1220
BILATERAL
4. Sheridan SM: Traumatic neuroma following sagittal split mandibular osteotomy. Br J Oral Surg 21:201, 1983 5. Shafer GW, Hine MK, Levy BM: Textbook of Oral Pathology (ed 3). Philadelphia, PA, Saunders, 1974, pp 189-190 6. Cawson RA, Eveson JW: Oral Pathology and DiagnosisColour Atlas with Integrated Text. London, Heinmann, 1987, p 10.12 7. Fiamminghi I, Aversa C: Lesions of inferior alveolar nerve in sagittal osteotomy of the ramus-Experimental study. J Maxillofacial Surg 7: 125, 1979 8. Clausen F, Paulsen H: Metastatic carcinoma to the jaws. Acta Path01 Microbial Immunol Stand 57:361, 1963
J Oral Mawllofac
SUBMANDIBULAR
SIALOLITHIASIS
9. Meyer I, Shklar G: Malignant tumours metastatic to mouth and jaws. Oral Surg 20:350,1965 10. Browne RM: The odontogenic keratocyst: Clinical aspects. Br Dent J 128:225, 1970 11. Browne RM: The odontogenic keratocyst: Histological features and their correlation with clinical behaviour. Br Dent J 128:249, 1970 12. Lucas RB: Pathology of Tumours of the Oral Tissues (ed 4). Edinburgh, Churchill Livingstone, 1984. pp 357-358 13. Sugar AW, Walker DM, Bounds GA: Surgical (postoperative maxillary) cysts following mid-face osteotomy. Br J Oral Maxillofac Surg 28:264. 1990
Surg
49:1220-1222.7991
Bilateral Submandibular Sialolithiasis Concurrent Sialadenitis:
and
A Case Report GREGORY J. LUTCAVAGE,
DDS,” AND SIEGFRIED J. SCHABERG,
Sialolithiasis is a common cause of obstructive sialadenitis. However, bilateral sialolithiasis is a relatively rare occurrence. An unusual case is reported in which a patient presented with bilateral submandibular sialolithiasis, concurrent sialadenitis, and unilateral sialodocholithiasis. Report of a Case A 76-year-old woman was referred for evaluation and treatment of severe lymphadenitis by her dentist. The patient related a history of bilateral submandibular swelling associated with intermittent pain of 3 years’ duration. She sought treatment because the pain had become more persistent and had increased in frequency and intensity in the last 2 months. Review of systems was remarkable for hypertension, which was controlled through a combined preparation of methyldopa 50 mg and hydrochlorothiazide 15 mgid. The patient also related that she had been hospitalized 2 years before for a myocardial infarction. She affirmed having had an allergic response to penicillin consisting of urticaria. Physical examination was remarkable for bilateral sub-
Received from Wayne Memorial Hospital, Goldsboro, NC. * Chairman, Department of Surgery; in private practice, Goldsboro, NC. t Attending Surgeon; in private practice, Goldsboro, NC. Address correspondence and reprint requests to Dr Lutcavage: 2400 Wayne Memorial Dr, Goldsboro, NC 27534. 0 1991 American geons
Association
0278-2391/91/491
l-0016$3.00/0
of Oral and Maxillofacial
DDS, PHDt
mandibular gland enlargement with focal tenderness. The glands were indurated, but not fixed to the underlying tissues. Prominent calcifications were palpable within the submandibular glands bilaterally. No appreciable salivary flow was elicited from the submandibular ducts. Two small calculi were noted in the left submandibular duct on bimanual palpation. The mandibular occlusal radiograph showed two radiopacities in the distal portion of the left submandibular duct (Fig I). The panoramic radiograph showed prominent bilateral submandibular gland calcifications (Fig 2). A diagnosis of bilateral submandibular sialolithiasis with obstructive sialadenitis, and left submandibular sialodocholithiasis was made. Oral antibiotic therapy consisting of cefadroxil monohydrate (1 g/d) was initiated. in addition to supportive measures consisting of massage of the glands, moist heat, and lemon drops to increase salivary flow. A computed tomography (CT) scan was ordered to better delineate the size and extent of the calcifications. Seven days later, the patient’s condition on physical examination was unchanged, except for a purulent discharge flowing from the left submandibular duct. A CT scan showed multiple calcifications in the right and left submandibular glands (Fig 3) and in the left submandibular duct (Figs 3, 4). The patient subsequently underwent bilateral submandibular sialadenectomies and a left transoral sialodocholithotomy under general anesthesia without complications. The surgical specimens showed prominent intraglandular calcifications and fibrosis. The patient had an uncomplicated postoperative course. Discussion
Sur-
Bilateral submandibular sialolithiasis is a rare finding, considering the paucity of reports found in
LUTCAVAGE
AND SCHABERG
FIGURE 1. Mandibular occlusal radiograph showing two sialoliths in the left distal submandibular duct (arrows).
