Auris Nasus Larynx 41 (2014) 528–531

Contents lists available at ScienceDirect

Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl

Minimally invasive surgery of sialolithiasis using sialendoscopy Takeshi Matsunobu *, Takaomi Kurioka, Yoshihiro Miyagawa, Koji Araki, Atsushi Tamura, Katsuki Niwa, Masayuki Tomifuji, Taku Yamashita, Akihiro Shiotani Department of Otolaryngology – Head and Neck Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan

A R T I C L E I N F O

A B S T R A C T

Article history: Received 3 February 2014 Accepted 2 May 2014 Available online 23 June 2014

Objective: The introduction of minimally invasive surgical procedures using sialendoscopy has significantly reduced the rate of major salivary gland removal due to sialolithiasis. The present study assessed the utility of sialendoscopy and identified potential factors influencing successful sialendoscopic salivary stone retrieval. Methods: Medical records of sialendoscopic procedures performed at the Department of Otolaryngology of the National Defense Medical College in Japan from November 2007 to January 2014 were retrospectively reviewed. We identified 78 patients diagnosed with sialolithiasis and treated with sialendoscopy (SE). Factors analyzed included stone location, size, symptom duration, surgical methods, and complications. Results: The mean age at presentation was 41 years (range, 11–76 years) with a male-to-female gender ratio of 1:1.89. In total, 73 submandibular and 5 parotid endoscopies were performed. Stone size ranged from 2 to 20 mm in diameter. Submandibular stones were removed either by SE alone (9.6%), by transoral stone removal (19.2%), or a combined approach (57.5%). Only 13.7% (10/73) of the cases required submandibular gland removal. Stone size and shape were significant predictors for successful endoscopic stone removal, and stone size and location were significant predictors for submandibular gland removal. Conclusion: Sialendoscopy is a reasonable, minimally invasive treatment option for sialolithiasis that avoids salivary gland removal. The present results indicate that sialendoscopy is the first treatment of choice for submandibular gland sialolithiasis. Complete surgical excision is becoming uncommon as a first-line treatment, but it remains indispensable in certain cases. ß 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords: Sialendoscopy Salivary gland Sialolithiasis Transoral stone removal Gland preservation

1. Introduction Sialolithiasis is the most common cause of large salivary gland inflammatory disease and occurs in approximately 1.2% of the population, primarily in the submandibular gland (87%) [1,2]. Single or multiple stones of various shapes and sizes can occur. Chronic sialadenitis is one of the major disorders causing salivary hypofunction; therefore, correct diagnosis and management are essential for recovery. Traditionally, sialolithiasis is treated medically with antibiotics and anti-inflammatory drugs or surgically with salivary gland removal. Sialodochotomy is associated with the risk of postoperative duct and papilla stenosis as well as lingual or facial nerve injury.

* Corresponding author. Tel.: +81 4 2995 1686; fax: +81 4 2996 5212. E-mail address: [email protected] (T. Matsunobu). http://dx.doi.org/10.1016/j.anl.2014.05.009 0385-8146/ß 2014 Elsevier Ireland Ltd. All rights reserved.

Sialendoscopy is an innovative method to diagnose and treat salivary duct diseases. Since its introduction into clinical practice in the late 1990s, diagnostic and therapeutic sialolithiasis management has fundamentally changed. This procedure enables safe ductal stone extraction while avoiding the need for salivary gland excision. As a result, risks associated with traditional submandibular and parotid gland surgery are eliminated. However, sialendoscopy has several limitations. Endoscopic removal of a sialolith using a wire basket is typically limited to submandibular gland stones less than 4 mm and parotid gland stones less than 3 mm in diameter [3]. Large stone removal requires either prior fragmentation using alternative techniques such as lithotripsy, or a combined technique incorporating endoscopy. The present study assesses the utility of sialendoscopy and identifies potential factors influencing successful salivary stone retrieval using interventional sialendoscopy.

