Abscess presenting as fluctuant tender swelling of left submandibular area.
Copious thick pus discharge from left submandibular duct opening.
The majority of submandibular salivary gland calculi are radiopaque and visible on X-ray. This patient has inflamed and swollen left floor of mouth with pus emanating from the Wharton's duct. Intraocclusal view showed at least 2 radiopaque stones with the bigger one situated more anteriorly.
Stone retrieved from the submandibular duct.
A longstanding distal submandibular duct calculi (X) in a patient presenting with episodic left submandibular swelling during meals.
Watch video of distal submandibular duct calculi @ YouTube
CT-scan view showing a significant size radiopaque calculi along left submandibular duct anatomy. History revealed repeated non-painful left submandibular swelling while eating which subsides slowly.
Another example of distal submandibular duct calculi just beyond its opening. (LI 1 - left 1st incisor, RI 1-right 1st lower incisor, RI 2 - right 2nd lower incisor)
In this video, the left submandibular duct was blocked by a small stone (calculi) which had caused infection of the gland with pus formation. Imaging study showed no evidence of calculi within the gland itself and the implicated stone was located just before the natural duct opening. Local anaesthesia infiltration was given followed by incision using radiofrequency device along the long axis of the duct where the stone felt (the natural duct opening was spared). Pus gush out as the duct lumen reached. Careful suctioning and manipulation enable the small stone to be retrieved (attached to suction device end). The opening was left unsutured as it can healed readily. An antibiotic course and mouth rinse were prescribed.
Left submandibular duct pinched and retracted. (F - frenulum, VT - central surface of tongue, R - right, L - left]
Incision made using scalpel blade (SB) along the long axis of the duct.
Submandibular duct opened by using small artery forceps to reveal the calculi (arrow).
Rod-shaped calculi removed (C).
Intraoral view taken 24 hours after surgery with absorbable sutures in view (rectangle).
Submandibular bed after the gland removed.
A- anterior, MM- myelohyoid muscle, MB- mandibular bone, arrow- digastric tendon, blue forceps hypoglossal nerve, metal forceps- lingual nerve.
The excised submandibular gland.
SM- submandibular gland, arrow- duct.
Intraoperative view of right submandibulectomy due to recurrent sialoadenitis with sialolithiasis. A large salivary calculi seen blocking the proximal segment of the submandibular duct (C). (M - myelohyoid muscle, 1 - lingual nerve, 2 - submandibular duct, 3 - hypoglossal nerve, X - submandibular gland involving the superficial and retromandibular segments, interrupted yellow line - outline of lower border of mandible, red arrow - towards anterior, yellow arrow - towards posterior).
Surgical scar (arrows) after right submandibulectomy.
Figure 1 Figure 2
Figure 3 Figure 4
Figure 1: Axial view CT-scan
Figure 2: Coronal view CT-scan
Figure 3: Sagittal view CT-scan
Figure 4: Intraoperative view showing (+) - the cystic component, (X) - the submandibular gland, M - inferior border of mandible, S - superior, I - inferior, P - posterior.
The typical site of a parotid lump is shown (X). [Line - inferior border of mandible]
A histologically-proven parotid pleomorphic adenoma.
Left parotid lump with CT-scan finding suggestive of Warthin's tumour.
Figures showing intraoperative view of right submandibular adenoma excision (top left) and the close-up view of the tumour specimen (top left). (Arrow - lobule of right pinna, T- tumour, C - chin)
Arrow - sinus emanating clear salivary fluid upon eating surrounded by induration. CT-scan showed bilateral bilateral parotitis. The patient had two similar infections within two years. Tuberculosis was ruled out.
Combination of CT-scan and sialogram allows simultaneous assessment of salivary gland drainage patency and intrinsic parenchymal salivary lesions. [green arrow - distal Stensen's duct heading towards its opening opposite upper second molar tooth, yellow arrow - sialogram contrast well distributed inside right parotid gland, white arrow- parotid duct lying in outer surface of masseter muscle].