PATHOLOGY
The Treatment of Large Sialoliths by Sialendoscopic Combined Approach Hila Klein, DMD,* and Leon Ardekian, DDSy Purpose:
To investigate the advantages, disadvantages, and complications of the combined surgical technique for removing large sialoliths from the salivary glands.
Materials and Methods:
This retrospective study analyzed 37 patients with obstructive sialadenitis caused by sialolithiasis who could not undergo surgery using a purely sialendoscopic technique because of the stone size or because of a tight distal stricture obstructing the passage of stone removal by an endoscope.
Results:
Six patients had parotid gland obstruction, and the other 31 patients had submandibular gland obstruction. The calculi varied in size from 5 to 45 mm (average, 10.4 mm). Twenty-three stones were located at the hilar part of the gland or in the proximal part of the duct close to the hilum. The other 14 stones were located in the middle third of the duct. Thirty patients had no complications and were free of symptoms, with normal saliva secretion checked by milking the gland. Five patients developed minor complications that were treated under local anesthesia. Only 2 patients developed severe ductal restenosis and required further sialadenectomy.
Conclusions: The combined technique showed good results for removing large sialoliths or proximally located sialoliths that could not have been removed by sialendoscopy alone. The use of an endoscope enables further exploration of the remaining duct, allowing for the removal of further sialolith and reconstruction of the duct after sialolith removal. The technique is not limited to stone size or location along the duct. Crown Copyright Ó 2014 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons. All rights reserved J Oral Maxillofac Surg 72:737-743, 2014
Sialolithiasis is a common pathology of the salivary glands, which causes mechanical obstruction and swelling of the salivary glands. Sialoliths can vary from 1 mm to a few centimeters.1 With new minimally invasive techniques and changes in attitudes toward organ preservation, the stone can be removed through the salivary gland ductal system using interventional sialendoscopy that avoids damaging the essential structures of the salivary glands.2 However, sialolith extraction through the salivary duct system using sialendoscopy as the sole modality is suitable only for sialoliths up to 4 to 5 mm
(Fig 1). The treatment for larger sialoliths or sialoliths located deep in the hilum is still considered a challenge for surgeons (Figs 2,3). The traditional treatment for large submandibular stones are through a transoral approach (sialolithotomy) in cases of well-palpated and distally located stones3 or through a complete sialadenectomy.4,5 Although submandibular gland (SMG) sialadenectomy is considered a common procedure, it is not free of complications. Some complications include facial and lingual neural damage,6-8 infections, and even
*Sialendoscopy and Minimal Invasive Surgery Service, Department
Received June 11 2013
of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa,
Accepted September 2 2013
Israel; Technion Faculty of Medicine, Haifa, Israel.
Crown Copyright Ó 2014 Published by Elsevier Inc on behalf of the American
ySialendoscopy
and
Minimal
Invasive
Surgery
Service,
Association of Oral and Maxillofacial Surgeons. All rights reserved
Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel; Technion Faculty of Medicine, Haifa, Israel.
