Minimally invasive surgery of sialolithiasis using sialendoscopy

Recurrent Sialolithiasis following Intraoral Deep Hilar/Intraparenchymal Stone Removal from Wharton's Duct

(1) Background: Submandibular gland (SMG) sialolithiasis treatment has shifted significantly, favouring minimal invasiveness. Nonetheless, transoral stone removal remains viable for distal, deep hilar, and intraparenchymal stones. However, data are limited regarding recurrence and revision surgery; (2) Patients/Methods: This retrospective study included 226 patients with SMG stones treated using Wharton's duct slitting and marsupialisation over nine years; 138 had deep hilar or intraparenchymal stones, while 88 had distal stones. Of the former group, 18 experienced symptom recurrence post-surgery, 12 with stones and 6 with duct stenosis; (3) Results: Of the 126 patients without recurrent stones, 71% were male and 29% were female. Their mean age was 51.02 ± 9.36 years. The stones of the 126 patients without recurrence had a diameter of 8.3 mm ± SD: 4 mm, which was significantly smaller than those of the patients who experienced recurrence (13.8 mm ± SD: 2.4 mm; p < 0.05). The mean estimated stone growth recurrence rate was 8.4 ± SD: 1.8 mm per year. A secondary operation was performed 34 ± SD: 14.7 months after the first. Of the patients with recurrence, 91.7% were treated under general anaesthesia. The preferred treatment for 58.4% of patients was intraoral revision operation; the remainder underwent total gland resection. The mean follow-up period was 43 ± SD: 18 months; (4) Conclusions: The rate of revision surgery was relatively low. In recurrent SMG sialolithiasis, new stones may grow faster than the primary stones, which are already larger than those in patients without recurrence. The slitting and marsupialisation of Wharton's duct can treat recurrent cases.

Evaluation of patients' quality of life using novel "Multidisciplinary Salivary Gland Society" questionnaire in minimally invasive management of obstructive sialadenitis

OBJECTIVE

The introduction of minimally invasive surgical procedures has significantly reduced the rate of major salivary gland removal. This study aimed to assess these procedures in relieving patients' complaints and their impact on quality of life using the newly introduced Multidisciplinary Salivary Gland Society questionnaire.

STUDY DESIGN

Between January 2021 and October 2021, a case series was treated with minimally invasive surgical procedures. Data such as stone size, number and location, surgical approach, symptoms relief, and improvement of quality of life were collected and analyzed. Thirty-six patients were included (22 males and 14 females); 28 had stones in the submandibular gland and 8 in the parotid gland with largest stone diameter ranging from 0.2 to 2.8 cm. The approach was selected according to stone size and location, so 17 patients were treated with sialendoscopy (alone or using a combined approach), and 19 patients were treated without sialendoscopy using a transoral approach.

RESULTS

After a 6-month follow-up, the questionnaire scores showed a statistically significant difference in comparison to preoperative ones.

CONCLUSIONS

Minimally invasive surgical procedures present an excellent option for sialolithotomy, after which the relief of symptoms, restoration of gland function, and a significant improvement in quality of life are achieved.

Treatment outcomes of sialendoscopy for submandibular gland sialolithiasis

OBJECTIVE

Sialendoscopy is a procedure used to remove salivary stones intraorally using a sialendoscope. In this study, we identified treatment outcomes of sialendoscopic surgery and identified predictive factors for successful stone removal by sialendoscopy alone.

METHODS

We assembled the medical records of 144 patients who underwent sialendoscopic surgery for submandibular gland sialolithiasis at the Department of Otolaryngology-Head and Neck Surgery, Asahikawa Medical University, from October 2010 to November 2021, and collected patient backgrounds, medical condition, perioperative factors including operation method and complications, postoperative course, and stone constituents from a clinical laboratory testing company.

