Sialendoscopy with holmium:YAG laser treatment for multiple large sialolithiases of the Wharton duct: a case report and literature review

Holmium:YAG laser-assisted intraductal sialendoscopic lithotripsy under local anesthesia

OBJECTIVES

This retrospective multi-institutional chart review study aims to present results from patients treated with Holmium:YAG laser-assisted sialendoscopic intraductal lithotripsy under local anesthesia.

METHODS

Preoperative ultrasound and/or CT were used for location and measurement of the stones. Local anesthesia was applied in all patients, Marchal all-in- one 1.3 mm and Erlangen 1.6 sialendoscopes were used. The laser was used with power settings limited by discomfort or pain. Inclusion criteria were stone size (all >5 mm) and fixed stones.

RESULTS

42 patients, 48 stones were treated (30 males/12 females), 21 submandibular and 21 parotid. Ages ranged from 20 to 70 years (95 % CI: 43.37-51.58). Mean size was 6.2 mm (95 % CI: 5.71-6.72). Complete fragmentation was achieved in 66.7 % and incomplete in 33.3 %. Out of the incomplete fragmented 14 cases, seven (50 %) remained symptom free on follow-up. Maximum duration was 120 min. Minimum power settings of the laser was 4.8 Watts and maximum 18 Watts. Six patients expressed pain or discomfort that limited power increase and duration of the procedure. Total follow up time was 10 years. There were no major complications such as hemorrhage, nerve paresis or skin ulceration.

CONCLUSION

The procedure is safe under local anesthesia, well tolerated by most patients and should be used in cases of small fixed and "intermediate-sized" stones as a single modality. Discomfort may limit power settings and duration. The later is the major disadvantage of the method.

Laser-Assisted Sialolithotripsy: A Correlation of Objective and Subjective Outcomes

OBJECTIVE

To analyze the long-term symptomatic results of laser-assisted sialolithotripsy (LAS) in cases of obstructive sialolithiasis and correlate with objective criteria using diagnostic sialendoscopy (DS) as a method of examination.

METHODS

This is a retrospective study comprising 50 consecutive patients who underwent holmium-YAG LAS and completed follow-up of at least 6 months. Symptom scoring and endoscopic scoring were done at 6 weeks and 6 months intervals for further study purposes.

RESULTS

At the end of 6 weeks post-LAS, 70% patients were asymptomatic (A-sym) and only 30% had residual symptoms (Sym). However, obstructed duct (OB-duct) was observed on endoscopic scoring in 88% due to stenosis, residual stones, or both stenosis and residual stones. The obstructed ducts were treated in outpatient clinic and followed up over time, leading to 98% of patients being in A-sym group at the end of study period of 6 months. At the end of study, 82% of patients had clear duct (CL-duct).

CONCLUSION

Holmium LAS is a viable option for the management of intermediate-sized stones. LAS if used judiciously, and in properly selected cases, has high rate of stone fragmentation and symptom resolution. A vigilant postoperative protocol taking into account residual mealtime symptoms and altered salivary characteristics combined with early DS can help identify and treat patients with residual stone fragments and ductal stenosis.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2344-2349, 2022.

Treatment of Sialolithiasis: What Has Changed? An Update of the Treatment Algorithms and a Review of the Literature

Treatment for sialolithiasis has undergone significant changes since the 1990s. Following the development of new minimally invasive and gland-preserving treatment modalities, a 40–50% rate of gland resection was reduced to less than 5%. Extracorporeal shock-wave lithotripsy (ESWL), refinement and extension of methods of transoral duct surgery (TDS), and in particular diagnostic and interventional sialendoscopy (intSE) are substantial parts of the new treatment regimen. It has also become evident that combining the different treatment modalities further increases the effectiveness of therapy, as has been especially evident with the combined endoscopic–transcutaneous approach. In the wake of these remarkable developments, a treatment algorithm was published in 2009 including all the known relevant therapeutic tools. However, new developments have also taken place during the last 10 years. Intraductal shock-wave lithotripsy (ISWL) has led to remarkable improvements thanks to the introduction of new devices, instruments, materials, and techniques, after earlier applications had not been sufficiently effective. Techniques involving combined approaches have been refined and modified. TDS methods have been modified through the introduction of sialendoscopy-assisted TDS in submandibular stones and a retropapillary approach for distal parotid sialolithiasis. Recent trends have revealed a potential for significant changes in therapeutic strategies for both major salivary glands. For the submandibular gland, ISWL has replaced ESWL and TDS to some extent. For parotid stones, ISWL and modifications of TDS have led to reduced use of ESWL and the combined transcutaneous–sialendoscopic approach. To illustrate these changes, we are here providing an updated treatment algorithm, including tried and tested techniques as well as promising new treatment modalities. Prognostic factors (e.g., the size or location of the stones), which are well recognized as having a strong impact on the prognosis, are taken into account and supplemented by additional factors associated with the new applications (e.g., the visibility or accessibility of the stones relative to the anatomy of the duct system).