0278-2391/13/01142-7$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.09.003
Address correspondence and reprint requests to Dr Klein: Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel; e-mail: [email protected]
737
738
SIALOENDOSCOPIC TREATMENT OF LARGE SIALOLITHS
plex anatomy of the duct. Indeed, only a very short part of the Stensen duct is approachable transorally, whereas the rest of the duct, which is lateral to the masseter muscle, is unapproachable. For large hilar or parenchymal parotid stones, parotidectomy with Stensen duct ligation has been the treatment of choice despite the great risk of neural damage, possible infection, and scar formation.12-17 In 2007, Marchal18 described an endoscopic technique combined with additional incisions for the treatment of large sialoliths located in the parotid gland and the SMG. The purpose of this study was to investigate the advantages, disadvantages, and complications of the combined technique for sialolith removal. FIGURE 1. Small stone that could have been removed by sialendoscopy with a basket. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
hypertrophic scars.9,10 Transoral stone removal carries a high risk of lingual nerve damage11 and thus is useful only for retrieving well-palpated and proximally located stones. In cases of parotid stones, transoral access for stone removal is more complicated because of the com-
Material and Methods This retrospective study included the clinical and radiologic data of 37 patients who were referred to the Sialendoscopy and Minimal Invasive Surgery Service, Department of Oral and Maxillofacial, Rambam Health Care Campus (Haifa, Israel) from January 2011 through December 2012. This study followed the Declaration of Helsinki on medical protocol and ethics and was approved by the regional ethical review board of the Rambam Health Care Campus before data
FIGURE 2. Multiple large stones (arrow) in the parotid gland that could not be removed by pure sialendoscopy. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
739
KLEIN AND ARDEKIAN
FIGURE 3. Large stone of the proximal Wharton duct. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
collection. Included in this study were patients who had obstructive sialadenitis caused by sialolithiasis that could not be retrieved by a purely endoscopic technique because of the stone size or because of a tight stricture distal to the stone that could not be passed by the endoscope. Excluded from this study were patients with intraglandular stones and pediatric patients. SURGICAL PROCEDURE
All patients were treated by the combined approach for the SMG or parotid gland as described by the Marchal protocol in 2007.18 For the SMG, the procedure was performed under local anesthesia (lingual block) with light intravenous sedation using midazolam 2 to 5 mg. Cases with parotid stones were operated on only under general anesthesia. The aim of this approach was to identify and locate the stone using a diagnostic endoscope in combination with its illumination effect (Fig 4). For the SMG, after the location of a stone was identified, the sialendoscope was fixated and the sialolith could be removed by making a minimal intraoral incision that enabled the separation and protection of the lingual nerve (Fig 5). For the parotid gland, the facelift ap-
proach with a Superficial muscular aponeurotic system (SMAS) flap was implemented (Fig 4). After identifying the Stensen duct, an incision was made along the duct and the stone was extracted. The buccal branch of the facial nerve was encountered, in 4 of the 6 parotid cases, along the crossing of the Stensen duct. In those cases, the nerve was safely separated from the duct. After stone extraction, further exploration of the duct by the sialendoscope was performed to remove more sialolith and maintain ductal integrity through ductal reconstruction. The duct was reconstructed with the aid of a pediatric nasogastric feeding tube that bridged the area between the ductal orifices (the original papilla) to the area behind the cut (Figs 6,7 it was removed 2 to 3 weeks after the procedure). The operating time for the SMG was 30 to 60 minutes (average, 45 minutes). The operating time for the parotid gland was 150 to 210 minutes (average, 180 minutes).
Results Thirty-seven patients (11 female, 26 male; average age, 49.4 yr; age range, 26 to 90 yr) were included in
740
SIALOENDOSCOPIC TREATMENT OF LARGE SIALOLITHS
FIGURE 4. Localization of the stone with the sialendoscope illumination effect. (arrow). Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
this study. Six patients had parotid gland obstruction and the other 31 had SMG obstruction. Seventeen patients had computed tomographic scan data performed by the referral institution; 18 patients had
Panorex radiographic data visualizing the sialoliths performed by the referral institution. Two patients who were directly referred to the authors’ department did not undergo any salivary
FIGURE 5. A minimal intraoral incision enables the separation and protection of the lingual nerve (black arrow). The stone within the Wharton duct (blue arrow) is visible. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
741
KLEIN AND ARDEKIAN
FIGURE 6. A stent (pediatric nasogastric tube) (arrow) bridging the gap in the Stensen duct. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
gland imaging before the sialendoscopy and the diagnosis was based on only clinical examination and direct visualization of the stone by the sialendoscope. The calculi varied from 5 to 45 mm (average, 10.4 mm). In 23 cases (62%), stones were located at the hilar part of the gland or in the proximal part of the duct
close to the hilum. In the other 14 cases (38%), the stones were located in the middle third of the duct. Seven patients had more than 1 stone in the duct that needed to be extracted by sialendoscopy with the aid of the basket, which was performed at the same session with the combined approach. In 2 cases in which the stone could not be identified by the endoscope
FIGURE 7. Panorex radiograph showing the stent (pediatric nasogastric tube) bridging the gap in the Wharton duct. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
742 because of the ductal stricture, the Stensen duct was explored from the location of the stricture to the stone. The follow-up period ranged from 4 to 23 months. Thirty patients had no complications and were free of symptoms, with normal saliva secretion checked by milking the gland. Six patients with SMG sialolithiasis developed restenosis of the duct orifice and required additional sialodochoplasty, which was performed under local anesthesia. Only 2 of them required further sialadenectomy. One patient developed postoperative ranula, which was resolved by simple marsupialization administered under local anesthesia. None of the patients had neural damage. The 2 patients who required gland removal were regarded as having a major complication and the other 5 patients who required additional sialodochoplasty under local anesthesia were regarded as having a minor complication.
