No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Extraoral parotid sialolithotomy
Abstract
The extraoral approach to duct surgery for the removal of parotid stones can be a simple procedure once the stone is accurately located in relation to the skin surface. The combination of sialography and sonography can provide this information. A case report demonstrates the step-by-step approach to diagnosis, localization, and surgery for the management of such extraglandular sialoliths.
... Transfacial stone removal with combined endoscopic and transfacial techniques have been described as an alternative for large parotid stones (6-8 mm and greater), intraglandular stones, and stones adherent to the duct wall. [12][13][14][15][16][17] The combined transfacial approach is defined as a technique of stone localization with either ultrasound and/or sialendoscope followed by stone removal through an external incisional approach, most commonly the modified Blair incision. Outcomes and safety regarding facial nerve preservation have been shown to be favorable in the literature to date. ...
... Outcomes and safety regarding facial nerve preservation have been shown to be favorable in the literature to date. [12][13][14][15][16][17] In addition, in the current medical climate, maximizing efficiency and resources is paramount. The aim of this investigation was to review outcomes of our series of combined transfacial and endoscopic parotid stone removal, and perform a cost-effective analysis comparing it to traditional parotidectomy. ...
... The transfacial gland-sparing approach to parotid stones described by Baurmash and Dechiara in 1991 relied on preoperative planning using radiographs and ultrasound, without intraoperative imaging. 12 This first approach developed involved an incision directly over the stone. With the advent of sialendoscopy, Nahlieli et al. reported a series of twelve patients using a similar external approach aided by transillumination from the salivary endoscope in 2002. ...
Objective:
Examine outcomes of transfacial gland-preserving removal of difficult parotid stones and compare the cost and operative time to traditional parotidectomy.
Study design:
Cost-effectiveness analysis and retrospective chart review.
Methods:
Patients who underwent transfacial removal of symptomatic parotid sialoliths at a tertiary medical center from June 2010 to July 2015 were evaluated. Outcomes included operative technique, stone size, stone location, complications, and symptom relief. In addition, patients who underwent traditional parotidectomy for chronic sialadenitis were identified. The charges and times for both procedures were reviewed and compared.
Results:
Forty-four patients underwent transfacial resection for symptomatic parotid sialolithiasis. Stones were most often located in the main duct and hilum (53.3%), with fewer intraglandular stones (46.7%). No facial nerve weakness was observed. Of those with follow-up, 33 (87%) patients reported at least partial resolution of symptoms. Overall transfacial technique charges were significantly less expensive (U.S.$) than parotidectomy (mean difference -8,064.09; 95% confidence interval [CI] -13,472.78 to -2,655.40; P = 0.033). Anesthesia charges (mean difference -2,997.85; 95% CI, -5,748.81 to -246.89; P = 0.035) and operating room charges (mean difference -4,793.91; 95% CI, -8,958.09 to -629.72; P = 0.028) were also less expensive for the transfacial technique. Finally, mean procedure time for transfacial removal of parotid stones was shorter than for parotidectomy (120.2 ± 49.9 vs. 178.4 ± 41.3 minutes, respectively; P = 0.002).
Conclusion:
Transfacial gland-preserving removal of difficult parotid stones is a well tolerated and effective alternative to parotidectomy. Moreover, it is faster and less expensive than parotidectomy, maximizing both surgeon time and hospital resources.
Level of evidence:
4. Laryngoscope, 127:1080-1086, 2017.
... Plain radiographs have little role, because the majority of parotid sialoliths (67%) have been reported to be radiolucent [6]. CT is very sensitive in detecting even small deposits of calcium and can demonstrate coexisting diseases [7]. However, artifacts due to dental fillings may obscure small, semicalcified, or distally located stones. ...
... Advanced damage to the parotid gland may require removal of the gland. The size and location of the sialolith determines the treatment options, which may vary from institution to institution [6,7]. The puffed-cheek technique is useful in detecting small, distally located sialoliths. ...
Despite advances in technology, the radiologic assessment of certain head and neck lesions may still pose difficulties because of the complex anatomy of this region, the small and mobile structures that this region harbors, and the apposition of mucosal surfaces in the neutral position. Certain maneuvers have been described in the literature to overcome these difficulties. We review the use of the Valsalva and the modified Valsalva maneuver, the puffed-cheek technique, phonation, and inspiration, with possible applications in head and neck imaging.
... Baurmash reported a case in which transcutaneous stone extraction was carried out after ultrasound and sialographic marking. 15 Three publications describe the technique of transcutaneous stone extraction with simultaneous sialendoscopic guidance. The main indications were refractory or large stones. ...
... The transcutaneous surgical procedure presented here completes the concept of minimally invasive surgery. Transcutaneous stone extraction alone, under ultrasound guidance, as described by Baurmash et al, 15 does not allow protection of the tissues in the way that the additional use of sialendoscopy does. In our cases, transillumination of the tip of the endoscope introduced into the duct system turned out to be an important prerequisite for a technique with minimum tissue damage, as it marked the surgical approach precisely (Figs 1 and 2). ...
Despite all the advances of minimally invasive surgery, refractory stones remain in 10 to 20 percent of all cases of parotid gland sialolithiasis, and persistence of the symptoms makes removal of the gland inevitable. In some of these cases, however, it may be possible to conserve the gland using a combination of endoscopic and transcutaneous procedures.
Case series with chart review.
Tertiary referral center.
Nine patients treated with a combined endoscopic transcutaneous operation were evaluated. During this procedure, the stone is removed through a skin incision under endoscopic guidance. Indications were sialolithiasis refractory to treatment (n = 5), sialolithiasis with complications (n = 2), contraindications to primary minimally invasive surgery (n = 1), and primary treatment (n = 1). In seven cases, the stones were extracted. Simultaneous resection of a sialocele was carried out in one case, and simultaneous resection of a saliva-cutaneous fistula was carried out in another. A stent was inserted in 66.7 percent of the cases.