RESULTS

Submandibular gland stones were successfully removed using sialendoscopy in 58 patients (40%). In multivariate analysis, location, major axis, and mobility of the stones were independent factors for successful removal. In receiver operating characteristic analysis, <7.5 mm of a major axis may be used as a measuring standard for successful removal. Removal of parenchymal stones is prone to involve prolonged operation times, increased postoperative complications, and development of retained stones. The stones mainly consisted of calcium phosphate and protein, with content percentages ranging from 0 to 98% (median 37%) and from 0 to 100% (median 63%), respectively. The percentage of calcium phosphate was negatively correlated with the number of floating stones and successful stone removal.

CONCLUSION

Sialendoscopy is an aesthetically attractive treatment for sialolithiasis that avoids cervical incisions. The present results showed not only known but also new predictive factors for the successful removal of stones (<7.5 mm) and percentage of calcium phosphate. Moreover, our results suggest that careful consideration is required regarding the indication of sialendoscopic surgery in patients with parenchymal stones.

The first experience of laser lithotripsy in sialolithiasis

Relevance. The current limits of endoscopic removal of sialolithes are limited to 3-5mm, larger sialolithes require crushing, but an effective and safe technology has not yet been found. The solution to this problem is primarily related to the technologies of shock wave lithotripsy. Currently, various methods of lithotripsy using extracorporeal and intracorporeal sources are described in the literature. The positive experience of urological laser lithotripsy served as the basis for our study of the possibilities of using the thule laser device FiberLase U2 for the fragmentation of sialolithes. Materials and Methods. The study included 16 clinical observations of patients diagnosed with sialolithiasis who underwent sialoendoscopy with additional application of the technique of intra-c urrent crushing of the concretion with a thule laser device FiberLase U2 with subsequent extraction of fragments. Results and Discussion. Sialolithes were fragmented in all 16 clinical cases, regardless of shape and structure. Large fragments were removed using basket traps and endoscopic forceps. In 9 out of 16 observations, the operation ended with the complete removal of the stone and all its visible fragments (until the duct was completely cleaned). In 7 patients, fragments remained in the duct, which could not be removed. During the crushing process, we observed an undesirable effect of retrograde migration of the stone with a pulse impact, as well as the resulting suspension of small fragments and air bubbles complicated the visibility and the operation process. Also, in 3 cases, when the stone was destroyed, the laser beam hit the duct wall, which was accompanied by weak bleeding and for a while hindered endoscopic visibility and required active irrigation. Conclusion. At the first time, the technology of thule laser lithotripsy was used that made possible the destruction of sialolithes and remove stones larger than 5 mm. This approach expands the limits of endoscopic surgery of sialolithiasis. At the same time, there is a number of important problems that require further study and improvement of the method.

Patient Outcomes After Unsuccessful Endoscopic Sialolith Extraction

OBJECTIVE/HYPOTHESIS

To evaluate clinical outcomes following failed endoscopic extraction of salivary calculi and to assess any relation between clinical outcome and calculi location, number, size, and mobility. If sialendoscopy fails to extract the calculus, subsequent spontaneous passage of the calculus out of the ductoglandular system or secondary effects of sialendoscopy could mitigate the clinical impact of a residual sialolithiasis.

STUDY DESIGN

Prospective observational study.

METHODS

Prospective comparative study of endoscopic procedures for sialolithiasis performed in the Manukau Surgery Center, in Auckland, New Zealand, from 2010 to 2020. The recurrent symptoms and the variables related to the need for additional surgical intervention for salivary calculi were analyzed.

RESULTS

Among the 465 sialendoscopy procedures, 154 (33.1%) were for obstructive sialolithiasis. Among these, there were 30 (19.4%) with unsuccessful stone extraction with re-operation for these failures performed in 14 of the 27 failed submandibular cases (52%) and 2 of the 3 parotids (66.7%). Location of calculi was a significant factor in predicting the need of further surgery. Patients with perihilar stones were 5 times more likely to have a failed procedure (P = .001). If the stone was intraglandular, the likelihood increased to 8.5 times (P = .005). The likelihood for a revision procedure increased almost 11 times if the stone was intraglandular (P = .004). Calculi size, mobility, multiple calculi, and presence of concurrent stenosis did not correlate with need for further surgery.

