Management of obstructive salivary disorders by sialendoscopy: a systematic review

Success rate of sialendoscopy. A systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis on the efficacy and safety of sialendoscopy in the treatment of obstructive diseases of the major salivary glands.

MATERIALS AND METHODS

We searched four databases for literature. The primary outcome assessed was the success rate. Secondary outcomes included the use of supportive devices, number of sialadenectomies and complications. Risk of bias was assessed. Meta-analyses with subgroup analysis were performed.

RESULTS

In total, 91 studies were included, comprising 8218 patients undergoing 9043 sialendoscopic procedures. The majority of studies had a medium or high risk of bias. The incidence of sialadenectomy varied from 0% to 14%. No major complications were reported. Meta-analysis revealed a weighted pooled success rate of 80.9%. Subgroup analyses showed the weighted pooled success rate in patients with sialoliths (89.6%), stenoses (56.3%), submandibular glands (88.3%), parotid glands (81.2%), patients treated by an endoscopic-assisted transoral removal of a sialolith (86.3%), patients treated by a combined approach of the parotid gland (78.2%), patients with JRP (67.0%) and with RAIS (45.8%).

CONCLUSION

The success rate of sialendoscopy did not considerably change in the last 9 years. Sialendoscopy is an efficient and safe procedure for the treatment of major salivary gland obstructive disease.

Introducing Sialendoscopy in a Veteran Population: Effect on Benign Salivary Disease Treatment

OBJECTIVE

To compare rates of sialadenectomy in a veteran population before and after introduction of sialendoscopy.

MATERIALS AND METHODS

All Veterans Affair (VA) Northern California Healthcare System (NCHS) encounters from 2006 to 2021 for benign obstructive salivary etiologies were identified using International Classification of Disease 9/10 codes. This cohort was then cross referenced with Current Procedural Terminology codes to identify patients who underwent a procedure for their salivary pathologies. The rates of sialadenectomy and minimally invasive procedures were measured before and after sialendoscopy was introduced to the VA NCHCS in 2016. Data was obtained via chart review and demographic information, diagnosis, and procedure type were extracted. Rates of sialadenectomy, minimally invasive procedures, and other patient and procedural characteristics were compared between the Pre-Sialendoscopy Era (PSE) and Sialendoscopy Era (SE). Statistical analysis was performed using Microsoft Excel (Microsoft, version 16.66).

RESULTS

An increasing number of patients per year sought care for benign obstructive salivary pathology in the SE when compared to the PSE cohort and a higher rate of female patients were treated in the SE cohort. A simultaneous reduction in sialadenectomy rates and increase in minimally invasive procedure rates was observed in the SE. Sialendoscopy represented most of the increase in minimally invasive techniques, but there was a slight increase in other procedure types. Submandibular gland obstructive pathologies required the most procedures and resulted in the most gland excisions.

CONCLUSION

This retrospective review strongly suggests introducing sialendoscopy reduced the incidence of sialadenectomy for benign non-tumor obstructive pathology in this VA NCHS population. Further prospective studies are needed to evaluate this in a more generalized setting.

The anatomical pattern of ductal arborization in parotid glands using cone-beam computerized sialography

Cone-Beam Computed Tomography-Sialography (Sialo-CBCT) is used to demonstrate salivary ductal structure. This study aimed to conduct a volumetric analysis of the anatomical morphology of Normal-Appearing Glands (NAGs) in parotid sialo-CBCT. Our retrospective study included 14 parotid sialo-CBCT scans interpreted as NAGs in 11 patients with salivary gland impairment. The main duct length and width, as well as number and width of secondary and tertiary ducts were manually evaluated. We found that the main parotid duct showed an average width of 1.39 mm, 1.15 mm, and 0.98 mm, for the proximal, middle and distal thirds, respectively. The arborization pattern showed approximately 20% more tertiary (average number 11.1 ± 2.7) than secondary ducts (average number 9.0 ± 2.4) and approximately 8% narrower tertiary ducts (average width 0.65 ± 0.11 mm) compared to the secondary ducts (average width 0.77 ± 0.14 mm). Our anatomical analysis of NAGs in parotid sialo-CBCT demonstrated progressive narrowing of the main duct and increasing arborization and decreasing lumen size starting from the primary to the tertiary ducts. This is the most updated study regarding the anatomy of the parotid glands as demonstrated in sialo-CBCT. Our results may provide clinicians with the basic information for understanding aberration from normal morphology, as seen in salivary gland pathologies as well facilitate planning of treatment strategies, such as minimally invasive sialo-endoscopies, commonly practiced today.

Sialendoscopy for treatment of major salivary glands diseases: a comprehensive analysis of published systematic reviews and meta-analyses

OBJECTIVES

Sialendoscopy is a minimally invasive procedure used to diagnose and treat obstructive salivary gland diseases. Previous studies in the topic have shown mixed results. The present study aimed to evaluate the efficacy and safety of sialendoscopy through previous systematic reviews for different outcomes of several diseases. We also aimed to assess studies' methodological quality and heterogeneity.

METHODS

We conducted a comprehensive systematic literature search of Pubmed, Embase, Lilacs and Cochrane Library. We included systematic reviews and meta-analyses that used sialendoscopy to treat both lithiasic and alithiasic salivary glands diseases. Data extraction included studies' characteristics and results. We assessed studies' methodological quality using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews 2) tool.

RESULTS

13 studies were included in the review, being 9 in adult populations and 4 in pediatric populations. Sialendoscopy proved to be effective at the treatment of different lithiasic and other obstructive diseases, but with important heterogeneity. The technique was also considered highly safe in most studies. However, studies had a critically low quality of evidence.

CONCLUSIONS

Most studies demonstrated high efficacy and safety of sialendoscopy, but with critically low quality of evidence. We still lack randomized studies in this field, and future systematic reviews on the topic should follow current guidelines to improve conduction and reporting.

Symptom Outcomes After Sialendoscopy-Assisted Salivary Duct Surgery: A Prospective 6-Year Study

OBJECTIVE

The objective is to evaluate the long-term impact of sialendoscopic-assisted salivary duct surgery (SASDS) on sialadenitis symptoms using the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire.

METHODS

The COSS questionnaire, which scores symptoms on a 0-100 scale, was administered prospectively to adult patients pre-operatively, 1-year, and 6-years post-operatively. We examined COSS scores and categories representing complete (<10), partial (10-25), and no (>25) resolution of symptoms with attention to factors significantly associated with incomplete resolution (≥10).