Discussion Sialolithiasis is the main cause of salivary gland obstruction and is detectable in more than 65% of cases.11 It was thought that 80% of sialolithiasis were located in the SMG and only 5% in the parotid gland.11 Recent works have shown that sialolithiasis of the parotid gland is not so rare and is found in up to 40% of patients.2 Sialendoscopy is a relatively new technique that enables the removal of calculi through the ductal system without having to perform gland removal. For the treatment of stones larger than 5 mm, a combination of sialendoscopy with additional techniques is required. Several methods have been described, such as the use of fiber optic laser to fragment large stones and retrieve the fragments through the Dormia basket.2 The limitations of this technique are numerous: the surgeon must have direct vision of the entire stone, this procedure is impossible to implement in a stenotic duct, and in cases of large stones located behind a stenosis, there is a strong possibility of damaging the ductal walls by the heat that is generated during the fragmentation phase in narrow ducts.18 Another limitation of this technique is the stone size, because it was found effective in fragmenting stones of only up to 6 mm.2 Extracorporeal shock wave lithotripsy is another method that attempts to fragment large stones in the salivary gland to cause spontaneous extraction through the salivary ductal system or in combination with endoscopic assistance. With this method, however, favorable results are achieved mostly with stones 7 to 12 mm.19,20 A further disadvantage of this method is that it requires several sessions to sufficiently fragment the stone. Nahlieli et al21 described an external approach for parotid stone removal through a horizontal cut above the stone after its identification by the sialoendoscope. However, this technique is limited to stones close to the outer skin surface (and should
SIALOENDOSCOPIC TREATMENT OF LARGE SIALOLITHS
not exceed 6 mm from the surface). In addition, this method can leave visible scar and provides limited exploration of the duct. The present study of the combined technique showed good results for removing a large sialolith or proximally located sialolith, which could not have been removed by sialendoscopy alone. The main advantage of this method is that it provides an easy solution for salivary obstructive disease caused by a sialolith and is not limited to stone size or its location along the salivary ductal system. The combined procedure for the SMG can be an in-office procedure without the need for general anesthesia. This fact alone expands treatment options and makes it suitable for treating elderly and medically compromised patients who cannot be treated under general anesthesia. The benefit of using the sialendoscope in the combined technique is not only for stone location. The use of the endoscope enables further exploration of the remaining duct to remove more sialoliths. The sialendoscopy serves as a diagnostic and treatment tool in this matter. The authors insisted on having computed tomographic scans only in cases in which the sialolith could not be located by the endoscope because of a distal stricture. In the authors’ department, the average time of the SMG combined approach is almost equal to SMG removal owing to sialolithiasis, but in the combined approach for the SMG, there is no need for hospitalization or general anesthesia. The authors could not compare the operating time of parotid combined approach with an open approach or parotidectomy because they do not perform parotidectomy as a treatment for sialolithiasis. However, they believe that the operating time would not be shorter because of the scars and glandular hyperemia caused by chronic infections and the necessity for facial nerve preservation. The rate of major complications for the combined approach was very low: Only 2 of 37 cases required gland removal after the procedure. None of the patients developed nerve injury after the procedure. Patients with minor complications were treated in an ambulatory setting with local anesthesia. The combined technique showed good results for removing larger sialolith or proximally located sialoliths that could not have been removed by sialendoscopy alone. Use of the endoscope enables further exploration of the remaining duct to remove further sialolith and to reconstruct the duct after sialolith removal. The technique is not limited to stone size or location along the duct. Acknowledgment The authors thank Professor Francis Marchal for his support and guidance in implementing this technique in the Sialendoscopy and Minimal Invasive Surgery Service, Department of Oral and Maxillofacial Surgery, Rambam, Health Care Campus.