Treatment was successful in 88.9 percent of the patients. All of these patients were free of stones and symptoms, and glandular function was maintained both clinically and on ultrasound assessment. Complete parotidectomy had to be carried out in one case because it was not possible to reconstruct the duct system.
The combined operation offers a further option for gland-conserving treatment in cases with obstructive salivary gland disease, especially sialolithiasis. At present, it is indicated for cases that are resistant to treatment after sialendoscopy or extracorporeal shock wave lithotripsy. The gland resection rate can thus be further reduced.
... The integration of external and endoscopic techniques is not a novel concept. Early innovators like Baurmash and Dechiara [5] pioneered extra-oral sialolithotomy without parotidectomy, using plain radiographs and high-definition ultrasound to locate and remove stones. This marked a significant shift away from traditional gland removal. ...
Background/Objectives: The failure rate of minimally invasive surgical approaches to parotid stones is about 10%, primarily due to the presence of large, impacted, or unpalpable deep stones. When stones are palpable and exceed 7 mm in size, a combined transfacial and sialendoscopic approach offers a safe and effective surgical option, while unpalpable and impacted stones located in the parenchyma, not visible or accessible through sialendoscopy, can be treated with a CT-guided transfacial approach. Methods: Twenty-two patients (three females, mean age 53 years, range 32–73 years) underwent CT navigation-assisted transfacial removal of unpalpable and impacted parotid stones at the Department of Otolaryngology and Head and Neck Surgery of Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan between 2017 and 2024. Results: The mean size of the stones was 7.4 mm (range 4–14 mm), while the mean depth of stones, calculated as the distance from the skin surface, was 8.7 mm (range 4–14 mm). Stones were removed successfully in all but five patients (77% success rate). Failure of the procedure was significantly associated (p < 0.05) with the depth of the stone (>12 mm); in all these cases, patients were treated immediately by means of traditional parotidectomy. Conclusions: The CT-navigation-assisted transfacial approach can be considered a safe, reliable, and efficacious option for the treatment of difficult unpalpable parotid stones, impacted and deeply located in the gland parenchyma. Stones deeper than 10 mm can be more effectively treated by means of traditional parotidectomy if extracorporeal lithotripsy is not available.
... 10 The role for transfacial gland-preserving removal of parotid stones is still being defined-but has been reported to be a successful alternative to parotidectomy to often maintain salivary flow. 11,[14][15][16] We report lengthy follow-up results of a large series of patients with parotid sialolithiasis in an evaluation of transoral and transfacial sialendoscopy-assisted stone removal. ...
Objectives
Present follow‐up data comparing transoral and transfacial parotid gland procedures for stone removal to offer insight addressing technical considerations and complications.
Methods
Retrospective study of a consecutive series of surgical treatments for parotid sialolithiasis from 2013 to 2018 at an academic institution by one surgeon provided review of 16 transoral and 10 transfacial procedures supplemented by long‐term follow‐up through telephone or mail. Clinical and radiographic parameters, additional treatment, and persistence of symptoms were evaluated.
Results
Four of 10 patients treated with the transfacial approach had parotid‐cutaneous fistulas addressed with transdermal scopolamine patches and pressure dressings (one also with intraductal steroid infusion) with closure at a median of 12.5 days. A fifth fistula failed to resolve at 23 days and was addressed with parotidectomy. All 8 patients who were contacted (median: 106 months) reported complete resolution of symptoms. None had facial weakness.
Six of 16 patients treated by a transoral approach had persistent stone fragments at the conclusion of operation. Four of these 6 patients underwent subsequent procedures (two transoral, one transfacial, one parotidectomy). Among the 11 patients who responded to long‐term follow‐up (median: 107 months), one reported mild symptoms insufficient to request treatment. Larger stone size coupled with proximal location correlated with the conversion from transoral to include transfacial approach.
Conclusion
Patients with retained stone remnants at the conclusion of transoral stone removal are more likely to require additional procedures that result in long‐term favorable results. The transfacial approach to stone removal offers long‐term favorable results following the common short‐term complication of salivary fistula.
Level of Evidence
OCEBM Level 4.
... In the present patient, the quite-small adenoid cystic carcinoma was discovered coincidentally during an operation to remove a sialolith [6,7]. Some previous reports described a case of a large AdCC accompanying submandibular salivary gland sialolithiasis [8,9]. ...
... Patients are discharged with a pressure dressing and a 1-week course of antibiotics. The technique builds on that developed by Baurmarsh et al 19 where the stones were first localised through plain radiographs and high-resolution ultrasound, before a horizontal skin incision was made directly over the calculus to deliver the stone. This technique was limited to larger, more superficial stones, towards the anterior border of the masseter muscle. ...
Superficial parotidectomy has significant morbidity, and minimally invasive techniques have therefore been developed, including those involving sialendoscopy, to remove sialoliths and preserve the gland along with its function. The size, mobility and location of the sialolith, alongside the presence of strictures, all dictate management. We outline basic treatment paradigms and describe two sialoendoscopy-assisted surgical procedures developed for treating stones, one intraoral and one extraoral.
... The surgical option for these is parotidectomy with its attendant complications, notably injury to the facial nerve (9%), damage to the great auricular nerve, and Frey syndome [6]. Extraoral sialolithotomy without parotidectomy was first described by Baurmarsh and Dechiara in 1991 using plain radiographs and ultrasonography [7]. Later, extra-corporeal shock wave lithotripsy (ESWL) was proposed as an alternative therapeutic approach in the treatment of salivary stones [3]. ...
... celui-ci permet d'adapter au mieux la dissection pour atteindre le conduit parotidien en regard de la lithiase. Certains auteurs décrivent une incision cutanée directement en regard de la lithiase [8,9], outre une rançon cicatricielle majorée, cette technique donne une moins bonne visibilité lors de la dissection parotidienne et un risque accru de lésion du nerf facial, ce risque peut néanmoins être réduit en utilisant un monitorage nerveux. Le problème majeur de l'abord direct reste le risque de fistule salivaire cutanée au niveau de l'incision (nous en avons observé un cas sur un patient opéré par cette technique avant d'utiliser l'abord combiné). ...
