Case Report Rapport de cas

Abnormal changes in both mandibular salivary glands in a dog:

Non-mineral radiopaque sialoliths
Hyun-Jung Suh, Dai Jung Chung, A-Jin Lee, Hyo-Jin Chung, Dae-Hyun Kim, Ki-Dong Eom,
Sun Hee Do, Hwi-Yool Kim

Abstract — A 10-year-old Maltese dog was presented with a firm mass on the left side of his neck. Physical
examination confirmed a firm mass in the left and a submandibular swelling in the right cervical region.
Sialolithiasis and associated sialocele in both mandibular salivary glands were suspected and bilateral
sialoadenectomy was performed. The stones were identified as non-mineral sialoliths.

Résumé — Changements anormaux dans les deux glandes salivaires mandibulaires chez un chien : sialolithes
radiopaques non minéraux. Un chien Maltais âgé de 10 ans a été présenté avec une masse ferme du côté droit
du cou. L’examen physique a confirmé une masse ferme dans l’enflure gauche et sous-mandibulaire dans la région
cervicale droite. La sialolithiase et une sialocèle connexe dans les deux glandes salivaires mandibulaires ont été
suspectées et une sialoadénectomie bilatérale a été réalisée. Les pierres ont été identifiées comme des sialolithes
non minéraux.
(Traduit par Isabelle Vallières)
Can Vet J 2015;56:1025–1028

S ialolithiasis, the formation of calculi in the salivary system,

is a rare condition in dogs (1,2). Clinical signs include
painful or non-painful subcutaneous swelling surrounding
affected glands following obstruction of ducts by sialoliths
(1,3). Sialoliths in dogs usually occur unilaterally in the parotid
salivary duct (3–8) and are mainly composed of minerals such
as calcium carbonate and calcium phosphate (1,9). Sialoliths
that are mainly composed of organic components have not been
reported. Surgical removal is generally effective in the treatment
of sialolithiasis, and recurrence or serious complications are
rarely reported (3).
This report describes a case showing abnormal changes of
Figure 1. Plain radiograph. Left lateral view (a). Multiple
both mandibular salivary glands that were different from the radiopaque spots on the ventrocaudal aspect of the mandibular
typical cases of sialocele or sialolithiasis in dogs. In addition, we region were identified. Ventrodorsal view (b). The spots visible
analyzed the major component of the sialoliths and monitored on the lateral view are evident on both sides. On the left, they
are concentrated in the caudal mandibular regions. On the right,
the prognosis of the patient after surgical removal. they are spread throughout the caudal mandibular region and the
caudal aspects of the spots were partially superimposed on the
right atlas wing region.

Department of Veterinary Surgery (Suh, DJ Chung, Lee,

H-J Chung, H-Y Kim), Department of Veterinary Radiology
and Diagnostic Imaging (Eom), Department of Veterinary
Clinical Pathology (Do), Department of Veterinary Surgery,
College of Veterinary Medicine, Konkuk University, Seoul,
Republic of Korea (D-H Kim).
Address all correspondence to Dr. Dae-Hyun Kim; e-mail:
hykim@konkuk.ac.kr
Use of this article is limited to a single copy for personal study.
Anyone interested in obtaining reprints should contact the
CVMA office (hbroughton@cvma-acmv.org) for additional
copies or permission to use this material elsewhere.
Case description
A 10-year-old, castrated male Maltese dog was referred to the
Konkuk Veterinary Medical Teaching Hospital, Seoul, South
Korea, for evaluation of a mass on the left side of his neck. The
mass was first noticed by the owner 3 wk earlier and the size of
the mass had not changed remarkably over this period. There
was no history of trauma and the demeanor of the dog was
unaffected by the presence of the mass.
On physical examination, the dog was bright and alert. The
mass was firm, freely mobile, non-painful, measured 4 3 2 cm,
and palpable in the left cervical region. In addition, a soft,

CVJ / VOL 56 / OCTOBER 2015 1025

R A P P O R T D E CA S

Figure 2. Ultrasonograph. Sonogram of the left cervical region (a). A hyperechoic line (red dotted line) with
acoustic shadowing and normal left mandibular lymph node (asterisk) were identified. Sonogram of the right
cervical region (b). Hyperechoic foci (green dotted circular line) within an anechoic region (yellow dotted line) were
thought to represent the mucocele and sialoliths of the mandibular salivary gland. The right mandibular lymph node
(asterisk) was considered normal.