RESULTS

Approximately 6-years after SASDS, 111 patients reported scores for 128 symptomatic glands (72 with sialolithiasis, 56 without sialolithiasis). For glands with sialolithiasis, the median COSS score pre-SASDS was 27.5 (interquartile range [IQR]: 13.5-43), which was significantly reduced to 1.0 (IQR: 0-5.5) at 1-year and 1.5 (IQR 0-5) at 6-years postoperatively. Glands without sialolithiasis had a median COSS score of 40.5 (IQR: 23-52.5) preoperatively, that significantly reduced to 13.5 (IQR 5-21) at 1-year and 14 (IQR 6.5-25.5) at 6-years post-operatively. There was no significant difference in scores from 1- to 6-years. Intraoperative presence of sialolith, absence of stenosis, stenosis in the distal duct, and submandibular gland involvement were significant predictors of complete resolution of symptoms at 6-years.

CONCLUSION

Approximately 6-years after SASDS for sialadenitis, the majority of patients have durable symptom improvement. The sialolithiasis group had higher rates of complete resolution compared to the non-sialolithiasis group. Presence of ductal stenosis on sialendoscopy, non-distal stenoses, and parotid gland involvement were risk factors for persistent long-term sialadenitis symptoms. Laryngoscope, 133:792-800, 2023.

Sialendoscopy-Based Analysis of Submandibular Duct Papillae with a Proposal for Classification

Identifying a submandibular (Wharton's) duct punctum often hinders sialendoscopy; however, there is a paucity of evidence on whether the appearance of Wharton's duct papilla impacts the sialendoscopic procedure. A classification of Wharton's duct papillae based on the macroscopic appearance, size of dilatation probes, and sialendoscopic approach was proposed herein. The classification describing four main types of papillae, A, B, C, and D, was prospectively evaluated on 351 Wharton's duct papillae in 315 patients. For each papillae type, the demographic/clinical data, intraoperative complications, and time required for sialendoscope introduction were analyzed. Estuary-like papilla (type A) was commonly seen after spontaneous stone extrusion, had no intraoperative complications noted, and had the shortest time required for the sialendoscope introduction. Normal papilla (type B) was the most frequently observed papilla (48.1%), reflecting diverse underlying pathology, while difficult papilla (type C) was often associated with unfavorable anatomical variations of the mandible or floor of the mouth. Substantially closed papilla (type D) had the highest rate of intraoperative complications, namely, perforation with a false passage, and required the longest time for the sialendoscope introduction. In seven patients (2.0%), the entrance into the duct was feasible only through the fistula, while the sialendoscope introduction failed in eight patients (2.3%). In conclusion, the appearance of Wharton's duct papillae may be influenced by the underlying pathology. Based on the proposed classification, papilla typology affects the duration of sialendoscope introduction and may influence the frequency of intraoperative complications.

Ultrasound shear wave elastography for patients with sialolithiasis undergoing interventional sialendoscopy

Objective

Ultrasound shear wave elastography is an objective tool to evaluate the stiffness of human tissues. Patients with sialolithiasis could be treated by interventional sialendoscopy with a high success rate. Sialolithiasis could be extracted, and the diseased gland could be preserved and evaluated after treatment. Whether ultrasound shear wave elastography could be used for objective outcome measurement and short-term follow-up of the parenchyma of gland in patients with sialolithiasis remains unclear.

Methods

This retrospective self-controlled study was conducted. Patients with sialolithiasis treated by interventional sialendoscopy and followed by high-resolution ultrasound shear wave elastography were selected between January and September 2017.

Results

Seventeen patients with sialolithiasis (mean age: 39.63 ± 12.49 years), including 10 women and 7 men, were enrolled. Fifteen patients had sialolithiasis in the submandibular gland and two in the parotid gland. The preoperative value of shear wave velocity was significantly higher in the diseased gland than in the contralateral normal gland (p < .001; 95% confidence interval [CI], 0.3915-0.6046). After successful treatment by interventional sialendoscopy surgery, the shear wave velocity of the diseased gland decreased significantly (p = 0.001; 95% CI, -0.38792 to -0.20474). However, there was a significant difference between the diseased and contralateral normal glands (p = 0.001; 95% CI, 0.0423-0.2895) after 1.55 months of surgery.

Conclusion

Ultrasound shear wave elastography could be an adjuvant tool to distinguish sialolithiasis-affected diseased glands from contralateral normal glands and assess the short-term treatment outcome objectively. The changing trend of shear wave velocity could help monitor the healing process of the parenchyma in the diseased gland after treatment.

Level of Evidence

4.

Evaluating YouTube videos on sialendoscopy as an educational resource for patients

Objectives

Patients are increasingly relying on YouTube for health information. We objectively evaluated the quality and comprehensiveness of sialendoscopy YouTube videos available to patients. We further investigated the relationship between video content and video popularity.

Methods

We identified 150 videos using the search term "sialendoscopy." Videos were excluded if they were lectures for medical professionals, operating room (OR) recordings, unrelated, non-English, or non-audio. Video quality and comprehensiveness were evaluated using modified DISCERN criterion (range: 5-25) and novel sialendoscopy criterion (NSC, range: 0-7), respectively. Secondary outcomes included standard video metrics and Video Power Index to measure popularity. Videos were classified binarily by uploader type as from an academic medical center or from other sources.

Results

Twenty-two (14.7%) of 150 videos were included for review, with 7 (31.8%) uploaded from academic medical institutions. One hundred-nine (72.7%) videos were excluded as lectures for medical professionals or OR recordings. Overall mean modified DISCERN (13.45 ± 3.42) and NSC (3.05 ± 0.96) scores were low; however, videos uploaded by academic medical institutions were significantly more comprehensive (NSC mean difference = 0.98, 95% CI: 0.16-1.80, p = .02). There were no significant correlations between video popularity and objective measures of quality or comprehensiveness.

Conclusions

This study highlights the paucity and low quality of sialendoscopy videos for patients. More popular videos are not higher quality, and most videos are targeted more toward physicians rather than patients. As YouTube becomes increasingly used by patients, there is opportunity for otolaryngologists to produce more informative videos for patients while implementing targeted strategies to increase viewership.

Level of Evidence

NA.

Epidemiologic, radiologic, and sialendoscopic aspects in chronic obstructive sialadenitis

PURPOSE

Chronic obstructive sialadenitis (COS) is a recurring inflammation of the salivary gland. To date, there are no known predisposing factors for COS. Given the advances seen in radiology and sialendoscopy, we must update our knowledge of COS, analyzing factors that can favor its development.

METHODS

We prospectively analyzed 333 patients who underwent sialendoscopy between 2012 and 2021. Epidemiologic, radiologic, and sialendoscopy-related factors were correlated. Suspected diagnosis was established based on the clinical and radiologic data. The final diagnosis was determined on the basis of sialendoscopic findings.

