The Journal of Emergency Medicine, Vol. 44, No. 1, pp.

e125e127, 2013
Copyright 2013 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

doi:10.1016/j.jemermed.2012.02.065

Visual Diagnosis
in Emergency Medicine

ACUTE WHARTONS DUCT SIALADENITIS AND SUBMANDIBULAR INFECTION

Joan Medina, MS III, Nicole Corey, BS, and Barry Hahn, MD

Department of Emergency Medicine, Staten Island University Hospital, Staten Island, New York
Reprint Address: Barry Hahn, MD, Department of Emergency Medicine, Staten Island University Hospital,
475 Seaview Avenue, Staten Island, NY 10305

CASE REPORT
A healthy 22-year-old woman presented to the Emer-
gency Department (ED) with progressive pain and swell-
ing under her tongue and left submandibular region for 2
days. Physical examination revealed a slightly deviated
frenulum. Purulent material was expressed from a dilated
and prominent Wharton duct (Figure 1). A firm, circum-
scribed, mobile mass was appreciated in the left subman-
dibular region (Figure 2). Computed tomography (CT)
revealed an opacity along the course of the Wharton
duct (Figure 3) and soft tissue haziness in the left subman-
dibular space (Figure 4).
The patient was treated as an outpatient with oral
hydration, analgesics, compression, and antibiotics. All
acute symptoms resolved within 1 week and the patient
was completely asymptomatic at 1-month follow-up.
DISCUSSION
Sialolithiasis, defined as the presence of calculi in the sal-
ivary glands or ducts, is a common condition. The major-
ity of stones arise from the submandibular glands and
obstruct the submandibular duct, also known as the Whar-
ton duct. Often, these stones remain asymptomatic, but
occasionally cause pain or swelling or progress to acute
sialadenitis, an acute inflammation of a salivary gland (1).
The exact cause of stone formation is not known, but it
is felt to be secondary to the stagnation of saliva that is rich
in calcium, in a setting of partial obstruction. Risk factors
thought to be associated with salivary gland stones include
dehydration, diuretic or anticholinergic medications,
trauma, gout, and smoking history. Individuals may de-
velop salivary duct stones at any age, but the incidence is
higher in debilitated or dehydrated patients. Causes range
from simple infection to autoimmune etiologies. The
Wharton duct may be more prone to stone formation be-
cause it has a long course, the flow of saliva is slow and
gravity dependent, and the saliva is more alkaline (1).
Stones may present as painless swelling or may be
noted incidentally on physical examination or radio-
graphs. When symptomatic, sialolithiasis manifests
with swelling or pain in the involved gland, which
worsens with eating. Acute sialadenitis in the setting of
sialolithiasis presents with pain, swelling, and erythema
in the area of the gland, and with pus draining from the
respective duct. Systemic symptoms, including fevers
and chills, may be present (2).
In patients with a suspected submandibular stone, pal-
pation of the floor of the mouth in a posterior-to-anterior
direction is recommended to find a stone impacted in the
Wharton duct. The ductal opening should be examined
for purulence. Palpation of the gland is important as
well. A functioning gland should be spongy and elastic,
and in this setting may be quite tender.

RECEIVED: 17 January 2012;

ACCEPTED: 22 February 2012

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e126 J. Medina et al.

Figure 1. Purulent material was expressed from a dilated and

prominent Wharton duct (arrow).

Numerous radiologic techniques are available. Imag-

ing studies are reserved for when the diagnosis is unclear
or when symptoms do not improve. CT is currently the
modality of choice. More than 90% of stones larger Figure 3. Computed tomography scan demonstrating an
than 2 mm can also be detected by an experienced ultra- opacity along the course of the Wharton duct (arrow).
sonographer (3).
ued for 7 to 10 days. In cases refractory to antibiotics, vi-
Most individuals can be treated conservatively. Pa-
ral and atypical bacterial or abscess formation should be
tients should be instructed to keep well hydrated, apply
considered. Although less common than bacteria, several
moist heat to the affected area, and massage the gland.
Stones < 2 mm typically pass with the above measures.
Sialogogues, which promote ductal secretions, are often
helpful. If appropriate, patients should discontinue med-
ications with anticholinergic effects that reduce salivary
flow. Pain can generally be controlled with non-
steroidal anti-inflammatory drugs or opioid analgesics.
Patients with acute sialadenitis or abscesses should also
be treated with antibiotics. The most common organism
is Staphylococcus aureus, and therapy should be contin-

Figure 2. Firm, circumscribed, mobile mass in the left sub- Figure 4. Computed tomography demonstrating soft tissue
mandibular region (arrow). haziness in the left submandibular space (arrow).
Whartons Duct Sialadenitis and Submandibular Infection
viruses have been implicated in submandibular sialadeni-
tis. These include the mumps virus, which typically
affects the parotid gland, but can affect the subman-
dibular gland as well. In some cases, surgical interven-
tion is required. Surgical management may become
necessary in cases of recurrence or persistence, and
includes incision and drainage, lithotripsy, or excision
of the gland.
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