INTRODUCTION
Sialendoscopy, extracorporeal lithotripsy and transoral removal are the usual treatments for parotid lithiasis. These techniques cannot treat all the patients. In fact, removal of lithiasis bigger than the ductal diameter and situated in the middle or posterior third of the duct may fail with such techniques. For this reason the combined approach has been developed. Our technical note describes this procedure.
TECHNICAL NOTE
Preoperative check-up needs an ultrasound or a CT scan of the parotid region. The procedure is conducted under general anesthesia. It begins with the localization of the lithiasis with help of the sialendoscope light visible through the skin. A face lift approach is performed giving access to the SMAS that is opened over the lithiasis and the transilluminated area. A window is opened on the duct and the lithiasis is removed. Proximal duct permeability is assessed with the sialendoscope. The different layers are sutured and a suction drainage is left in place.
DISCUSSION
Combined approach is indicated in case of failure of conservative techniques. It provides good results in removal of lithiasis located in the posterior or middle thirds of the duct. Its morbidity is low. It can avoid performing a parotidectomy and lowers the risk of facial palsy. In case of failure, botulinum toxin injection may be indicated.
Copyright © 2015 Elsevier Masson SAS. All rights reserved.
... For these patients, the combined endoscopic and transcutaneous technique for the management of parotid salivary gland stones is an excellent choice. According to the literature, this technique was first used in 1991, when a stone was located with the help of ultrasound and extracted through a small cutaneous incision [11] . The technique was later modified, and the light of the endoscope was used as transillumination to locate stones; a classic parotid incision was then made, and the stones were extracted through the duct with open access [12] . ...
Sialendoscopy is used in the diagnosis and treatment of various symptoms relating to the salivary gland, e.g. chronic swelling or obstruction and inflammation of the salivary duct. Small intraductal stones can be removed with various instruments during sialendoscopy, whereas larger ones can be fragmented with extracorporeal shockwave lithotripsy or laser. However, 5-10% of the patients with parotid stones cannot be treated with these methods. In patients with large impacted stones or stones in a hilus area, a combined endoscopic and transcutaneous technique can be employed. The stone is approached endoscopically, a skin flap is raised over or a small incision is made through the illuminated area, and the stone is removed by an external route with minimal morbidity. This retrospective study analysed the cases of 8 patients treated using the combined technique, 6 of whom became symptom free. Superficial parotidectomy was performed in 1 patient. No complications were observed, and ductal stents were not used. The average diameter of the stones was 7.6 mm (range 7.0-10.2). The combined technique is recommended for the removal of large and impacted intraductal stones in the parotid gland. No major complications have been reported. © 2014 S. Karger AG, Basel.
... To fill the gap, a new technique combining external and endoscopic surgery has recently been proposed as a less invasive alternative to traditional parotidectomy. Baurmash and Dechiara, 1991 described the first extra-oral sialolitothomy without parotidectomy supported by plain radiographs and high definition ultrasound. Nahlieli et al. (2002) similarly located stones by means of ultrasonography and/or sialendoscopy, and then removed them using a vertical skin incision. ...
Minimally invasive surgical approaches to parotid stones (such as extra-corporeal shockwave lithotripsy and sialendoscopy) have proved to be effective in a high percentage of cases, although success depends on factors such as the localisation of the stone, its size and its mobility. The failure rate of 10% is largely due to large and impacted stones and, in such cases, a combined external and sialendoscopic approach can be used to avoid morbidity and the risks of more invasive superficial parotidectomy. We treated eight patients with large parotid stones (>7 mm) using a sialendoscopy-assisted transfacial surgical approach that was effective in all but one case, which was successfully solved by combining this procedure with extra-corporeal lithotripsy and operative sialendoscopy. Our results confirm that the combined approach is a valid alternative to parotidectomy for large parotid stones and should be added to other minimally invasive techniques aimed at restoring the function of the affected parotid gland.
... The transcutaneous and endoscopic approach seems to be beneficial also in those cases, where ESWL is not available. The transcutaneous removal of stones under ultrasound guidance was described in 1991 by Baumarsh et al. [1]. The authors did not, however, use an endoscope to monitor the incision line of the duct. ...
Unlabelled:
The introduction of minimally invasive surgical procedures has significantly reduced the rate of major salivary gland removal due to sialolithiasis. The aim of this study is to assess the effectiveness of sialoendoscopy, rate of salivary fistula or natural ostium stenosis in parotid sialolithiasis treatment. The endpoint was to analyse the efficiency of a combined transcutaneous and endoscopic approach in the removal of refractory and impacted stones in most difficult cases.
Study design:
prospective study, tertiary university centre, between XII 2008 and XI 2011, 185 sialendoscopies (SE) were performed in 162 patients. Within the group of 29 patients with parotid sialolithiasis endoscopy was the definite treatment in 15 cases (53 %), in 9 cases lithotripsy (ESWL) was necessary and in 5 patients who failed SE and lithotripsy, a combined approach was performed. This approach comprised both SE and open surgery. We observed no salivary fistula formation after the incision of the duct. Stenosis of the natural ostium thanks to the insertion of stent was observed only in one case. Sialoendoscopy is the method of choice with a high rate of success and gland preservation in small and medium stones. The combined transcutaneous and endoscopic approach is indicated for large stones, for complications after and contraindications in using minimally invasive procedures. Short and medium term follow up shows that surgery can be performed with a high rate of success.