RESULTS

The most common etiology of COS was stricture (40.8%). Lack of papilla distensibility (LPD) was also described as an etiology. COS was related to patient gender and age. Submandibular gland involvement was significantly more associated with lithiasis and LPD, while COS of the parotid gland was most frequently caused by stricture. Radioiodine sialadenitis and Sjögren's syndrome were significantly associated with stricture. MR sialography (MR-Si) showed the best overall sensitivity and specificity.

CONCLUSION

In our series, stricture was the most common cause of COS. We describe LPD as a frequent cause of COS in this series; ours is the first study to report this finding. There was a significant association between the salivary gland involved, patient sex and age, and the cause of COS. MR-Si showed the greatest diagnostic yield.

Validation of a Spanish chronic obstructive sialadenitis quality of life questionnaire (CSOC)

BACKGROUND AND OBJECTIVES

Interest in chronic obstructive sialadenitis is increasing with the introduction of sialendoscopy. A self-administered instrument to assess quality of life in patients with chronic obstructive sialadenitis is needed to improve clinical management and support research. The objectives of this study are to design a Spanish questionnaire to assess quality of life in chronic obstructive sialadenitis, named CSOC and assess its reliability, validity and feasibility.

MATERIAL AND METHODS

A prospective, multicentre, observational study was conducted. Patients with diagnosis of chronic obstructive sialadenitis were included in the study. The item generation process included a review of published data as well as interviews with patients. An expert panel then tested the content validity of the instrument, and the construct validity was tested in 120 patients and 100 controls. Patients completed a self-administered CSOC questionnaire, a Short Form-36 and a Visual Analogue Scale. Feasibility, reliability, internal consistency, construct validity and responsiveness were assessed.

RESULTS

All the patients found the instrument understandable. Cronbach α coefficient was high (0.85). The time required to fill out was 5.7 and 4.5min for pre and postsialendoscopy CSOC respectively. Cronbach α coefficient was very high for both pre and postsialendoscopy CSOC (0.90 and 0.94 respectively). The correlation with the SF-36 dimensions was negative and positive with the VAS. The mean score of CSOC was 28.63 and 8.33 for pre and postsialendoscopy. In the control group the mean score of CSOC was 1.31.

CONCLUSIONS

The CSOC questionnaire is understandable, feasible, reliable and representative of quality of life in chronic obstructive sialadenitis.

Patient experiences of sialendoscopy with monitored anesthesia care versus general anesthesia

OBJECTIVE

To compare the experiences of patients who received sialendoscopy under general anesthesia (GA) with those who received monitored anesthesia care (MAC).

METHODS

Patients who underwent sialendoscopy for sialadenitis or sialolithiasis from July 1, 2020, to July 31, 2021, were offered inclusion to this prospective observational study. A survey was sent to consenting patients on post-operative day 1 to record aspects of their pre-, intra-, and post-operative experience. The primary outcome was overall satisfaction. Secondary outcomes included pain tolerability and preference for similar anesthetic modality in the future.

RESULTS

Seventy-five patients completed the post-operative survey (86% response rate), of which 39 patients received GA and 36 received MAC. Patient overall satisfaction was similar between groups (GA: "Poor/Average/Good" = 23%, "Excellent" = 77%; MAC: "Poor/Average/Good" = 25%, "Excellent" = 75%, p = 1.00). Tolerability of immediate post-operative pain was likewise similar between the GA (82%) and MAC (97%) groups (p = 0.058). Patients who received MAC reported intra-operative pain as "none/tolerable" 72% of the time and "uncomfortable" 28% of the time. Patients who received GA would prefer the same anesthetic in the future more often than in the MAC group (85% versus 61%, respectively, OR 3.50, 95% CI 1.17-10.50, p = 0.035).

CONCLUSION

In regard to patient satisfaction, both MAC and GA are acceptable anesthetic choices in sialendoscopy for appropriate cases. Patients report similar overall satisfaction and post-operative pain tolerance under either anesthetic modality. Patients who undergo GA report higher rates of preference for similar anesthetic modality in the future. Further study is needed to determine the most appropriate criteria for anesthesia modality selection.

Impact on quality of life in obstructive sialadenitis predicting outcomes after sialendoscopy

PURPOSE

Sialendoscopy is a minimally invasive procedure considered a paradigm shift in the treatment of obstructive sialadenitis. However, it shows an average need for revision procedure in up to 24% of operated cases. This study analyzed whether patient-related variables could predict the need for a revision during postoperative follow-up.

METHODS

From 2012 to 2020, this prospective comparative study analyzed demographic data as well as preoperative responses to the "Manukau Salivary Symptoms Score" (MSSS) questionnaire as predictors of the need for a revision procedure due to symptoms recurrence.

RESULTS

188 sialendoscopies (39.4% for stones/60.6% for stenoses) in 112 parotid (59.6%) and 76 submandibular glands (40.4%) were included in this study. Forty patients (21.3%) required a revision procedure. The variable "Impact on quality of life" in the preoperative period of patients with sialoliths showed that the likelihood of a revision procedure increases by 33.6% with each increase in the 10-point Likert scale presented in the MSSS (p = 0.010, OR = 1336, CI = 1.071 to 1.667). This finding was not influenced by the location of the sialolith in the duct (p = 0.415), size (p = 0.058) or number of stones (P = 0.476). Other demographic variables related to the patient showed no association with the need of a revision procedure.

CONCLUSION

Further studies should be performed to exclude the influence of other variables on the results; however, special attention should be given to patients who report a greater pre-operative impact on quality of life due to sialolithiasis.

LEVEL OF EVIDENCE

II.

A Retrospective Analysis of Multiple Affected Salivary Gland Diseases: Diagnostic and Therapeutic Benefits of Interventional Sialendoscopy

OBJECTIVES

Multiple affected salivary gland diseases are rare compared to single gland diseases and represent a major diagnostic challenge. These cases are commonly neglected in the scientific literature, despite the considerable suffering of these patients. The aim of this retrospective study was to report disease characteristics, diagnostic pathways, and therapeutic options, including sialendoscopic treatment of multiple affected salivary gland disorders.

METHODS

Patients experiencing multiple affected salivary gland diseases treated between 2013 and 2020 were consecutively identified. Data regarding demographics, clinical presentation, disease characteristics, treatment, complications, and follow-up were analyzed retrospectively.

