From the Research
The initial management for a patient with calculus of Wharton's duct involves conservative measures aimed at stimulating saliva flow and facilitating spontaneous passage of the stone. Patients should be instructed to increase hydration, apply warm compresses to the affected submandibular region, and perform gentle massage of the gland toward the duct opening. Sialogogues such as lemon drops or sugar-free sour candies can be used to stimulate saliva production. Pain management with NSAIDs like ibuprofen 400-600mg every 6-8 hours is recommended. If infection is suspected, empiric antibiotics such as amoxicillin-clavulanate 875/125mg twice daily for 7-10 days should be prescribed. These conservative measures are often effective for small stones (less than 5mm) located in the distal portion of the duct. The rationale behind this approach is that increased salivary flow can help push the stone forward through the duct for spontaneous expulsion. If these measures fail after 48-72 hours, or if the patient presents with severe symptoms, significant swelling, or signs of infection, referral to an otolaryngologist for more advanced interventions such as sialendoscopy, lithotripsy, or surgical removal may be necessary, as supported by recent studies 1, 2. Some studies suggest that surgical removal of the submandibular calculi, ending with shortening of Wharton's duct, reduces the recurrence rate for sialolithiasis 1. However, the use of advanced techniques such as 3D 4K exoscope-assisted removal of calculus of the Wharton's duct may provide a valid option for transoral removal of calculi, allowing for precise surgical dissection of the oral floor, thus reducing the risks for iatrogenic lesion of the lingual nerve 2. It is essential to consider the size and location of the stone, as well as the presence of multiple stones, when choosing the surgical option, as highlighted in the study by 3. Overall, the management of calculus of Wharton's duct should prioritize conservative measures, with referral to an otolaryngologist for advanced interventions if necessary, and consideration of the latest advancements in surgical techniques.
Some key points to consider in the management of calculus of Wharton's duct include:
- Conservative measures such as hydration, warm compresses, and sialogogues should be the initial approach
- Pain management with NSAIDs and empiric antibiotics if infection is suspected
- Referral to an otolaryngologist for advanced interventions if conservative measures fail or if the patient presents with severe symptoms
- Consideration of the size and location of the stone, as well as the presence of multiple stones, when choosing the surgical option
- The use of advanced techniques such as 3D 4K exoscope-assisted removal of calculus of the Wharton's duct may provide a valid option for transoral removal of calculi.
It is crucial to prioritize the patient's morbidity, mortality, and quality of life when making management decisions, and to consider the latest evidence and advancements in the field, as highlighted in the studies by 4, 1, 5, 2.