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.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).7 The transoral approach is recommended for palpable, impacted, large lithiases (diameter >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,1even for large lithiases.
McGurk et al.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.