T. Matsunobu et al. / Auris Nasus Larynx 41 (2014) 528–531

2. Materials and methods We retrospectively reviewed the medical records of 78 patients receiving sialendoscopy at the Department of Otolaryngology of the National Defense Medical College in Japan from November 2007 to January 2014. Demographic and clinical data collected included information on age and gender; physical examination, CT, and intraoperative findings; and data pertaining to anesthetic protocol and complications. The procedures were performed using Marchal sialendoscopes (Karl Storz, Tuttlingen, Germany), which included a 1.3-mm diagnostic endoscope and a 1.7-mm endoscope with a working channel. The endoscope was introduced into the ductal lumen by first dilating the papilla with salivary dilators and a conical probe (Karl Storz, Tuttlingen, Germany). If this technique was unsuccessful, then a small papillotomy incision was made. Stones were removed using a wire basket or grasping forceps introduced through the working channel. The duct was continually irrigated using 10 ml of isotonic saline to maintain duct dilation and adequate visibility. If stones were irretrievable using a wire basket or grasping forceps, then intraoperative lithotripsy was performed using a holmium yttrium–aluminum–garnet (Ho:YAG) laser carried by a semiflexible fiber. The Ho:YAG laser was set at 2.5– 3.5 W of power, at 5 Hz/s rate, and 0.5–0.7 J of energy. We obtained preoperative consent for a combined approach in all cases. In the combined approach, the stone was visualized and located endoscopically, then removed using a standard intraoral surgical approach. If this treatment failed or the stone primarily localized to the gland parenchyma, then the entire salivary gland was removed. All data were analyzed statistically using JMP 10.0.0 (SAS Institute Japan Inc., Tokyo, Japan). Logistic regression analyses (Pearson’s chi-square test) identified the factors independently associated with surgical approach. A p value was considered significant if p < 0.05. 3. Results 3.1. Patients’ clinical characteristics In total, 78 patients were treated and they comprised 27 men and 51 women aged 11–76 years (mean, 41 years), as summarized in Table 1. The submandibular gland (n = 73) was most frequently affected, followed by the parotid gland (n = 5). The stone size ranged from 2.0 to 20.0 mm, with a mean size of 8.3 and 5.0 mm for submandibular and parotid stones, respectively. The mean symptom duration preoperatively was 16.3 months. Multiple stones were identified in 14 patients with affected submandibular

529

Table 1 Demographic and clinical characteristics of the patients.

Gender, no. (%) Male Female Mean age, years (min–max) Stone size, mm (min–max) Mean symptom duration, month (min–max) Stone shape Round-oval Irregular edge Location Distal duct Hilus Parenchyma Anesthesia General Local

Submandibular gland patients

Parotid gland patients

All patients

n = 73 (93.6%)

n = 5 (6.4%)

n = 78 (100%)

25 (34.2%) 48 (65.8%) 40.3 (11–76)

2 (40.0%) 3 (60.0%) 53.6 (41–64)

27 (34.6%) 51 (65.4%) 41.1 (11–76)

8.3 (2.0–20.0) 16.3 (1–300)

5.0 (3.0–10.0) 16.2 (4–36)

8.1 (2.0–20.0) 16.3 (1–300)

34 (46.6%) 39 (53.4%)

3 (60.0%) 2 (40.0%)

37 (47.4%) 41 (52.6%)

21 (28.8%) 45 (61.6%) 7 (9.6%)

4 (80.0%) – 1 (20.0%)

25 (32.1%) 45 (57.7%) 8 (10.2%)

64 (87.7%) 9 (12.3%)

5 (100%) 0 (0%)

69 (88.5%) 9 (11.5%)

glands. In addition, most submandibular gland stones were located at the hilus (61.6%; 45/72) and distal duct (28.8%; 21/72). 3.2. Surgical methods During the study period, we surgically treated 78 patients (Fig. 1), with 5 patients diagnosed with parotid sialolithiasis. Parotid stones were removed by sialendoscopy alone (60%; 3/5), a combination of sialendoscopy and transoral stone removal (20%; 1/5), or parotidectomy (20%; 1/5). The stone removed by parotidectomy was localized to the glandular parenchyma. In total, 73 of the 78 patients were diagnosed with submandibular sialolithiasis. Submandibular stones were removed by sialendoscopy alone (9.6%; 7/73), transoral stone removal (19.2%; 14/73), combined sialendoscopy and transoral stone removal (47.9%; 35/73), sialendoscopy and lithotripsy (9.6%; 7/73), or submandibular gland removal (13.7%; 10/73) (Table 2). The vast majority of cases required a combined approach. Sialendoscopy alone was successful for regularly shaped stones (round-oval), small stones with a 4.3-mm mean diameter, and stones located in the hilus (85.7%; 6/7). The largest stone removed sialendosopically was 5 mm in diameter. Transoral stone removal or a combined approach addressed the removal of large stones (mean diameter, 10.3 or 9.0 mm). The mean symptom duration

Fig. 1. Flowchart of the patients treated for sialolithiasis. SE, sialendoscopy; TSR, transoral stone removal.

