Minimally invasive surgery of sialolithiasis using sialendoscopy

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.     

Diagnostic and treatment effects of sialendoscopy for patients with swelling of the parotid gland when sialoliths are undetected with computed tomography

Between August 2009 and May 2016, 74 patients underwent sialoendoscopic surgery. 32 patients had parotid gland disease and 9 patients had intermittent swelling of the parotid gland and sialoliths were not detected with CT imaging. 4 patients were diagnosed with idiopathic Stensen’s duct stenosis. Sialendoscopy directly confirmed Stensen’s duct stenosis in 2 patients. However, the sialendoscope was unable to be inserted in the other 2 patients, who had stenosis of the orifice of the Stensen’s duct. Balloon expansion of the duct was performed in these 2 patients and a steroid drug was injected into the duct in one patient. Complete remission was archived in one patient treated with sialendoscopy. Three patients had sialolithiasis. Microsialoliths and/or white floating matter was observed and removed using sialendoscopy. All patients experienced complete remission. In cases of Sjögren syndrome and recurrent parotitis, sialendoscopic surgery was performed, but the symptoms showed no improvement. For patients with microsialoliths, sialendoscopy may be most useful for diagnosis and treatment when the sialoliths are not detected with CT imaging. At present, sialendoscopic surgery have limitation in the treatment of Stensen’s duct stenosis and may similarly have limitation in the treatment of Sjögren’s syndrome and recurrent parotitis.     

Combined sialendoscopic/mini-preauricular microscopic approach for large proximal parotid sialolithiasis

ObjectiveTo describe and evaluate a combined approach for sialendoscopic stone localization with microscopic mini-preauricular incision external stone extraction as a gland-sparing minimally invasive surgical management in cases of large proximal duct or intraparenchymal parotid gland sialolithiasis.MethodsA retrospective chart review of a single primary surgeon's patient series of 21 cases operated in a 5-year period in a tertiary care university and private practice hospitals.ResultsStudy included 16 males and five females, with age range 12–68 years (mean 40.9 ± 14.5). Nineteen out of the 21 patients had their stones completely removed (90.5%), with two not completing the procedure due to inability of intraoperative endoscopic stone visualization. In total 25 stones were extracted with six patients having two stones. Longest diameter of single (or first) stone was 5–16 mm (mean 9.1 ± 2.9) and second was 3–5 mm (mean, 3.9 ± 0.6). Endoscopic findings showed 14/25 stones in the proximal main parotid duct and 11/25 in one of its secondary parenchymal branches. Stents were used in 4/19 cases (21.1%). No major complications occurred. Minor complications included two postoperative conservatively managed seromas. All 19 cases had completely intact facial nerve function, good parotid salivary flow and acceptable esthetic result after median follow-up period of 26 months (range 6–62).ConclusionThe combined sialendoscopic/microscopic mini-preauricular approach is a highly effective and safe gland-preserving method for large proximal parotid sialolithiasis management with a main limitation being inability to visualize the stone endoscopically.     

Sialendoscopy and associated complications: a preliminary experience

OBJECTIVES/HYPOTHESIS: To review our experience with diagnostic and therapeutic sialendoscopy for the management of major salivary gland disorders with respect to complications and also to validate its use in our patient population. STUDY DESIGN: Retrospective chart review. METHODS: We identified 56 consecutive cases of sialendoscopy procedures performed over 2 years in the Department of Otolaryngology at the University of Pittsburgh from July 2005 to August 2007. RESULTS: The mean age of presentation was 43 (range, 7-77) years, with a male to female sex ratio of 1:2. The most common indications included sialolithiasis (52%) followed by salivary gland swelling (16%). The average size of the stones ranged from 2 to 12 mm. The overall success rate for endoscopic stone removal was 74% (14 of 19). Three (3 of 29) patients required a planned combined technique for stone removal. The overall complication rate was 25% (14 of 56). The major and minor complication rates were 2% (1 of 56) and 23% (13 of 56), respectively. CONCLUSIONS: Sialendoscopy is a safe and effective technology for treating major salivary gland disorders. In the early phases of sequential learning, complications rates are significant. However, major complications are infrequent and in general can be salvaged by standard salivary gland surgery.     