The aim of this study was to comparatively evaluate the indications and treatment outcomes of two transcutaneous approaches for the removal of impacted parotid stones. Sixty-eight consecutive patients with impacted parotid stones underwent endoscopy-assisted lithotomy via a direct mini-incision or a peri-auricular flap. Clinical safety and outcomes were evaluated. Complete stone extraction was achieved in all patients. In the mini-incision group (52 patients), the stones were in the middle third of the main duct in 31 patients, at the hilum in 16, and in the intraglandular duct in five. In the flap group (16 patients), they were in the middle third of the main duct in one patient, at the hilum in seven, and in the intraglandular duct in eight. Salivary fistula occurred in five mini-incision group patients (9.6%) and four flap group patients (25%). The clinical outcome in the mini-incision group (47 patients, median 25 months of follow-up) was good in 28 patients, fair in 13, and poor in six (12.8%). The clinical outcome in the flap group (16 patients, median 84 months of follow-up) was good in nine patients, fair in five, and poor in two (12.5%). The direct mini-incision approach was found to be safe and effective for impacted stones in the middle third, hilum, and proximal third of the main duct, while the peri-auricular approach would be best reserved for deeper intraglandular stones.
Objectives
The purpose of the present scoping review was to determine the contribution of ultrasound (US) images in the diagnosis of inflammatory and obstructive diseases of the major salivary glands (MSG).
Methods
A search of studies of ultrasonographic assessments of human samples was performed in several electronic databases and grey literature up to July 2021. The extracted data were the examined MSG; the diagnostic value of US (sensibility, specificity, positive and negative predictive value, accuracy); features of lesions, including number, echogenicity, echotexture, form, margins, size, posterior acoustic aspect, and location; and related clinical information, such as swelling, palpation, sensible to pain, salivation, lymph nodes, recurrence, duration, and causes.
Results
After verifying the eligibility criteria, 91 articles focused on detecting inflammatory, and obstructive diseases of the MSG were gathered, with variable study designs and size samples. A wide variety of pathologies were assessed, including sialolitiasis (n = 45), acute sialadenitis (n = 30), chronic sialadenitis (n = 25), granulamatous diseases (n = 15), Kuttner’s tumor (n = 11), juvenile recurrent parotitis (n = 9), abscess (n = 7), post radiotherapy sialadenitis (n = 6), sialadenosis (n = 9), abscess (n = 7), post radiotherapy sialadenitis (n = 6), sialadenosis (n = 9), IgG4 related disease sialadenitis (n = 5), HIV-sialadenitis (n = 4), obstructive sialadenitis (n = 3), iodinated contrast-induced sialadenitis (n = 2), and pneumoparotitis (n = 1). Most studies were case reports or series of cases. Few studies exhibited data about the accuracy of US in detecting MSG diseases.
Conclusions
The present scoping review concluded that US aspects of different MSG pathologies are similar but contribute to their differential diagnosis and can be considered as a valuable initial method for assessing the MSG of adults and children.
Objectives
To assess the long-term outcome of sialendoscopy-assisted combined approach for parotid sialolithotomy with gland preservation.
Patients and Methods
A retrospective study of patients treated with a combined sialendoscopic and open approach was conducted between 2011 and 2020. Demographic data of patients such as operative technique, stone size, stone location, complications, and symptom relief were collected. Patients were followed up via clinical examination and questionnaires.
Results
Seventy-four patients were included and underwent endoscopy-assisted combined operations for the removal of 98 parotid stones. Of the 98 stones, 92(94%) stones were completely removed and 6(6%) were partially removed. At a mean follow-up of 47.1±35 months, 65 of 74 patients (88%) achieved long-term success. Patients with stone incomplete removal were significantly more often to develop the recurrence of obstructive symptoms (P=0.000) There were no cases of facial nerve injury or fistula formation. Gland function was preserved in 73 of 74 patients (99%).
Conclusions
The combined approach for parotid stones is a safe and gland-preserving alternative to parotidectomy. The techniques described here show high success rates and good long-term results, and they avoided the need for gland resection in >95% of cases.
Résumé
Introduction
Les techniques mini-invasives (TMI) doivent être privilégiées pour le retrait des lithiases parotidiennes. Elles regroupent la sialendoscopie, la lithotripsie extracorporelle et la taille endobuccale. En cas d’échec, un abord combiné intra- et extra-oral peut être réalisé. Le but de ce travail était d’évaluer l’efficacité et les complications de ces abords combinés.
Matériels et méthodes
Une étude rétrospective a été réalisée sur des patients pris en charge entre 2006 et 2015. Tous les patients majeurs présentant une ou plusieurs lithiases parotidiennes et chez lesquels les TMI classiques avaient échouées ont été inclus. L’âge et le sexe des patients, le nombre, la taille et la localisation des lithiases, la réussite ou non de l’intervention, la survenue de douleurs, de gonflements ou d’infections ont été relevés.
Résultats
Neuf patients ont été inclus (âge moyen : 56 ans). Le recul moyen était de 48 mois. Quatre-vingt-huit pour cent des patients présentaient une seule lithiase. Neuf lithiases ont été extraites par abord combiné. Le diamètre moyen des lithiases était de 8,5 mm et 33 % d’entre elles étaient localisées à la jonction tiers moyen-tiers postérieur du conduit parotidien. Tous les patients présentaient des épisodes rétentionnels pluriquotidiens préopératoires avec des coliques (55 %) et des hernies salivaires (100 %). Deux patients présentaient une complication infectieuse à type de sialadénite et périsialodocholite. Soixante-quinze pour cent (9/12) des lithiases ont été extraites. Les complications ont été 1 fistule, 1 parésie faciale, 3 récidives. Sept patients sur 9 (77 %) ont été complètement soulagés après l’intervention.
Discussion
La chirurgie par abord combiné des lithiases parotidiennes est indiquée en cas d’échec des TMI lorsque les symptômes altèrent la qualité de vie.
To analyze the efficacy and safety of sialendoscopy and a combined transoral or transcutaneous and sialendoscopic approach in the removal of parotid gland sialoliths.