CONCLUSIONS

A significant proportion of "failed" sialendoscopy did not require further intervention. Stone location was a significant factor in predicting a failed procedure and the need for re-intervention. Laryngoscope, 2021.

An Update on Nontumorous Disorders of the Salivary Glands and Their Management for Internists

Salivary disease may present as pain or swelling in unilateral or bilateral salivary glands. Symptoms may be periprandial or recurrent and inflammatory. If a patient fails conservative treatment, they should be referred to an otolaryngologist. If there is no clear cause based on history and physical examination, sialendoscopy can be performed to directly visualize tissues, provide a diagnosis, drive treatment plans, and sometimes concurrently provide therapeutic intervention. Based on the pathology visualized on sialendoscopy, treatment options include endoscopic intervention, Botox, and gland-preserving surgical techniques, which promote healing of glandular tissue, ultimately preserving function.

Classification of submandibular salivary stones based on ultrastructural studies

INTRODUCTION

Sialolithiasis remains a clinical problem with unclear etiopathogenesis, lack of prevention methods, and only surgical treatment.

MATERIALS AND METHODS

An ultrastructure examination of submandibular sialoliths obtained from patients with chronic sialolithiasis was conducted using a scanning electron microscope and X-ray photoelectron spectroscopy.

RESULTS

Based on the results, we divided sialoliths into three types: calcified (CAL), organic/lipid (LIP), and mixed (MIX). The core structure of the CAL and MIX is very similar. The core of the LIP has a prevalence of organic components. The intermediate layers' structure of the CAL is different from LIP and MIX. In LIP and MIX, the organic component begins to increase in intermediate layers rapidly. The structure of the superficial layers for all types of sialoliths is similar.

CONCLUSIONS

We introduced a new classification of the submandibular salivary gland stones. Based on the results, it can be said that sialoliths type CAL and LIP have their separate path of origin and development, while MIX is formed as CAL stone, and the further pathway of their growth passes as LIP stones. Organic components were much more than inorganic in all layers of salivary gland stones, which highly prevents their dissolution in the patient's salivary gland duct.

Long-Term Outcomes of Sialendoscopy in the Management of Sialolithiasis and Idiopathic Chronic Sialadenitis with Ductal Scars

Objective

We aimed to present the long-term outcomes and sialendoscopic findings in only patients with sialolithiasis and ductal scars in idiopathic chronic recurrent sialadenitis who experienced unsuccessful results with conservative treatment and were treated with sialendoscopy.

Methods

We retrospectively analyzed the patients with a diagnosis of only sialolithiasis and ductal scars in chronic recurrent sialadenitis who underwent sialendoscopy between January 2011 and June 2016. We collected clinical and intraoperative data including patient age, sex, date of the procedure, the involved gland, operative findings and complications. Follow-up data included whether the symptoms were resolved or recurred and whether any further procedures were performed.

Results

Of a total of 38 patients, 16 were excluded from the study due to missing clinical or follow-up data, and analysis was conducted on 22 patients. Twelve were diagnosed with sialolithiasis, while the remaining 10 were diagnosed with idiopathic chronic sialadenitis and had ductal scars. Stone sizes ranged from 2 mm to 10 mm. Mean follow-up time was 39.5 months. The final success rate was 100%. Of the 10 patients with ductal scarring, five had scar in the parotid gland duct, and five in the submandibular gland duct. The mean follow-up time of all ductal scar patients was 47.1 months. The final success rate was 70%.

Conclusion

Sialendoscopy is a minimally invasive method for the diagnosis and treatment of sialolithiasis and ductal scars of the salivary glands after failure of conservative treatments in adults.

