Dr Paulose

Submandibular Gland Calculi

Dr Paulose — Thu, 17 May 2012 12:04:03 +0000

Dr.K.O.Paulose FRCS DLO, Consultant ENT Surgeon, Jubilee Hospital, Trivandrum, Kerala, India

Submandibular Gland Calculi

The formation of stones, or calculi, may occur throughout the body, including the gallbladder, urinary tract, and salivary glands.

Salivary gland stones are the most common disease of salivary glands. Salivary gland stones (calculi) are the commonest intraluminal cause of recurrent salivary gland swelling. Salivary stone occasionally forms in a salivary gland or duct, usually by deposition of calcium salts around a nidus of organic material, and has a layered microscopic structure.

About salivary glands

The salivary glands make saliva. Saliva is important in the breaking down of the food that you eat. It makes food moist, lubricating it as it passes from the mouth to the stomach. It also contains enzymes which break down some of the starch and fat in your food.

There are three pairs of glands that make saliva. The submandibular glands are under the floor of your mouth – one on each side – and drain saliva up into the floor of your mouth. The parotid glands lie just below and in front of your ears. Saliva passes down the parotid duct into the inside of your cheeks. The sublingual glands are just beneath your tongue.

You make small amounts of saliva all the time to keep your mouth moist. When you eat, you normally make much more saliva which pours into your mouth.

About Salivary Gland Stones

A salivary gland stone is sometimes called a sialolith or a salivary calculus. Most salivary stones are mainly made of calcium. However, there is no abnormality of the blood calcium level or any other problem with calcium in your body. Salivary gland stones are not usually associated with any other diseases. The size of the stone can vary from less than 1 mm to a few cm in diameter.

Why Stones are more in SM gland

Submandibular calculi are more common as its saliva is more alkaline, and has an increased concentration of calcium and phosphate. The saliva here has a higher mucous content than saliva of the parotid and sublingual glands. In addition, the submandibular duct is longer and the gland has an antigravity flow when compared with parotid gland.

Symptoms

When saliva cannot exit a blocked duct, it backs up into the gland, causing pain and swelling of the gland. The most common symptoms are pain and swelling of the affected gland at mealtimes. This occurs if the stone completely blocks a duct. The pain can be sudden and intense just after starting a meal. Swelling soon follows. The pain and swelling ease over about 1-2 hours after a meal.

However, most stones do not block a duct completely. A stone may only partially block saliva flow or not block the flow at all if it is embedded in the body of the gland. In these situations the symptoms can vary and include one or more of the following:

• Dull pain from time to time over the affected gland.

• Swelling of the gland. Swelling may be persistent or vary in size from time to time.

• Infection of the gland may occur causing redness and pain. This may develop into an abscess.

Diagnosis

An ordinary X-ray test can detect and show the position of the stones. No further tests are then needed. A CT scan, ultrasound scan, sialogram can all be of use.

Treatment

Most stones that cause symptoms will not go away unless they come out or are removed. Sometimes a small stone comes out into the mouth by itself. If that does not occur, possible treatment options and procedures include the following:

• Gentle probing into the duct from inside the mouth with a thin blunt instrument can sometimes free a stone which then falls into the mouth.

• A small operation to cut out the stone is the traditional treatment, described below.

• Shock wave treatment (lithotripsy) may be an option. This uses ultrasound waves to break up stones. The broken fragments then pass out along the duct. This is a relatively new treatment for salivary stones (although it has been used for many years to treat kidney stones). However, it is not satisfactory as the broken stones cannot be easily removed.

Surgical procedure: (described in the next video clip)

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Large Submandibular Gland Removal Under GA

Dr Paulose — Thu, 17 May 2012 11:56:48 +0000

Dr.K.O.Paulose FRCS DLO, Consultant ENT Surgeon, Jubilee Hospital, Trivandrum, Kerala, India
www.drpaulose.com www.snorefreesleep.com

Surgical procedure

Removal of long standing salivary gland stone requires a delicate and careful handling to avoid unnecessary damage to the duct and adjacent structures.

Usually this is done under local anesthesia. But in the above shown case I was forced to do it under GA as many attempts failed by infiltration anesthesia causing lot of fibrosis.

The possibility to removal of the stone under local anesthesia was abandoned at patients request as he had 3 attempts from different doctors all failed. It will be embarrassing for me for one more trial if it fails.