RESULTS

In total, 71 patients were identified with these diseases and included obstructive disease without sialolithiasis (n = 22), inflammation (n = 15), immune disease (n = 19), radioiodine-induced sialadenitis (RAI) (n = 5), sialadenosis (n = 2), and juvenile recurrent parotitis (JRP) (n = 8). Diagnostic and therapeutic sialendoscopy was performed on 113 salivary glands in 42 patients, leading to completely (n = 27, 64.3%) or partially (n = 11, 26.2%) improved symptoms in most cases. In total, 4 patients did not improve after interventional therapy.

CONCLUSIONS

Multiple affected salivary gland diseases are rare and diagnostically challenging. Interventional sialendoscopy offers an effective and safe therapeutic option and should be considered in this specific cohort.

The Need for Studies on Oral Corticosteroids After Sialendoscopy for Obstructive Salivary Gland Disease: Systematic Review

OBJECTIVES

This qualitative systematic review evaluates the evidence in support of the use of oral corticosteroids in patients undergoing sialendoscopy for the treatment of obstructive sialadenitis.

DESIGN

Qualitative systematic review.

METHODS

A literature search was conducted from January 1985 and September 2020. Inclusion criteria embraced peer-reviewed articles in which adult patients undergoing interventional sialendoscopy for obstructive salivary gland disease received oral corticosteroids. The results were initially screened based on title and abstract, and the remaining articles were reviewed for eligibility.

RESULTS

About 218 papers were selected by title and abstract, 96 were selected for full-text review, and 9 met the inclusion criteria. Eight published reports were retrospective observational studies and 1 was a prospective comparative study. Overall, the heterogeneity of clinical data stood out in this systematic review. The pooled success rate in the studies was 873/979 (89%). Only 5 studies described a rationale for oral corticosteroid use as part of the post-operative management. In 4 studies, a prednisone total daily dose of 40 to 50 mg was used. One study clearly showed a lower recurrence rate in patients who received oral steroids for more than 7 days in addition to sialendoscopy for management of ductal stenoses.

CONCLUSION

This systematic review showed that most centers that prescribe oral corticosteroids after sialendoscopy are unaware of the specific results with this treatment. For ductal stenoses, only 1 paper clearly showed the benefits of oral corticosteroids after sialendoscopy but more high-quality evidence is required in the form of a comparative study or randomized controlled trial, with appropriate long-term follow up.

The Manukau Salivary Symptoms Score for Assessing the Impact of Sialendoscopy in Recurrent Obstructive Sialadenitis

OBJECTIVE

To examine the Manukau Salivary Symptom Score (MSSS) questionnaire as a validated tool to assess obstructive sialadenitis-specific symptoms to both indicate disease severity and assess the outcome after sialendoscopic procedures.

STUDY DESIGN

A prospective observational study was performed from 2010 to 2019 comprising 164 patients undergoing sialendoscopy for nonneoplastic chronic obstructive salivary gland disease (COSGD).

SETTING

Department of Otolaryngology-Head and Neck Surgery at the Manukau Surgical Centre, Auckland, New Zealand, between June 2010 and September 2019.

METHODS

A prospective observational study was performed from 2010 to 2019 comprising 164 patients undergoing sialendoscopy for nonneoplastic COSGD. Patients completed the MSSS preoperatively and at postoperative follow-up. Statistical tests were used to compare pre- and postoperative answers. Cronbach's α was used to measure internal consistency. Finally, construct validity was determined by comparing the 5-question MSSS questionnaire to the preexisting 20-question Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire.

RESULTS

Postoperatively, patients had significant improvements in pain, eating, talking, swelling, and quality of life (P < .001). The MSSS questionnaire was found to have high internal consistency (α = 0.938). Questions in the MSSS had a very strong positive correlation with 3 COSS questions, a strong positive correlation with 8, a moderate positive correlation with 4, and a weak positive correlation with 1. Four COSS questions were not considered relevant and were not included in the MSSS questionnaire.

CONCLUSION

The MSSS questionnaire is a simple, validated questionnaire that is useful for assessing the impact of sialendoscopy in patients with COSGD.

Sialendoscopy increases saliva secretion and reduces xerostomia up to 60 weeks in Sjögren's syndrome patients: a randomized controlled study

Objective

To assess the effect of sialendoscopy of the major salivary glands on salivary flow and xerostomia in patients with Sjögren’s syndrome (SS).

Methods

Forty-five patients with SS were randomly assigned to a control group (no irrigation, control, n = 15), to irrigation of the major salivary glands with saline (saline, n = 15) or to irrigation with saline followed by corticosteroid application (triamcinolone acetonide in saline, saline/TA, n = 15). Unstimulated whole saliva flow (UWSF), chewing-stimulated whole saliva flow (SWSF), citric acid-stimulated parotid flow, Clinical Oral Dryness Score (CODS), Xerostomia Inventory (XI) and EULAR SS Patient Reported Index (ESSPRI) scores were obtained 1 week before (T0), and 1, 8, 16, 24, 36, 48 and 60 weeks after sialendoscopy. Data were analysed using linear mixed models.

Results

Irrespective of the irrigation protocol used, sialendoscopy resulted in an increased salivary flow during follow-up up to 60 weeks. Significant between-group differences in the longitudinal course of outcomes were found for UWSF, SWSF, XI and ESSPRI scores (P = 0.028, P = 0.001, P = 0.03, P = 0.021, respectively). UWSF at 60 weeks was higher compared with T0 in the saline group (median: 0.14 vs median: 0.10, P = 0.02) and in the saline/TA group (median: 0.20, vs 0.13, P = 0.035). In the saline/TA group SWSF at 48 weeks was higher compared with T0 (median: 0.74 vs 0.38, P = 0.004). Increase in unstimulated salivary flow was also reflected in improved CODS, XI and ESSPRI scores compared with baseline.

Conclusion

Irrigation of the major salivary glands in patients with SS increases salivary flow and reduces xerostomia.

Sialendoscopy: A Four-Year Single Center Experience

PURPOSE

Sialendoscopy is a relatively new technique designed to diagnose and treat benign obstructive salivary gland disease using a minimally invasive approach. The purpose of this study is to present our experiences regarding the use of sialendoscopy in the form of a 4-year, single center experience and to demonstrate its usefulness in oral and maxillofacial practice.

METHODS

We collected data on patients who underwent sialendoscopy at the Oral-Maxillofacial Surgery Department of UZ Leuven between November 2015 and August 2019, including age, gender, sex, initial clinical presentation and symptoms, gland involvement, type of diagnostic investigations, diagnosis, localization of the obstruction, therapeutic intervention, surgeon, type of anesthesia, materials used, complications, secondary treatment, duration of follow-up, and outcome. Statistical analyses were performed, chi-squared was used to compare the different variables with P < .05 being considered significant.