KLEIN AND ARDEKIAN
References 1. Bodner L: Giant salivary gland calculi: Diagnostic imaging and surgical management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:320, 2002 2. Marchal F, Dulguerov P: Sialolithiasis management: The state of the art. Arch Otolaryngol Head Neck Surg 129:951, 2003 3. Roh JL, Park CI: Transoral removal of submandibular hilar stone and sialodochoplasty. Otolaryngol Head Neck Surg 139:235, 2008 4. O’Brien CJ, Murrant NJ: Surgical management of chronic parotitis. Head Neck 15:445, 1993 5. Amin MA, Bailey BM, Patel SR: Clinical and radiological evidence to support superficial parotidectomy as the treatment of choice for chronic parotid sialadenitis: A retrospective study. Br J Oral Maxillofac Surg 39:348, 2001 6. Bates D, O’Brien CJ, Tikaram K, et al: Parotid and submandibular sialadenitis treated by salivary gland excision. Aust N Z J Surg 68: 120, 1998 7. Berini-Aytes L, Gay-Escoda C: Morbidity associated with removal of the submandibular gland. J Craniomaxillofac Surg 20:216, 1992 8. Gallo O, Berloco P, Bruschini L, et al: Treatment for non-neoplastic disease of the submandibular gland, in McGurk M, Renehan AG (eds): Controversies in the management of salivary gland disease. Oxford, UK, Oxford University Press, 2001, pp 297–310 9. Bhatty MA, Piggot TA, Soames JV, et al: Chronic non-specific parotid sialadenitis. Br J Plast Surg 51:517, 1998 10. Preuss SF, Klussmann JP, Wittekindt C, et al: Submandibular gland excision: 15 Years of experience. J Oral Maxillofac Surg 65:953, 2007
743 11. Mayers EN, Ferris RL: Salivary Gland Disorders. Springer, 2007, p 131 12. Baurmash HD: Chronic recurrent parotitis: A closer look at its origin, diagnosis, and management. J Oral Maxillofac Surg 62:1010, 2004 13. Motamed M, Laugharne D, Bradley PJ: Management of chronic parotitis: A review. J Laryngol Otol 117:521, 2003 14. Cohen D, Gatt N, Olschwang D, et al: Surgery for prolonged parotid duct obstruction: A case report. Otolaryngol Head Neck Surg 128:753, 2003 15. Moody AB, Avery CM, Taylor J, et al: A comparison of one hundred and fifty consecutive parotidectomies for tumors and inflammatory disease. Int J Oral Maxillofac Surg 28:211, 1999 16. Patel RS, Low TH, Gao K, et al: Clinical outcome after surgery for 75 patients with parotid sialadenitis. Laryngoscope 117:644, 2007 17. Nouraei SA, Ismail Y, Ferguson MS, et al: Analysis of complications following surgical treatment of benign parotid disease. Aust N Z J Surg 78:134, 2008 18. Marchal F: A combined endoscopic and external approach for extraction of large stones with preservation of parotid and submandibular glands. Laryngoscope 117:373, 2007 19. Capaccio P, Torretta S, Pignataro L: Extracorporeal lithotripsy techniques for salivary stones. Otolaryngol Clin North Am 42: 1139, 2009 20. Zenk J, Koch M, Iro H: Extracorporeal and intracorporeal lithotripsy of salivary gland stones: Basic investigations. Otolaryngol Clin North Am 42:1115, 2009 21. Nahlieli O, London D, Zagury A, et al: Combined approach to impacted parotid stones. J Oral Maxillofac Surg 60:1418, 2002
The Treatment of Large Sialoliths by Sialendoscopic Combined Approach Hila Klein, DMD,* and Leon Ardekian, DDSy Purpose:
To investigate the advantages, disadvantages, and complications of the combined surgical technique for removing large sialoliths from the salivary glands.
Materials and Methods:
This retrospective study analyzed 37 patients with obstructive sialadenitis caused by sialolithiasis who could not undergo surgery using a purely sialendoscopic technique because of the stone size or because of a tight distal stricture obstructing the passage of stone removal by an endoscope.