Sialendoscopy plus laser lithotripsy in sialolithiasis of the submandibular gland in 64 patients: A simple and safe procedure

ObjectiveTo demonstrate the safety and efficiency of holmium laser-assisted lithotripsy during sialendoscopy of the submandibular gland using a retrospective, interventional consecutive case series.MethodsWe performed 374 sialendoscopies between 2008 and 2015 and evaluated all patients regarding clinical symptoms, clinical findings, therapy and outcome. We performed 109 procedures of holmium laser-assisted lithotripsy in 64 patients whose sialoliths measured 5 mm or more in diameter. In addition to retrospective case note reviews, we performed telephone interviews of all patients in January 2017.ResultsWe performed 374 consecutive submandibular gland sialendoscopy procedures in 276 patients between 2008 to 2015. Sialolithiasis had either previously been diagnosed, or symptoms highly suggestive of sialolithiasis of the submandibular gland presented in 197 patients.Holmium laser-assisted Laser lithotripsy was performed in 109 cases (64.9%). Smaller mobile concrement was removed directly either by forceps or wire basket, or following marsupialisation of the submandibular duct. This was the case in 88 patients (29.1%). Three patients (0.8%) required surgical removal of the submandibular gland due to early abscess. The majority of patients (n = 374 procedures; 90.1%) remained symptom-free after two or more years following intervention. In the remaining procedures (n = 37 procedures; 9.9%), patients reported discreet postprandial problems but did not seek medical attention. In total, we managed to preserve the submandibular gland and avoid open surgery in 99% of patients through endoscopic management of submandibular concrement and duct stenosis.ConclusionHolmium laser-assisted lithotripsy is a simple, safe, and effective procedure for treating patients with sialolithiasis of the submandibular gland. Removal of the gland is rarely required, and removing the gland without prior sialendoscopy is no longer recommended. It should be offered to all patients with submandibular gland sialolithiasis, or such patients should be referred to the appropriate centre for sialendoscopy before submandibulectomy is considered.     

Sialendoscopy for sialodocholithiasis following submandibular gland excision: six variations on a theme

Sialendoscopy is a minimally invasive technique that facilitates the diagnosis and treatment of sialolithiasis. This case series presents the novel use of sialendoscopy to treat sialodocholithiasis in six patients with a non-functional or surgically absent submandibular gland by a single surgeon at the University of Pennsylvania Health System between March 2013 and December 2019. The four female and two male patients had a median age of 56 years and mean follow-up of 16.2 months (range 1–44.5). All stones were successfully removed using sialendoscopy, and in 5 patients a combined approach was utilized. All patients remain asymptomatic at last clinical follow-up. We conclude that sialendoscopy is a viable, minimally invasive method for managing sialodocholithiasis in patients with prior submandibular gland excision or atretic gland. It is also useful as an assistive tool when approaching complex transcervical or transoral procedures in previously instrumented patients.     

Sialendoscopy of the salivary glands

INTRODUCTION: Sialoendoscopy is a simple efficient mode of treatment for major salivary gland sialoliths and strictures. METHODS: Sialendoscopy procedure requires specific devices, diagnostic and therapeutic sialendocopes, minigrasping forceps, wire baskets, lasers, balloons and stents. The sialendoscopy procedure is divided in three steps: the duct introduction step (through the papilla or through the duct wall); the diagnostic step (from main duct to third or fourth salivary division branches) and the therapeutic step (stone removal with a Dormia basket or miniforceps and stenosis balloon dilatation). The feasibility of stone removal depends on the size, the position, the mobility and the shape of the stone. The only contraindication is acute sialadenitis. DISCUSSION: Sialendoscopy complications are minor. Its success rate for stone removal is greater than 90%, and it has dramatically reduced the rate of sialadenectomy (to less than 5%).     

