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\begin{document}

\title{Transoral removal of a hilo-parenchymal submandibular sialolith}



\author[1]{Yo-hei KATAOKA}%
\author[1]{Yoshihiro Kojima}%
\author[1]{Ruri Ishibashi}%
\author[1]{Yuji Nakao}%
\author[1]{Koji Yamamura}%
\author[1]{Shotaro Takahashi}%
\author[1]{Takafumi Hashiba}%
\author[1]{Takahito Matsue}%
\affil[1]{Self Defence Forces Central Hospital}%


\vspace{-1em}



  
  \date{April 26, 2024}


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\selectlanguage{english}
\begin{abstract}
Often, the lithiasis is large and located at the junction of the middle
and posterior third of the duct, in the hilum region. In such cases,
transoral approach for submandibular lithiases (TASL) is useful
treatment of choice in patients with large submandibular stones that can
be palpated bimanually.%
\end{abstract}%



\sloppy


Transoral removal of a hilo-parenchymal submandibular sialolith

Yo-Hei Kataoka, Yoshihiro Kojima, Ruri Ishibashi, Yuji Nakao, Koji
Yamamura, Shotaro Takahashi, Takafumi Hashiba, Takahito Matsue

\textbf{{[}Affiliations{]}}

\textbf{Corresponding author:}

Yo-Hei Kataoka, DDS, PhD

Department of Dentistry, Self-defense Forces Central Hospital

1-2-24 Ikejiri, Setagayaku, Tokyo 154-0001, Japan

e-mail:\emph{pqxh5pcp@okayama-u.ac.jp}

\textbf{Co-authors' emails:}

\textbf{Abstract}

\section*{Introduction}

{\label{introduction}}

Sialolithiases mainly affect the submandibular gland (SMG). Often, the
lithiasis is large and located at the junction of the middle and
posterior third of the duct, in the hilum region. In such cases,
proximal stones are generally removed from the SMG by a transcervical
submandibular sialoadenectomy.

Recently, a gland-preserving technique has been introduced for transoral
proximal sialolith removal, which is also termed as the transoral
approach for submandibular lithiases (TASL).\textsuperscript{1} Herein,
we report a case of transoral removal of a hilo-parenchymal
submandibular sialolith by TASL.

\section*{Case History}

{\label{case-history}}

A 42-year-old man was referred to our hospital for the assessment of an
asymptomatic radiopaque lesion in the left submandibular region.
Panoramic radiography and computed tomography confirmed two calcified
lesions in the posterior and anterior regions of Wharton's duct,
respectively (Figs 1 and 2). Intraoral examination by bimanual palpation
revealed a small, firm, and non-tender swelling in the anterior floor of
the mouth and a large, firm and non-tender swelling in the posterior
floor. The final diagnosis was sialolithiasis in the left Wharton's duct
and hilo-parenchymal submandibular area.

In the operating room, the patient was placed in the dorsal decubitus
position. After transnasal intubation and proper oral preparation, the
buccal floor was infiltrated under the mucosa with a saline solution with
2\% epinephrine (0.50 mg in 20 cc). An incision was made through the
mucosa of the lateral floor of the mouth, from the orifice of Wharton's
duct to the lingual side of the retromolar region, leaving a cuff of
normal lingual mucosa to facilitate subsequent wound closure. The
anterior sialolith was pushed out of the duct and removed via manual
manipulation. Careful dissection was performed between Wharton's duct
and the lingual nerve. External digital pressure was applied to
facilitate the isolation of the duct from the lingual nerve up to the
hilum of the SMG. After localizing the posterior stone with bimanual
palpation, the duct was incised, and the stone was removed (Fig. 3). The
duct was then irrigated with normal saline to clean the region and
remove stone debris. The incised mucosa at the floor of the mouth was
sutured back to its original position, without repairing the incision
site of Wharton's duct.

