[Clinical aspects of non-tumorous diseases of the salivary glands]

Nuances and Management of Hilar Submandibular Sialoliths With Combined Transoral Robotic Surgery-Assisted Sialolithotomy and Sialendoscopy

OBJECTIVE

To describe the management, technical nuances, and success rates of transoral robotic surgery (TORS)-assisted sialolithotomy.

STUDY DESIGN

Retrospective database review.

SETTING

Quaternary academic medical center.

METHODS

Between the months of January 2015 and May 2019, patients with hilar submandibular gland stones underwent 2 main variations of TORS-assisted sialolithotomy and sialendoscopy: (1) TORS followed by sialendoscopy for patients with palpable predominantly single stones and (2) either sialendoscopy followed by TORS and sialendoscopy or sialendoscopy followed by TORS only for patients with nonpalpable or multiple stones. Clinical charts were reviewed to collect data, including stone size (imaging review, intraoperative measurement), palpability, duration of operation, TORS variation, operative challenges, symptom improvement, gland preservation rate, and complications.

RESULTS

Thirty-seven patients were identified. Patients were 26 to 80 years old (mean, 57.2 years), and 40.5% were female. Twenty-four patients (64.9%) underwent TORS followed by sialendoscopy; 10 (27.0%), sialendoscopy followed by TORS and sialendoscopy; and 3 (8.1%), sialendoscopy followed by TORS only. The mean stone size was 12.4 mm (range, 4-28 mm). Eleven patients had multiple stones with a mean 4 stones per patient (range, 2-9). Procedural success was 91.9% (34/37) at a mean follow-up of 34.2 weeks (range, 1.4-262.1), and the gland preservation rate was 97.3% (36/37). No patients reported symptoms of lingual nerve injury at 3-month follow-up.

CONCLUSION

TORS combined with sialendoscopy for hilar submandibular gland sialolithiasis allows for improved visualization of critical anatomy, tissue manipulation, and operative flexibility. In our experience, the operative success rate is high, and duration of surgery compares favorably with conventional combined hilar approaches.

Recurrent sialoliths after excision of the bilateral submandibular glands for sialolithiasis treatment: A case report

Sialolithiasis is a common disease that is characterized by the obstruction of the salivary gland. Sialolithiasis mainly affects the submandibular glands and the Wharton's duct. However, bilateral sialolithiasis is a rare condition. In addition, recurrence of sialoliths subsequent to surgical excision of the submandibular gland for the treatment of sialolithiasis has been rarely reported. The present study reported a case presenting with recurrent sialoliths with sialadenitis in the residual Wharton's duct following the excision of bilateral submandibular glands. An 81-year-old man presented with a solid and painful mass in the left submandibular area. The patient had a history of bilateral submandibular sialolithiasis, and had undergone excision of bilateral submandibular glands with the right Wharton's duct 4 years earlier. Computed tomography scans demonstrated two calculi in the residual Wharton's duct, which were surgically removed without any complications. The present study discussed the mechanisms underlying sialolith formation subsequent to the excision of submandibular glands.

Sonography: the leading diagnostic tool for diseases of the salivary glands

Ultrasound examination is the imaging procedure with the best predictive diagnostic capability for the salivary glands. Due to the salivary glands' relatively superficial anatomical location, clear boundary from surrounding tissue and comparatively typical echogenicity, therefore sonography is ideal for diagnosis. In addition, the technical advances in recent years, including higher resolution, color Doppler sonography, contrast-enhanced ultrasound, elastography, and tissue harmonic have lead to an improvement in diagnostic accuracy of sonography further resulting in an expansion of the range of indications. Sonography allows detection of obstructive salivary gland diseases such as stenosis or sialolithiasis, as well as sialadenosis such as Sjögren syndrome. Ultrasound examination alone is sufficient to diagnose benign tumors. However, in the case of malignant tumors, computer tomography or MRI may be also required, especially to determine the question of infiltration of the skull base.