RESULTS

During the 4-year timeframe, a total of 44 patients (31 female, 13 male) underwent sialendoscopy in a total of 47 procedures. The average age at time of sialendoscopy was 47.4 years. The most frequent cause of obstruction was sialolithiasis (70%). Cone-beam computed tomography (CBCT) was the most accurate preoperative investigation for the diagnosis of lithiasis (57%). Symptom improvement occurred in 57.9% of patients, with a complication rate of 11%. None of the complications were permanent.

CONCLUSION

Sialendoscopy can be considered safe and effective for both the diagnosis and treatment of benign obstructive salivary gland disease, with a useful place in oral and maxillofacial surgical practice. We recommend the inclusion of CBCT and/or ultrasound in the diagnostic workup prior to endoscopy.

Interpretation of the mucous plug through sialendoscopy

OBJECTIVE

The purpose of this manuscript is to highlight the behaviour of mucus inside the ducts of the major salivary glands, in presence of typical pathologies, through images obtained with sialendoscopy.

SUBJECT

The authors present and comment on some sialendoscopies that show mucous plug in the ducts of the major salivary glands.

RESULTS

In primary Sjogren's syndrome, mucous plugs confirm the qualitative anomaly of the mucins and acidification saliva. Instead, salivary calculations behave like foreign bodies that generate mechanical pressure and friction on the duct walls of major salivary glands, so mucus deposits in the duct in its defence; in case of infected stone, mucous plugs are formed also with the function of protecting the ducts from the aggression of germs. During sialadenitis, there is a conflict between mucus and bacteria which explains sialendoscopic evidence such as white duct walls and mucous plugs.

CONCLUSIONS

The study of the salivary ducts through sialendoscopy often confirms the clinical diagnosis or hypothesize it. During its execution, it is necessary not only to liberate the ducts of the major salivary glands but also analyse the appearance of the mucous plugs and the ductal walls as they are useful to guide the physician towards diagnosis.

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.

Sialendoscopy in Chronic Obstructive Sialadenitis Without Sialolithiasis: A Prospective Cohort Study

OBJECTIVES

To evaluate long-term chronic sialadenitis symptoms in patients without sialolithiasis following sialendoscopy-assisted salivary duct surgery (SASDS) compared to a control group managed conservatively.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

METHODS

Thirty-six patients (52 glands) with chronic sialadenitis without sialolithiasis completed the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire at presentation and at 3-month time intervals thereafter for 1 year. Lower COSS scores represent lower symptom severity. We compared 27 patients who underwent SASDS to 9 control patients who elected conservative management.

RESULTS

COSS gland-specific scores from 38 SASDS-treated glands (cases) and 14 control glands were similar at baseline. At 6 to 12 months (mean, 8.4 months), the surgically treated group had significantly lower scores and a greater score reduction from baseline compared to controls (mean score change [95% confidence interval] cases: 20.7 points [15.7-25.8]; controls: 11.7 points [4.9-18.4]; P = .04). There was a significant difference in scores between the 2 groups over time (P < .001). A greater proportion (72%) of cases reported partial or complete resolution of overall sialadenitis symptoms at 6 to 12 months compared to the controls (22%, P < .05).

CONCLUSION

Compared to patients electing for conservative management, patients with sialadenitis without sialolithasis treated with SASDS had improved symptom scores and a greater reduction of symptom severity after 6 months. With SASDS, patients had higher rates of significant overall symptom improvement. In evaluating chronic sialadenitis, assessment at multiple time points is necessary to capture the intermittent and cyclical pattern of obstructive symptoms.

Do Postoperative Oral Corticosteroids Improve Results After Sialendoscopy for Ductal Stenosis?

OBJECTIVES

This study aims to review the effects of short- and long-term oral administration of postoperative corticosteroids in patients undergoing sialendoscopy for the treatment of obstructive sialadenitis due to ductal stenosis.

STUDY DESIGN

Prospective comparative study.

METHODS

A prospective observational study was conducted at Manukau Surgical Center in Auckland, New Zealand, where patients undergoing sialendoscopic surgery for recurrent obstructive sialadenitis due to ductal stenoses were reviewed. Univariable and multivariable analysis, and also logistic regression were performed to identify variables correlated with the likelihood of the need for revision surgery for persistent or recurrent symptoms.

RESULTS

In this study, sialendoscopy was performed in 142 patients: 162 parotid glands (86.6%) and 25 submandibular glands (13.4%). Postoperative oral steroids were prescribed for 48 patients (34%); 19 (13%) were prescribed for less than 7 days and 29 (20%) for more than 7 days. In total, 33 patients (23.2%) required a revision sialendoscopy during follow-up due to recurrence of symptoms. Oral steroids prescribed for more than 7 days after a sialendoscopy reduced the likelihood of a revision procedure by 93% when compared with patients who did not receive this medication, and by 96% when compared with patients who received steroids for less than 7 days.

CONCLUSION

The results showed that in our population oral administration of corticosteroids for more than 7 days after sialendoscopy for the treatment of recurrent obstructive sialadenitis due to ductal stenosis markedly reduced the need for later revision surgery. Routine use of corticosteroids for more than 7 days is recommended after sialendoscopy in patients with ductal stenosis.

LEVEL OF EVIDENCE

II Laryngoscope, 131:E1503-E1509, 2021.

Robotic Management of Salivary Glands

There are numerous salivary gland pathologies for which robotic surgery can provide benefit. This article reviews the primary indications for use of transoral robotic surgery for salivary gland neoplasms. It also discusses transoral and retroauricular robotic approaches for pathology of the submandibular gland and prestyloid parapharyngeal space. These approaches have the advantage of avoiding a visible scar and are additionally minimally invasive in other ways as well. Robotic surgery offers advantages in several different modules of salivary gland surgery, similar to those it offers for oropharyngeal cancer, including improved optics, manual dexterity, and teamwork.

Radiotheragnostics Paradigm for Radioactive Iodine (Iodide) Management of Differentiated Thyroid Cancer

This review of radioactive iodide treatment (RAIT) extends from historical origins to its modern utilization in differentiated thyroid cancer (DTC). The principles embedded in the radiotheragnostics (RTGs) paradigm are detailed. The diverse approaches in current practice are addressed, and this broad variability represents a major weakness that erodes our specialty's trust-based relationship with patients and referring physicians. The currently developing inter-specialty collaboration should be hailed as a positive change. It promises to clarify the target-based terminology for RAIT. It defines RAIT of post total thyroidectomy (PTT), presumably benign thyroid as 'remnant ablation' (RA). 'Adjuvant treatment' (AT) referrers to RAIT of suspected microscopic DTC that is inherently occult on diagnostic imaging. RAIT directed at DTC lesion(s) overtly seen on diagnostic imaging is termed 'treatment of known disease' (TKD). It was recently recognized that a 'recurrent' DTC is actually occult residual DTC in the majority of cases. Thyroglobulin with remnant uptake concord (TRUC) method (aka Tulchinsky method) was developed to validate that a benign remnant in the post-thyroidectomy neck bed, as quantified by the RAI uptake, is concordant with a measured thyroglobulin (Tg) level at the time of the initial post-thyroidectomy evaluation. It allows recognition of occult residual DTC contribution to post-thyroidectomy Tg. Case examples demonstrate the application of the TRUC method for a logical selection of a specific RAIT category, using imaging-guided identification and management of RAI-avid versus RAI-nonavid residual DTC, i.e. the radiotheragnostics paradigm.

