A conservative treatment for chronic obstructive sialoadenitis by intraductal instillation of mucolytic, steroids and antibiotic solution

Purposes

Reporting our experience in treating chronic obstructive sialadenitis with a protocol consisting of sialoendoscopy and intraductal instillation of antibiotics, steroids and n-acetyl-cysteine (NAC) solution.

Methods

Prospective study of patients with chronic obstructive sialadenitis with no apparent lithiasic obstructions, with recurrent non-lithiasic sialoadenitis and patients with lithiasic sialoadenitis not solved with sialoendoscopy. In all cases, a sialoendoscopy was performed. All the patients affected by lithiasic sialoadenitis where the chronic inflammation was resolved with sialoendoscopy were excluded from the study. The mid-term follow-up was performed at 12 months via phone interview, to understand whether patients had developed any further symptoms after the treatment.

Results

This study included 26 patients. All the patient without sialolithiasis have not reported any symptoms during the follow-up period. Two of those with sialolithiasis have not shown any signs of recurrence. The remaining three patients with non-resolved sialolithiasis had a recurrence of symptoms which were treated again with 1 intraductal administration of betamethasone, gentamicine and NAC, showing immediately a regression of the symptoms.

Conclusions

Intraductal administration of gentamicin + NAC + betamethasone seemed effective for the therapy of chronic obstructive sialoadenitis. Our protocol seemed effective also in that cases where it was not possible to remove or detect endoscopically an obstruction. In all these cases we have noticed an increase in the symptom-free time even in cases where it was not possible to remove the stones.

Interventional sialendoscopy in parotidomegaly related to eating disorders

BACKGROUND

To evaluate the viability and efficacy of sialendoscopy for the management of parotidomegaly related to eating disorders, 6 patients suffering from eating disorders and recurring symptoms of glandular swelling were followed up at the Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, AOU University of Campania "Luigi Vanvitelli". After the detection of the impaired gland through clinical and radiographical analysis, the diagnostic unit was introduced into the duct and was advanced in, reaching the ductal system. Plaques were washed out, any strictures were dilated both by hydrostatic pressure application and steroid solution injection directly in the fibrotic area.

RESULTS

Both glands resulted affected in 83% of patients. 11 parotid glands were explored and treated. Strictures were found in 2 glands (33%), sialectasis in 3 glands (50%), strictures and sialectasis together in 1 glands (17%). In 3 parotid glands (50%) Stenon's duct was affected, in two (33%) only secondary ducts, in 1 (17%) both. We reached symptomatic improvement in 5 patients (83%), reporting the spherical volume of the parotid region and pain reduction.

CONCLUSIONS

Our results demonstrate that sialendoscopy is a safe and effective therapeutic method to treat EDs salivary symptoms. Treating the underlining psychiatric pathology should be the primary goal in patient care to lower the possible recurrence rate and increase the successful outcome of this technique.

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.

Reliable ductal access in sialoendoscopy

During sialoendoscopy, insertion of the endoscope through the ductal orifice is usually a challenging procedure, especially for beginners. Based on our experience, we have found that using the Kolenda Salivary Access Introducer Set is the most reliable and easily learned ductal access approach. We report details of the technique and discuss the advantages of this approach.

[Inflammation grading and sialoendoscopic treatment of 131I radioiodine-induced sialadenitis]

OBJECTIVE

To investigate the inflammation grading of ¹³¹I radioiodine-induced sialadenitis based upon sialoendoscopic and sialographic appearances, and to evaluate the results of sialoendoscopic intervention.

METHODS

The patients diagnosed with ¹³¹I radioiodine-induced sialadenitis and underwent sialoendoscopic exploration and intervention procedures in Peking University Hospital of Stomatology from Nov. 2012 to Oct. 2018 were included in this study. The appearances of sialogaphy and sialoendoscopy were analyzed and classified. The treatment options included irrigation with saline and dexamethasone and mechanical dilatation by sialoendoscope. The patients were followed up after treatment.

RESULTS

Forty-two patients with ¹³¹I radioiodine-induced sialadenitis were included. There were 5 males and 37 females, with a male-to-female ratio of 1 ∶7.4. Symptoms included recurrent swelling and pain in the parotid glands, and dry mouth. Sialography showed stenosis in the main duct,and in some cases nonvisua-lization of the branches. Sialoendoscopy showed narrowing of the main duct, and the branch duct atresia was seen. The appearances of sialogaphy and sialoendoscopy were analyzed and classified into 3 groups: (1) Mild inflammation: stenosis and ectasia occurred in the main duct, whereas the 0.9 mm sialoendoscope could pass through easily. (2) Moderate inflammation: one point of severe stricture could be seen in the main duct where 0.9 mm sialoendoscope could not be passed through. (3) Severe inflammation: two points or more of severe strictures or diffused strictures occurred in the main duct. Thirty-three patients with 65 affected glands were examined by both sialography and sialoendoscopy. Eight glands were classified as mild inflammation, 23 glands moderate inflammation, and 34 glands severe inflammation. The duration of follow-up ranged from 3-72 months. The clinical results were evaluated as good in 22 glands, fair in 22 glands, and poor in 19 glands, with an overall effective rate of 69.8% (44/63).