Ultrasound guided lithotripsy of salivary calculi using an electromagnetic lithotriptor

Sialolithiasis is a common disease of the major salivary glands. A supplement to the traditional therapies is extracorporeal shock wave lithotripsy of the calculus. This method has been adopted from the therapy of renal or bladder calculi. Patients with a solitary calculus of parotid or submandibular gland were treated with a specially designed lithotriptor. In a retrospective study the results of this therapy were analysed. The success rate was far better for parotid gland calculi than for submandibular calculi. We could not find better results than those published in literature with other devices. In our therapeutic concept, sialolithotripsy is the therapy of first choice for single parotid gland calculi. For submandibular gland calculus this method is advisable in selected cases only.

Sonography and scintigraphy in the diagnosis of diseases of the major salivary glands

This is a prospective study of 73 patients with diseases of the major salivary glands. The sonographic diagnosis could be confirmed by the course of the disease and/or the histologic result after operation in 67 (93%). In 29 patients, salivary gland scintigrams also were carried out. There was a tendency for signs of hypervascularization to be seen in patients with acute inflammation and reduction or loss of function in the presence of a chronic inflammation of the salivary glands. Scintigraphy did not provide diagnostic information on tumors of the salivary glands with regard to the type and location, with the exception of the Warthin's tumor. In selected cases it adds additional information, especially in functional therapy control.

New concepts in the treatment of chronic recurrent parotitis

The release of glandular kallikrein into the interstitium of the parotid gland appears to play an important role in the occurrence of the inflammatory interstitial edema in chronic recurrent parotitis. This provides fresh impetus for the treatment of this parotid disease with a kallikrein inhibitor. In our present study, seven patients with acute exacerbated chronic recurrent parotitis were treated with the kallikrein inhibitor aprotinin (Trasylol, Bayer AG, Leverkusen). With this therapy all patients were free of pain 12 h after the start of the therapy and most salivary gland function had returned to normal by 48 h after beginning treatment. Within this period of time, concomitant swelling of the affected parotid gland disappeared completely in five patients and resolved in the other two patients after 1 week.

Immunoglobulin-containing plasma cells in chronic parotitis and malignant lymphomas of the parotid gland. Comparing immunocytochemical observations of frequency and localization

IgA-containing plasma cells in the periductal gland tissue are part of the special secretory immune system of the salivary glands. The reaction of Ig-containing plasma cells (localization, frequency, specific Ig-content) was analyzed by the indirect immunoperoxidase method in chronic recurrent parotitis (9 cases), chronic myoepithelial parotitis (benign lymphoepithelial lesion, Sjögren's syndrome; 8 cases), and malignant lymphoma associated with chronic myoepithelial parotitis (11 cases). The following results were obtained: 1. In chronic recurrent parotitis, parallel to the increase in IgA in the salivary secretion, a marked multiplication of IgA-containing plasma cells was found in the inflammatory infiltrate and the remaining non-inflamed periductal parenchyma of the parotid gland. In the marginal zone of inflammation, a slight increase of IgG-containing plasma cells was also observed. 2. In chronic myoepithelial parotitis, the total plasma cellular infiltration was slightly less distinct than in chronic recurrent parotitis. The most remarkable increase in Ig-containing plasma cells developed in the marginal zones--away from the myoepithelial cellular islands--as well as in the area of ductular proliferations, and was characterized by a strong increase of IgG-containing plasma cells. At the same time, a slight increase of IgM-containing plasma cells was observed. No plasma cells were found in the myoepithelial cellular islands. 3. In the malignant lymphomas associated with myoepithelial parotitis, which were mainly highly differentiated lymphomas (immunocytomas, centrocytic-centroblastic lymphomas) and rarely poorly differentiated immunoblastic lymphomas, there was a distinct decrease of IgG-containing plasma cells when compared with the numbers in this group without lymphoma. The differing degrees of prevalence and Ig-content of the plasma cells partly describe the change taking place in the local secretory immune system of the parotid gland. The possible relationships between chronic recurrent parotitis and auto-immune myoepithelial parotitis on one hand and the stages of transition (prelymphoma) to malignant lymphoma on the other, are discussed.