Medical Minute 6-13: Removing the Stones Growing in Your Mouth

By: Vanessa Welch Email
By: Vanessa Welch Email

For 32-year-old civil engineer Akhil Chauhan, planning and problem-solving for a variety of projects is all in a day's work. But he never knew he had a problem until it showed up on a dental visit.

"He took X-rays of my full mouth and then like he saw this like on the X-ray, he saw this calcified mass thing," said Akhil Chauhan.

It was a stone -- as big as an olive -- deep in Akhil's salivary gland. Standard procedure: Remove the stone and the gland through an incision in his neck.

"I was worried about having a scar like after the surgery."

LSU head and neck surgeon Doctor Rohan Walvekar offered him a much less invasive alternative. He's pioneered a procedure that merges miniaturized endoscopy with surgical robotics to remove even large, deeply-imbedded stones without open surgery.

"When I saw this, when I read about it, I said, 'Let's go for it.'"

"And what we did is use salivary endoscopy to document and identify the location of the stone, and then, we use the robot to do the dissection in the mouth," said Rohan Walvekar, M.D., Head and Neck Surgeon at LSU Health Sciences Ctr.

Doctor Walvekar says three-D imaging, endoscopic magnification and the precision of the robotic arms improves visibility and accuracy.

"My assistants can do a better job because they're seeing what I'm doing, and I get a three-dimensional view."

Now, less than a year after Akhil's salivary stone surgery, there's no visible sign he had surgery at all.

A busy problem-solver, who now has one less problem to worry about.

For more information on other series produced by Ivanhoe Broadcast News contact John Cherry at (407) 691-1500, jcherry@ivanhoe.com.

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MEDICAL BREAKTHROUGHS - RESEARCH SUMMARY:

BACKGROUND: Salivary duct stones are a type of salivary gland disorder. The stones are crystallized minerals in the ducts that drain the salivary glands. The painful stones are caused when chemicals in the saliva crystallize into a stone that can block the salivary ducts. When saliva is unable to exit a blocked duct, it backs up into the gland and causes pain and swelling of the gland. Salivary stones most often affect the back of the mouth on both sides of the jaw, but they can also affect glands on the sides of the face.
(SOURCE: MedlinePlus)

SYMPTOMS: Salivary stones can create extreme pain in the mouth. The symptoms can range from difficulty opening the mouth or swallowing to pain in the face and mouth to dry mouth. Some people will also experience facial or neck swelling. While the stones can cause a large amount of discomfort, they are not dangerous and can be removed with minimal discomfort.
(SOURCE: MedlinePlus)

TREATMENT: If a person experiences repeated stones or infections, the affected salivary gland may have to be surgically removed. Physicians and dentists can use a number of techniques to try and remove the stone. The dentist may be able to push the stone out, or the stone may be surgically cut out. Oftentimes, the stone can be flushed out just by increasing the flow of saliva. Doctors can stimulate the flow of saliva by giving the patient sour candy or citrus and combining it with fluids and a massage.

ABOUT THE DOCTOR: In November 2010, Dr. Rohan Walvekar, from LSU Health Sciences Center, reported the first use of a surgical robot guided by a miniature salivary endoscope to remove a salivary stone. Dr. Walvekar was able to remove a 20 mm salivary stone and repair the salivary duct. This new technique not only saves the salivary gland, but it also reduces blood loss, scarring, and hospital stay time.
Salivary endoscopes allow surgeons to remove the stone while preserving the gland. The endoscopes improve surgical view, exposure, and magnification of the surgical field using a two-dimensional view. The robotic units produce high-definition, three-dimensional images.
(SOURCE: LSU Health Sciences Center)

FOR MORE INFORMATION, PLEASE CONTACT:
Leslie Capo, Media Relations
LSU Health Sciences Center
(504) 568-4806
LCapo@lsuhsc.edu

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THE FOLLOWING IS AN IN-DEPTH INTERVIEW WITH THE DOCTOR FROM THE STORY ABOVE:

Rohan Walvekar, MD, a head and neck surgeon from LSU Health Sciences Ctr., discusses a new technique to remove salivary stones.

Tell me about this patient and his particular problem. What was wrong with this particular patient?

Rohan Walvekar, M.D.: We see a lot of patients who have these particular issues. Mr. Chauhan essentially, came to us with complaints of swelling in the neck. He had this swelling for several years, over ten years. It was essentially asymptomatic, which is not causing any problems, but then it began to cause problems.

What kind of problems?

Rohan Walvekar, M.D.: Causing discomfort, some pain occasionally and that led him to our clinic. Most patients who have salivary stones will have similar symptoms and they can sometimes be much more severe. The pain can be extreme. The patient can have infection of the saliva gland and swelling of the saliva gland. Fortunately for Mr. Chauhan, he basically did not have those severe symptoms, but he did have discomfort in the region of the saliva gland and he had an abnormal swelling of the gland.

