Intraductal Fragmentation in Sialolithiasis Using Pneumatic Lithotripsy: Initial Experience and Results

Recurrent obstructive salivary disease after sialendoscopy. A narrative literature review

Over the last 20 years, interventional sialendoscopy has become the therapy of choice for the management of obstructive salivary disorders, favouring a significant reduction in the number of patients undergoing traditional sialadenectomy. The overall success rate of sialendoscopy is around 90% as reported by the largest case series published; recurrence is expected in about 10% of cases, and the patient should be informed about the possibility to undergo further conservative procedures to improve symptoms. Adequate pre-operative assessment, based on ultrasonography, cone beam 3D CT and MR-sialography, is mandatory to reduce the risk of unsuccessful procedures and, therefore, recurrence of obstructive sialadenitis; moreover, in case of recurrence, the surgeon should be experienced enough to manage these cases and be able to perform additional interventions, such as transoral/transfacial sialendoscopy-assisted procedures and imaging-assisted procedures in case of difficult anatomical situations. Botulinum toxin injection and traditional sialadenectomy would be considered as possible salvage treatments in case of failure of all conservative approaches.

Comparison of two transcutaneous approaches for the removal of impacted parotid stones

The aim of this study was to comparatively evaluate the indications and treatment outcomes of two transcutaneous approaches for the removal of impacted parotid stones. Sixty-eight consecutive patients with impacted parotid stones underwent endoscopy-assisted lithotomy via a direct mini-incision or a peri-auricular flap. Clinical safety and outcomes were evaluated. Complete stone extraction was achieved in all patients. In the mini-incision group (52 patients), the stones were in the middle third of the main duct in 31 patients, at the hilum in 16, and in the intraglandular duct in five. In the flap group (16 patients), they were in the middle third of the main duct in one patient, at the hilum in seven, and in the intraglandular duct in eight. Salivary fistula occurred in five mini-incision group patients (9.6%) and four flap group patients (25%). The clinical outcome in the mini-incision group (47 patients, median 25 months of follow-up) was good in 28 patients, fair in 13, and poor in six (12.8%). The clinical outcome in the flap group (16 patients, median 84 months of follow-up) was good in nine patients, fair in five, and poor in two (12.5%). The direct mini-incision approach was found to be safe and effective for impacted stones in the middle third, hilum, and proximal third of the main duct, while the peri-auricular approach would be best reserved for deeper intraglandular stones.

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).