Figure 5.8b. At first glance of the radiograph, submandibular sialolithiasis is a reasonable consideration. Close examination of the radiograph reveals multicentric lamellated calcifications in the submandibular and preauricular regions, as well as a calcification superimposed on the left mandibular second molar roots. A complete physical examination revealed signs consistent with a hemangioma associated with the left mandibular gingiva. As such, the calcifications are presumed to represent phlebo-liths, and are not removed. It is important, therefore, to diagnose sialolithiasis based on a review of a radiograph as well as a physical examination.

Figures 5.9b, 5.9c, and 5.9d. Computerized tomograms were not obtained preoperatively, and a differential diagnosis of submandibular sialolithiasis was established. The calcification, however, does not show typical radiographic signs of a sialolith, including its irregular borders. The patient underwent exploration of the left submandibular region, whereupon the calcified mass was identified as a distinct entity from the left submandibular gland (b). The mass was removed (c) and the left submandibular gland remained in the tissue bed (d). A histopathologic diagnosis of osteoma was made. A subsequent diagnosis of Gardner's syndrome was made, and the patient underwent colectomy when a diagnosis of adenocarcinoma of the colon was established.

b c d gland stones and are intimately associated with the mandible. Phleboliths are commonly multiple in number and also exist within the neck outside of the submandibular triangle. They are scattered and have a classic lamellated appearance with a lucent core. Finally, phleboliths are smaller than sialoliths and demonstrate an oval shape, compared to the sialolith, whose elliptical shape has been created by a salivary duct (Mandel and Surattanont 2004). One further entity worthy of mention is calcified atheromas of the carotid artery, which is sufficiently distant from the submandibular triangle so as to not be confused with a submandibular sialo-lith. These are most commonly located inferior and posterior to the mandibular angle adjacent to the intervertebral space between cervical vertebrae 3 and 4 (Friedlander and Freymiller 2003).

While the diagnosis of sialolithiasis is frequently confirmed radiographically, it is important for the clinician to not obtain radiographs prior to performing a physical examination. Bimanual palpation of the floor of the mouth may reveal evidence of a stone in a large number of patients. Similar palpation of the gland may also permit detection of a stone as well as the degree of fibrosis present within the gland. Examining the opening of Wharton's duct for the flow of saliva or pus is an important aspect of the evaluation. It has been estimated that approximately one-quarter of symptomatic submandibular glands that harbor stones are non-functional or hypofunctional. Radiographs should be obtained and may reveal the presence of a stone. It has been reported that 80% of submandibular stones are radio-opaque, 40% of parotid stones are radio-opaque, and 20% of sublingual gland stones are radio-opaque (Miloro 1998).

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