How big was the stone that you found?

Rohan Walvekar, M.D.: Salivary stones, typically, are fairly uncommon. They occur in about 1.2% of the general population. However, we are finding many patients who have this problem. They usually tend to be from 83 mm upwards to 5 cm reported in literature. But, generally they are about 6 to 8 mm in size. This particular patient had a stone, which was 2 cm in size and was located in the submandibular gland, which is beneath the jaw.

Two cm is how big? Is it about the size of an olive?

Rohan Walvekar, M.D.: Slightly bigger than an olive.

What is the traditional approach for removing these kinds of stones?

Rohan Walvekar, M.D.: Traditionally, you do a removal of the saliva gland. The saliva gland is removed through an incision in the neck. It’s an open operation. It involves the removal of the entire gland and a section of important structures, vessels as well as nodes in that region. The risks involved usually are risks to the mouth. Lingual and hypoglossal nerves make the tongue move and also gives sensation to the tongue. So, it’s a safe operation when it’s done with someone who has experience doing that kind of surgery but obviously something to be avoided if possible. So, that’s how salivary stone removal is traditionally done.

Now, is there an additional problem once you remove the salivary gland?

Rohan Walvekar, M.D.: Yes. Essentially, what can happen is that it can reduce the amount of saliva that’s produced on that side of the mouth. Usually, it is not a problem but in some cases, especially people who have a dry mouth to begin with. It can cause increased tendencies to have dental cavities, and also feeling a dry sensation in the mouth which can be very uncomfortable.

So, the new approach is sort of two parts. You started doing the endoscopic thing. How have you taken that a step further?

Rohan Walvekar, M.D.: We do salivary endoscopy, which is the cutting edge of what we are doing in otolaryngology, using miniature endoscopes to remove these stones. We found that by preserving the salivary gland and removing the stones endoscopically we are able to maintain the function of the gland and make patients asymptomatic. However, there are certain limitations to this procedure. These miniature endoscopes, which are about 1 to 1.6 mm in size, have the capability of removing stones, which are about 5 or 6 mm in diameter. Stones which are slightly larger, can sometimes be broken up with a laser and removed in pieces. However, stones which are larger than that about 9 mm to 1 cm and above, are extremely difficult to remove endoscopically, using any form of technique. So, in these situations you have to make an incision in the back of the mouth to be able to release these stones from the saliva glands and take them out.

What is the new approach that you have just started to do? And, how does it improve on the old way?

Rohan Walvekar, M.D.: Traditionally, for large stones, one would do a transoral incision. A transoral incision is making a small cut in the mouth, delivering the stone and then either leaving the saliva duct open or repairing it. This is easy to do when the stones are placed very close to the tongue. But when stones are placed right back inside the gland, what we call hillier stones or glandular stones, they are very hard to access. In this situation, you can imagine, if I put a light on my head, just like a dentist would, and tried to do a delicate operation through the mouth having the need for assistants to also help me, it can be challenging. And so we tried to merge two technologies together. So, we are doing salivary endoscopy and we are also doing robotic surgery, which is traditionally used for tumors of the tongue, tonsils and also for thyroid surgery. But we use the robotic technology and salivary endoscopy and merge it together. And what we did is use salivary endoscopy to document and to identify the location of the stone. And then we used the robot to do the dissection in the mouth. This allows us to get to the postural part of the oral cavity and do a dissection with the robot under magnification and with dexterity.

It makes it much easier?

Rohan Walvekar, M.D.: I believe it does. It makes it much easier and also makes it more refined. It’s not that this cannot be done without the robot, but it makes it a more sophisticated operation, makes it more predictable. Everybody on the team can see exactly what I am doing. My assistants can do a better job because they are seeing what I am doing. And I need a three dimensional view of the postural part of the oral cavity and create magnification to be able to dissect out the lingual lobe, which is at risk in this procedure, and to define the salivary gland, salivary duct and make the incision to deliver the stone. More importantly, the robot has angulated instruments, which are just like using my hands at the back of the mouth. And this allows me to even make stitches in a much more controlled fashion to be able to repair the saliva duct.

What is the recovery time for the patients after this kind of procedure?

Rohan Walvekar, M.D.: Well, it does involve an incision in the mouth. So, it really depends on the patient. Some patients will bounce back very quick after surgery and will be up and doing regular activities in a couple of days and some patients may take a few weeks to recover from that incision. It can be a source of discomfort for a couple of weeks, but usually people do well. The surgery itself is same day surgery. I send all my patients home the same day. And they are also able to eat food as you would in a regular fashion with some restrictions that you would eat obviously, from the side opposite to that on which you had surgery.


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