Risk Factors for Complications of Intraoral Removal of Submandibular Sialoliths

PURPOSE

Intraoral removal of submandibular sialoliths is a surgical technique for the treatment of sialolithiasis and is reported to have excellent outcomes. The aim of this study was to determine the risk factors leading to complications of this procedure.

PATIENTS AND METHODS

The medical records of 200 patients who had undergone intraoral removal of sialoliths from January 2006 through June 2015 were retrospectively reviewed. A telephone survey was used to check postoperative symptoms. Dry mouth, wound infection, lingual nerve dysfunction, and recurrence were considered complications. Computed tomograms of the neck were reviewed for location, shape, number, and size of the stone.

RESULTS

Forty-four patients reported a complication. The incidence of complications was significantly higher in patients with stones in the proximal region of the salivary duct (proximal group) than in those with middle or distally located stones (middle/distal group; P < .05). The average stone size was larger in the proximal group; the operation time and length of admission also were longer in the proximal group, with a statistically significant difference (P < .05). Complaints of lingual nerve dysfunction were significantly higher in the proximal group than in the middle/distal group (P < .05).

CONCLUSION

Patients with proximally located stones had more complications, especially lingual nerve dysfunction, than those with middle or distally located stones. The former group also required a longer operation time and hospital stay.

Prognostic factors for therapeutic sialendoscopy

Objective:

To review our experience with therapeutic sialendoscopy in both the submandibular and parotid glands in order to determine prognostic factors and improve successful outcomes.

Study design:

Single-centre, retrospective chart review.

Method:

The medical records of patients who had undergone sialendoscopy for sialolithiasis were reviewed, and demographic details, stone data (location, size, multiplicity, mobility), and operative technique and success were recorded.

Results:

Eighty-five patients were included: 70 patients with submandibular stones and 15 with parotid stones. Sialendoscopy was successful in all cases. Complete endoscopic removal was successful in 51 per cent of patients with submandibular stones and 47 per cent of those with parotid stones. Size (less than 5 mm) and distance from the papilla (less than 3 cm) were significant factors affecting success for patients with submandibular duct stones. However, this was not the case for patients with parotid duct stones, with neither variable achieving significance; nevertheless, numbers were small.

Conclusion:

Stone size and location significantly affect the success of therapeutic sialendoscopy in submandibular glands.

Nonvisualization of Sialoliths during Sialendoscopy

Objectives

Analyze the characteristics of patients undergoing interventional sialendoscopy for sialolithiasis whose stones were not visualized intraoperatively.

Study Design

Case series with chart review.

Setting

Tertiary care hospital.

Subjects and Methods

Patients (n = 276) undergoing sialendoscopy between June 2008 and December 2014 were reviewed for patient characteristics, imaging characteristics, and outcomes. Nonvisualization was defined as a sialolith that was documented on imaging preoperatively but not visualized intraoperatively during sialendoscopy, despite successful ductal cannulation and evaluation.

Results

A total of 337 sialendoscopy procedures were preformed. Preoperative imaging documented a sialolith in 203 (60%) cases. Nonvisualization occurred in 31 (15%) cases with sialolith. The parotid gland was involved in 58% (18 of 31) of nonvisualization cases, as opposed to 21% (43 of 203) of all sialolith cases. The submandibular gland was involved in 42% (13 of 31) of nonvisualization cases, as compared with 79% (160 of 203) of all sialolith cases. Nonvisualization occurred in 42% (18 of 43) of parotid cases versus 8% (13 of 160) of submandibular cases, a statistically significant difference ( P < .001). Parotid stones located posterior to the plane of insertion of the posterolateral edge of the masseter were significantly more likely to experience nonvisualization (73%) than those along and anterior to the masseter (25% and 0%, respectively; P = .009).

Conclusions

Intraoperative nonvisualization of a sialolith is more likely to occur in the parotid gland. Proximal stone location may predict nonvisualization. These factors should be considered during treatment planning and counseling for patients with sialolithiasis.