T. Matsunobu et al. / Auris Nasus Larynx 41 (2014) 528–531

530 Table 2 Results of the treatment of submandibular stones.

Gender, no. (%) Male Female Mean age, years (min–max) Stone size, mm (min–max) Mean symptom duration, month (min–max) Stone shape Round-oval Irregular edge Location Distal duct Hilus Parenchyma Mean operation time, min (min–max)

SE alone

TSR

Combined approach

Submandibular gland removal

All patients

n = 7 (9.6%)

n = 14 (19.2%)

n = 42 (57.5%)

n = 10 (13.7%)

n = 73 (100%)

2 (28.6%) 5 (71.4%) 38.6 (11–61) 4.3 (3–5) 6.7 (1–24)

6 (42.9%) 8 (57.1%) 42.8 (20–75) 10.3 (3–18) 6.5 (1–15)

11 (26.2%) 31 (73.8%) 40.5 (14–76) 9.0 (2–17) 21.2 (1–300)

6 (85.7%) 1 (14.3%)

6 (42.9%) 8 (57.1%)

1 (14.3%) 6 (85.7%) 0 (0%) 70.3 (39–132)

8 (57.1%) 6 (42.9%) 0 (0%) 48.8 (11–98)

18 (42.9%) 24 (57.1%) 12 (28.6%) 27 (64.3%) 3 (7.1%) 98.4 (21–213)

6 (60.0%) 4 (40.0%) 37.1 (11–74) 5.6 (3–10) 16.3 (2–25) 4 (40.0%) 6 (60.0%) 0 (0%) 6 (60.0%) 4 (40.0%) 189.5 (136–242)

25 (34.2%) 48 (65.8%) 40.3 (11–76) 8.3 (2.0–20.0) 16.3 (1–300) 34 (46.6%) 39 (53.4%) 21 (28.8%) 45 (61.6%) 7 (9.6%) 96.2 (11–242)

Abbreviations: SE, sialendoscopy; TSR, transoral stone removal.

Table 3 Logistic regression analysis on the removability of stone by sialendoscopy alone. Variable

Gender Mean age Stone size Symptom duration Stone shape Length from the papilla *

Univariate analysis

Multivariate analysis

p value

p value

Odds ratio

Confidence interval

0.0110*

1.6289

1.0980–2.9272

0.2289

3.5909

0.4831–74.7985

0.7393 0.9064 0.0221* 0.2756 0.0290* 0.6828

p < 0.05.

Table 4 Logistic regression analysis on the necessity of submandibular gland removal. Variable

Gender Mean age Stone size Symptom duration Stone shape Length from the papilla *

Univariate analysis

Multivariate analysis

p value

p value

Odds ratio

Confidence interval

0.0222*

1.3251

1.0355–1.8703

0.0026*

1.0928

1.0256–1.2122

0.0647 0.6852 0.0420* 0.9968 0.6536 0.0246*

p < 0.05.

preoperatively was longer in the combined approach group (21.2 months) than in the other groups. The mean time duration for all submandibular procedures was 96.2 min. The mean operation time is increased in the order of TSR, SE, combined approach, and submandibular gland removal. We performed logistic regression analysis with sialendoscopy alone to accommodate covariates, shown in Table 3. On univariate analysis, stone size (p = 0.0221) and stone shape (p = 0.0290) significantly predicted sialendoscopic stone removal, and on multivariate analysis, stone size (p = 0.0110) significantly predicted the same. Logistic regression analysis predicting the risk factors for submandibular gland removal is shown in Table 4. On univariate analysis, stone size (p = 0.0420) and distance from the papilla (p = 0.0246) significantly predicted submandibular gland removal. Patient gender (p = 0.0647) was only marginally significant. On multivariate analysis, stone size (p = 0.0222) and distance from the papilla (p = 0.0026) were also significant predictors for submandibular gland removal.