\section*{Discussion}

{\label{discussion}}

Sialolithiasis is the most common salivary gland pathology. SMG
resection is the standard operative procedure used for the management of
proximal sialolithiasis. However, the associated incidence of iatrogenic
injuries is relatively high. Recently, several conservative and
minimally invasive techniques have been developed for salivary lithiasis
surgery, with the development of the sialendoscope and
lithotripter.\textsuperscript{2-6} The management of SMG lithiases is
based on three criteria: the gland involved, topography of the
lithiasis, and the diameter of the lithiasis, according to the GTD
classification: the gland involved (G), topography of the lithiasis (T),
and the diameter of the lithiasis (D).\textsuperscript{7} The transoral
approach is recommended for palpable, impacted, large lithiases
(diameter \textgreater{}8 mm) situated in the posterior third of
Wharton's duct. Using the GTD classification, lithiases classified as
submandibular lithiases over 8 mm in diameter (large and impacted) and
situated in the posterior third of Wharton's duct are better operated
with TASL. This surgical procedure is minimally invasive, repeatable,
allows functional recovery of the gland after obstruction removal, and
minimizes scarring,\textsuperscript{1}even for large lithiases.

McGurk et al.\textsuperscript{8} reported that small stones that cannot
be palpated are a contraindication for intraoral removal. In their
patient cohort, they observed that stones that were palpable on bimanual
examination tended to be easier to retrieve; this was attributed to the
fact that non-palpable stones reside in the gland and their position is
masked by the surrounding tissues. Intraoral dissection is rarely
performed when the stone is severely adherent to the surrounding
tissues, as the approach to the transcervical route may be altered.
Thus, appropriate preoperative assessment via manual palpation is
important in the context of informed consent.

Our case demonstrated that intraoral removal of proximal submandibular
stones with the preservation of the gland and ductal system is safe and
efficacious and is therefore a valid alternative to traditional
transcervical surgery.

\section*{Conclusions}

{\label{conclusions}}

TASL should be considered as the treatment of choice in patients with
large submandibular stones that can be palpated bimanually.

\section*{Acknowledgments}

{\label{acknowledgments}}

The authors did not receive any external funding by any
organization/society for this study. Informed consent was obtained from
the participant in this study.

\textbf{Conflicts of interest:} The authors declare that they have no
conflict of interest

\textbf{Consent for publication}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy























\section*{References}

{\label{references}}

1. Carbonnel, E., Le Roux, M.K., Chossegros, C., Scemama, U., and N.
Graillon. 2020. Tips \& tricks for transoral approach for submandibular
lithiasis (TASL). Journal of Stomatology and Oral Maxillofacial Surgery
121:736--739.

2. Zenk, J., Bozzato, A., Winter, M., Gottwald, F., and H. Iro. 2004.
Extracorporeal shock wave lithotripsy of submandibular stones:
evaluation after 10 years. Annals of Otology, Rhinology, and Laryngology
113:378--383.

3. Drage, N.A., Brown, J.E., Escudier, M.P., and M. McGurk. 2000.
Interventional radiology in the removal of salivary caluculi. Radiology
214:139--142.

4. Nahlieli, O., and A.M. Baruchin. 2000. Long-term experience with
endoscopic diagnosis and treatment of salivary gland inflammatory
disease. Laryngoscope 110:988--993.

5. Marchal, F., Dulguerov, P., Becker, M., Barki, G., Disant, F., and W.
Lehmann. 2001 Specificity of parotid sialendscopy. Laryngoscope
111:264--271.

6. Ottaviani, F., Capaccio, P., Campi, M., and A. Ottaviani. 1996.
Extracorporeal electromagnetic shock lithotripsy for salivary gland
stone. Laryngoscope 106:761--764.

7. Foletti, J.M., Graillon, N., Avignon, S., Guyot, L., and C.
Chossegros. 2008. Salivary calculi removal by minimally invasive
techniques: A decision tree based on the diameter of the calculi and
their position in the excretory duct. Journal of Oral and Maxillofacial
Surgery 76:112--118.

8. McGurk, M., Makdissi, J., and J.E. Brown. 2004. Intra-oral removal of
stones from the hilum of the submandibular gland: report of technique
and morbidity. International Journal of Oral and Maxillofacial Surgery
33:683--686.



\section*{Figure Captions}

{\label{figure-captions}}

\textbf{Fig. 1} Three-dimensional cone-beam computed tomography
reconstruction of the left submandibular parenchymal stones.

\textbf{Fig. 2} Axial computed tomography images showing the left
anterior and posterior stones. The posterior (A, 27.0 mm) and anterior
(B, 9.4 mm) stones are visible.

\textbf{Fig. 3} The stone extracted from the parenchyma and its
relationship with Wharton's duct and the lingual nerve.

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