Patient under GA, the tongue was retracted by a piece of gauze. The duct sutured loosely behind the stone to prevent its posterior dislodgment, about 2-cm mucosal incision was performed against the stone position in the longitudinal axis of the duct. Upon dissection to reach the stone sublingual salivary gland structure encountered, it was a little bit difficult to expose the stone after incising the duct lining because the fibrous adhesions resulting from recurrent inflammatory processes.

After its exposure, I grasped the stone gently by mosquito artery forceps, and the adhesions were relieved by excavator end of the surgical curette, which facilitated its removal. The size of the stone was about 1cm.

Copious irrigation and suction was done to ensure removal of possible minor stones posterior to the removed stone, and a clear mucous secretion was noticed through the wound incision. After ensuring homeostasis, Closure of mucosal wound was done with 3/0 catgut suture. Postoperative analgesic and antiseptic mouthwash were prescribed

Ear Surgery in Jubilee Hospital part-2

Dr Paulose — Thu, 17 May 2012 09:34:26 +0000

Dr.K.O.Paulose FRCS DLO, Consultant ENT Surgeon, Jubilee Hospital, Trivandrum, Kerala, India
www.drpaulose.com www.snorefreesleep.com

Ear Surgery in Jubilee Hospital part-1

Dr Paulose — Thu, 17 May 2012 09:26:39 +0000

Ear Surgery-Micro Ear Surgery in Trivandrum.Tympanoplasty with Mastoid Exploration.

Dr.K.O.Paulose FRCS DLO, Consultant ENT Surgeon, Jubilee Hospital, Trivandrum, Kerala, India

Reconstructive Septorhinoplasty

Dr Paulose — Thu, 17 May 2012 05:16:59 +0000

Open Rhinoplasty Procedure:
Dr.K.O.Paulose FRCS DLO.Consultanat ENT Surgeon and Dr. Archana MS Associate ENT Surgeon.

Orbital Cellulitis and Ethmoiditis in Children

Dr Paulose — Thu, 17 May 2012 00:53:19 +0000

ENT:EYE:PEDIATRIC EMERGENCY

Orbital complications of ethmoiditis primarily affect children. Although orbital cellulitis may be caused by acute frontal sinusitis, it is most frequently a complication of acute ethmoiditis. Unfortunately, the association of acute ethmoid and frontal sinusitis with orbital cellulites is often unrecognized. If the basic site of infection remains unknown, optimum therapy is delayed.

Orbital cellulitis is known to occur in three varying situations:

• It may appear as an extension from the orbital structures, most probably the paranasal sinuses, or the face and other head injuries. Venous drainage from the middle third of the face, including the paranasal sinuses, is mainly via the orbital veins, which are without valves allowing the passage of infection both interrogates and retrograde.

• It may occur due to direct inoculation of the orbit from trauma or surgery. Infectious material may be introduced into the orbit directly from accidental or surgical trauma.

• It may in certain instances represent a hematogenous spread from bacteremia. Bacteremia is the presence of bacteria in the bloodstream.

About 75 percent of orbital cellulitis cases are related to sinusitis, especially ethmoiditis. Ethmoid sinusitis is commonly due to aerobic non-spore-forming bacteria.

Symptoms of orbital cellulitis include:

• Erythema or edema of the eyelids (common to all orbital infections)

• Proptosis

• Ophthalmoplegia (suggestive of orbital cellulitis, orbital or subperiosteal abscess)

• High Fever

• Pain

• Decreased visual acuity (associated with advanced infection)

• Conjunctivitis or pinkeye

Orbital cellulitis is more prevalent in children over five years of age. This is because most cases of ethmoiditis are associated with ethmoid sinus which is more prevent in school going kids than in adults.

As already mentioned, orbital cellulitis is more prevalent in kids. So if you observe any of the above-mentioned symptoms in your child, rush him/her to the clinic.

Diagnosis:

By CT scan. The CT scan imaging is done after giving sedative like Pedicloryl syrup.

Treatment

If cellulitis becomes severe, one or both eyes may be affected, and eye sockets or sinus cavities may have to be drained. These surgical procedures should be performed by an ophthalmologist (eye specialist) or otolaryngologist (ear, nose and throat specialist).

The antibiotics with anti inflammatory drugs and short course of hydrocortisone do clear the cellulites. The abscesses which are more frequent in older children require surgical drainage. Surgical drainage is indicated when subperiosteal abscess is documented by CT scan.