This retrospective study included 29 patients diagnosed with parotid gland sialolithiasis who required endoscopic-assisted gland preserving therapy. Ultrasonography and computed tomography were used to diagnose parotid sialolithiasis. The use of interventional sialendoscopy, sialendoscopic-transoral, or sialendoscopic-transcutaneous procedures was determined by the characteristics of the parotid gland stones.
The stones were extracted by interventional sialendoscopy in nine patients. The transoral procedure was performed in 15 patients with large stones which were impacted in the ductal wall. The remaining five patients were managed through an external approach via a local incision under sialendoscopy. No postoperative complications occurred. The parotid glands were functioning normally after the procedures.
The combined sialendoscopic-transoral and sialendoscopic-transcutaneous operation appears to be a good alternative for parotid gland sialolithiasis in the absence of lithotripsy devices. This type of therapy can, therefore, decrease the rate of parotidectomy.
Copyright © 2015 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Purpose:
This article describes the use of endoscopy for diagnostic and surgical intervention in the major salivary glands of patients who have obstructive pathology, reviews past experience with this technique, and describes the microanatomy and pathophysiologic findings encountered during endoscopy of these glands.
Patients and methods:
A total of 154 salivary glands (96 submandibular glands, 57 parotid glands, 1 sublingual gland) suspected of having obstructive pathology (89 males, 65 females; aged 5 to 72 years) were treated using a mini-endoscope. Most procedures were performed under local anesthesia in an outpatient clinic. All patients underwent preoperative and postoperative screening by routine radiography, sialography, and ultrasound. The indications for endoscopy were: 1) calculus removal that could not be performed by conventional methods, 2) screening of the salivary ductal system for residual calculi after sialolithotomy, 3) positive evidence of ductal dilatation or stenosis on the sialogram or ultrasound examination, and 4) recurrent episodes of major salivary gland swellings without known cause.
Results:
Of the 154 endoscopies performed, 9 were immediate failures as a result of technical problems. Of the remaining 145 glands, 112 had obstructions and 33 had sialadenitis alone. The success rate was 82% for calculus removal. Thirty-two percent of the submandibular and 63% of the parotid sialoliths, and the 1 stone in the Bartholin's duct, were undetected before sialoendoscopy. Multiple endoscopic findings were encountered. No major complications were noted.
Conclusions:
Sialoendoscopy is a minimal invasive technique for the diagnosis and removal of obstructive pathologic tissue in the major salivary glands.
Calcifications found in the salivary ducts or glands are called sialolithiasis or salivary gland stones. Submandibular gland is most commonly affected followed by parotid. The treatment options are limited, but include its surgical removal via dissection into the duct or gland. We present a case of 36 years male patient having large parotid duct sialolithiasis with sialo-oral fistula which was treated by intraoral surgical approach.
The etiology for salivary gland stone formation, one of the most common salivary gland problems, is still unkown. In many cases the diagnosis is easy due to obvious clinical features, but for treatment considerations, imaging studies are very often necessary. Sonography or MR sialography have replaced sialography in the evaluation of patients with sialolithiasis. Besides traditional surgical procedures, new conservative treatment modalities like extracorporeal shock wave lithotripsy or interventional sialendoscopy are now available for the management of salivary gland stones.
Objective
Review surgical techniques and outcomes of ultrasound-guided, transfacial, gland-preserving removal of difficult parotid stones.Study DesignCase series with chart review.SettingTwo academic tertiary care centers.Methods
Patients who underwent ultrasound-guided, combined transfacial-endoscopic operation for symptomatic parotid sialolithiasis from June 2010 through June 2012 at 2 tertiary care university hospitals were evaluated. Outcome measurements included stone size, stone location, complications, symptom relief, and gland preservation rate.ResultsA total of 14 patients underwent ultrasound-guided, transfacial operation for symptomatic parotid sialolithiasis. Ten of 14 patients (71%) had completely successful therapy defined by no symptoms postoperatively with a preserved, functional gland. Three of the 4 patients without complete symptom resolution did endorse symptom improvement, whereas the fourth patient eventually underwent parotidectomy. Needle localization was used to aid in transfacial stone retrieval in 57% of cases.Conclusion
Ultrasound-guided, combined transfacial-endoscopic removal of certain parotid stones is an alternative to parotidectomy for patients in whom endoscopy or shock wave therapy for stone retrieval is ineffective, unavailable, or contraindicated. Needle localization is a useful adjunct in stone retrieval.
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.
ISSN 1407-009X This paper reports seven cases of the treatment of salivary calculi disease in the origin of submandibular ducts. Extraoral sialolithectomy was performed. The cut of the ductal wall was sutured, using magnification, microsurgical instruments and suture material (size 8/0-10/0). The success of the operation was estimated by sialometry, sialography and scintigraphy. In six of seven cases, good flow of saliva was observed and the glands had well regenerated. In one case the salivary duct had closed, and in another case, recurrence of salivary stone 5-6 years after operation was observed.
10% of symptomatic parotid stones cannot be removed by minimally invasive radiological or endoscopic techniques alone. In these cases endoscopically assisted surgical parotid sialolithectomy can be performed via an extraoral approach, reconstituting the duct and preserving functioning glandular tissue. Between 2003 and 2010, 55 consecutive patients underwent endoscopically assisted surgical removal of parotid stones from 57 glands, two having bilateral procedures. Outcome was assessed using a structured questionnaire. 39/55 patients (71%) patients were successfully contacted (40 procedures; one bilateral case). At median follow-up of 3.1 years 28 glands (70%) were symptomless, whilst 11 (28%) were much improved but causing mild or occasional residual symptoms. One patient required postoperative lithotripsy and basket retrieval of a retained stone, but was subsequently symptom free. A further patient was initially symptom free then relapsed, did not respond to lithotripsy and is awaiting further assessment. In 10% of cases a short-lived sialocoele developed postoperatively. No individual reported facial weakness and one had a scar of concern. 37/39 (95%) patients were pleased to have had the operation and would have the procedure contralaterally in similar circumstances. Endoscopically assisted surgical removal of parotid stones is a successful technique with low morbidity that is well received by patients.