f­luctuant, non-painful submandibular swelling was also pal-

pated in the right cervical region. No other abnormalities were
observed upon physical examination and routine hematologic
or serum biochemistry analyses.
On lateral view of plain radiographs, multiple radiopaque
spots were identified on the ventrocaudal aspect of the man-
dibular region. On ventrodorsal view, these spots were present
on both sides on the caudal aspect of the mandibular region
(Figure 1). On ultrasonography, hyperechoic lines with acoustic
shadowing were evident in the left cervical region (Figure 2a).
The right region included an anechoic region with hyperechoic
spots (Figure 2b). The mandibular lymph nodes on both sides
were normal in size and echogenicity. A tentative diagnosis
of bilateral mandibular sialolithiasis and associated sialocele
formation was made and bilateral mandibular sialoadenectomy
was performed.
The dog was premedicated with buprenorphine (Renolphan;
Hanlim Pharmacy, Seoul, Korea), 10 mg/kg body weight (BW),
and midazolam (Vascam; Hana Pharmacy, Seoul, Korea),
0.3 mg/kg BW, and then anesthetized with propofol (Anepol; Figure 3. Photographs of the left mandibular gland (a,b).
Hana Pharmacy), 6 mg/kg BW and 2% isoflurane (Ifran; Hana The gland was full of numerous sialoliths and no normal glandular
Pharmacy). The patient was positioned in lateral recumbency. tissue remained. Photographs of the right mandibular
gland (c,d). Mucocele formation, including sialoliths, was noted.
An incision was made through the skin, subcutaneous tissue,
and platysma muscle over the region of the mandibular glands
on both sides in order to visualize the glands. A firm, single
mass filled with multiple sialoliths was present on the left side the mass was removed with the capsule after duct ligation. On
and no glandular tissue remained. The capsule was difficult to the right side, a soft, fluctuant, sizable cystic mass was visible
dissect as it was adhering tightly to the firm mass. Therefore, on the right gland. The right gland was discolored (appearing