Results:
Six patients had parotid gland obstruction, and the other 31 patients had submandibular gland obstruction. The calculi varied in size from 5 to 45 mm (average, 10.4 mm). Twenty-three stones were located at the hilar part of the gland or in the proximal part of the duct close to the hilum. The other 14 stones were located in the middle third of the duct. Thirty patients had no complications and were free of symptoms, with normal saliva secretion checked by milking the gland. Five patients developed minor complications that were treated under local anesthesia. Only 2 patients developed severe ductal restenosis and required further sialadenectomy.
Conclusions: The combined technique showed good results for removing large sialoliths or proximally located sialoliths that could not have been removed by sialendoscopy alone. The use of an endoscope enables further exploration of the remaining duct, allowing for the removal of further sialolith and reconstruction of the duct after sialolith removal. The technique is not limited to stone size or location along the duct. Crown Copyright Ó 2014 Published by Elsevier Inc on behalf of the American Association of Oral and Maxillofacial Surgeons. All rights reserved J Oral Maxillofac Surg 72:737-743, 2014
Sialolithiasis is a common pathology of the salivary glands, which causes mechanical obstruction and swelling of the salivary glands. Sialoliths can vary from 1 mm to a few centimeters.1 With new minimally invasive techniques and changes in attitudes toward organ preservation, the stone can be removed through the salivary gland ductal system using interventional sialendoscopy that avoids damaging the essential structures of the salivary glands.2 However, sialolith extraction through the salivary duct system using sialendoscopy as the sole modality is suitable only for sialoliths up to 4 to 5 mm
(Fig 1). The treatment for larger sialoliths or sialoliths located deep in the hilum is still considered a challenge for surgeons (Figs 2,3). The traditional treatment for large submandibular stones are through a transoral approach (sialolithotomy) in cases of well-palpated and distally located stones3 or through a complete sialadenectomy.4,5 Although submandibular gland (SMG) sialadenectomy is considered a common procedure, it is not free of complications. Some complications include facial and lingual neural damage,6-8 infections, and even
*Sialendoscopy and Minimal Invasive Surgery Service, Department
Received June 11 2013
of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa,
Accepted September 2 2013
Israel; Technion Faculty of Medicine, Haifa, Israel.
Crown Copyright Ó 2014 Published by Elsevier Inc on behalf of the American
ySialendoscopy
and
Minimal
Invasive
Surgery
Service,
Association of Oral and Maxillofacial Surgeons. All rights reserved
Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel; Technion Faculty of Medicine, Haifa, Israel.
0278-2391/13/01142-7$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.09.003
Address correspondence and reprint requests to Dr Klein: Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel; e-mail: [email protected]
737
738
SIALOENDOSCOPIC TREATMENT OF LARGE SIALOLITHS
plex anatomy of the duct. Indeed, only a very short part of the Stensen duct is approachable transorally, whereas the rest of the duct, which is lateral to the masseter muscle, is unapproachable. For large hilar or parenchymal parotid stones, parotidectomy with Stensen duct ligation has been the treatment of choice despite the great risk of neural damage, possible infection, and scar formation.12-17 In 2007, Marchal18 described an endoscopic technique combined with additional incisions for the treatment of large sialoliths located in the parotid gland and the SMG. The purpose of this study was to investigate the advantages, disadvantages, and complications of the combined technique for sialolith removal. FIGURE 1. Small stone that could have been removed by sialendoscopy with a basket. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
hypertrophic scars.9,10 Transoral stone removal carries a high risk of lingual nerve damage11 and thus is useful only for retrieving well-palpated and proximally located stones. In cases of parotid stones, transoral access for stone removal is more complicated because of the com-
Material and Methods This retrospective study included the clinical and radiologic data of 37 patients who were referred to the Sialendoscopy and Minimal Invasive Surgery Service, Department of Oral and Maxillofacial, Rambam Health Care Campus (Haifa, Israel) from January 2011 through December 2012. This study followed the Declaration of Helsinki on medical protocol and ethics and was approved by the regional ethical review board of the Rambam Health Care Campus before data
