glands

○ Glands may be enlarged, hyperdense, and associated with stranding

● MRI: ○ Stones visualized as low signal regions on all sequences, saliva will be high signal on T2

○ Can distinguish acute vs. chronic (inflammatory vs. atrophic changes)

○ Reveals ductal anatomy

● Sialography: ○ Duct cannulated and iodinated contrast injected, followed by plain films

○ Filling defect within duct

○ Able to demonstrate exact size and location of stone within duct

Sialolithiasis- Management

● Conservative treatment first-line: ○ Hydration, warm compresses, massage gland and milk duct

○ Promoting salivary flow may help, use tart/hard candies

○ Avoid medications with anticholinergic side profile (Antihistamines and TCA’s)

○ Pain control with NSAIDs

● Suspected infection: ○ Antistaphylococcal agents: Dicloxacillin 500mg QID or Cephalexin 500mg QID for 7-10 days

● Failure to improve: ○ <4mm: Sialoendoscopy

○ >5mm: Sialoendoscopy + laser assisted lithotripsy

○ Rare cases require open surgical extraction with possibility of excision of affected gland

References

● Work WP, Hecht, DW. Inflammatory Diseases of the Major Salivary Glands. In: Otolaryngology,

Papparella MM, Shumrick DF (Eds), WB Saunders, Philadelphia 1980. p.2235.

● McKenna JP, Bostock DJ, McMenamin PG. Sialolithiasis. Am Fam Physician 1987; 36:119.

● Huoh KC, Eisele DW. Etiologic factors in sialolithiasis. Otolaryngol Head Neck Surg 2011; 145:935.

● Chow A. Infections of the Oral Cavity, Neck, and Head. In: Principles and Practice of Infectious

Diseases, Mandell G, Bennett JE, Dolin R (Eds), Churchill Livingstone, Inc., Philadelphia 2000.

p.699.