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.