Algorithm changes in treatment of submandibular gland sialolithiasis

Our research was conducted to determine the algorithm changes during the treatment of submandibular sialolithiasis. Two time periods were compared between 2004–2008 and 2009–2012. The turning point was December 2008, when sialendoscopy procedure was introduced. In the first period, 48 patients were treated: 31 outpatient duct incisions with stone evacuation and 17 surgical excision of submandibular gland. In the second period, 207 sialendoscopy procedures were performed on 197 patients. Out of this particular group, 158 patients were diagnosed with pathological obstruction of salivary glands and 64 of them were confirmed to have sialolithiasis of submandibular gland. Deposits of calcifications in 40 individuals (62.5 %) affected by sialolithiasis were removed endoscopically; however, in 21 patients, due to the increased circumference of the stone, the intimate association of deposits within the wall of the duct along with its presence inside the deep portions of the gland, double approach (incision of the floor of the mouth in hilar area and sialendoscopy) was performed. Three individuals had their salivary glands totally removed due to the presence of calcified deposits within the glandular parenchyma. Our results allow us to affirm that sialendoscopy is the current treatment of choice for submandibular glands affected by sialoliths. Indication for a complete removal of the gland is becoming uncommon as a first line treatment although still indispensable in chosen cases.     

Pediatric salivary gland obstructive swelling: sialendoscopic approach

OBJECTIVE: To assess the efficacy of sialendoscopy as a diagnostic and interventional procedure for salivary ductal pathologies of children. DESIGN: Prospective case series study. SETTING: Tertiary care teaching hospitals. PATIENTS: Eight children were investigated under general anesthesia by sialendoscopy for recurring salivary gland swellings between 2003 to 2004 in two university centers. INTERVENTION: Diagnostic sialendoscopy was used for classifying ductal lesions as sialolithiasis or stenosis. Interventional sialendoscopy was used to treat these disorders. Different variables were analyzed: type of endoscope used, intraoperative findings, type of device used for sialoliths fragmentation or extraction, total number of procedures, and size and number of sialoliths removed. RESULTS: Five cases of parotid and three cases of submandibular gland recurring swellings were included in the present study. Diagnostic sialendoscopy was possible in all cases. Salivary stones were found in six patients and parotid ductal stenosis in the remaining two. Multiple stones were seen in two cases. Interventional sialendoscopy was also possible in all cases, allowing an intraductal retrieval of the stones in three cases, and a marsupialization of the duct in two cases. Two cases required laser fragmentation of the stone. No major complications occurred intraoperatively or during follow-up (mean 18 months). CONCLUSION: Diagnostic sialendoscopy is a new technique allowing a reliable evaluation of salivary ductal disorders in children, with low morbidity. Interventional sialendoscopy allows early treatment of pediatric sialoliths and stenosis in most cases, avoiding classical open surgery.     

Minimally invasive options for salivary calculi

The aim of this study was to review the advantages, limitations, and international interdisciplinary expert perspectives and contrasts of salivary gland endoscopy and transoral techniques in the diagnosis and management of salivary gland calculi and their adaptation in North America. The transition from transcervical approaches to strictly sialendoscopic approaches is a broad chasm and often not feasible. Sialendoscopy, sialendoscopy-assisted, intraoral, and transcervical approaches all have surgical value. Diagnostic sialendoscopy, interventional sialendoscopy, sialendoscopy-assisted, and transoral techniques have been a major step forward, not only in providing an accurate means of diagnosing and locating intraductal obstructions, but also in permitting minimally invasive surgical treatment that can successfully manage blockages precluding sialoadenectomy in most cases. A flexible methodology is required. Multiple or combined measured may prove effective.     

The landmark for removal of sialoliths using sialendoscopy alone in parotid gland sialolithiasis

Objective

To assess the general guidelines for removal of sialoliths in parotid gland sialolithiasis using sialendoscopy alone.

Treatment outcomes of sialendoscopy for submandibular gland sialolithiasis: The minor axis of the sialolith is a regulative factor for the removal of sialoliths in the hilum of the submandibular gland using sialendoscopy alone

Objective

To assess the general guidelines for the removal of sialoliths for submandibular gland sialolithiasis using sialendoscopy alone.