There are many different management strategies for salivary calculi within the parotid ducts. Commonly, the stones can be extracted via an intra-oral approach. Stones that are farther from the papillae require more complex management. This article describes a technique for extra-oral excision of palpable salivary calculi using known external facial landmarks and dissection. Two cases are discussed and illustrations shown, and a brief discussion of other techniques for the management of salivary stones is included.
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.
Treatment of obstructive diseases of the major salivary glands has undergone a dramatic change in the last 10 to 15 years. New minimally invasive techniques have been developed, covering all different entities that are included in the complex of salivary gland obstruction, and can help the physician to find the right diagnosis and an adequate treatment plan and to perform a gland-preserving form of therapy. Sialolithiasis or stenosis is the cause of about 90% of all obstructive salivary gland diseases. The development of radiologically or fluoroscopically controlled methods, but especially the introduction of sialendoscopy, has led to changes in the treatment protocol. Knowledge from the authors' experience and from a thorough investigation of the literature has been combined to elaborate algorithms for the treatment of the different obstructive diseases of the salivary glands. Sialoliths and stenoses can be successfully treated by radiologically or fluoroscopically controlled or sialendoscopically based methods in approximately 80% of cases. Extracorporeal shock-wave lithotripsy (ESWL) is successful in up to 50% of cases. Transoral duct slitting is an important method for extraparenchymal submandibular stones, with a success rate of 90%. Operative duct procedures and the combined endoscopic-transcutaneous approach complete the spectrum of treatment modalities of the parotid gland. Sialendoscopy plays a central role in the treatment of obstructive salivary gland diseases, but maximum success can only be attained by the reasonable combination of all these new minimally invasive techniques. Altogether, in well over 95% of cases, resection of the gland can be prevented, thus reducing morbidity and the surgical risks for patients.
The results of endoscope-assisted parotid surgery are presented as a minimally invasive alternative to parotidectomy for large parotid stones. From 1999 to 2007, 70 patients with parotid sialoliths were treated by minimally invasive surgical techniques in three specialist centres. At surgery a combination of sialoendoscopic and ultrasound examination was used to locate the stone within the duct. The calculus was released by incising the duct through a pre-auricular approach (40 patients) or by direct transcutaneous incision over the stone (27 patients). Four patients were treated using other minimally invasive procedures. Local anesthesia was used in 22 patients and general anesthesia in 48. The average follow-up was 25.5 months with two patients lost to review. In 3 patients treatment had long-term complications (persistent stone fragment; obstructive symptoms due to a fibrous stricture; a visible scar on the cheek). In one patient, endoscopy was abandoned due to stricture. 85 stones were retrieved successfully from 69 patients. The average size of the stones was 7.2 mm. There were no cases of facial nerve weakness or salivary fistula. The data suggest that endoscopic-assisted surgery is a viable alternate to adenectomy for the treatment of large or recalcitrant parotid stones.
To review our experience with the combined approach, which includes an internal (endoscopic) and open approach for the management of large salivary stones.
Retrospective.
Clinical data was reviewed on patients who underwent combined approach for large salivary stones from July 2005 to August 2008 under an institutional review board approved protocol.
Of 106 patients who underwent sialendoscopy, 19 patients (18%) had 20 combined procedures. Thirteen patients (68%) were women and six men (32%) with a mean age of 52 years (range, 15-69 years). Operative times were shorter for submandibular stones (mean, 90 minutes) as compared to parotid stones (mean, 133 minutes). Stone removal was successful in 90% (18/20) with no major complications and minor complications in four patients (20%).
The combined procedure allows complete removal of large or impacted sialoliths without the need for removal of the entire gland with acceptable complication rates. We also recommend consenting patients for this approach when a difficult endoscopic removal is anticipated. Laryngoscope, 2009.
Removal of a parotid duct calculus using a Dormia basket is described and the literature reviewed. To our knowledge, this procedure has not previously been reported.
We emphasise the importance of high-resolution CT with reconstruction in the demonstration of submandibular gland (SMG) sialolithiasis and its role in monitoring treatment. We studied 76 patients with swollen and tender SMG, some with fever. They underwent conventional radiography, sonography (US) and high-resolution CT with reconstructions. Conventional radiographs demonstrated single stones in 29 patients. Axial CT, before reconstructions, demonstrated single stones in 63 patients and multiple stones in another 5. Following CT reconstructions, multiple stones were demonstrated in 37 patients. On US stones were diagnosed in only 33 patients, and multiple stones in only 1. All 68 patients with stones shown on imaging and 2 without stones underwent surgery, with good clinical results. Total removal of the SMG and its duct was performed in patients with multiple stones, chronic inflammatory changes in the SMG, or a solitary stone in the SMG or deep in the duct. A small incision for removal of a solitary stone in the distal aspect of Wharton's duct was performed in 15 patients, with excellent clinical results. Another 14 patients with multiple salivary gland stones, diagnosed on CT reconstructions, did not improve following this procedure and needed further surgery; clinical improvement occurred following excision of the SMG and Wharton's duct. Histological examination in all of these confirmed the presence of additional stones. Conservative anti-inflammatory treatment was recommended for 6 patients in whom CT reconstructions did not demonstrate stones.
Sialolithiasis is one of the most common problems that afflict the salivary glands and is a major cause of salivary gland dysfunction. Sialolithiasis is frequently encountered in clinical practice. The mechanism for stone formation is incompletely understood. The clinical diagnosis and standard management of sialolithiasis are discussed, and new modalities for treatment are also presented in this article.
Small, semi-calcified parotid stones are difficult to diagnose as imaging can be extremely difficult. Understanding how to diagnose parotid stones is important to dentists, however, because people with this condition develop parotid swellings and may seek routine dental care.
