The Laryngoscope C 2013 The American Laryngological, V
Rhinological and Otological Society, Inc.
Case Report
Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy for Complete Parotid Duct Stenosis William R. Ryan, MD; Jolie L. Chang, MD; David W. Eisele, MD, FACS A 57-year-old man presented with a 16-month history of right parotid swelling since undergoing a transoral sialolithotomy of the parotid duct. An ultrasound and a computed tomography scan showed a 6 cm-long dilated parotid duct without evidence of sialolithiasis or tumor mass. The complete Stensen’s duct stenosis that was found was managed by a surgeonperformed ultrasound-guided transfacial needle catheterization of the dilated parotid duct, anterograde sialoendoscopy, recanalization of the duct, and stent placement. At 15 month follow-up, the patient reported no recurrent facial swelling or discomfort. Surgeon-performed ultrasound, combined with sialoendoscopy, can provide unique advantages for managing parotid duct stenosis and obstructive sialadenitis. Key Words: Surgeon-performed ultrasound; sialoendoscopy; parotid duct stenosis; obstructive sialadenitis; transfacial. Laryngoscope, 124:418–420, 2014
INTRODUCTION
CASE REPORT
Parotid duct stricture can be a challenging clinical problem that can lead to a unilateral diffuse enlargement of the gland; noticeable dilation of the parotid duct; discomfort; and/or recurrent infection with parotitis, cellulitis, and/or abscess.1–4 Conservative therapy is usually not effective because the saliva has little to no course of exit. Management options include sialoendoscopy, ductal dilation, duct incision (if the stricture is distal), botulinum toxin chemodenervation to suppress salivary flow, or ultimately a parotidectomy with facial nerve dissection and preservation.1–4 Other options include the emerging techniques of surgeon-performed ultrasound and sialoendoscopy, which together can provide unique advantages for managing obstructive sialadenitis. We report a case of parotid duct stricture, duct dilation, and chronic sialadenitis treated successfully using surgeon-performed ultrasound and sialoendoscopy in combination.
A 57-year-old man presented with a 16-month history recurrent right parotitis and a persistent visible and palpable horizontal, linear, cord-like mass along the right parotid and cheek region since undergoing a right parotid duct sialolithotomy by an outside surgeon for a right parotid sialolith. A right parotid ultrasound showed an enlarged hypoechoic tract extending from medial-anterior to lateral-posterior, without evidence of a distal sialolith or mass. Analysis with ultrasound-guided needle aspiration of the ductal fluid detected no malignant cells and grew no bacterial or fungal cultures. A computed tomography scan showed a dilated right parotid duct (1 cm in width and 6 cm in length), with extensive soft tissue stranding surrounding the duct and parotid gland atrophy (Fig. 1). The duct had an abrupt caliber change and narrowing as it crossed anterior to the right masseter muscle, suspicious for parotid duct stricture. No radiopaque stones or masses were visualized. We performed the following procedure in the operating room under general anesthesia: a transfacial surgeon-performed ultrasound-guided needle catheterization of the right parotid duct, anterograde sialoendoscopy, recanalization, stent placement, and retrograde sialoendoscopy. At first, we attempted retrograde dilation of the right Stensen’s duct transorally. Examination revealed a scarred, completely closed meatus. Under ultrasound guidance, we then placed a 12-gauge angiocatheter needle transfacially at the midportion of the dilated duct and removed the needle (Figs. 2 and 3). Next, a 1.1 mm sialoendoscope was passed through the catheter to visualize the distal duct lumen in the anterograde direction. We encountered the distal duct complete obstruction (Fig. 4). A size 3 salivary ductal dilator probe was passed through
From the Department of Otolaryngology–Head and Neck Surgery (W.R.R., J.L.C.), University of California, San Francisco, San Francisco, California, U.S.A, Department of Otolaryngology–Head and Neck Surgery (D.W.E.), Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A Editor’s Note: This Manuscript was accepted for publication on December 11, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to William R. Ryan, MD, Assistant Professor, Head and Neck Oncologic/Endocrine/Salivary Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, 2233 Post St, 3rd Floor, San Francisco, CA 94115. E-mail: [email protected] DOI: 10.1002/lary.23968
Laryngoscope 124: February 2014
418
Ryan et al.: Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy
Fig. 1. Computed tomography scan with contrast showing a dilated right parotid duct measuring 6 x 1 cm. No obvious sialolith or obstructive mass.