Specificity of parotid sialendoscopy

OBJECTIVE: To present our initial experience with sialendoscopy of the parotid duct. STUDY DESIGN: METHODS: Diagnostic and interventional sialendoscopy procedures were performed in 79 and 55 cases, respectively. Diagnostic sialendoscopy was used to classify ductal lesions into sialolithiasis, stenosis, sialodochitis, and polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolithiasis fragmentation and/or extraction device used, the total number of procedures, the type of anesthesia, and the number and size of the sialoliths removed were the dependent variables. The outcome variable was the endoscopic clearing of the ductal tree and resolution of symptoms. RESULTS: Diagnostic sialendoscopy was possible in all cases, with an average duration of 26+/-14 minutes and no complications. Interventional sialendoscopy was successful in 85% of cases, with an average duration of 73+/-43 minutes (+/- standard deviation). Multiple procedures were performed in 45% of cases, general anesthesia was used in 24%, and parotidectomy in 2%. Multiple sialoliths were found in 58% of ducts and associated with more procedures under general anesthesia and longer operations. The average size of sialoliths was 3.2+/-1.3 mm; larger stones were associated with more procedures under general anesthesia, longer and multiple procedures, use of fragmentation, and sialendoscopy failures. Sialolithiasis fragmentation was required in 10% of cases, with a success rate of 70%. Semirigid sialendoscopes performed better than flexible ones. Complications were mostly minor but were encountered in 12% of cases. CONCLUSIONS: Diagnostic sialendoscopy is a new technique for evaluating salivary duct disease, a technique which is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, preventing open gland excision.     

Moderne Konzepte zur Diagnostik und Therapie der Sialolithiasis

Sialoliths are the underlying cause of salivary gland obstructive disease in 60%–70% of cases. Modern minimally invasive techniques have enabled accurate diagnosis and findings-specific therapy with the aim of full gland-function preservation. This article provides an overview of the current diagnostic measures for and therapy of sialolithaisis. Ultrasound is the investigation of first choice and is able to recognize stones in well over 90% of cases. Sialendoscopy is a directly visualizing technique which is superior to all other diagnostic measures for the assessment of pathologic changes in the salivary duct system and the detection of stones. Treatment was significantly improved with the introduction of extracorporal shock wave lithotripsy (ESWL), sialographic-controlled techniques, surgical procedures of the duct system and in particular by interventional sialendoscopy. Interventional sialendoscopy, especially when combined with other treatment modalities, has a success rate of 85%–95%. Cases which respond poorly to therapy can be treated successfully with the endoscopic transcutaneous approach in about 90% of cases. When sialendoscopy is performed in combination with other minimally invasive treatment options the gland can be preserved in 95%–98% of all cases.     

Economic analysis of the contribution of sialendoscopy in managing non-tumoral principal salivary gland pathology in the Réunion Island: Economic evaluation following the CHEERS methodology

GoalsCost analysis of the contribution of sialendoscopy in the treatment of non-tumoral pathologies of the main salivary glands, in Réunion Island, a French overseas territory.ObjectivesCalculation and comparison of median pricing (i.e., median payment to the healthcare establishment) per patient before and after the introduction of sialendoscopy, in the only regional establishment practicing sialendoscopy and in the whole of Réunion Island.Material and method A multicenter retrospective cost study was conducted over an 8-year period, before and after the introduction of sialendoscopy (period A: 2011–2014 and period B: 2015–2018), according to the CHEERS guidelines for economic studies, and included inpatients with non-tumoral pathology of the main salivary glands, whether treated by sialendoscopy or not.ResultsTwo hundred sixty-five patients were included, 139 of whom were treated by sialendoscopy: 74 in 2011–2014 and 191 in 2015–2018. Between the two periods, median pricing in the only center practicing sialendoscopy did not vary significantly: €3468 vs. €3368 (i.e., +2.9% (P = 0.1)). In the Island as a whole, pricing increased significantly: €598 vs. €2332, (i.e., +390% (P < 0.0001)).ConclusionSialendoscopy is cost-effective in France in the public healthcare sector if outpatient management is optimal, but significantly increases the public health budget. It makes it possible to recruit and manage previously untreated patients (small stones, salivary strictures, etc.).     