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.

Parotid ductal stenosis after facial cosmetic surgery (2 case reports)

RATIONALE

Facial cosmetic surgery sometimes causes complications involving surrounding tissues. In particular, parotid damage may cause fibrous tissue formation, ductal stenosis, and obstruct salivary flow. Affected patients usually complain of symptoms such as pain and swelling.

PATIENT CONCERNS

The authors report 2 cases of obstructive parotitis, arising as a complication of facial cosmetic surgery that were treated successfully using sialendoscopic procedures.

DIAGNOSIS

A diagnosis of parotid ductal stenosis was made based on medical history, clinical manifestations, imaging studies, and sialendoscopic findings for the 2 patients.

INTERVENTIONS

The successful sialendoscopic procedures was given to the 2 patients.

OUTCOMES

The 2 patients have shown no recurrent symptoms during follow-up.

LESSONS

Surgeons that perform facial cosmetic procedures should attain a thorough knowledge of the surgical anatomy of the parotid region and sialendoscopic procedure may be helpful for the management of obstructive parotitis due to complication of cosmetic surgery.

Salivary duct stenosis: diagnosis and treatment

The management of stenoses of the major salivary glands had undergone a significant change during the last 15-20 years. Accurate diagnosis forms the basis of adapted minimal invasive therapy. Conventional sialography and MR-sialography are useful examination tools, and ultrasound seems to be a first-line investigational tool if salivary duct stenosis is suspected as cause of gland obstruction. Sialendoscopy is the best choice to establish final diagnosis and characterise the stenosis in order to plan accurate treatment. In all major salivary glands, inflammatory stenosis can be distinguished from fibrotic stenosis. In the parotid duct system, an additional stenosis associated with various abnormalities of the duct system has been reported. Conservative therapy is not sufficient in the majority of cases. The development of a minimally invasive treatment regime, in which sialendoscopy plays a major role, has made the preservation of the gland and its function possible in over 90% of cases. Ductal incision procedures are the most important measure in submandibular duct stenoses, but sialendoscopy becomes more important in the more centrally located stenoses. Sialendoscopic controlled opening and dilation is the dominating method in parotid duct stenoses. In 10-15% of cases, success can be achieved after a combined treatment regime had been applied. This review article aims to give an overview on the epidemiology, diagnostics and current state of the art of the treatment of salivary duct stenoses.

Complications of traditional and modern therapeutic salivary approaches

The morbidity following traditional surgery of the salivary glands is well documented and includes postsurgical complications such as the Frey's syndrome, complete or partial facial nerve damage, facial scarring, greater auricular nerve numbness, sialocoeles and salivary fistula. The avulsion of the salivary duct, secondary strictures, gland swelling, salivary fistulas and perforations (false rout), traumatic ranulas, and the lingual nerve paraesthesia are the main endoscopy-related complications. In general, the rate of postsurgical complications after modern advanced minimally invasive surgical interventions is significantly lower compared with traditional surgery of the salivary glands. However, such comparisons cannot be performed because up-to-date traditional and minimally invasive surgical techniques are applied to different salivary disorders. Combinations of various minimally invasive techniques are also possible. There is no clear borderline between "traditional" and "modern" surgery of the salivary glands. It is appropriate to write about gradual replacement of old techniques with newer ones, and this process has no traffic lights.

Sialendoscopy for salivary stones: principles, technical skills and therapeutic experience

Obstructive sialadenitis is the most common non-neoplastic disease of the salivary glands, and sialendoscopy is increasingly used in both diagnosis and treatment, associated in selected cases with endoscopic laser lithotripsy. Sialendoscopy is also used for combined minimally invasive external and endoscopic approaches in patients with larger and proximal stones that would require excessively long laser procedures. The present paper reports on the technical experience from the Ear, Nose and Throat Unit of the Sant'Orsola-Malpighi Hospital of Bologna, and from the Department of Otorhinolaryngology of the University Hospital of Cagliari, Italy, including the retrospective analysis of the endoscopic and endoscopic assisted procedures performed on 48 patients (26 females and 22 males; median age 45.3; range 8-83 years) treated for chronic obstructive sialadenitis at the University Hospital of Cagliari from November 2010 to April 2016. The results from the Sant'Orsola-Malpighi Hospital of Bologna have been previously published. The technical aspects of sialendoscopy are carefully described. The retrospective analysis of the University Hospital of Cagliari shows that the disease was unilateral in 40 patients and bilateral in 8; a total of 56 major salivary glands were treated (22 submandibular glands and 34 parotids). Five patients underwent bilateral sialendoscopy for juvenile recurrent parotitis. 10 patients were treated for non-lithiasic obstructive disease. In 33 patients (68.75%) the obstruction was caused by salivary stones (bilateral parotid lithiasis in 1 case). Only 8 patients needed a sialectomy (5 submandibular glands and 3 parotids). The conservative approach to obstructive sialadenitis is feasible and can be performed either purely endoscopically or in a combined modality, with a high percentage of success. The procedure must be performed with dedicated instrumentation by a skilled surgeon after proper training since minor to major complications can be encountered. Sialectomy should be the "extrema ratio" after failure of a conservative approach.

Dynamic imaging with sialography combined with sialendoscopy to manage a foreign body in Stensen's duct

OBJECTIVE

We describe sialography as a dynamic imaging modality useful in establishing the diagnosis and planning for treatment of a parotid gland ductal foreign body.

METHODS

Chart and radiographic imaging review of a 75 year-old male who had obstructive sialadenitis symptoms two years after welding slag pierced the cheek skin and identified as a 'piece of steel stuck in his cheek'.

RESULTS

Sialography was used to demonstrate a foreign body adjacent to the parotid gland to indicate its presence as a mobile element within the ductal system associated with marked pre-obstructive duct dilation. Sialendoscopy was used to successfully remove the foreign body.

