Sir, having read the paper by Kraajj et al. on salivary stones1 we recently saw a rather large sialolith. Further reading revealed that it was in fact a megalith which are defined as a sialolith which exceeds 15 mm in any one of its dimensions2,3 and are most commonly found in the Wharton's duct. These stones have usually been present as a partial obstruction for prolonged periods of time and in the absence of infection can lead to atrophy, reduced secretory function and fibrosis of the gland.4

Our patient was in her sixties and was referred by her GDP regarding an acute swelling affecting her right floor of mouth and right submandibular region. She complained of intermittent swelling which was exacerbated by eating. A recent course of penicillin had provided little relief and she now described an acidic taste in her mouth.

Clinical examination revealed tenderness of the right submandibular gland. Intraorally there was a large firm palpable swelling in the right floor of the mouth with distended overlying mucosa and a purulent discharge. A lower occlusal radiograph revealed the megalith, in the right floor of the mouth (Fig 1), which we removed under local anaesthesia. It was largely extra-luminal and measured 17.6 × 12.4 mm (Fig 2).

Figure 1
figure 1

Megalith on the floor of the mouth

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Figure 2
figure 2

The megalith measured 17.6 × 12.4 mm

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Megaliths are likely to have been present for many years in order to reach their size and they tend to continue to grow unhindered and undiscovered until infection intervenes. Early intervention reduces the chance of long term irreversible structural and functional changes to the submandibular gland.4 We therefore feel that it is important to palpate the submandibular ducts as part of the routine oral soft tissue examination in primary care as many of these sialoliths could be detected before they give rise to symptoms.