FIGURE 3. Computed tomography scan showing bilateral submandibular gland calcifications and a single left intraductal sialolith (arrows).
the literature. I-5 Interestingly, Perrotta et al5 reported a case of bilateral parotid and submandibular gland calculi in which an attempt was made during the course of the workup to correlate the head and neck findings with the presence of possible renal and gallbladder calculi. An intravenous pyelogram and oral cholecystogram, however, were negative. Differentiation should be made between intraglandular and intraductal calculi. A variety of diagnostic imaging studies are available to aid in anatomic localization of such stones. These include sialography. conventional radiography, computerized tomography, and magnetic resonance imaging. In this case, conventional radiographic techniques, which included panoramic and mandibular occlusal
radiographs, showed prominent intraglandular calcifications bilaterally in addition to two left anterior intraductal calcifications. These calcifications were also prominently demonstrated on CT scan. Of particular interest in this case was the patient’s long-term use of methyldopa-hydrochlorothiazide therapy to control hypertension. It is known that methyldopa can inhibit salivation through both central and peripheral mechanisms,6 thus setting the stage for a retrograde infection in the salivary glands. Goldberg and Topazian’ note that in their experience, many of their patients have been on diuretic therapy, which can predispose to the development of a retrograde sialadenitis after a decrease in salivation and salivary stasis in the
FIGt_JRE 2. Panoramic radiogr .aph sho wing bilateral subm andit Iular gland calcifications.
MANAGEMENT
OF OROFACIAL VASCULAR
LESIONS
secretions are more alkaline and contain higher concentrations of calcium and phosphates than parotid secretions. These secretions, taken in conjunction with the anatomic location of the submandibular duct, its length, its tortuous course, and its lack of dependent drainage, can create an environment in which salivary stones are more prone to form, especially under conditions of salivary stasis. Thus, conditions are ideal for deposition of calcium salts around foci of desquamated epithelium. References
FIGURE 4. Computed tomography scan showing a second left intraductal sialolith and bilateral submandibular gland calcifications (arrows).
gland. Indeed, a link may be postulated between the chronicity of this patient’s symptoms and her longterm use of combination antihypertensive therapy. Goldberg and Topazian state that submandibular
J Oral Maxillofac
1. Sellari FA: Simultaneous bilateral submandibular sialolithiasis. Ann Laringol Otol Rhino1 Faring01 65:366, 1966 2. Forman G: Bilateral submandibular sialolithiasis. Br Dent J 120:84, 1966 3. Reczyk J, Plewinska H: Bilateral submandibular sialolithiasis. Czas Stomatol 28:1193, 1975 4. Sujaku C, Kameyama T, Kawano K. et al: A case of sialolithiasis in the bilateral submandibular ducts. Nippon Koku Geka Gakkai Zasshi 17:35, 1971 5. Perrotta RJ, Williams JR, Selfe RW: Simultaneous bilateral parotid and submandibular gland calculi. Arch Otolaryngol 104:469, 1978 6. Sweet CS, Gaut SL: Antagonism of conditioned salivation in
Surg
49:1222-1225,1991
A Conservative Approach to the Management of Orofacial Vascular Lesions in Infants and Children: Report of Cases HAROLD BAURMASH,
DDS,* AND SHARON DECHIARA, DDSt
* Clinical Professor of Oral and Maxillofacial Surgery, School of Dental and Oral Surgery, Columbia University, New York. t Senior Resident in Oral and Maxillofacial Surgery, Columbia Presbyterian Medical Center, New York. Address correspondence and reprint requests to Dr Baurmash: Columbia Presbyterian Medical Center, 630 W 168th St, New York, NY 10032. 0 1991 American geons
Association
0278-2391/9114910-0017$3.00/0
of Oral and Maxillofacial
Sur-
Mulliken and Glowacki have categorized vascular birthmarks as hemangiomas or vascular malformations based on their clinical behavior and endothelial cell characteristics.’ The term hemangioma is restricted to the very common vascular lesion of infancy that usually appears 2 to 4 weeks after birth, grows rapidly until the age of 6 to 8 months, and then slowly and predictably involutes by age 5 to 8 years. On a cellular level, hemangiomas are characterized by increased endothelial turnover and in-
BILATERAL