The authors describe a classic case of parotid sialadenitis secondary to a small lucent stone in Stensen's duct. They discovered the stone only because of the keen sensitivity of computerized tomography, or CT, to minimal amounts of calcific salts. The CT scan's ability to accurately locate the stone and its position within 1 centimeter of the orifice facilitated a successful intraoral surgical approach.
CT can be a significant aid in early diagnosis and therapy of patients with parotid stones, who eventually develop sialadenitis. With early intervention, further gland degeneration and parotidectomy will be prevented.
The results achieved by experimental microsurgical suturing of salivary ducts in dogs are presented. Nine partial lesions and one complete transection of the ducts were made on parotid and submandibular ducts. Four to seven interrupted microsutures were used for each lesion. The operations were successful in seven out of 10 cases, as observed by sialography. Histologically, granulation tissue compressing the ducts was observed after suturing the lesions. Four venous graft transplantations were performed and none were successful. After venous graft transplantation, the transplant was not apparent histologically, raising doubt as to the potential success of this technique. The use of stenting is discussed based on a summary of the published literature. Those reports indicate that long-term stenting can benefit the outcome of salivary duct repair. The use of dogs as a model for experimental salivary duct operations has been shown to be valuable in assessing various surgical techniques.
This article describes the use of combined endoscopic and ultrasound approach to locate and to extract impacted parotid stones, which cannot be retrieved by intraoral approach alone.
A total of 12 parotid glands from 7 women and 5 men (age range, 35 to 62 years) with parotid sialoliths were treated with the combined method. Eleven of 12 of the procedures were performed under local anesthesia in an outpatient clinic. The identification of the calculi was done in 5 patients with 1.3-mm sialoendoscope (Nahlieli Sialoendoscope; Karl Storz, Tuttlingen, Germany) in 6 patients with the aid of high-resolution ultrasound, and in 1 patient the location was combined endoscopy and ultrasound. The removal of the calculi was performed extraorally via minimal incision. The indications for the combined approach were 1) calculus in the posterior third of the Stensen's duct with too narrow duct anterior to it, 2) obstruction of the posterior or middle third of the Stensen's ducts leading to the calculus, 3) large (>5-mm) stones in the middle or posterior part of the duct that cannot be dilated for intraductal removal, and 4) intraparenchymal stones.
Of the 12 patients, 9 had complete removal (75%); in 1 case with 3 sialoliths, we removed 2 and the gland remained asymptomatic. In 7 cases, the glands returned to function, 3 glands became atrophic with no function, but the gland remained asymptomatic. The aesthetic results were satisfactory in all cases, no major complications were noted.
Combined endoscopic ultrasound approach is another minimal invasive technique for identification and removal of impacted parotid sialolithiasis.
The treatment of large parotid stones remains a problem. We describe a technique in which microendoscopy is used to locate the stone and facilitate its removal. Over a 12-month period, eight patients were treated and seven stones removed successfully. The remaining duct was obstructed by a stricture. In six instances, the parotid duct was repaired and in two ligated. The mean follow up was 10 months (range 6-18) and there have been no complications. Our initial experience suggests that microendoscopy to locate the stone and facilitate its removal is an option in the management of persistent parotid stones.
Over the last fifteen years, increasing public demand for minimally-invasive surgery and recent technological advances have led to the development of a number of conservative options for the therapeutic management of obstructive salivary disorders such as calculi and duct stenosis. These include extracorporeal shock-wave lithotripsy, sialoendoscopy, laser intra-corporeal lithotripsy, interventional radiology, the video-assisted conservative surgical removal of parotid and sub-mandibular calculi and botulinum toxin therapy. Each of these techniques may be used as a single therapeutic modality or in combination with one or more of the above-mentioned options, usually in day case or one-day case under local or general anaesthesia. The multi-modal approach is completely successful in about 80% of patients and reduces the need for gland removal in 3%, thus justifying the combination of, albeit, time-consuming and relatively expensive techniques as part of the modern and functional management of salivary calculi. With regard to the management of salivary duct anomalies, such as strictures and kinkings, interventional radiology with fluoroscopically controlled balloon ductoplasty seems to be the most suitable technique despite the use of radiation. Operative sialoendoscopy alone is the best therapeutic option for all mobile intra-luminal causes of obstruction, such as microliths, mucous plugs or foreign bodies, or for the local treatment of inflammatory conditions such as recurrent chronic parotitis or autoimmune salivary disorders. Finally, in the case of failure of one of the above techniques and regardless of the cause of obstruction, botulinum toxin injection into the parenchyma of the salivary glands using colour Doppler ultrasonographic monitoring should be considered before deciding on surgical gland removal.
AND CONCLUSION
Sonography and computed tomography play complementary roles in imaging mass lesions in the salivary glands and their surroundings. Ninety per cent of parotid tumors originate from the superficial lobe, and we consider sonography to be the method of choice for imaging these lesions. The sensitivity of high-resolution sonography in detecting intraparotid tumors approaches 100 per cent, and ultrasound is therefore an excellent method to evaluate patients with parotid swelling. It may provide clinically useful information by precisely outlining the tumor borders or by detecting multiple or bilateral lesions. We restrict our use of CT to tumors that appear to extend beyond the borders of the parotid gland with possible invasion of surrounding soft tissues or bone. CT is also the method of choice for differentiating lesions of the deep lobe from parapharyngeal tumors and for staging carcinomas.
Although ultrasound supplemented with computed tomography should replace conventional sialography in the work-up of parotid neoplasms, sialography remains the method of choice for evaluating patients with chronic sialadenitis, autoimmune diseases, and sialolithiasis. The role of sonography in these conditions is limited to ruling out a parotid neoplasm, assessing the extent of abscess formation, or assisting in localizing calculi in selected patients.