Fig. 3. Transfacial placement of sialoendoscope into right parotid duct through catheter port. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
the catheter and the distal duct until its tip could be palpated trasorally at the area of the scarred Stensen’s duct meatus. With a 15 blade, we made an incision transorally over the probe through the scar to allow the probe to pass into the mouth from the parotid duct. The dilator was removed. The catheter was advanced through the newly reopened and dilated meatus. The catheter was secured to the buccal mucosa with 3-0 silk suture (Fig. 5). The proximal end of the catheter was trimmed to remove the hub. The proximal end of the catheter was then guided under the facial skin into the midportion of the duct lumen. Its placement in the lumen was confirmed by intraoperative ultrasonography. The sialoendoscope was then inserted transorally through the catheter in the
retrograde direction to visualize the proximal duct and ductules. The ductal system was then irrigated. No other areas of stenosis or sialoliths were found proximally. We closed the facial skin puncture site with a 5-0 fast absorbable suture. The patient’s facial nerve was intact postoperatively. There were no other complications. The patient was discharged home on a week-long course of amoxicillin/clauvulanic acid and directions to massage the gland, increase hydration, and use sialogogues regularly. The catheter was removed in clinic 2 weeks later. Active salivary flow from the right Stensen’s duct was observed. In the clinic, ultrasound confirmed resolution of the ductal dilation.
Fig. 2. Surgeon-performed ultrasound-guided transfacial placement of needle-catheter into dilated right parotid duct. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 4. Transfacial anterograde sialoendoscopic view of right parotid duct showing narrowing (complete stenosis not shown). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Laryngoscope 124: February 2014
Ryan et al.: Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy
419
Fig. 5. Catheter stent in the right Stensen’s duct sutured into place for 2 weeks. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
A 15-month telephone follow-up confirmed that the patient had experienced no further parotitis, swelling, or discomfort.
DISCUSSION This is the first report of using the combination of surgeon-performed ultrasound and sialoendoscopy in a transfacial approach for parotid duct stenosis. Both modalities helped us achieve our goal of reconstituting the parotid duct salivary pathway with an increased degree of safety. For complete parotid duct stenosis, the treatment objectives of recanalization, stent placement, and salivary duct irrigation carry the risks of creating a false passage in the facial soft tissue, bleeding/hematoma, facial nerve injury, and failure to recanalize the parotid duct. These risks were reduced by the added visualization provided by both modalities of ultrasound and sialoendoscopy. The ultrasound guidance helped assure proper insertion of the needle catheter and full placement of the stent into the length of the duct. The sialoendoscope helped us directly visualize the condition of the stricture; confirm placement of the stent catheter; evaluate the proximal ductules for additional strictures, mucus plugs, sialoliths, and debris; and provide irrigation to the ductal system to reduce the risk of recurrence. Few drawbacks exist with the use of these modalities, aside from the need for additional training and experience and the costs of the initial investment of the equipment. While the management of this case and the presentation of a cord-like dilation of the parotid duct were unique, this presentation of parotid duct complete stenosis corresponds well with the general literature on the topic. Salivary duct strictures are the second most
Laryngoscope 124: February 2014
420
common cause of obstructive sialadenitis after sialolithiasis.3,4 Other causes of salivary gland obstructions include mucus plugs; accessory ducts; sphincter-like mechanisms located near the papilla; pelvis-like duct formations, which are basin-like structures at the glandular hilum, instead of a bifurcation or trifurcation; intraductal evaginations; and kinks.4 Strictures are most often found in the parotid ductal system (75% of the time1), whereas sialolithiasis usually affects the submandibular ducts. Strictures are usually caused by injuries following recurrent infections, sialolith-related traumas, or iatrogenic surgical procedures,1 the later etiology being the likely cause of this case. There are separate growing bodies of literature on the use of surgeon-performed ultrasound and sialoendoscopy for the diagnosis and treatment of obstructive sialoadenitis.5–9 Sialoendoscopy has been used in the treatment of strictures with techniques such as dilation with saline under pressure, balloon catheters, forced manipulation, and stent placement; and it has been used in the treatment of kinks by advancement ductoplasty and balloon contouring.5–7 Transfacial anterograde sialoendoscopic approaches are well described.6,7 Ultrasound can be used to help identify sialoliths, dilated ducts, inflamed glands, cysts, neoplasia, and abscesses.8,9 Ultrasound can assist guiding needle aspiration, fine needle aspiration biopsies, incision and sialoendoscope placement for sialoliths, and for instrumentation of sialoliths.8,9 Further applications and advancements of sialoendoscopy and ultrasound in the management of obstructive sialadenitis are warranted.