4. Discussion Sialolithiasis is one of the most common causes of major salivary gland inflammation [4,5]. Stones most frequently form in the submandibular gland (80%), with 20% occurring in the parotid gland [6,7]. In our study, the submandibular gland was affected more frequently than the parotid gland (93.6% vs. 6.4%). The condition primarily affects patients aged 40–50 years [8]. The precise etiology is not fully understood, but several hypotheses have been proposed: an anatomic aberrant, at the Wharton’s duct hilus, for example; desquamated epithelium and postinfection detritus; and foreign bodies enabling calcium deposition [7–9]. Typical sialolithiasis symptoms result from duct obstruction and include glandular pain and swelling, particularly during meal times. Traditionally, an open surgical approach is used to treat sialolithiasis, but a number of complications are associated with surgery. Postoperative neurologic damage is a primary concern. Other complications, including sialoceles, salivary fistula, facial

T. Matsunobu et al. / Auris Nasus Larynx 41 (2014) 528–531

scarring, and Frey syndrome, also contribute to patient morbidity [10]. In parotid or Stenon’s sialolithiasis, the traditional therapeutic approach is radical parotidectomy. As branches of the facial nerve cross the duct, there might be a greater risk of facial palsy. Also, an external incision may lead to a nonclosure of the duct, and might lead to a salivary fistula. We believe that sialendoscopy is a very important tool for removing the parotid stones and confirming the diagnosis of inflammatory and obstructive diseases of the parotid duct. The main advantages of parotid sialendoscopy are its low complication rate and direct visualization and screening of the ductal system. Sialendoscopy was first introduced in 1988 and is currently established for diagnosis and treatment of salivary ductal disorders [11]. Suspicion of salivary ductal system obstruction is the chief diagnostic indication. Additionally, with the popularization of minimally invasive surgery in recent years, as well as advances in instruments and technology, sialendoscopy has become the primary surgical treatment for salivary gland obstructive disorders [12]. Therapeutic indications include sialolithiasis treatment, stricture dilation, and recurrent juvenile sialadenitis management [11]. The only contraindication is acute sialadenitis [13]. Sialendoscopy is established as the first choice for sialolithiasis treatment of small stones [14,15]. The removal of submandibular stones less than 4 mm is amenable to sialendoscopy with wire basket or forceps retrieval, whereas larger stones may require ancillary techniques such as fragmentation [3]. In addition to stone size, stone location, and mobility also significantly affect therapeutic success of sialendoscopy [16]. Based on the results of our present study, stone size and shape are important for therapeutic success using sialendoscopy alone. The combined approach is by far the most common treatment for submandibular gland stones (57.5%). Some patients with large, impacted, or hard stones cannot be managed effectively by sialendoscopy alone. As expected, the mean stone size in these patients was considerably larger than in patients receiving only sialendoscopy. The recommended combined approach begins with stone localization in the ductal system using transillumination, followed by transoral stone removal. In the other combined approach, lithotripsy is performed to mobilize or fragment the stone, and the fragments are removed using sialendoscopy. In our study, all patients underwent sialendoscopy initially to gauge the feasibility of stone extraction or the need for lithotripsy mobilization. After fragmentation using lithotripsy, large stones can be successfully removed using a wire basket. The success rate for sialendoscopic sialolithotomy of intact large stones was as low as 35% [17]. Furthermore, complications such as ductal tear or avulsion may occur when these large stones are approached sialendoscopically [18]. In our limited experience performing lithotripsy in seven patients, results were excellent, with no complications. Transoral stone removal is used primarily for stones located in the submandibular distal duct or hilus. The mean stone size in this group was considerably larger than in the other groups. Irrespective of stone size, these sites are the ideal indication for transoral stone removal. Even stones difficult to palpate (

Minimally invasive surgery of sialolithiasis using sialendoscopy.

The introduction of minimally invasive surgical procedures using sialendoscopy has significantly reduced the rate of major salivary gland removal due ...
356KB Sizes 1 Downloads 4 Views