Combined endoscopic and transcutaneous approach for immobile parotid stones

Conclusion: Salivary stones in the parotid gland that are not amenable to endoscopic extraction can safely be removed by a combined, endoscopic-external approach. Objective: Limitations for endoscopic removability of salivary stones from the parotid gland are immobile stones in the deeper salivary duct system. A combined endoscopic and transcutaneous approach gives access to these stones with possible preservation of the parotid gland. Methods: A total of 10 consecutive patients were treated using the combined approach for the management of sialolithiasis of the parotid gland. The patients had previously undergone a sialendoscopy under local anesthesia and were proven to have large, immobile salivary stones in the salivary duct. Results: In all patients, the procedure was successfully conducted with extraction of impacted stones. In 60% of the patients, a temporary stenting of the salivary duct was performed. All patients showed good clinical results with restored drainage of the salivary duct system and preserved gland function.     

Salivary gland endoscopy: new limits?

Sialendoscopy is a new minimally invasive technique allowing exploration of the submandibular and parotid ducts with treatment for sialolithiasis and stenosis. Used for diagnostic purposes, sialendoscopy may be an alternative to classical radiological methods. As an interventional technique, it allows a significant reduction in the number of indications for submandibular and parotid resections.     

Salivary stones and stenosis. A comprehensive classification

INTRODUCTION: Sialendoscopy and sialoMRI enables diagnosis of salivary gland obstructive pathologies, such as lithiasis, stenosis, and dilatations. Therefore, a classification of these pathologies is needed, allowing large series comparisons, for better diagnosis and treatment of salivary pathologies. MATERIAL AND METHODS: With help from people from the European Sialendoscopy Training Center (ESTC), the results of sialographies, sialoMRI and sialendoscopies, a comprehensive classification of obstructive salivary pathologies is described, based on the absence or presence of lithiasis (L), stenosis (S), and dilatation (D) ("LSD" classification). DISCUSSION: It appears that a classification of salivary gland obstructive pathologies should be described. We hope it will be widely used and of course criticized to be improved and to compare the results of salivary gland diagnostic methods, such as sialography and sialendoscopy, and also the results and indications for salivary gland therapeutic methods, such as lithotripsy, sialendoscopy, and/or open surgery.     

Sialendoscopy in children

Background

The definitive cause of most cases of recurrent salivary gland inflammation in children remains unknown. Relatively little has been written about the use of sialendoscopy as a diagnostic and therapeutic tool in children.

Objective

To evaluate the safety and efficacy of sialendoscopy as a diagnostic and therapeutic tool for recurrent salivary gland inflammation in children.

Study Design

Retrospective case series.

Methods

Medical records of all patients who underwent sialendoscopy for recurrent salivary gland inflammation from a single tertiary-care pediatric otolaryngology practice were reviewed. Comparison of pre-procedure vs. post-procedure frequency and severity of disease was reviewed. Operative reports, images, and video were analyzed for causes of inflammation.

Results

Six patients (aged 3-16 years old) underwent sialendoscopy (3/6 bilateral parotid, 2/6 unilateral parotid, 1/6 unilateral submandibular). There were no complications. No post-operative recurrence was noted in 3/6 patients; decreased frequency of recurrence was noted in 2/6 patients; repeat sialendoscopy was required in 1/6. Operative findings from sialendoscopy from 10 parotid glands showed fibrinous debris (7/10), mucoid debris (1/10), purulent debris (1/10), or duct stenosis (1/10). No stones were noted.

Conclusions

Sialendoscopy is a safe, minimally invasive procedure that may decrease the frequency of recurrences for salivary gland inflammation in children. In contrast to previously published work, the most common cause of salivary gland obstruction in this series was debris, rather than stones. Increased use of sialendoscopy as a diagnostic and therapeutic tool will allow for improved understanding of the causes of and management for recurrent salivary gland inflammation in children.