A Novel Approach for the Treatment of Sialolithiasis that Preserves Salivary Duct Anatomy

OBJECTIVE

The sialendoscopy era in the treatment of salivary gland stones has reduced the use of classical surgical methods. However, the miniature ducts and tools may cause difficulties in removing large sialoliths. Therefore, invasive combined oral surgeries or gland resection may be considered. We searched for the most suitable method in order to stay in line with the minimally invasive approach that preserves the ductus anatomy, and that can reduce the surgical fears of patients.

MATERIALS AND METHODS

The study included 84 cases (23 parotid and 61 submandibular) in whom stones were fragmented by pneumatic lithotripsy and removed between January 2015 and January 2020. The parotid cases comprised 7 females and 16 males, and the submandibular cases comprised 25 females and 36 males. Intraductal lithotripsy was performed using pneumatic lithotripter. This study has fourth level of evidence.

RESULTS

Based on total number of cases (n = 84), success rate was 67/84 (79.7%) immediately after sialendoscopy, and overall success rate was 77/84 (91.6%). Based on number of stones treated (n = 111), our immediate success rate was 94/111 (84.6%), and overall success rate was 104/111 (93.7%). The success criteria were complete removal of the stone and fragments in a single sialendoscopy procedure and resolution of symptoms.

CONCLUSIONS

We successfully treated salivary gland stones, including L3b stones, in our patient cohort with sialendoscopy combined with pneumatic lithotripsy. The lithotripsy method that we have adapted seems to be more useful and cost-effective compared to its alternatives. We were also able to preserve the ductus anatomy and relieve patients' concerns.Level of Evidence: Level IV.

Sialendoscopy-assisted intraoral incision approach for the treatment of posterior Wharton's duct stones: our experience and outcomes

INTRODUCTION

Sialoliths can be removed by sialendoscopy in some cases. But sometimes it fails if the stone is located in the proximal or hilum of Wharton's duct.

AIM

To evaluate the clinical efficacy of the sialendoscopy-assisted intraoral incision approach to remove large stones located in the proximal or hilum of Wharton's duct, when sialendoscopy alone fails.

MATERIAL AND METHODS

Twenty patients with large stones located in the proximal or hilum of Wharton's duct were included in our study. We used a sialendoscopy-assisted intraoral incision approach to remove large stones located in the proximal or hilum of Wharton's duct when endoscopy failed. The complications and treatment effect were observed.

RESULTS

The stones were removed successfully in this way in all patients. Two cases had tongue numbness after the operation, and recovered 3 months later without additional intervention. No swelling or pain appeared during the 3-month to 1-year follow-up. Saliva could be observed from the orifice in 15 patients, with little or none in 5 patients.

CONCLUSIONS

The sialendoscopy-assisted intraoral incision approach to remove large stones located in the proximal or hilum of Wharton's duct is effective and safe.

Ultrasound-Guided Sialendoscopy with Holmium: Yttrium Aluminum Garnet (YAG) Laser Treatment of Parotid Sialolithiasis

BACKGROUND At present, promptly diagnosing sialolithiasis is easy with the assistance of various noninvasive diagnostic procedures. However, the treatment of parotid sialolithiasis remains inadequate. An immense challenge for oral maxillofacial practitioners is the treatment of large radiolucent stones, especially of those that are located in a hard-to-approach positions in the salivary ducts. This case report aims to propose the protocol of a new technique to improve the management of parotid salivary stones. In 2017, our hospital was the first medical center in Vietnam to implement this technique in the treatment of parotid sialolithiasis. CASE REPORT A 38-year-old man was diagnosed with parotid sialolithiasis based on ultrasound and computed tomography (CT) scanning results. He underwent ultrasound-guided sialendoscopy with holmium: yttrium aluminum garnet (YAG) laser lithotripsy. The stone was large (22×12 mm) and in an unfavorable position. A narrow strip of fibrous tissue in front of the stone was also noted. However, 1 week after surgery the patient had local swelling of the parotid gland and no manifestation of inflammation, facial paralysis, or obstructed saliva through the drainage ducts. The patient was examined for clinical symptoms and glandular ultrasound at 3 months and 6 months after the procedure. The follow-up examination results showed normal parotid gland function, no complications or recurrence of stones, and no narrowing of the gland duct. CONCLUSIONS Ultrasound-guided sialendoscopy with holmium: YAG laser is safe and effective for treating parotid salivary gland stones.