To our knowledge, this is the first report of the use of ultrasound to demonstrate and localize calculi within the parotid gland. The preoperative localization of stones in superficial structures, such as the salivary glands, is beneficial in limiting the degree of surgical exploration. The diagnostic and therapeutic implications of preoperative ultrasonic assessment of salivary gland masses are not absolute and specific at present; however, ultrasound can give valuable information related to the surgical approach, since it clearly defines the size of the lesion and permits assessment of its character—calculus, cyst, or solid tumor. The technique is painless. It has been used effectively in both parotid and submaxillary gland masses.
In a blinded retrospective study of the efficacy of sonography of the salivary glands, we obtained sonograms on 849 patients. The patients were referred over the last 5 years from the ear, nose, and throat department of our university hospital. Eight-eight percent of the patients had symptoms related to the salivary glands. One hundred fifty-six of the patients (18%) were subsequently proved to be normal. The remaining 693 patients had diseases confirmed by histologic examination (332 patients), sialography (274 patients), or clinical follow-up (87 patients). Of these, 289 had salivary gland tumors (231 benign, 58 malignant), 185 had calculi, 154 had inflammation, 48 had autoimmune disease, 14 had cysts, and three had trauma. Two hundred eighty-seven (95%) of the 302 space-occupying lesions could be completely delineated by sonography, and the benign or malignant nature of the lesions was correctly assessed in 272 (90%). Of the 185 patients with calculi, the calculi were visualized and localized (intraductal vs intraglandular) on the sonograms in 174 (94%) patients. Abscesses were shown on the sonograms in 13 patients, and acute inflammation was shown on the sonograms in 84 patients. These results indicate that sonography is a useful procedure for diagnosis of diseases of the salivary glands.
Ultrasound examination for sialolithiasis was carried out in ten cases, and the findings were compared with those from sialography. Salivary stones were recognized as high-level reverberation echoes accompanied by posterior acoustic shadows in eight cases, whereas in the remaining two they appeared only as hyperechoic masses. In a case of sialolithiasis of the parotid gland that was difficult to detect by simple radiographic examination, a salivary stone was detected by both sialographic and ultrasonographic examination. Clearly separated salivary stones were also easily detected in each case by the ultrasonographic method, but multiple, gathered calculi were not precisely detected. The smallest sialolith that could be detected was approximately 2 x 3 mm in size. The rate of detection of salivary stones by using the ultrasonographic method was as high as that from using sialography. Because the examination is simple and noninvasive, its use to evaluate sialolithiasis is probably indicated more frequently, especially when there is acute infection in the gland.
Sonography and computed tomography play complementary roles in imaging mass lesions in the salivary glands and their surroundings. Ninety per cent of parotid tumors originate from the superficial lobe, and we consider sonography to be the method of choice for imaging these lesions. The sensitivity of high-resolution sonography in detecting intraparotid tumors approaches 100 per cent, and ultrasound is therefore an excellent method to evaluate patients with parotid swelling. It may provide clinically useful information by precisely outlining the tumor borders or by detecting multiple or bilateral lesions. We restrict our use of CT to tumors that appear to extend beyond the borders of the parotid gland with possible invasion of surrounding soft tissues or bone. CT is also the method of choice for differentiating lesions of the deep lobe from parapharyngeal tumors and for staging carcinomas. Although ultrasound supplemented with computed tomography should replace conventional sialography in the work-up of parotid neoplasms, sialography remains the method of choice for evaluating patients with chronic sialadenitis, autoimmune diseases, and sialolithiasis. The role of sonography in these conditions is limited to ruling out a parotid neoplasm, assessing the extent of abscess formation, or assisting in localizing calculi in selected patients.
Der Wert der Sonographie bei Speichelsteinen wurde anhand von 23 Patienten untersucht. Der Steinnachweis gelang in 91 %. 3 von 4 Konkrementen konnten eindeutig im Hauptausführungsgang der Speicheldrüsen lokalisiert werden. Aufgrund der hohen Trefferquote und der geringen Patientenbelastung sowie der Möglichkeit des Nachweises nicht schattengebender Konkremente sollte die Sonographie bei nativ-radiologisch nicht eindeutigem Befund vor der Sialographie durchgeführt werden. Im Rahmen der Sonolithotrypsie kann sie zur Dokumentation der extraglandulären Lokalisation von drüsennahen Ausführungskonkrementen verwendet werden.
Summary
In 23 patients with sialolithiasis the value of real time sonography was investigated. The calculi were correctly diagnosed in 91 % of the patients. 3 of 4 calculi could be localized in the main duct of the salivary gland. Because of the high accuracy and the possibility to detect non opaque stones, sonography should be performed, if on plain film the localisation of the calculi is questionable, before sialography is done. In sonolithotrypsy, sonography can be used to document the extraglandular localisation of intraductal calculi.
74 non-selected patients with suspected tumors of the major salivary glands were examined by high-resolution real-time sonography (7 MHz). The different tumors presented with characteristic but nonspecific echomorphological features. Cysts of the salivary glands, intraglandular lymphadenitis, and paraglandular lesions can be distinguished from real tumors of the salivary glands. In case of uncertain palpatory findings the demonstration of an intact echographic texture pattern proves the absence of a tumor. No false negative ultrasound tumor diagnoses were encountered (sensitivity 100%). In salivary-gland neoplasms high-resolution real-time sonography completes the clinical findings and provides important informations about size, number and type of space occupying lesions.
Anatomic surgery for salivary calculi. Oral Surg Oral Med Oral Path01 25:813
- Seward
- Gr
Seward GR: Anatomic surgery for salivary calculi. Oral Surg Oral Med Oral Path01 25:813, 1968
Ultrasonography of the salivary glands.
- Wittich G
- Sherble W
- Halek P
High resolution realtime sonography in salivary gland Diseases.
- Schwerk W
- Schroeder H
- Eichorn T
Sonographic examination of sialolithiasis.
- Yoshimura Y
- Inone Y
- Odogania T
Anatomic surgery for salivary calculi
- Seward