What is the management plan for submandibular stones?

Management of Submandibular Stones

The management of submandibular stones should begin with conservative approaches for small, accessible stones and progress to minimally invasive surgical techniques for larger or inaccessible stones, with submandibulectomy reserved only for cases where gland preservation is not possible.

Diagnostic Approach

• Imaging evaluation:

  • Ultrasound is the first-line imaging modality for salivary stones (sensitivity ~75%)
  • CT scan may be used for definitive diagnosis in unclear cases (sensitivity ~97%)
  • Bimanual palpation should be performed to locate stones in the duct or gland

• Clinical presentation:

  • Intermittent pain and swelling, characteristically occurring just before or during meals
  • Tenderness of the involved salivary gland
  • Reduced or absent salivary flow from the affected duct 1

Management Algorithm

1. Conservative Management (First-Line for Small, Accessible Stones)

• Hydration: Increase fluid intake to at least 2.5 liters daily to promote salivary flow 1
• Sialagogues: Use of lemon drops or sour candy to stimulate salivary flow
• Massage and milking of the duct: Gentle manipulation to help expel small stones
• NSAIDs: For pain and inflammation control 1
• Heat application: To reduce inflammation and discomfort 1

2. Minimally Invasive Approaches (For Stones Not Responsive to Conservative Measures)

• Transoral sialolithotomy:

  • Indicated for stones that can be palpated bimanually and localized by ultrasound within the perihilar region 2
  • Success rates of 91-100% for distal and perihilar stones 2
  • Low complication rates (<1% for lingual nerve damage and recurrence) 2

• Endoscopy-assisted sialolithotomy:

  • Particularly effective for superficial lobe stones
  • 93% success rate for stone removal
  • Preserves gland function with minimal morbidity
  • 89.6% of patients remain stone-free at follow-up 3

3. Surgical Management (For Large, Inaccessible Stones or Recurrent Disease)

• Submandibulectomy:
  • Reserved for cases where minimally invasive techniques fail
  • Indicated for stones >10mm that are deeply embedded in the gland
  • Required in only 1.7-4% of cases after attempted transoral removal 2, 4

Special Considerations

• Stone size and location:

  • Stones <5mm are more amenable to conservative management
  • Stones >10mm ("sialoliths of unusual size") often require surgical intervention 5
  • Location relative to the mylohyoid muscle edge affects treatment approach:
    • Distal to mylohyoid: Higher success with transoral removal (100%)
    • Proximal/hilar: Still high success with transoral approach (91%) 2

• Post-procedure follow-up:

  • Clinical evaluation at 1-2 weeks
  • Ultrasound assessment to confirm stone clearance
  • Long-term follow-up shows 76% of patients become completely symptom-free after transoral removal 4

Complications to Monitor

• Lingual nerve injury (rare: <1% with transoral approach)
• Recurrent stones (2-4% at 2-year follow-up)
• Persistent sialadenitis requiring subsequent submandibulectomy (4-7%)

Treatment Outcomes

Transoral stone removal techniques demonstrate excellent outcomes:

• 93-99% success rate for stone removal
• 76-89% of patients become symptom-free
• Only 4% of patients ultimately require submandibulectomy
• 93% of patients report satisfaction with the procedure 4

The evolution of minimally invasive techniques has dramatically reduced the need for submandibulectomy, preserving gland function while effectively treating submandibular stones.