The holmium:YAG laser lithotripsy-a non-invasive tool for removal of midsize stones of major salivary glands

Incorporeal lithotripsy by using holmium:YAG laser has been recently successfully spread and used in the treatment of urolithiasis. Although this method is not as common in salivary gland surgery, it is also recommended for endoscopic treatment of sialolithiasis. In this study, we decided to analyse effectiveness of holmium:YAG laser method among patients with midsize stones as the treatment in this particular population is still not determined and remains in dispute. Thus, the primary aim of the study is a prospective, complex analysis of incorporeal holmium:YAG laser lithotripsy effectiveness and safety in patients suffering from sialolithiasis. The examined group consisted of 32 consecutive patients, 17 female (53%) and 15 male (47%). The average age was 42 (age range 22-70). In our series, sialoendoscopy with intraductal lithotripsy was performed in patients with wide range of stone's diameter (3 to 10 mm). The calculi were removed with foreign body forceps or retrieval basket, after stone fragmentation with holmium:YAG laser. The power of the laser during surgery was set at 2.5 to 3.5 W. One shot energy equalled 0.5-0.7 J with frequency of 5 Hz. The bivariate Pearson Correlation and a point-biserial correlation were used to analyse the data. Total success rate of holmium:YAG laser lithotripsy in this consecutive group was equal to 90% and efficacy in the group with excluded cases when endoscopic approach difficulties were experienced (stone not visible) reached 93%. The long-term follow-up revealed that in 26 patients (84%), complete recovery was achieved. Two patients developed Wharton's duct stenosis and one Stensen's duct orifice stenosis (9.5%), of whom one required reoperation. Two patients eventually underwent total excision of submandibular gland. Sialoendoscopy combined with incorporeal laser-assisted lithotripsy proved to be effective and safe method for treatment of sialothiasis with midsize stones (4-8 mm) in population of clinic. Even taking into account the prevalence of complications associated with holmium:YAG laser, it is still safer alternative compared to open surgery where there is a significant risk of the bleeding, wound infection or injury of the facial nerve.

Ultrastructural analysis of the submandibular sialoliths: Raman spectroscopy and electron back-scatter studies

The aim of work was the epidemiological analysis of the occurrence of sialolithiasis of the submandibular gland in adults and the evaluation of the ultrastructure of salivary stones. The study sample consisted of 44 sialoliths. Analysis of the structure and chemical composition of sialoliths was performed using a Scanning Electron Microscope and Raman Spectroscopy. Comparing our results with the literature we can say that the epidemiology of sialolithiasis has not changed significantly over the past 50 years. A wide variety of sialoliths structure was observed. In 75% (33) cases a layered structure of salivary stones was observed, while in 25% (11) - homogeneous structure. The various distribution of organic and inorganic components was observed among all the analyzed sialoliths. Raman spectroscopy allows for preliminary analysis of the sialoliths structure with only a qualitative assessment of their composition, which significantly reduces the research value of this method. The presence of organic and inorganic compounds in the core and inner layers of the salivary glands stones confirms 2 basic theories of the formation of sialoliths: inflammation and deposition of the inorganic component as a result of disruption of saliva flow in the salivary glands.

3D video-assisted trans-oral removal of deep hilo-parenchymal sub-mandibular stones

The aim of this paper is to describe the intra-operative findings and surgical results of the first application of 3D high-definition (HD) endoscopic support to the trans-oral surgical treatment of five patients with deep hilo-parenchymal sub-mandibular stones who underwent clinical and ultrasonographic (US) follow-up examinations at one month after the procedure. Five patients undergoing 2D-HD video-assisted transoral surgery for the same condition were used as controls. The results were classified as successful (US - demonstrated complete clearance) or unsuccessful (US - demonstrated total or partial persistence). Visual analogue scales (VAS) were used post-surgically to evaluate the sharpness and brightness of the 2D and 3D images on the screen and stereoscopic depth perception (SDP) of the 3D-HD endoscope. Successful stone removal and significant subjective improvement (lack of obstructive symptoms) was obtained in all but one of the patients in the 3D group, in whom the one-month US evaluation revealed a residual 3 mm asymptomatic hilo-parenchymal stone that was successfully treated by sialendoscopy-assisted intra-corporeal laser lithotripsy. Wharton’s duct and the lingual nerve were identified and preserved in all cases. The mean 3D-HD VAS results were brightness 7 (range 6-8), sharpness 7.8 (range 7-9) and SDP 8.2 (range 8-9); the mean 2D-HD results were brightness 7.8 (range 7-9) and sharpness 7 (range 7-8). Our findings confirm the safety and efficacy of conservative transoral surgical treatment of hilo-parenchymal sub-mandibular stones. From a surgeon’s perspective, 3D-HD guided exploration of the oral floor seems to provide a better view of Wharton’s duct and the lingual nerve, especially near the sub-mandibular parenchyma. The 3D-HD video-assisted transoral removal of deep hilo-parenchymal sub-mandibular stones can therefore be considered a useful new means of preserving the function of an obstructed salivary gland.