4. Sheridan SM: Traumatic neuroma following sagittal split mandibular osteotomy. Br J Oral Surg 21:201, 1983 5. Shafer GW, Hine MK, Levy BM: Textbook of Oral Pathology (ed 3). Philadelphia, PA, Saunders, 1974, pp 189-190 6. Cawson RA, Eveson JW: Oral Pathology and DiagnosisColour Atlas with Integrated Text. London, Heinmann, 1987, p 10.12 7. Fiamminghi I, Aversa C: Lesions of inferior alveolar nerve in sagittal osteotomy of the ramus-Experimental study. J Maxillofacial Surg 7: 125, 1979 8. Clausen F, Paulsen H: Metastatic carcinoma to the jaws. Acta Path01 Microbial Immunol Stand 57:361, 1963
J Oral Mawllofac
SUBMANDIBULAR
SIALOLITHIASIS
9. Meyer I, Shklar G: Malignant tumours metastatic to mouth and jaws. Oral Surg 20:350,1965 10. Browne RM: The odontogenic keratocyst: Clinical aspects. Br Dent J 128:225, 1970 11. Browne RM: The odontogenic keratocyst: Histological features and their correlation with clinical behaviour. Br Dent J 128:249, 1970 12. Lucas RB: Pathology of Tumours of the Oral Tissues (ed 4). Edinburgh, Churchill Livingstone, 1984. pp 357-358 13. Sugar AW, Walker DM, Bounds GA: Surgical (postoperative maxillary) cysts following mid-face osteotomy. Br J Oral Maxillofac Surg 28:264. 1990
Surg
49:1220-1222.7991
Bilateral Submandibular Sialolithiasis Concurrent Sialadenitis:
and
A Case Report GREGORY J. LUTCAVAGE,
DDS,” AND SIEGFRIED J. SCHABERG,
Sialolithiasis is a common cause of obstructive sialadenitis. However, bilateral sialolithiasis is a relatively rare occurrence. An unusual case is reported in which a patient presented with bilateral submandibular sialolithiasis, concurrent sialadenitis, and unilateral sialodocholithiasis. Report of a Case A 76-year-old woman was referred for evaluation and treatment of severe lymphadenitis by her dentist. The patient related a history of bilateral submandibular swelling associated with intermittent pain of 3 years’ duration. She sought treatment because the pain had become more persistent and had increased in frequency and intensity in the last 2 months. Review of systems was remarkable for hypertension, which was controlled through a combined preparation of methyldopa 50 mg and hydrochlorothiazide 15 mgid. The patient also related that she had been hospitalized 2 years before for a myocardial infarction. She affirmed having had an allergic response to penicillin consisting of urticaria. Physical examination was remarkable for bilateral sub-
Received from Wayne Memorial Hospital, Goldsboro, NC. * Chairman, Department of Surgery; in private practice, Goldsboro, NC. t Attending Surgeon; in private practice, Goldsboro, NC. Address correspondence and reprint requests to Dr Lutcavage: 2400 Wayne Memorial Dr, Goldsboro, NC 27534. 0 1991 American geons
Association
0278-2391/91/491
l-0016$3.00/0
of Oral and Maxillofacial
DDS, PHDt
mandibular gland enlargement with focal tenderness. The glands were indurated, but not fixed to the underlying tissues. Prominent calcifications were palpable within the submandibular glands bilaterally. No appreciable salivary flow was elicited from the submandibular ducts. Two small calculi were noted in the left submandibular duct on bimanual palpation. The mandibular occlusal radiograph showed two radiopacities in the distal portion of the left submandibular duct (Fig I). The panoramic radiograph showed prominent bilateral submandibular gland calcifications (Fig 2). A diagnosis of bilateral submandibular sialolithiasis with obstructive sialadenitis, and left submandibular sialodocholithiasis was made. Oral antibiotic therapy consisting of cefadroxil monohydrate (1 g/d) was initiated. in addition to supportive measures consisting of massage of the glands, moist heat, and lemon drops to increase salivary flow. A computed tomography (CT) scan was ordered to better delineate the size and extent of the calcifications. Seven days later, the patient’s condition on physical examination was unchanged, except for a purulent discharge flowing from the left submandibular duct. A CT scan showed multiple calcifications in the right and left submandibular glands (Fig 3) and in the left submandibular duct (Figs 3, 4). The patient subsequently underwent bilateral submandibular sialadenectomies and a left transoral sialodocholithotomy under general anesthesia without complications. The surgical specimens showed prominent intraglandular calcifications and fibrosis. The patient had an uncomplicated postoperative course. Discussion
Sur-
Bilateral submandibular sialolithiasis is a rare finding, considering the paucity of reports found in
LUTCAVAGE
AND SCHABERG
FIGURE 1. Mandibular occlusal radiograph showing two sialoliths in the left distal submandibular duct (arrows).
