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



(1) diameter of the stone

(2) location of the stone


Diameter of the Stone



<= 9 mm


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


removal with advancement dochoplasty

> 9 mm

mid or proximal duct

endoscopic-open OR intra-oral with stent OR intra-oral with FOM flap



• 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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