CONCLUSION Surgeon-performed ultrasound and transfacial sialoendoscopy are tools that in combination may be helpful in the management of obstructive sialadenitis.
BIBLIOGRAPHY 1. Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L. Modernmanagement of obstructive salivary diseases. Acta Otorhinolaryngol Ital 2007;27:161–172. 2. Koch M, Zenk J, Iro H. Algorithms for treatment of salivary gland obstructions. Otolaryngol Clin. North Am 2009;42:1173–1192. 3. Ngu RK, Brown JE, Whaites EJ, Drage NA, Ng SY, Makdissi J. Salivary duct strictures: nature and incidence in benign salivary obstruction. Dentomaxillofac Radiol 2007;36:63–67. 4. Nahlieli O, Bar T, Shacham R, Eliav E, Hecht-Nakar L. Management of chronic recurrent parotitis: current therapy. J Oral Maxillofac Surg 2004;62:1150–1155. 5. Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin North Am 2009;42:1029–1052. 6. Nahlieli O, Nakar LH, Nazarian Y, Turner MD. Sialoendoscopy: a new approach to salivary gland obstructive pathology. J Am Dent Assoc. 2006 Oct;137(10):1394–1400. 7. Koch M, Bozzato A, Iro H, Zenk J. Combined endoscopic and transcutaneous approach for parotid glandsialolithiasis: indications, technique, and results. Otolaryngol Head Neck Surg 2010;142:98–103. 8. Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands. Otolaryngol Clin North Am 2009;42:973–1000. 9. Gritzmann N, Rettenbacher T, Hollerweger A, Macheiner P, Hubner E. Sonography of the salivary glands. Eur Radiol 2003;13:964–975. Epub 2002.
Ryan et al.: Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy
Rhinological and Otological Society, Inc.
Case Report
Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy for Complete Parotid Duct Stenosis William R. Ryan, MD; Jolie L. Chang, MD; David W. Eisele, MD, FACS A 57-year-old man presented with a 16-month history of right parotid swelling since undergoing a transoral sialolithotomy of the parotid duct. An ultrasound and a computed tomography scan showed a 6 cm-long dilated parotid duct without evidence of sialolithiasis or tumor mass. The complete Stensen’s duct stenosis that was found was managed by a surgeonperformed ultrasound-guided transfacial needle catheterization of the dilated parotid duct, anterograde sialoendoscopy, recanalization of the duct, and stent placement. At 15 month follow-up, the patient reported no recurrent facial swelling or discomfort. Surgeon-performed ultrasound, combined with sialoendoscopy, can provide unique advantages for managing parotid duct stenosis and obstructive sialadenitis. Key Words: Surgeon-performed ultrasound; sialoendoscopy; parotid duct stenosis; obstructive sialadenitis; transfacial. Laryngoscope, 124:418–420, 2014
INTRODUCTION
CASE REPORT
Parotid duct stricture can be a challenging clinical problem that can lead to a unilateral diffuse enlargement of the gland; noticeable dilation of the parotid duct; discomfort; and/or recurrent infection with parotitis, cellulitis, and/or abscess.1–4 Conservative therapy is usually not effective because the saliva has little to no course of exit. Management options include sialoendoscopy, ductal dilation, duct incision (if the stricture is distal), botulinum toxin chemodenervation to suppress salivary flow, or ultimately a parotidectomy with facial nerve dissection and preservation.1–4 Other options include the emerging techniques of surgeon-performed ultrasound and sialoendoscopy, which together can provide unique advantages for managing obstructive sialadenitis. We report a case of parotid duct stricture, duct dilation, and chronic sialadenitis treated successfully using surgeon-performed ultrasound and sialoendoscopy in combination.