CONCLUSIONS

In selected cases, the management of obstructive sialadenitis can be improved with sialography in permitting dynamic imaging of salivary duct anatomy. Although ultrasound has evolved as a standard component of salivary gland assessment, sialography may complement imaging with ultrasound (or CT as in this case) to offer the highest acuity definition of the salivary ducts.

Outcomes of interventional sialendoscopy for obstructive salivary gland disorders: an Italian multicentre study

Interventional sialendoscopy has become the predominant therapeutic procedure for the management of obstructive salivary disorders, but only a few multicentre studies of large series of patients with a long-term follow-up have been published. This Italian multicentre study involved 1152 patients (553 females; mean age 50 years) who, after at least a clinical and ultrasonographic evaluation, underwent a total of 1342 diagnostic and interventional sialendoscopies, 44.6% of which involved the parotid gland. 12% (n = 138) of patients underwent multiple treatments. The procedure was successful in 1309 cases. In 33 cases (2.4%) the procedure could not be concluded mainly because of complete duct stenosis (21 cases). Salivary stones were the main cause of obstruction (55%), followed by ductal stenosis and anomalies (16%), mucous plugs (14.5%) and sialodochitis (4.7%). Complete therapeutic success was obtained in 92.5% of patients after one or more procedures, and was ineffective in < 8%. Untoward effects (peri and postoperative complications) were observed in 5.4% of cases. Sialendoscopy proved to be an effective, valid and safe procedure in the diagnostic and therapeutic management of non-neoplastic obstructive salivary gland diseases.

Sialendoscopy enhances salivary gland function in Sjögren's syndrome: a 6-month follow-up, randomised and controlled, single blind study

OBJECTIVES

To assess the effect of sialendoscopy of the major salivary glands on salivary flow and xerostomia in patients with Sjögren's syndrome (SS).

METHODS

Forty-nine patients with SS were randomly assigned to a control group (n=15) and two intervention groups: irrigation of the major glands with saline (n=16) or with saline followed by triamcinolone acetonide (TA) in saline (n=18). Unstimulated whole saliva flow (UWS), chewing-stimulated whole saliva flow (SWS), citric acid-stimulated parotid flow (SPF), Clinical Oral Dryness Score (CODS), Xerostomia Inventory (XI) score and the European League Against Rheumatism (EULAR) SS Patient-Reported Index (ESSPRI) were obtained 1 week (T0) before, and 1 (T1), 8 (T8), 16 (T16) and 24 (T24) weeks after sialendoscopy.

RESULTS

Median baseline UWS, SWS and SPF scores were 0.14, 0.46 and 0.22 mL/min, respectively. After intervention, significant increases in UWS and SWS were observed in the saline group (at T8 (P=0.013) and T24 (P=0.004)) and the saline/TA group (at T24 (P=0.03) and T=16 (P=0.035)). SPF was increased significantly in the saline/TA group at T24 (P=0.03). XI scores declined after sialendoscopy in both intervention groups. Compared with the control group, CODS, XI and ESSPRI improved in the intervention groups. UWS, SWS and SPF were higher in the intervention groups compared with the control group, but these differences were not significant except for SPF in the saline/TA group at T24 (P=0.005).

CONCLUSIONS

Irrigation of the major salivary glands in patients with SS enhances salivary flow and reduces xerostomia up to 6 months after sialendoscopy.

Sialendoscopy in the Management of Radioiodine Induced Sialadenitis: A Systematic Review

Objectives:

Salivary gland dysfunction as a consequence of radioiodide ablation is present in as many as two-thirds of patients, and unfortunately, many of these individuals do not respond to conservative measures. Sialendoscopy as a minimally invasive therapeutic modality may have utility in the treatment of radioiodide induced sialadenitis (RAIS). Our aim was to explore whether sialendoscopy resulted in clinical improvement in patients with RAIS.

Methods:

A systematic review of studies on sialendoscopy for RAIS was conducted using MEDLINE database, Embase, and Cochrane Library. The outcomes of interest included the proportion of patients demonstrating clinical improvement after intervention, patient demographics, radiation dose, specific procedural variations, specific salivary gland, failure rate, and recurrence.

Results:

Eight studies met inclusion criteria. Data reviewed showed an increased predilection of parotid sialadenitis relative to submandibular gland sialadenitis. All but 2 studies employed sialendoscopy only after failure of conservative measures. An overall rate of clinical improvement ranging from 75% to 100% was reported.

Conclusion:

This systematic review encompassing 122 patients represents the largest pooled sample to date of patients undergoing sialendoscopy for RAIS. Sialendoscopy represents an invaluable minimally invasive modality that may obviate the need for more invasive surgery as intervention was associated with a high success rate.

Surgeon-Performed Ultrasound for Chronic Obstructive Sialadenitis Helps Predict Sialendoscopic Findings and Outcomes

Objective

To determine the accuracy of surgeon-performed ultrasound (SP-US) features for predicting intraoperative sialendoscopic findings and to correlate ultrasound features with short-term symptomatic outcomes following sialendoscopy-assisted salivary duct surgery (SASDS).

Study Design

Case series with chart review.

Setting

The practices of 2 academic sialendoscopy surgeons.

Subjects and Methods

Between February 2014 and September 2015, 82 patients with 105 symptomatic glands underwent SASDS, of whom 56 patients (75 glands) met inclusion criteria. SP-US and sialendoscopic findings were reviewed for patients with chronic obstructive sialadenitis who underwent SASDS and who had been prospectively evaluated with the University of California–San Francisco Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire (scored 0-100) administered preoperatively and 3 months postoperatively.

Results

The positive predictive value (PPV) and negative predictive value (NPV) of SP-US for identifying sialoliths intraoperatively were 94% (33/35) and 91% (39/43), respectively. Of glands with sialoliths on SP-US, 97% (34/35) had complete symptom resolution (COSS ≤10) after SASDS. The PPV and NPV of salivary duct dilation on SP-US for finding a corresponding stenosis on sialendoscopy were 93% (14/15) and 50% (14/28), respectively. Nonsialolith SP-US features with the highest PPV for complete or partial symptom resolution (COSS ≤25) following SASDS included distal duct dilation of all glands (86%; 6/7) and dilation of both distal and proximal parotid ducts (75%; 6/8).

Conclusion

SP-US has high accuracy for ruling in and ruling out sialoliths, as well as for ruling in but not for necessarily ruling out stenosis presence and location. Ultrasound is helpful in estimating degree of short-term symptom response following SASDS.

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.

Sialendoscopy-assisted transfacial removal of parotid sialoliths: A systematic review and meta-analysis

OBJECTIVE

To review the literature and conduct a meta-analysis to determine the effectiveness and safety of the combined endoscopic-transfacial approach for parotid sialolith management.

