Shockwave lithotripsy of salivary duct stones

Ultrasound-guided piezoelectric extracorporeal shock wave lithotripsy of parotid gland calculi

PURPOSE

The introduction of piezoelectric extracorporeal shock wave lithotripsy (ESWL) has changed therapy for salivary calculi. This method seems especially suitable for treating calculi in the parotid gland. The purpose of this study was to evaluate ESWL in patients with such calculi.

METHODS

From November 1990 to November 1999, all patients with sialolithiasis of the parotid gland were treated with piezoelectric ESWL. Three different lithotriptors were used over the 9-year study period. Results were analyzed according to both the patients' clinical status and follow-up sonograms.

RESULTS

In total, 42 patients (21 women, 21 men; mean age, 59 years) were treated with ESWL. The mean follow-up period for all patients was 63 months (range, 7-96 months). After ESWL had been performed, 71% of the patients were completely free of symptoms, and 21% had marked improvement of their symptoms. Sixty-seven percent were completely free of calculi, and 27% had a marked reduction in the size of their calculi. Adverse effects of ESWL included temporary glandular swelling (4 patients), blood-tinged salivary secretions (9 patients), petechiae on the skin surface (3 patients), and parotid abscess (1 patient).

CONCLUSIONS

ESWL is an outpatient procedure that can be performed without anesthesia and with scarcely any discomfort for patients. Conventional surgical procedures such as subtotal parotidectomy may be almost entirely replaced by ESWL because of the excellent treatment results and a very low rate of complications associated with ESWL. ESWL should be considered the treatment of choice for parotid calculi.

Correlations between the duration of pain and the success of shock wave therapy

Patients who have had successful treatment for either chronic heel pain (plantar fasciitis) or humeral epicondylitis subsequently were evaluated for a comparable problem in the contralateral heel or elbow. Patients who had experienced symptoms in the contralateral heel or elbow for a shorter period were less likely to have a positive result from shock wave therapy than those patients who had received treatments for more chronic symptoms.

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.

The management of sialolithiasis in 2 children through use of extracorporeal shock wave lithotripsy

The management of salivary calculi in children may prove difficult for a number of reasons. Traditional investigations require ionizing radiation and in cases of sialography may be poorly tolerated. Similarly, any surgical treatment is likely to require general anesthesia and, in a number of cases, removal of the affected gland, which is associated with attendant risks. As an alternative, ultrasound and extracorporeal shock wave lithotripsy therapy offers low morbidity and outpatient procedures that are well tolerated, as illustrated by these 2 cases.

Multiple sialoliths and a sialolith of unusual size in the submandibular duct: a case report

A 49-year-old man with multiple sialoliths in the submandibular duct is described. One of the sialoliths was of remarkable size. This report is of interest because of the unusual size and weight of this sialolith and because of the patient's symptoms, which were relatively mild and of short duration.

Extracorporeal shock wave lithotripsy of parotid stones. Results of a prospective clinical trial

The extracorporeal shock wave treatment of parotid stones is a rather new therapy. Its usefulness was determined in a prospective study. Seventy-six patients (36 female, 40 male, 2 to 80 years of age) with symptomatic, sonographically detectable solitary sialoliths of the parotid gland were treated with an extracorporeal piezoelectric shock wave therapy after unsuccessful conservative therapy (sialagogues, gland massage, bougienage of the secretory duct). At most, 3 treatments per patient were performed. Altogether, 38 of the 76 patients (50%) were free of stones and no longer suffered from complaints after completion of shock wave treatment and a mean follow-up period of 48 months (range 6 to 71 months). During the follow-up period, in no case could renewed stone formation be observed. Residual stone fragments were detectable in 20 patients (26%), but did not cause further symptoms. Thirteen patients (17%) with residual stone fragments stated a significant improvement of their complaints after therapy. Five patients (7%) did not observe any changes of their pretherapeutic complaints and underwent parotidectomy. The therapeutic success was not influenced by stone size or by stone localization within the gland. During the follow-up period, no side effects of the therapy were identified. With stones of the parotid gland, extracorporeal shock wave lithotripsy is -- after one has used conservative therapies (sialagogues, gland massage) -- the treatment of choice, avoiding in the majority of cases a parotidectomy with its operative risks (paresis of the facial nerve, Frey's syndrome).

Unusual elimination of a salivary calculus. A case report

Salivary calculi are frequently formed in the submandibular duct. The most common sites are where the duct turns round the distal edge of the mylohyoid, where the duct crosses the lingual nerve, and just distal to the duct orifice. Untreated calculi can cause obstruction and glandular atrophy, and then may exfoliate through the floor of the mouth. An unusual case of cutaneous exfoliation of a salivary gland stone is presented. The importance of early diagnosis and treatment of sialolithiasis are discussed.