A 57-year-old man presented with a 16-month history recurrent right parotitis and a persistent visible and palpable horizontal, linear, cord-like mass along the right parotid and cheek region since undergoing a right parotid duct sialolithotomy by an outside surgeon for a right parotid sialolith. A right parotid ultrasound showed an enlarged hypoechoic tract extending from medial-anterior to lateral-posterior, without evidence of a distal sialolith or mass. Analysis with ultrasound-guided needle aspiration of the ductal fluid detected no malignant cells and grew no bacterial or fungal cultures. A computed tomography scan showed a dilated right parotid duct (1 cm in width and 6 cm in length), with extensive soft tissue stranding surrounding the duct and parotid gland atrophy (Fig. 1). The duct had an abrupt caliber change and narrowing as it crossed anterior to the right masseter muscle, suspicious for parotid duct stricture. No radiopaque stones or masses were visualized. We performed the following procedure in the operating room under general anesthesia: a transfacial surgeon-performed ultrasound-guided needle catheterization of the right parotid duct, anterograde sialoendoscopy, recanalization, stent placement, and retrograde sialoendoscopy. At first, we attempted retrograde dilation of the right Stensen’s duct transorally. Examination revealed a scarred, completely closed meatus. Under ultrasound guidance, we then placed a 12-gauge angiocatheter needle transfacially at the midportion of the dilated duct and removed the needle (Figs. 2 and 3). Next, a 1.1 mm sialoendoscope was passed through the catheter to visualize the distal duct lumen in the anterograde direction. We encountered the distal duct complete obstruction (Fig. 4). A size 3 salivary ductal dilator probe was passed through
From the Department of Otolaryngology–Head and Neck Surgery (W.R.R., J.L.C.), University of California, San Francisco, San Francisco, California, U.S.A, Department of Otolaryngology–Head and Neck Surgery (D.W.E.), Johns Hopkins Medical Institutions, Baltimore, Maryland, U.S.A Editor’s Note: This Manuscript was accepted for publication on December 11, 2012. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to William R. Ryan, MD, Assistant Professor, Head and Neck Oncologic/Endocrine/Salivary Surgery, Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, 2233 Post St, 3rd Floor, San Francisco, CA 94115. E-mail: [email protected] DOI: 10.1002/lary.23968
Laryngoscope 124: February 2014
418
Ryan et al.: Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy
Fig. 1. Computed tomography scan with contrast showing a dilated right parotid duct measuring 6 x 1 cm. No obvious sialolith or obstructive mass.
Fig. 3. Transfacial placement of sialoendoscope into right parotid duct through catheter port. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
the catheter and the distal duct until its tip could be palpated trasorally at the area of the scarred Stensen’s duct meatus. With a 15 blade, we made an incision transorally over the probe through the scar to allow the probe to pass into the mouth from the parotid duct. The dilator was removed. The catheter was advanced through the newly reopened and dilated meatus. The catheter was secured to the buccal mucosa with 3-0 silk suture (Fig. 5). The proximal end of the catheter was trimmed to remove the hub. The proximal end of the catheter was then guided under the facial skin into the midportion of the duct lumen. Its placement in the lumen was confirmed by intraoperative ultrasonography. The sialoendoscope was then inserted transorally through the catheter in the
retrograde direction to visualize the proximal duct and ductules. The ductal system was then irrigated. No other areas of stenosis or sialoliths were found proximally. We closed the facial skin puncture site with a 5-0 fast absorbable suture. The patient’s facial nerve was intact postoperatively. There were no other complications. The patient was discharged home on a week-long course of amoxicillin/clauvulanic acid and directions to massage the gland, increase hydration, and use sialogogues regularly. The catheter was removed in clinic 2 weeks later. Active salivary flow from the right Stensen’s duct was observed. In the clinic, ultrasound confirmed resolution of the ductal dilation.
Fig. 2. Surgeon-performed ultrasound-guided transfacial placement of needle-catheter into dilated right parotid duct. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 4. Transfacial anterograde sialoendoscopic view of right parotid duct showing narrowing (complete stenosis not shown). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Laryngoscope 124: February 2014
Ryan et al.: Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy
419
Fig. 5. Catheter stent in the right Stensen’s duct sutured into place for 2 weeks. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
A 15-month telephone follow-up confirmed that the patient had experienced no further parotitis, swelling, or discomfort.