FIGURE 3. Computed tomography scan showing bilateral submandibular gland calcifications and a single left intraductal sialolith (arrows).
the literature. I-5 Interestingly, Perrotta et al5 reported a case of bilateral parotid and submandibular gland calculi in which an attempt was made during the course of the workup to correlate the head and neck findings with the presence of possible renal and gallbladder calculi. An intravenous pyelogram and oral cholecystogram, however, were negative. Differentiation should be made between intraglandular and intraductal calculi. A variety of diagnostic imaging studies are available to aid in anatomic localization of such stones. These include sialography. conventional radiography, computerized tomography, and magnetic resonance imaging. In this case, conventional radiographic techniques, which included panoramic and mandibular occlusal
radiographs, showed prominent intraglandular calcifications bilaterally in addition to two left anterior intraductal calcifications. These calcifications were also prominently demonstrated on CT scan. Of particular interest in this case was the patient’s long-term use of methyldopa-hydrochlorothiazide therapy to control hypertension. It is known that methyldopa can inhibit salivation through both central and peripheral mechanisms,6 thus setting the stage for a retrograde infection in the salivary glands. Goldberg and Topazian’ note that in their experience, many of their patients have been on diuretic therapy, which can predispose to the development of a retrograde sialadenitis after a decrease in salivation and salivary stasis in the
FIGt_JRE 2. Panoramic radiogr .aph sho wing bilateral subm andit Iular gland calcifications.
MANAGEMENT
OF OROFACIAL VASCULAR
LESIONS
secretions are more alkaline and contain higher concentrations of calcium and phosphates than parotid secretions. These secretions, taken in conjunction with the anatomic location of the submandibular duct, its length, its tortuous course, and its lack of dependent drainage, can create an environment in which salivary stones are more prone to form, especially under conditions of salivary stasis. Thus, conditions are ideal for deposition of calcium salts around foci of desquamated epithelium. References
FIGURE 4. Computed tomography scan showing a second left intraductal sialolith and bilateral submandibular gland calcifications (arrows).
gland. Indeed, a link may be postulated between the chronicity of this patient’s symptoms and her longterm use of combination antihypertensive therapy. Goldberg and Topazian state that submandibular
J Oral Maxillofac
1. Sellari FA: Simultaneous bilateral submandibular sialolithiasis. Ann Laringol Otol Rhino1 Faring01 65:366, 1966 2. Forman G: Bilateral submandibular sialolithiasis. Br Dent J 120:84, 1966 3. Reczyk J, Plewinska H: Bilateral submandibular sialolithiasis. Czas Stomatol 28:1193, 1975 4. Sujaku C, Kameyama T, Kawano K. et al: A case of sialolithiasis in the bilateral submandibular ducts. Nippon Koku Geka Gakkai Zasshi 17:35, 1971 5. Perrotta RJ, Williams JR, Selfe RW: Simultaneous bilateral parotid and submandibular gland calculi. Arch Otolaryngol 104:469, 1978 6. Sweet CS, Gaut SL: Antagonism of conditioned salivation in
Surg
49:1222-1225,1991
A Conservative Approach to the Management of Orofacial Vascular Lesions in Infants and Children: Report of Cases HAROLD BAURMASH,
DDS,* AND SHARON DECHIARA, DDSt
* Clinical Professor of Oral and Maxillofacial Surgery, School of Dental and Oral Surgery, Columbia University, New York. t Senior Resident in Oral and Maxillofacial Surgery, Columbia Presbyterian Medical Center, New York. Address correspondence and reprint requests to Dr Baurmash: Columbia Presbyterian Medical Center, 630 W 168th St, New York, NY 10032. 0 1991 American geons
Association
0278-2391/9114910-0017$3.00/0
of Oral and Maxillofacial
Sur-
Mulliken and Glowacki have categorized vascular birthmarks as hemangiomas or vascular malformations based on their clinical behavior and endothelial cell characteristics.’ The term hemangioma is restricted to the very common vascular lesion of infancy that usually appears 2 to 4 weeks after birth, grows rapidly until the age of 6 to 8 months, and then slowly and predictably involutes by age 5 to 8 years. On a cellular level, hemangiomas are characterized by increased endothelial turnover and in-
