Case Presentation
We present an interesting case of a 33-year-old male patient who had a persistent and problematic condition affecting the left submandibular area. He had growing swelling in the area for three years, with occasional discharge of purulent material from the bottom of his mouth. Interestingly, the patient stated that the discomfort was getting worse over time and that the mass getting larger in size while eating. Mass was bimanually palpable with hard gritty felling on the floor of mouth on same side. Ultrasound showed an enlarged gland with no calculi in gland itself.
Therefore, it was planned to move forward with submandibular duct exploration in order to find and remove any blocking calculus due to the symptoms’ prolonged length and disturbing nature. However, the situation turned out to be complicated since the patient’s medical history revealed that he had previously worked as a driver in Qatar, where he had a long-standing habit of eating betel nuts that lasted for ten years. This behavior led to submucosal fibrosis and a limited opening of mouth. He only had two fingers mouth opening which made the intubation process prior the surgery, exceedingly difficult. (Figure 1) . Fortunately, effective intubation was accomplished with the use of video laryngoscopy, overcoming the challenge provided by the small oral aperture. Intraoral approach was carried out where a noticeable white structure that was compatible with a submandibular stone was discovered. After which incision was made along the duct and carefully removed using Babcock forceps (Figure 2) , which was distinctive in its own right since such a massive stone (Figure 3).
Notably, the stone was removed with just marsupialization of Wharton’s duct preserving the submandibular gland’s anatomical integrity. Marsupialization only done without use of cautery or suture to avoid stenosis or stricture along the duct that can lead to recurrence. Patient was discharged on next day morning. He was instructed to schedule follow-up sessions to assess his progress and make sure there were no problems. It was also highly suggested that he stop eating betel nuts because doing so might considerably worsen the problem.