OT notes · ENT

Intraoral removal of submandibular duct stone

Usual anaesthesia
Local infiltration for a palpable, fixed stone in the front or middle of the duct; general anaesthesia (nasal intubation) for deep hilar stones or early in a surgeon's experience
Position
Supine, mouth held open with a mouth prop or gag on the opposite side, tongue retracted away from the operated side
Setting
elective

Operative note template for transoral removal of a stone from the submandibular (Wharton's) duct, with a filled example for a palpable stone in the anterior part of the duct removed under local anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding in the floor of the mouth
  • injury to the lingual nerve: numbness or loss of taste on that side of the tongue
  • swelling of the floor of the mouth; rarely admission
  • infection
  • narrowing of the duct and recurrent gland swelling
  • stone slipping back and not found, or more stones left behind
  • ranula (if the sublingual gland is cut)
  • later removal of the gland if symptoms continue

Pre-operative details for this operation

  1. SideRightLeft
  2. Stone positionAnterior thirdMiddle thirdPosterior third / hilumsize in mm on ultrasound or CT; single / multiple
  3. Bimanual palpationpalpable yes/no, mobile / fixed; repeated just before surgery
  4. ImagingUltrasoundOcclusal X-rayCBCT / CTSialendoscopy
  5. Gland infected at presentNoYes: antibiotics
  6. Lingual nerve function before surgerytongue sensation and taste on that side

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationGeneral, nasal intubationdrug, adrenaline strength, volume
  2. Mouth opened withMouth prop on opposite side (Ferguson)Doyen's gagDental props
  3. Tongue retracted bySurgeon's fingerMalleable retractorTraction suture

Operative findings

  1. Stonesize in mm, shape, number, colour
  2. Ductdilated, inflamed; pus or thick saliva after removal
  3. Lingual nerveseen and protected / not seen (anterior stone)
  4. PapillaPreservedOpened

Procedure (steps)

  1. Stone fixed from behindStay suture passed under the duct behind the stone (and in front)Assistant's pressure on the gland from outsidestops the stone slipping back to the gland
  2. Infiltrationlignocaine with adrenaline along the line of incision
  3. Mucosal incisionDirectly over the stoneRetropapillary, 5 mm behind the papilla, medial to the sublingual glandmucosa only; No. 15 blade on a long handle
  4. Duct found and followedlingual nerve looked for behind the first molar where it crosses the duct
  5. Ductotomyslit along the duct over the stone, extended beyond the front edge of the stone; medial or lateral to the nerve
  6. Stone removedHaemostatDental excavatorOtherwhole / fragments
  7. Duct irrigatedsaline; further stones flushed out and picked up so none is left in the mouth
  8. Bleeding controlBipolar cauteryPressure

Closure, drains and dressing

  1. DuctLeft openEdges sutured (6-0 absorbable)
  2. Floor of mouth mucosaClosed with absorbable 4-0Left open
  3. Stay sutures removedYes
  4. Saliva flow from duct at endclear / turbid

Specimens and implants

  1. StoneGiven to patientSent for analysisDiscardedsize recorded
  2. Pus / saliva for cultureSentNot sent

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Mouth carewarm saline or antiseptic mouthwash after meals until healed
  2. Dietcold, soft diet for the first days; avoid sour foods (sialogogues) at first
  3. Fluidsat least 2 litres of water a day
  4. AnalgesiaNSAID or other: drug, dose, frequency
  5. Antibioticsif prescribed (gland infected): drug, dose, duration
  6. Gland massagegently, to express stagnant saliva
  7. Warning signsincreasing swelling of the floor of the mouth, difficulty swallowing or breathing: come back at once
  8. Follow-update; ultrasound if swelling persists

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. M.A., 38 years, left submandibular swelling with meals for 4 months; a hard 7 mm stone is palpable in the anterior third of the left Wharton's duct.

Case details

Date: 07/07/2026. Elective, day case. ENT minor OT.

Start 10:15. End 10:45.

Surgeon: Dr A. (2nd-year resident, ENT). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Nurse: Sr E. Anaesthesia: local, by surgeon.

Indication and pre-op

Left submandibular sialolithiasis. Ultrasound: single 7 mm stone in the anterior third of the left Wharton's duct, duct dilated behind it, gland not infected.

