Fritsch reported an algorithm for managing a patient with a stone associated with the submandibular gland or its duct when extracorporeal lithotripsy is not available. The author is from Indiana University Medical Center in Indianapolis.
Situation: extracorporeal lithotripsy not available
Factors affecting stone removal:
(1) size of the stone
(2) changes in duct wall secondary to acute and chronic inflammation
(3) deposits on the outside of the stone causing adherence to the duct wall
Parameters:
(1) diameter of the stone
(2) location of the stone
Diameter of the Stone
Location
Intervention
<= 9 mm
NA
visualize with endoscopy or C-arm fluoroscopy; consider removal by laser or instrumentation or intra-oral approach; damaged duct may require repair and stenting; FOM flap may be needed if no duct found
> 9 mm
distal
removal with advancement dochoplasty
> 9 mm
mid or proximal duct
endoscopic-open OR intra-oral with stent OR intra-oral with FOM flap
where:
• Stent placement is needed after removal of a large stone to reduce the chance of duct stenosis during the healing.
• FOM = floor of mouth
• A FOM flap is sewn into the wall of the defect to create a mucosa-lined fistula to the floor of the mouth.
• Endoscopic-Open: endoscopic surgery using a cutaneous approach to the submandibular gland with dissection down to the stone.
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