DATA SOURCES

PubMed 1946-, Embase 1947-, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Review Effects, Cochrane Central Register of Controlled Trials, clinicaltrials.gov, Proquest Dissertations and Theses, and FirstSearch Proceedings to March 2015.

REVIEW METHODS

Published prospective or retrospective English-language studies with reported outcomes of more than one patient undergoing the combined endoscopic-transfacial procedure for parotid sialolithiasis were included. Two independent authors screened all eligible studies and reviewed and extracted data from relevant publications. Weighted pooled proportions for stone removal, symptom improvement, gland preservation, and complications were calculated.

RESULTS

Ten studies, primarily retrospective single-institution studies, were included in the final analysis, with a total of 184 patients. Overall, the procedure was noted to be successful with low risk; the weighted pooled proportions were 0.99 (95% confidence interval [CI]: 0.97 to 1.00) for stone removal, 0.97 (95% CI: 0.93 to 0.99) for symptom improvement, 1 (95% CI: 0.99 to 1.00) for gland preservation, and 0.06 (95% CI: 0.01 to 0.15) for complications.

CONCLUSIONS

Although our analysis is primarily based on retrospective data, the evidence shown here suggests that the combined endoscopic-transfacial technique is an effective treatment for parotid gland sialolithiasis not amenable to intraoral or purely endoscopic removal. This approach results in high rates of symptom improvement and gland preservation. The complication rates are low, further supporting the use of this technique. Laryngoscope, 127:2510-2516, 2017.

Complications of Sialendoscopy in Patients With Sjögren Syndrome

PURPOSE

Recent literature suggests that sialendoscopy of the major salivary glands could alleviate symptoms of Sjögren syndrome (SS) and restore salivary function. The aim of this study was to evaluate the authors' experience of sialendoscopy of the salivary glands in patients with SS.

MATERIALS AND METHODS

In this retrospective case series study, the surgical data of patients with SS who had undergone sialendoscopy at the VU University Medical Center (Amsterdam, The Netherlands) from November 2014 through April 2015 were used. Outcome measurements were successful entry to the salivary gland and completion of sialendoscopy as planned. Furthermore, pre- and postoperative complications were scored. Descriptive analysis of the data was performed.

RESULTS

Surgical data of sialoendoscopic procedures in 26 patients with SS (24 women and 2 men; mean age, 57 yr; range, 27 to 72 yr) were analyzed. Sialendoscopy was successfully performed in 78 of 104 salivary glands (75%; 50 parotid and 28 submandibular glands) in the 26 patients. Sialendoscopy failed in 26 of the 104 sialoendoscopic procedures (25%; 2 parotid and 24 submandibular glands). In 16 salivary glands, the ductal orifice could not be identified. In 7 salivary glands, sialendoscopy could not be performed because of partial or complete stenosis of the salivary duct. In 3 salivary glands, sialendoscopy was not performed because of a ductal perforation. Three patients developed a postoperative infection.

CONCLUSION

The overall rate of complications was limited and the sialoendoscopic complications in patients with SS could be regarded as minor. Most complications were seen for sialendoscopy of the submandibular glands in this specific patient category. Careful preoperative selection of patients and salivary glands could contribute to a lower rate of complications and more predictable results.

Sialendoscopy for non-stone disorders: The current evidence

OBJECTIVE

Review the current literature on the use of sialendoscopy in the treatment of non-stone disorders of the major salivary glands.

DATA SOURCES

Eligible articles that reported on the use of sialendoscopy in the treatment of non-stone disorders were identified using MEDLINE, Embase, and Google Scholar through May 2016. The search used key words sialendoscopy, salivary endoscopy, salivary scope, salivary duct stenosis, salivary duct stricture, Sjogren's disease, radioiodine sialadenitis, salivary duct obstruction, sialadenitis, chronic sialadenitis, juvenile recurrent parotitis, parotitis, and radiation sialadenitis.

REVIEW METHODS

Full-length prospective and retrospective original articles; systemic reviews; and meta-analysis, including adults and children with adequate data for evaluating the sialendoscopy for non-stone disorders, were included. Individual case reports were excluded.

RESULTS

There is an increasing trend for the use of sialendoscopy for salivary obstruction caused by a wide variety of non-stone disorders worldwide. The studies of sialendoscopy for non-stone disorders are often retrospective, of smaller sample size, and more subjective in measurement of patient outcome. The most common indications currently for the procedure are scars, juvenile recurrent parotitis, radioiodine sialadenitis, and Sjögren syndrome, respectively.

CONCLUSION

Although the initial evidence for the use of sialendoscopy for non-stone disorders is not as established as that for stones, it remains a promising gland-preserving tool in the management of non-stone disorders of major salivary 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.

Sialendoscopy of Salivary Glands Affected by Sjögren Syndrome: A Randomized Controlled Pilot Study

PURPOSE

Sialendoscopy of the major salivary glands could alleviate the oral symptoms of Sjögren syndrome (SS) and restore salivary function. The aim of this pilot study was to evaluate the effect of sialendoscopy of the major salivary glands on salivary flow, saliva composition, and mouthfeel in patients with SS and to collect data for sample size analysis for a larger clinical trial.

MATERIALS AND METHODS

Twenty patients diagnosed with SS were randomly assigned to a nonintervention control group or a sialendoscopy group. Unstimulated whole saliva flow, stimulated whole saliva flow, Clinical Oral Dryness Score, Xerostomia Inventory score, and EULAR Sjögren's Syndrome Patient Reported Index score were obtained 1 week before (T0), 1 week after (T2), and 8 weeks after (T3) sialendoscopy. Unstimulated whole saliva was analyzed for amylase concentration, activity, and mucin 5B concentration. Amylase and mucin 5B output were calculated.

RESULTS

In the sialendoscopy group, unstimulated and stimulated whole saliva flows were numerically higher at T2 and T3 compared with T0. Xerostomia Inventory score was significantly lower in the sialendoscopy group at T2 compared with T0 (P = .03). Unstimulated and stimulated whole saliva flows were higher in the sialendoscopy group compared with the control group at T2 and T3 (not meaningful). Significant differences were found between groups for the EULAR Sjögren's Syndrome Patient Reported Index score at T2 (P = .03) and T3 (P = .001). Xerostomia Inventory score and Clinical Oral Dryness Score in the sialendoscopy group were lower compared with the control group at T2 (P = .02) and at T3 (P = .04), indicating less oral dryness.

CONCLUSION

This pilot study indicates a positive effect of sialendoscopy on some parameters, but it cannot yet be concluded that it has a positive effect on salivary flow in patients with SS. These preliminary results need to be verified in a randomized controlled trial with a larger sample and longer follow-up period.