Diameters of the main excretory ducts of the adult human submandibular and parotid gland: a histologic study

In assessing new minimally invasive diagnostic techniques (duct endoscopy) and therapy (lithotripsy), it is of importance to know the true dimensions of the excretory ducts. Twenty-five ducts of the parotid gland and 20 ducts of the submandibular gland were examined histologically at different points of their anatomic course, and their in vivo diameters were evaluated with the use of a previously determined formalin-induced shrinking-factor. The mean diameter of Stensen's duct at four different points along its length ranged between 1.4 mm and 0.5 mm, with a maximum of 2.3 mm and a minimum of 0.1 mm, depending on the site. A narrowing at the middle of the duct was striking. In all preparations examined, the minimum width of the excretory duct was located at the ostium. In Wharton's duct the narrowest duct diameter was also identified at the ostium. The mean values for the duct diameters ranged between 1.5 mm and 0.5 mm. The largest duct diameter reached 2.2 mm; the smallest one, 0.2 mm. For diagnostic and therapeutic purposes, endoscopes, balloon catheters, and stone-extraction-baskets probably should, despite the extensibility of the duct, conform as much as possible to the physiologic duct widths. A diameter of 1.2 mm should be aimed at as an upper limit for these instruments. Our findings also suggest that, in the case of salivary stone lithotripsy, the best results will be achieved when the maximum size of stone fragments does not exceed 1.2 mm.

Use of extracorporeal shock waves in the treatment of pseudarthrosis, tendinopathy and other orthopedic diseases

PURPOSE

The use of shock waves in orthopedic diseases was reviewed with special regard to the clinical applications.

MATERIALS AND METHODS

Findings in the literature and results from our own studies were analyzed and summarized.

RESULTS

Extracorporeal shock waves induced osteoneogenesis in animal models with intact and fractured bones. Based on these findings shock waves were used for the treatment of pseudarthrosis in humans. Most patients had at least 1 unsuccessful operation before shock wave therapy. Complete reunion was noted in 62 to 91% of cases and shock waves are recommended by some as the first choice of treatment for hypertrophic pseudarthrosis. After failed nonoperative therapy shock waves were used for the treatment of patients with various diseases as secondary treatment. The success rate for treatment of tendinopathies, such as tennis elbow, periarthritis humeroscapularis or calcaneal spur, was approximately 80%. For calcific tendinitis shock wave therapy seems to be superior to all other minimal or noninvasive techniques without compromising a potential later operation.

CONCLUSIONS

Shock waves have changed medical therapy substantially. Accounting for the epidemiology of the treated diseases, this new change may equal or even surpass the impact of extracorporeal shock wave lithotripsy.

Interventional radiology for the non-surgical removal of sialoliths

OBJECTIVES

To clarify the usefulness and limitations of interventional radiology for sialolithiasis.

METHODS

Sixteen patients (5 with parotid and 11 with submandibular sialolithiasis) were treated with a stone retrieval catheter (Dormia basket) under fluoroscopy. Digital subtraction sialography (DSS) and direct digital dental imaging (RVG) were performed in addition for 11 of the cases (DSS for 7 and RVG for 4 cases).

RESULTS

The sialolith was successfully removed in 10 cases. DSS and RVG were useful. Four cases failed because the stone was adherent to the ductal wall and two because the catheter could not reach the stone because of the ductal anatomy.

CONCLUSION

Interventional radiology is less invasive than surgical treatment and is the recommended first choice for treatment in the majority of cases of sialolithiasis.

Endoscopic intracorporeal lithotripsy for sialolithiasis

PURPOSE

This article describes a technique of salivary gland endoscopy using a 2.1-mm endoscope with a 1-mm working channel. The technique allows intracorporeal lithotripsy under endoscopic control. Two types of energy to produce calculi fragmentation were analyzed.

PATIENTS AND METHODS

Of 39 patients who presented with obstructive sialoadenitis, endoscopic treatment was possible in 27. Eighteen had a diagnosis of sialolithiasis. Intracorporeal lithotripsy was done under endoscopic control in these patients. Laser energy was used to produce fragmentation in 3 cases and pneumobalistic energy in 9. In 6 cases, the calculi were extracted with forceps.

RESULTS

Fifteen patients are free of stones and symptoms after a 6-month follow-up. Fragmentation and extraction of the calculi were not possible in 3 patients. Two of these patients required open surgery. The other patient is under observation.

CONCLUSIONS

The use of endoscopes with a working channel allows irrigation to improve visibility during exploration. Both extraction of calculi and lithiasis fragmentation using different energies can be carried out through the channel. In this series, pneumoballistic energy (Lithoclast) has been shown to produce calculus fragmentation with more efficiency than lasertripsy (Dornier Impact). When dilation and placement of a cannula (Abocath 16 G) was done 2 days preoperatively, endoscopy was performed more easily. Postoperative drainage has proven effective in avoiding complications.

Treatment of salivary stones by extracorporeal lithotripsy

PURPOSE

This study was designed to evaluate the efficacy of extracorporeal lithotripsy (ECL) in the treatment of salivary stones.