Bimanual palpation just before surgery: stone palpable and fixed at the same place.

Tongue sensation and taste normal on both sides.

Consent: procedure-specific consent in Urdu. Bleeding, lingual nerve numbness, swelling, duct narrowing and later gland removal explained.

WHO checklist time out done: side (left) confirmed. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at 09:55, within 60 minutes before incision (incision through the floor-of-mouth mucosa, a clean-contaminated procedure).

Anaesthesia and position

Supine. Ferguson mouth prop on the right side. Tongue retracted to the right by the assistant with a malleable retractor.

Procedure and findings

Stone palpated. Silk stay sutures passed deep to the duct behind and in front of the stone and held up by the assistant so the stone could not slip back.

Lignocaine with adrenaline 1:200,000, 2 ml, infiltrated under the mucosa over the stone and around the duct.

Mucosa and duct slit over the stone between the stay sutures with a No. 15 blade on a long handle, incision carried just beyond the front edge of the stone.

Yellow-white stone 7 x 5 mm removed whole with a fine haemostat. Thick saliva followed, then clear saliva on pressing the gland.

Duct irrigated with saline: no further stone. Floor of mouth checked, nothing left behind.

Minor bleeding controlled with pressure. Lingual nerve not seen (stone well in front of the first molar).

Closure

Duct left open, not sutured. Stay sutures removed. Clear saliva flow from the opened duct at the end.

End of procedure

Blood loss about 5 ml.

Needle and sharps count correct.

Specimen: stone, 7 x 5 mm, shown to and given to the patient at his request.

No complications. Tongue sensation normal before discharge.

Discharged home at 12:00 in stable condition.

Post-op orders

Warm saline mouthwash after every meal until healed.

Cold, soft diet for the first few days. Avoid sour foods at first. Drink at least 2 litres of water a day.

Analgesia as per prescription.

Gentle massage of the gland to express saliva, as shown before discharge.

Come back at once for swelling under the tongue, difficulty swallowing or breathing.

Review in ENT OPD after 1 week.

Signature

Dr A., JR-2, ENT. Reg. no. ________. 07/07/2026, 11:00.

Must document for this operation

  • Side, size and position of the stone (anterior, middle or hilar third). The position decides the approach and the risk to the lingual nerve, and deep hilar stones may need a different operation.
  • How the stone was stopped from slipping back (stay suture or external pressure). A stone that slips back into the gland is a common reason for failure and a second operation.
  • Whether the lingual nerve was seen and protected. Tongue numbness or loss of taste is the main complication, and the note should show what was seen.
  • Stone removed whole or in pieces, and whether more stones were flushed out. Multiple stones occur in about one in six patients, and a stone left in the floor of the mouth can cause infection.
  • Whether the duct was left open or sutured. The next surgeon needs this if the duct later narrows.
  • Lingual nerve function before and after. A recorded baseline separates a new deficit from an old one.

Common mistakes in these notes

  • Not re-palpating the stone just before starting, so the stone has moved back to the hilum.
  • No record of stay sutures or of what stopped the stone slipping back.
  • Writing 'stone removed' with no size or number.
  • Not recording lingual nerve status before and after.
  • No warning about floor-of-mouth swelling for a day-case patient.

Indian practice and paperwork

  • Consent must be in a language the patient understands and must say who will do the procedure. (NABH 5th ed., PRE.4(c))
  • The operative note must be written before the patient leaves recovery, including for a day-case minor OT procedure, and post-op care must follow a written plan. (NABH 5th ed., COP.14(e) and (f))

Sources

  • Simo R, et al., eds. Atlas of Head and Neck Surgery. Springer Surgery Atlas Series. Springer Nature; 2024, Ch 18, Transoral removal of intracanalicular stones in the submandibular glands (Gottlieb JB, Cascarini L), pp. 181-190.
  • Ballantyne JC, Harrison DFN, eds. Rob & Smith's Operative Surgery: Nose and Throat. 4th ed. Butterworths; 1986, Removal of calculus from the submandibular duct (Shaheen OH), pp. 432-433.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Head and neck: incisions through oral mucosa are clean-contaminated; Table 2 (other clean-contaminated procedures): cefazolin or cefuroxime plus metronidazole, or ampicillin-sulbactam. Table 1: cefazolin 2 g, metronidazole 500 mg, within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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