SIALADENITIS AND SIALOLITHIASIS

Sialolith removal in the submandibular region using surgical diode laser: report of two cases and literature review

PURPOSE

Sialolithiasis is defined as the presence of one or more calcified structures within the duct of a major or minor salivary gland. It occurs as a result of deposition of calcium salts around an accumulation of organic debris in the duct lumen. The main signs and symptoms are edema and bacterial infection with abscess formation.

METHODS

This study aimed to report two cases of submandibular sialolithiasis treated surgically with diode laser and conduct a review of the literature by means of a systematic search. In the two cases, the calculi were located in the distal part of the submandibular duct and could be palpated intraorally. Surgery was performed in an outpatient setting under local anesthesia. A linear incision was made in the floor of the mouth, in the region of the opening of Wharton's duct, to expose and remove the calculi. Laser cutting was performed using a diode laser module coupled to a 400-μm optical fiber emitting at a wavelength of 980 nm (infrared), 2.5 W output power, and in continuous pulse mode.

RESULTS

The use of diode laser is a safe and minimally invasive option for this type of procedure.

CONCLUSION

Offering advantages such as enhanced coagulation properties and high-quality incision, absence of bleeding, low risk of nerve damage, and few comorbidities.

Submandibular giant sialoliths-2 case reports and review of the literature

Sialolithiasis is one of the most common diseases of the salivary gland. The submandibular gland and its duct appear to be the most susceptible. However, giant sialoliths have rarely been reported in the literature. Two case reports of giant sialoliths in the submandibular duct alone are presented. In both patients, a transoral removal of the stone was done under local anesthesia. The stones were 35 mm and 25 mm long, respectively. Follow-up showed asymptomatic and normal functioning glands. The etiology, pathogenesis and management of such giant sialoliths are discussed.It is interesting to note that both patients remained relatively asymptomatic in spite of such long-standing sialoliths. The glands also recovered normal function quickly following removal of stones, which is interesting as such longstanding stones usually produce irrereversible functional damage to the gland. A conservative approach to the gland will spare the patient the morbidity associated with gland removal.

An Er:YAG laser endoscopic fiber delivery system for lithotripsy of salivary stones

BACKGROUND AND OBJECTIVES

Endoscopic applications of Erbium:YAG lasers are still very limited due to lack of appropriate fiber delivery capabilities. Recent reports on potential advantages of this laser for lithotripsy of ureteral stones prompted us to develop an Er:YAG fiber delivery system for endoscopic lithotripsy of salivary stones. We report on the development of this system and its clinical use on 17 patients.

STUDY DESIGN/MATERIALS AND METHODS

Ho:YAG and Er:YAG laser fragmentation performances were initially compared. Optimal laser parameters for lithotripsy of salivary stones were then established ex vivo using a commercial dental Er:YAG laser (Lumenis Opusdent 20). Metal hollow waveguides optimized for Er:YAG laser transmission were end sealed with a polished sapphire rod of 0.63 mm diameter and designed to adapt to the Opusdent laser and to a Storz sialoendoscope. The system was tested ex vivo for durability and clinical compatibility at input energies up to 700 mJ, 10-20 Hz. Following Helsinki approval the system was clinically tested on 17 patients with sialolithiasis.

RESULTS

Lithotripsy threshold was around 80 mJ/pulse (26 J/cm2) while efficient fragmentation, with microscopic fragments, was observed at an output energy range of 150-300 mJ/pulse. At 10 Hz, fragmentation rates of about 1.8 mm3/second were achieved enabling lithotripsy of a 6 mm stone in about 2 minutes. Front surface damage to the sapphire rod occurred but did not contribute to significant loss in fragmentation efficiency. Of the 21 stones treated clinically, 5 were fully fragmented, 7 were prepared for extraction by mini forceps, and 9 were released from surrounding soft tissues for subsequent removal. Fifteen of the 18 treated glands returned to normal function without any symptoms.

CONCLUSIONS

The Er:YAG endoscopic delivery system described is a clinically viable and cost-effective device for a range of hard and soft tissue wet field applications accessible through rigid or semi-rigid endoscopes. Further improvements in the waveguide may allow access also through fully flexible endoscopes.

Submandibular duct repositioning after excision of floor of mouth cancer

PURPOSE

Floor-of-mouth cancers frequently involve the submandibular duct. When neck dissection, which removes the submandibular gland, is not planned, the duct requires repositioning and cannulation to avoid obstructive sialoadenitis caused by scarring and stricture after excision of the primary lesion. A swollen submandibular salivary gland may be difficult to differentiate from a metastatic node and complicate subsequent oncologic management. This study reviews the clinical course and complications after repositioning and cannulation of the submandibular duct.

PATIENTS AND METHODS

Thirteen patients who underwent 21 duct cannulations over a 25-month period were reviewed for assessment of submandibular gland function and complications of the procedure.

RESULTS

Only two patients (15%) had episodes of postoperative neck swelling during follow-up. The commonest complication was early loss of the cannula in 7 of 21 patients (33%). There were no cases of local recurrence of the tumor, and only 1 patient of 10 with carcinomas had later cervical metastasis.

CONCLUSIONS

Repositioning and cannulation of the submandibular duct is a sound procedure that does not compromise the cancer resection. The problem of later chronic swelling of the salivary gland is avoided. Fixation of the catheter has been inadequate in one third of patients.