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.

Salivary lithotripsy in the era of sialendoscopy

The traditional management of obstructive salivary disorders has been replaced by minimally-invasive gland-preserving techniques including shock-wave lithotripsy, sialendoscopy, interventional radiology and endoscopically video-assisted trans-oral and cervical stone retrieval, of which sialendoscopy is considered to be the method of first choice. Primary endoscopically controlled stone extraction without prior fragmentation is only possible in 15-20% of cases; in more than 80%, fragmentation is necessary because of the size, impactation and location of the stone, or an alternative treatment such as transoral duct surgery or combined approaches are required. Moreover, about 10-20% of all stones cannot be adequately accessed by means of a sialendoscope or any alternative surgical method and, in such cases, extra-corporeal shock wave lithotripsy (ESWL) is the treatment of choice. However, in endoscopically accessible stones, ESWL is being gradually replaced by endoscopically assisted intra-corporeal techniques, including endoscopically guided laser and pneumatic intracorporeal lithotripsy. We describe the currently most widely used techniques for salivary lithotripsy, including ESWL, and endoscopically guided laser, electrohydraulic, electrokinetic and pneumatic intra-corporeal lithotripsy, and discuss their indications given the widespread use of advanced rehabilitative sialendoscopy and combined therapeutic approaches.

Gland Preservation in Patients Undergoing Sialoendoscopy

Objective Sialoendoscopy is a minimally invasive technique for the treatment of obstructive sialadenitis. We aim to describe treatment considerations and report our ultimate rate of gland preservation. Study Design Case series with chart review. Setting Academic tertiary hospital. Subject and Methods A total of 128 consecutive sialoendoscopy cases for obstructive sialadenitis between 2009 and 2015 were evaluated. Procedures included endoscopic stricture dilation, basket-assisted stone retrieval, Holmium laser lithotripsy, and combined endoscopic transoral stone excision. Resolution of symptoms, need for additional procedures, and rate of subsequent adenectomy were investigated. Results Sialoendoscopy was completed in 120 of 128 patients (94%). There were 87 parotid gland cases and 41 submandibular gland cases. Endoscopic stricture dilation was attempted in 97 patients and successful in 99%. A sialolith was identified in 31 cases and removed by basket-assisted stone retrieval (10 cases), Holmium:YAG laser stone fragmentation (10 cases), and combined endoscopic transoral stone extraction (4 cases). In 8 cases overall, sialoendoscopy failed, with immediate adenectomy. At a mean follow-up of 18 months, 39 patients (33%) reported recurrence of symptoms, with 90% in the stricture group. For the entire cohort, gland preservation occurred in 112 of 128 patients (88%). Conclusions Sialoendoscopy is an effective technique, with few patients requiring additional procedures. Newer interventional approaches allow for stone retrieval without adenectomy. Patients in the stricture group were more likely to have recurrent symptoms as compared with the sialolithiasis group but often benefit from additional sialoendoscopic procedures, leading to a high overall rate of long-term gland preservation of 91%.

Pediatric sialendoscopy in Asians: A preliminary report

BACKGROUND/PURPOSE

The sialendoscopic approach in treating pediatric salivary gland disorders has been reported with great success through the years. Whereas this success has been widely reported in Caucasian populations, relatively little has been reported regarding the use of this procedure in pediatric patients in Asian countries. The purpose of this study is to report our preliminary experience in pediatric sialendoscopy.

METHODS

The data from 20 patients (<18years old), who underwent sialendoscopy for obstructive sialoadenitis in the Department of Otorhinolaryngology of Mackay Memorial Hospital between October 2013 and November 2015, were reviewed.

RESULTS

Twelve of our 20 patients (60%) were diagnosed with sialolithiasis and 8 of our 20 patients (40%) presented with non-lithiasis obstructive sialoadenitis. Ductal stenosis was found in 13 patients, and 18 patients had debris/mucous plug formation. The overall success rate was 95% (19/20) in our series, and 85% (17/20) of the patients had achieved a complete remission after a single sialendoscopy procedure.

CONCLUSIONS

Sialendoscopy is an ideal treatment in the management of obstructive sialoadenitis in Asian pediatric patients. If necessary, Holmium:YAG laser lithotripsy and sialostent placement could be applied, and both procedures are well tolerated in pediatric patients.