FIGURE 2. Multiple large stones (arrow) in the parotid gland that could not be removed by pure sialendoscopy. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
739
KLEIN AND ARDEKIAN
FIGURE 3. Large stone of the proximal Wharton duct. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
collection. Included in this study were patients who had obstructive sialadenitis caused by sialolithiasis that could not be retrieved by a purely endoscopic technique because of the stone size or because of a tight stricture distal to the stone that could not be passed by the endoscope. Excluded from this study were patients with intraglandular stones and pediatric patients. SURGICAL PROCEDURE
All patients were treated by the combined approach for the SMG or parotid gland as described by the Marchal protocol in 2007.18 For the SMG, the procedure was performed under local anesthesia (lingual block) with light intravenous sedation using midazolam 2 to 5 mg. Cases with parotid stones were operated on only under general anesthesia. The aim of this approach was to identify and locate the stone using a diagnostic endoscope in combination with its illumination effect (Fig 4). For the SMG, after the location of a stone was identified, the sialendoscope was fixated and the sialolith could be removed by making a minimal intraoral incision that enabled the separation and protection of the lingual nerve (Fig 5). For the parotid gland, the facelift ap-
proach with a Superficial muscular aponeurotic system (SMAS) flap was implemented (Fig 4). After identifying the Stensen duct, an incision was made along the duct and the stone was extracted. The buccal branch of the facial nerve was encountered, in 4 of the 6 parotid cases, along the crossing of the Stensen duct. In those cases, the nerve was safely separated from the duct. After stone extraction, further exploration of the duct by the sialendoscope was performed to remove more sialolith and maintain ductal integrity through ductal reconstruction. The duct was reconstructed with the aid of a pediatric nasogastric feeding tube that bridged the area between the ductal orifices (the original papilla) to the area behind the cut (Figs 6,7 it was removed 2 to 3 weeks after the procedure). The operating time for the SMG was 30 to 60 minutes (average, 45 minutes). The operating time for the parotid gland was 150 to 210 minutes (average, 180 minutes).
Results Thirty-seven patients (11 female, 26 male; average age, 49.4 yr; age range, 26 to 90 yr) were included in
740
SIALOENDOSCOPIC TREATMENT OF LARGE SIALOLITHS
FIGURE 4. Localization of the stone with the sialendoscope illumination effect. (arrow). Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
this study. Six patients had parotid gland obstruction and the other 31 had SMG obstruction. Seventeen patients had computed tomographic scan data performed by the referral institution; 18 patients had
Panorex radiographic data visualizing the sialoliths performed by the referral institution. Two patients who were directly referred to the authors’ department did not undergo any salivary
FIGURE 5. A minimal intraoral incision enables the separation and protection of the lingual nerve (black arrow). The stone within the Wharton duct (blue arrow) is visible. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
741
KLEIN AND ARDEKIAN
FIGURE 6. A stent (pediatric nasogastric tube) (arrow) bridging the gap in the Stensen duct. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
gland imaging before the sialendoscopy and the diagnosis was based on only clinical examination and direct visualization of the stone by the sialendoscope. The calculi varied from 5 to 45 mm (average, 10.4 mm). In 23 cases (62%), stones were located at the hilar part of the gland or in the proximal part of the duct
close to the hilum. In the other 14 cases (38%), the stones were located in the middle third of the duct. Seven patients had more than 1 stone in the duct that needed to be extracted by sialendoscopy with the aid of the basket, which was performed at the same session with the combined approach. In 2 cases in which the stone could not be identified by the endoscope
FIGURE 7. Panorex radiograph showing the stent (pediatric nasogastric tube) bridging the gap in the Wharton duct. Klein and Ardekian. Sialoendoscopic Treatment of Large Sialoliths. J Oral Maxillofac Surg 2014.
