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.