1026 CVJ / VOL 56 / OCTOBER 2015


Figure 4. Photomicrograph of the right mandibular salivary gland tissue (a). The salivary gland exhibited an almost normal
structure, and hemorrhage and a few inflammatory cells were detected. Staining: Hematoxylin & eosin (H&E). Magnification: 1003.
Bar = 140 mm. Photomicrograph of the sialocele (b). One large acidophilic homogenous material (*) was found, and infiltrations
of inflammatory cells and fibrosis were seen on the right side. Numerous proteinaceous materials of various sizes were also identified.
Staining: H&E. Magnification: 1003. Bar = 140 mm.
brick red), hemorrhagic in cross-section, and showed numerous
small white structures within the cystic mass (Figure 3). As the
mass was relatively large and adhered to the gland, the mass and
affected gland were carefully freed and removed together from
the surrounding soft tissue and vessels without dissecting the
capsule from the gland. The rostral portions of the sublingual
glands were not removed on either side. The superficial muscles
were reapposed with simple continuous absorbable sutures. The
subcutaneous tissue and skin were closed routinely. Postoperative
pain was managed with buprenorphine (Renolphan; Hanlim
pharmacy), 10 mg/kg body weight (BW), IM, after surgery and
q8h for 3 d. The dog was discharged on amoxicillin/clavulanate
(Clavamox; Pfizer, New York, New York, USA), 12.5 mg/kg
BW and celecoxib (Celebrex; Pfizer), 2 mg/kg BW, both PO,
q12h for 3 wk.
After surgery, complete removal of the sialoliths was con-
firmed with radiographic examinations. Both masses were sub-
mitted to the Minnesota Urolith Center (Saint Paul, Minnesota,
USA) for stone analysis. A quantitative analysis was done to
identify the major component of the stones. Both stones were
composed of 100% proteinaceous materials; no inorganic crys-
talline material was observed. In histopathological examinations,
the right salivary gland showed that the changes were consistent
with salivary gland mucocele and included eosinophilic homog-
enous sialolith material (Figure 4).
After surgery, the dog was able to move its tongue normally,
but when the dog was resting, the tongue protruded noticeably
to the left. There was no evidence of dysphagia. The severity
of the tongue protrusion was gradually reduced and 15 d after
the surgery, the tongue returned to its normal position. Two
years after the surgery, no recurrence of clinical signs had been
reported and the dog was clinically well.
Discussion
In dogs, the most common disease of the salivary glands is sali-
vary mucocele, while sialolithiasis is a rare condition (2). The
CVJ / VOL 56 / OCTOBER 2015
CA S E R E P O R T
etiologies of sialolithiasis remain unclear; previous reports have
suggested that mucous plugs, inflammatory debris, bacteria, and
foreign bodies act as nidi for the formation of sialoliths (3). To
the authors’ knowledge, only 9 cases of canine sialolithiasis have
been reported in veterinary medicine. Eight cases were reported
to have occurred in 1 side of the parotid duct (3–8,10,11); of
these, 2 cases occurred as a complication of parotid duct trans-
position (10,11). In the remaining case, sialolithiasis was present
in the sublingual gland on both sides (2). Based on previously
reported veterinary cases (2–8,10,11), the bilateral development
of sialoliths in the mandibular salivary glands is a rare condition.
A diagnosis of sialolithiasis can be made by palpation, radi-
ography, ultrasonography, or sialography (1). More recently,
computed tomography (CT) scans have provided more specific
and detailed information (3). Most previous cases were easily
diagnosed as sialolithiasis by radiography as sialoliths appeared
as focal opacities (2–6,8). On analysis, the stones were con-
firmed to be several different types of inorganic sialoliths, such
as calcium carbonate. This case also demonstrated some typical
features of sialolithiasis — stones appeared as radiopaque spots
on radiography and acoustic shadowing on ultrasonography,
leading to the tentative diagnosis of sialolithiasis, and both
lesions were subsequently surgically removed. However, con-
trary to expectations, the lesions contained 100% proteinaceous
material and did not contain any inorganic components. As
the stones were highly condensed, this could account for their
opaque appearance despite lacking typical radiopaque compo-
nents such as minerals.
Sialoliths are formed by varying ratios of organic and inor-
ganic matter (12). The organic matter includes glycoproteins,
mucopolysaccharides, and cellular debris, while the inorganic
matter includes mainly calcium carbonate and calcium phos-
phate (12). In previous veterinary reports, all analyzed stones
were inorganic sialoliths such as calcium carbonate (3,10,11),
calcium phosphate (3), magnesium carbonate (7), and mag-
nesium ammonium phosphate (5), but organic sialoliths have
1027
 not been reported. In a study of human sialoliths, out of the
21 sialoliths that were analyzed, 18 consisted of hydroxyapatite
and organic matter and 3 consisted solely of organic matter (9).
Owing to the recurrence of sialolithiasis, surgery is often
superior to medical treatment. In previously reported cases,
medical treatments were selected as the first choice in 6 of
R A P P O R T D E CA S
9 cases (3–7,11). Of these 6 cases, medical treatment was cura-
tive in only 1 (4). In the remaining 5 cases, treatment was either
not effective (7) or effective for only a short time before disease
recurred (3,5–6,11). After recurrence, surgery was performed
and resolved the problem without further recurrences. Several
surgical approaches have been used in previous cases, includ-
ing salivary gland resection (2–3,5,7), anastomosis of ruptured
parotid duct (6), incision of duct for stone removal and closure
(10,11) or healing by second intention (8).
Complications after sialoadenectomy in dogs are uncommon;
however, possible complications include general postoperative
problems, such as seroma, infections, and recurrence (13).
The patient in the current study had protrusion of the tongue
to the left. This was a sign of right hypoglossal nerve palsy. It
is thought that direct compressive damage to the hypoglossal
nerve during blunt dissection of the mucocele from the adjacent
tissue during right sialoadenectomy was possible. Nerve injury
has not been reported in veterinary medicine as a complication
of salivary gland resection. However, in humans, damage to the
marginal mandibular, lingual, and hypoglossal nerves has been
observed after transcervical sialoadenectomy (14). The most
commonly damaged nerve is the marginal branch of the facial
nerve, which has been reported to be injured in 1% to 36%
of cases (15,16). Damage to the lingual (0% to 22.5%) and
hypoglossal (0% to 7%) nerves has been reported less frequently
(15). Almost all neurological complications were transient and
patients who exhibited neurologic deficits made a complete
recovery several months after surgery (17,18). In our case,
protrusion of the tongue resolved completely 15 d after surgery.
We describe a case of abnormal changes accompanied by
numerous proteinaceous sialoliths of both mandibular salivary
glands in a dog. This case is uncommon and was dissimilar to
other typical sialocele or sialolithiasis cases. Bilateral mandibular
1028
sialoadenectomy was successful and there was no recurrence 2 y
following surgery.
Acknowledgments
The preparation of this paper was supported by Konkuk
University in 2014. CVJ
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