742 because of the ductal stricture, the Stensen duct was explored from the location of the stricture to the stone. The follow-up period ranged from 4 to 23 months. Thirty patients had no complications and were free of symptoms, with normal saliva secretion checked by milking the gland. Six patients with SMG sialolithiasis developed restenosis of the duct orifice and required additional sialodochoplasty, which was performed under local anesthesia. Only 2 of them required further sialadenectomy. One patient developed postoperative ranula, which was resolved by simple marsupialization administered under local anesthesia. None of the patients had neural damage. The 2 patients who required gland removal were regarded as having a major complication and the other 5 patients who required additional sialodochoplasty under local anesthesia were regarded as having a minor complication.
Discussion Sialolithiasis is the main cause of salivary gland obstruction and is detectable in more than 65% of cases.11 It was thought that 80% of sialolithiasis were located in the SMG and only 5% in the parotid gland.11 Recent works have shown that sialolithiasis of the parotid gland is not so rare and is found in up to 40% of patients.2 Sialendoscopy is a relatively new technique that enables the removal of calculi through the ductal system without having to perform gland removal. For the treatment of stones larger than 5 mm, a combination of sialendoscopy with additional techniques is required. Several methods have been described, such as the use of fiber optic laser to fragment large stones and retrieve the fragments through the Dormia basket.2 The limitations of this technique are numerous: the surgeon must have direct vision of the entire stone, this procedure is impossible to implement in a stenotic duct, and in cases of large stones located behind a stenosis, there is a strong possibility of damaging the ductal walls by the heat that is generated during the fragmentation phase in narrow ducts.18 Another limitation of this technique is the stone size, because it was found effective in fragmenting stones of only up to 6 mm.2 Extracorporeal shock wave lithotripsy is another method that attempts to fragment large stones in the salivary gland to cause spontaneous extraction through the salivary ductal system or in combination with endoscopic assistance. With this method, however, favorable results are achieved mostly with stones 7 to 12 mm.19,20 A further disadvantage of this method is that it requires several sessions to sufficiently fragment the stone. Nahlieli et al21 described an external approach for parotid stone removal through a horizontal cut above the stone after its identification by the sialoendoscope. However, this technique is limited to stones close to the outer skin surface (and should
SIALOENDOSCOPIC TREATMENT OF LARGE SIALOLITHS
not exceed 6 mm from the surface). In addition, this method can leave visible scar and provides limited exploration of the duct. The present study of the combined technique showed good results for removing a large sialolith or proximally located sialolith, which could not have been removed by sialendoscopy alone. The main advantage of this method is that it provides an easy solution for salivary obstructive disease caused by a sialolith and is not limited to stone size or its location along the salivary ductal system. The combined procedure for the SMG can be an in-office procedure without the need for general anesthesia. This fact alone expands treatment options and makes it suitable for treating elderly and medically compromised patients who cannot be treated under general anesthesia. The benefit of using the sialendoscope in the combined technique is not only for stone location. The use of the endoscope enables further exploration of the remaining duct to remove more sialoliths. The sialendoscopy serves as a diagnostic and treatment tool in this matter. The authors insisted on having computed tomographic scans only in cases in which the sialolith could not be located by the endoscope because of a distal stricture. In the authors’ department, the average time of the SMG combined approach is almost equal to SMG removal owing to sialolithiasis, but in the combined approach for the SMG, there is no need for hospitalization or general anesthesia. The authors could not compare the operating time of parotid combined approach with an open approach or parotidectomy because they do not perform parotidectomy as a treatment for sialolithiasis. However, they believe that the operating time would not be shorter because of the scars and glandular hyperemia caused by chronic infections and the necessity for facial nerve preservation. The rate of major complications for the combined approach was very low: Only 2 of 37 cases required gland removal after the procedure. None of the patients developed nerve injury after the procedure. Patients with minor complications were treated in an ambulatory setting with local anesthesia. The combined technique showed good results for removing larger sialolith or proximally located sialoliths that could not have been removed by sialendoscopy alone. Use of the endoscope enables further exploration of the remaining duct to remove further sialolith and to reconstruct the duct after sialolith removal. The technique is not limited to stone size or location along the duct. Acknowledgment The authors thank Professor Francis Marchal for his support and guidance in implementing this technique in the Sialendoscopy and Minimal Invasive Surgery Service, Department of Oral and Maxillofacial Surgery, Rambam, Health Care Campus.
KLEIN AND ARDEKIAN
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