DISCUSSION This is the first report of using the combination of surgeon-performed ultrasound and sialoendoscopy in a transfacial approach for parotid duct stenosis. Both modalities helped us achieve our goal of reconstituting the parotid duct salivary pathway with an increased degree of safety. For complete parotid duct stenosis, the treatment objectives of recanalization, stent placement, and salivary duct irrigation carry the risks of creating a false passage in the facial soft tissue, bleeding/hematoma, facial nerve injury, and failure to recanalize the parotid duct. These risks were reduced by the added visualization provided by both modalities of ultrasound and sialoendoscopy. The ultrasound guidance helped assure proper insertion of the needle catheter and full placement of the stent into the length of the duct. The sialoendoscope helped us directly visualize the condition of the stricture; confirm placement of the stent catheter; evaluate the proximal ductules for additional strictures, mucus plugs, sialoliths, and debris; and provide irrigation to the ductal system to reduce the risk of recurrence. Few drawbacks exist with the use of these modalities, aside from the need for additional training and experience and the costs of the initial investment of the equipment. While the management of this case and the presentation of a cord-like dilation of the parotid duct were unique, this presentation of parotid duct complete stenosis corresponds well with the general literature on the topic. Salivary duct strictures are the second most
Laryngoscope 124: February 2014
420
common cause of obstructive sialadenitis after sialolithiasis.3,4 Other causes of salivary gland obstructions include mucus plugs; accessory ducts; sphincter-like mechanisms located near the papilla; pelvis-like duct formations, which are basin-like structures at the glandular hilum, instead of a bifurcation or trifurcation; intraductal evaginations; and kinks.4 Strictures are most often found in the parotid ductal system (75% of the time1), whereas sialolithiasis usually affects the submandibular ducts. Strictures are usually caused by injuries following recurrent infections, sialolith-related traumas, or iatrogenic surgical procedures,1 the later etiology being the likely cause of this case. There are separate growing bodies of literature on the use of surgeon-performed ultrasound and sialoendoscopy for the diagnosis and treatment of obstructive sialoadenitis.5–9 Sialoendoscopy has been used in the treatment of strictures with techniques such as dilation with saline under pressure, balloon catheters, forced manipulation, and stent placement; and it has been used in the treatment of kinks by advancement ductoplasty and balloon contouring.5–7 Transfacial anterograde sialoendoscopic approaches are well described.6,7 Ultrasound can be used to help identify sialoliths, dilated ducts, inflamed glands, cysts, neoplasia, and abscesses.8,9 Ultrasound can assist guiding needle aspiration, fine needle aspiration biopsies, incision and sialoendoscope placement for sialoliths, and for instrumentation of sialoliths.8,9 Further applications and advancements of sialoendoscopy and ultrasound in the management of obstructive sialadenitis are warranted.
CONCLUSION Surgeon-performed ultrasound and transfacial sialoendoscopy are tools that in combination may be helpful in the management of obstructive sialadenitis.
BIBLIOGRAPHY 1. Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L. Modernmanagement of obstructive salivary diseases. Acta Otorhinolaryngol Ital 2007;27:161–172. 2. Koch M, Zenk J, Iro H. Algorithms for treatment of salivary gland obstructions. Otolaryngol Clin. North Am 2009;42:1173–1192. 3. Ngu RK, Brown JE, Whaites EJ, Drage NA, Ng SY, Makdissi J. Salivary duct strictures: nature and incidence in benign salivary obstruction. Dentomaxillofac Radiol 2007;36:63–67. 4. Nahlieli O, Bar T, Shacham R, Eliav E, Hecht-Nakar L. Management of chronic recurrent parotitis: current therapy. J Oral Maxillofac Surg 2004;62:1150–1155. 5. Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin North Am 2009;42:1029–1052. 6. Nahlieli O, Nakar LH, Nazarian Y, Turner MD. Sialoendoscopy: a new approach to salivary gland obstructive pathology. J Am Dent Assoc. 2006 Oct;137(10):1394–1400. 7. Koch M, Bozzato A, Iro H, Zenk J. Combined endoscopic and transcutaneous approach for parotid glandsialolithiasis: indications, technique, and results. Otolaryngol Head Neck Surg 2010;142:98–103. 8. Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands. Otolaryngol Clin North Am 2009;42:973–1000. 9. Gritzmann N, Rettenbacher T, Hollerweger A, Macheiner P, Hubner E. Sonography of the salivary glands. Eur Radiol 2003;13:964–975. Epub 2002.
Ryan et al.: Surgeon-Performed Ultrasound and Transfacial Sialoendoscopy