PATIENTS AND METHODS

In a prospective study, an additional 15 patients suffering from sialolithiasis were treated by applying extracorporeally generated shock waves. No patients needed general anaesthesia, sedatives, or analgesics.

RESULTS

Treatment was effective in 80% of the 15 patients in this series (5 total efficacy and 7 partial efficacy). Only minor complications were observed.

CONCLUSION

Lithotripsy is a promising nonsurgical therapy for the treatment of sialolithiasis.

Extracorporeal electromagnetic shock-wave lithotripsy for salivary gland stones

Sialoadenectomy for sialolithiasis is necessary when the stone cannot be removed through the salivary duct. In addition, extracorporeal. shock-wave lithotripsy has recently become available for this purpose. The safety and efficacy of this method was assessed in 52 outpatients bearing stones with an average diameter of 6.76 mm in the submandibular or parotid gland. Anesthetics, sedatives, and analgesics were not required. Twenty-four of the 36 patients with submandibular gland calculi and all 16 with parotid sialolithiasis had complete stone disintegration or fragmentation of the calculi, with possible spontaneous clearance. Untoward effects were observed in 15 patients, namely localized skin petecchiae, transitory swelling of the gland, and self-limiting bleeding from the duct. No persistent damage of the salivary glands or adjacent structures was noted during a mean follow-up period of 10 months.

Washington University experience with extracorporeal shock-wave lithotripsy of pancreatic duct calculi

OBJECTIVES

To ascertain the effectiveness and safety of extracorporeal shock-wave lithotripsy (ESWL) for pancreatic calculi.

METHODS

Fourteen ESWL treatments were performed in 12 patients with chronic pancreatitis.

RESULTS

Fragmentation was perceptible after 13 of 14 treatments. Subsequent endoscopic manipulation resulted in complete extraction, partial extraction, and failed extraction of the fragments after 7, 4, and 2 of the ESWL treatments, respectively. No complications occurred and no patient had pancreatitis following ESWL. At a median follow-up of 19 to 22 months, 4 patients have had complete relief of symptoms, 4 have had a decrease in both severity and frequency of pain, and 4 have had no improvement.

CONCLUSIONS

ESWL is a safe and useful noninvasive adjunct in the treatment of patients with pancreatic duct calculi.

Parotid duct stone--removal by a dormia basket

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.

Laser lithotripsy: a preliminary study on its application for sialolithiasis

The present study has established that a flashlamp pumped coumarin dye laser is capable of fragmenting salivary calculi. The refinement of spectroscopic feed-back techniques will allow laser lithotripsy to complement ultrasonic lithotripsy in the non surgical management of salivary calculi.

Current role of extracorporeal shockwave therapy in surgery

In urology the introduction of extracorporeal shockwave therapy brought a revolutionary change to the management of urinary calculi. This inspired the introduction of shockwave therapy in several fields of surgery; it has been applied as a potential alternative to several operative procedures but is still experimental. So far, the major application of shockwave therapy has been lithotripsy of stones in the gallbladder, common bile duct, pancreatic duct and salivary gland ducts. Other applications are in the non-operative management of bone healing disturbances and in the inhibition of tumour growth. Steps towards selective thrombus ablation and pretreatment of heavily calcified arteries have also been made. In this review, the applications of extracorporeal shockwave therapy in several areas of surgery are discussed. It is concluded that, for selected patients, shockwave treatment may serve as a useful addition to the surgical armamentarium.

The combined effects of high-energy shock waves and cytostatic drugs or cytokines on human bladder cancer cells

The effects of shock waves generated by an experimental Siemens lithotripter in combination with cytostatic drugs or cytokines on several bladder cancer cell lines were examined in vitro. Proliferation after treatment was determined with the 3-4,5-dimethylthiazol-2,5 diphenyl tetrazolium bromide assay. Dose enhancement ratios were calculated for each drug and each shock wave application mode in order to characterise the sensitising effect of shock wave pretreatment. The influence of the time between shock wave and drug treatment as well as the effects of different sequences of shock wave and drug treatment or concomitant treatment were assessed for selected combinations of cell lines and drugs. It was found that shock wave treatment could render certain cell lines more susceptible to subsequent cis-platinum, mitomycin C or actinomycin D incubation. Cell lines sensitive to tumour necrosis factor alpha or interferon alpha were further sensitised to these cytokines by shock wave pretreatment. The enhanced sensitivity to cis-platinum and actinomycin D decreased rapidly during the first hours after shock wave treatment. The antiproliferative effect was most pronounced after concomitant shock wave and drug treatment. The sensitisation to interferon alpha diminishes more slowly after shock wave exposure. From the results presented in this study it is concluded that transient shock wave-induced permeabilisation of cell membrane not only enhances drug efficiency, but also causes damage to cell organelles and alterations in cellular metabolism.