Long-term Study of Sialodochoplasty for Preventing Submandibular Sialolithiasis Recurrence

Impaired spontaneous secretion as a potential factor in the development of sialolithiasis in the submandibular gland: A preliminary sialoscintigraphic study

Objectives

The development of sialolithiasis is commonly related to local factors, such as the retrograde migration of foods, bacteria, or foreign bodies from the oral cavity. The association of sialolithiasis and saliva stasis resulting from decreased spontaneous secretion remains largely unexplored. The current study investigated the potential role of impaired spontaneous secretion in association with the formation of submandibular gland calculi.

Study Design

A retrospective cohort study.

Methods

Between September 2016 and December 2017, 11 patients with unilateral submandibular gland sialolithiasis confirmed with sialendoscopy were assigned to the experimental group. Another 35 patients clinically diagnosed with parotid obstructive sialadenitis were assigned as the control group. The slope changes of the isotope count curve of the unaffected submandibular gland in the experimental group and the bilateral submandibular glands in the control group were calculated and compared to estimate the spontaneous secretion differences. The degree of spontaneous secretion was defined as the slope changes in the steady ascending stage of the scintigraphic exam.

Results

The slope decline (degree of spontaneous secretion) on the unaffected side in patients with single-gland submandibular obstructive sialadenitis was significantly lower than that in the control individuals (p = .002). In contrast, the between-group comparison in the unaffected parotid glands revealed no difference in the slope decline.

Conclusion

The spontaneous secretion of the submandibular gland in patients with submandibular sialolithiasis was decreased compared to that in patients without submandibular sialolithiasis. This phenomenon might be associated with the development of sialolithiasis.

Level of Evidence

3.

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).

3D 4K VITOM-assisted transoral removal of distal stone in the Wharton's duct

BACKGROUND

The aim of this study was to describe the potential advantages of the transoral 3D 4K exoscope-assisted removal of calculus of the Wharton's duct.

METHODS

A 24-year-old female with swelling in the left oral pelvis was diagnosed of sialolithiasis of distal Wharton's duct. A CT scan confirmed the lithiasic formation and a transoral removal in local anesthesia was planned through the 3D 4K exoscope (VITOM 3D, Karl Storz).

RESULTS

A high-quality magnification of the oral pelvis was obtained, with an easy identification of the entrance of the left submandibular gland's duct and the calculus. After blunt dissection the Wharton's duct was incised and the calculus removed. An angiocatheter (20G) was carefully inserted in the duct and removed after 3 days. No postoperative complications occurred. At 7 days post-operative follow-up the patient had developed a neo-ostium 5 mm from the papilla. The exoscope provided a better involvement in the surgery and more interactions of all operating room personnel, residents and students, that had access to the same field of view of the first surgeon with the perception of the depth of the surgical field with 3D technology.

CONCLUSIONS

The exoscope could represent a valid option for transoral removal of calculi, allowing for precise surgical dissection of the oral floor, thus reducing the risks for iatrogenic lesion of the lingual nerve. It showed also a high potential for training and educational purposes.

Intraductal Pneumatic Lithotripsy after Extended Transoral Duct Surgery in Submandibular Sialolithiasis

Objective

Persistent, residual, or recurrent stones after transoral duct surgery are always associated with hilar to intraparenchymal and/or multiple sialolithiasis, causing difficulties in the treatment. This study was performed to assess the value of intraductal lithotripsy in the treatment of persistent, residual, or recurrent sialolithiasis after extended duct surgery in the submandibular gland.

Study Design

Retrospective study covering February 2015 to June 2018.

Study Setting

Tertiary referral center for salivary gland diseases.

Subjects and Methods

After extended ductal surgery, 39 patients presenting with persistent, residual, or recurrent stones were treated. Four patients had persistent stones; 16 had residual stones; and 19 presented with recurrent stones. Among these patients, 50 stones were treated with intraductal pneumatic lithotripsy. Fragmentation rate, stone-free rate, and symptom-free rate after treatment with intraductal lithotripsy were outcome measures.

Results

Of the 39 patients, 97.4% became stone-free, and all were symptom-free. Ninety-eight percent of the stones were completely fragmented. For 23.1% of the patients, >1 stone was treated with intraductal lithotripsy. All patients with persistent stones, 93.7% of those with residual stones, and all with recurrent stones became stone-free and symptom-free. No severe complications developed.

Conclusions

This study shows that patients presenting with difficult and/or multiple sialolithiasis after extended transoral submandibular duct surgery can be treated with success rates >97%. For multiple sialolithiasis in particular, a multimodal treatment approach with interventional sialendoscopy and intraductal lithotripsy as a central element is a prerequisite for success, as this enables the most difficult part to be performed with high success rates.

Anatomical recovery of the duct of the submandibular gland after transoral removal of a hilar stone without sialodochoplasty: evaluation of a phase II clinical trial

Transoral removal of stones for the treatment of submandibular sialolithiasis has been popularised, even for stones in the hilum. Without sialodochoplasty after surgical retrieval, the affected glands seem to recover well functionally, even without sialodochoplasty. However, the anatomical changes of structural recovery have not been fully studied. We investigated the outcomes and the changes to the salivary duct system after transoral removal of hilar stones using postoperative sialography. We enrolled 28 patients (29 sides) who had transoral removal of stones for submandibular hilar sialolithiasis without sialodochoplasty, and prospectively analysed the structural outcomes 3 months and 12 months postoperatively using sialography. We found 23 ducts (79%) recovered with a normal size, while 4 ducts (14%) developed saccular dilatation and one duct (3%) partially stenosed. Saccular dilatation developed after removal of stones larger than 10mm in diameter, but patients had no recurrent symptoms. By the 12 months' follow up, one stone had formed severe adhesions to the salivary duct that caused stenosis, and this patient had recurrent symptoms. Transoral removal of submandibular hilar stones without sialodochoplasty is an effective treatment with good anatomical restoration of the salivary duct and flow.

Objective and subjective outcome in 42 patients after treatment of sialolithiasis by transoral incision of Warthon's duct: a retrospective middle-term follow-up study

In this retrospective follow-up study, we present the middle-term results of transoral removal of submandibular calculi by incision in the floor of the mouth together with a patient satisfaction survey. These results will be compared with those of international studies. This is an individual retrospective cohort follow-up study. Forty-two patients had salivary calculi removed by incision in the mouth in the period from August 2009 to July 2012 at the Ear-nose-throat department of the North Zealand Hospital, Hillerød, Denmark. A retrospective study was carried out, focusing on the effects of the surgery and on patient satisfaction. The patients completed a questionnaire and underwent an objective physical exam. We found a high success rate (93 %), high patient satisfaction (94 %) and a high number of patients with no symptoms (92 %). In 94 % of the patients the gland was preserved, and there were no infections. One patient (3 %) suffered from damage to the lingual nerve, and 6 % (n = 2) claimed to suffer from continuous tingling of the tongue. Based on the present study and previous studies on transoral removal of calculi by incision in the floor of the mouth, we find this procedure effective, brief and safe for removal of large, immobile calculi from the hilum of the submandibular gland to the papilla.