V

Figure 5.6. This axial section of computerized tomograms shows the presence of bilateral sialoliths of the subman-dibular glands.

suggestive of a diagnosis of sialolithiasis. This notwithstanding, many patients are asymptomatic such that only a panoramic radiograph may allow for the diagnosis of submandibular sialolithiasis, as it may reveal calcifications within the subman-dibular triangle. It has been observed that subman-dibular stones located anteriorly are more often symptomatic than those lodged in the intraglandu-lar portion of the duct (Karas 1998). While such calcifications may lead to a diagnosis of subman-dibular sialolithiasis, it is important for the clinician to consider other diagnoses that present with submandibular calcifications, particularly when pain is absent. Among these are calcified lymph nodes associated with mycobacterial adenitis (scrofula) (Figure 5.7), phleboliths associated with oral/facial hemangiomas (Figure 5.8), and a mandibular osteoma as might occur in Gardner's syndrome (Figure 5.9). All of these calcifications may, at first glance, appear similar to submandibular sialolithiasis. Close examination of panoramic radiographs may, however, allow for the clinician to establish a radiographic diagnosis other than submandibular sialolithiasis (Mandel 2006). Most submandibular calculi contain smooth borders when they exist within the gland. Calcified lymph nodes generally show irregular borders, and osteo-mas of the mandible are larger than most salivary

Figures 5.7c, 5.7d, and 5.7e. The lymph nodes were removed (c) and bisected, showing macroscopic (d) and microscopic evidence of caseous necrosis (e). A diagnosis Figure 5.7b. Exploration of the neck showed indurated of tuberculous adenitis was therefore established. The lymph nodes present in association with the right subman- patient was subjected to a purified protein derivative (PPD) dibular gland, but clearly not sialoliths. skin test that was positive.

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