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HeadNeckPA

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44 yr-old white female who presents with a one week history of intermittent right jaw pain and swelling. Otherwise healthy with no medical problems and takes no meds. NKDA

 

Anything else you want to know?

 

What is the probe pointing to?

 

Presumed Diagnosis?

 

Treatment?

 

DSC_1163.jpg

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It is a little blurry on my computer but it looks like it is pointing to the sublingual caruncle and orifice of the submandibular duct. So, possible sialolith at the duct meatus? Does the pain occur with the typical triggers, eating sour things? However, the image appears errythemic which I've never seen with a duct stone.

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It is a little blurry on my computer but it looks like it is pointing to the sublingual caruncle and orifice of the submandibular duct. So, possible sialolith at the duct meatus? Does the pain occur with the typical triggers, eating sour things? However, the image appears errythemic which I've never seen with a duct stone.

 

That's what I was thinking...while we usually don't see erythema with a stone, is it possible it's infected, or red due to patient manipulation/rubbing?

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It is a little blurry on my computer but it looks like it is pointing to the sublingual caruncle and orifice of the submandibular duct. So, possible sialolith at the duct meatus? Does the pain occur with the typical triggers, eating sour things? However, the image appears errythemic which I've never seen with a duct stone.

 

You are correct.......the probe is in the patient's right submandibular duct. If you look close, you can actually see the small stone just under the surface (whitish-yellow) and about 3 mm to the left of the probe tip in the picture.

 

This is a classic case of sialolithiasis. Intermittent swelling of the jaw (neck is probably a better description) that is usually associated with eating (very important question to ask).......

 

Treatment is removal of the stone if accessible. We use increasing diameter lacrimal probes to enter the duct orifice. If resistance is met the SOP is to use local anesthesia and incise the duct. Frequently a small incision is all that it takes to extrude the stone and release a heavy flow of saliva, owing to the narrowing of the duct as it enters the oral cavity (think sphincter). If the saliva runs clear then no antibiotics are required. If the stone can not be located and removed then anti-staph meds are indicated. I use dicloxicillin in patient's without a PCN sensitivity....it's very cheap and works well. The downside is it is QID, as compared to say cephalexin which is TID.

 

Treatment of any infection or the inability to locate a stone should also include warm compresses and massage of the affected land at a minimum of 3x per day. Some also recommend sour candies such as lemonheads to stimulate saliva production...

 

Below is the stone immediately after incising the duct and massaging the gland.

 

DSC_1167.jpg

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Your 44 year old female looks like she has quite a bit of facial stubble...

 

Yea, well you should see what part of the world I practice in....this is nothin!

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I have my own occluded wharton's duct. My submandibular glands and big and tender. I'm going to the end soon as I waited to see if it would absolve on it's on.. no luck though.. here's a pic for learning purposes!

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I have my own occluded wharton's duct. My submandibular glands and big and tender. I'm going to the end soon as I waited to see if it would absolve on it's on.. no luck though.. here's a pic for learning purposes!

And ps, it's the lighting! I have really white teeth, believe it or not!

aefc031b-d55b-8098.jpg

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