CONCLUSION

The clinical, sialographic and sialoendoscopic appearances of ¹³¹I radioiodine-induced sialadenitis showed their characteristics. We proposed an inflammation grading standard for the ¹³¹I radioiodine-induced sialadenitis based on the appearances of sialography and sialoendoscopy. Sialoendoscopy can significantly alleviate the clinical symptoms, which is an effective therapy, and better for early lesions.

Transoral sialolitectomy combined with sialoendoscopy versus open submaxilectomy for the management of hilar lithiasis of the submandibular gland

INTRODUCTION

The treatment of salivary obstructive pathology by minimally invasive techniques has been an object of assessment by different studies for decades. Lithiasis at the level of the salivary duct will be the most frequent cause of obstruction, representing more than 50% of the pathology of the major salivary glands and almost 80% of these affecting the Wharton duct.

MATERIAL AND METHODS

A prospective study comparing the results of combined transoral sialolitectomy (CTS) and open submaxillectomy techniques by cervicotomy in 2 groups of patients treated by lithiasis at the level of the hilum of the submaxillary gland.

RESULTS

22 patients were included in the study 16 (72.7%) were men and 6 (27.3%) were women, the average age was 54.41 years ± 12.75 (Min: 30/Max: 77). Regarding the variables associated with the disease: average lithiasis, size of the stone, hospital stay, lingual nerve alteration or complications for both techniques, differences were not found between both groups. There were only statistically significant differences in the average stay in favor of the CTS (P=.001).

CONCLUSION

The minimally invasive approaches to the salivary ductal system, associated or not with sialoendoscopy, can be efficacy and can be associated with lower number of complications. The natural tendency should be aimed to gradually replacing open sialoadenectomy techniques, reserving its indication for the treatment of tumor pathology.

Rates of sialoendoscopy and sialoadenectomy in 5,111 adults with private insurance

OBJECTIVE

To determine frequencies and trends in sialoendoscopy and sialoadenectomy for the treatment of obstructive, nonneoplastic submandibular gland disease in the United States.

METHODS

Epidemiologic study of insurance claims from 2006 to 2013 in a large, private insurance claims database. Rates were calculated for patients undergoing one or both index procedures.

RESULTS

A total of 5,111 adults with sialadenitis who underwent sialoendoscopy or submandibular gland excision were included. Mean age was 47.6 years, and patients undergoing sialoendoscopy were less likely to be male (relative risk [RR] = 0.84; 95% confidence interval [CI], 0.78-0.89), more likely to have sialoadenitis without stones (RR = 1.60; 95% CI, 1.53-1.66), and had a similar number of comorbidities (RR = 1.00; 95% CI, 0.91-1.06) compared to patients undergoing sialoadenectomy. The most common complication after sialoadenectomy was surgical site infection (1.4%; 95% CI, 1.1-1.8%), and complications after sialoendoscopy were rare. From 2007 to 2013, use of sialoendoscopy increased from 0.13 (95% CI, 0.08-0.18) to 0.42 (95% CI, 0.40-0.45) per 100 thousand people, and sialoadenectomy decreased from 2.41 (95% CI, 2.39-2.42) to 1.43 (95% CI, 1.40-1.44) per 100 thousand. The highest mean rate of sialadenectomy was seen in the south (2.15 per 100,000; 95% CI, 2.13-2.16), the lowest was in the west (1.6 per 100,000; 95% CI, 1.57-1.62), and it decreased in all regions over time.

CONCLUSION

Utilization of sialoendoscopy has increased over time, and the overall rate of sialoadenectomy is decreasing. Both procedures are safe for treatment of patients with sialadenitis and sialolithiasis. Future research should examine whether availability of sialoendoscopy leads to a decreased rate of sialoadenectomy in patients with salivary gland disease.

LEVEL OF EVIDENCE

2c Laryngoscope, 129:602-606, 2019.

Sialoendoscopy: Review and Nuances of Technique

Introduction

Sialoendoscopy is a nuanced technique of transluminal management of obstructive and nonneoplastic pathology of the major salivary glands. Techniques have been refined in the last two decades due to advances in optical and endoscopic instrumentation. This minimally invasive technique has both diagnostic and therapeutic applications. Obstructive salivary gland disease due to mineralized stones causes the majority of salivary duct-related pathology. Mucus plugs and strictures are the other causes. Submandibular gland sialolithiasis comprises the majority of salivary ductal pathology, with less than ten percent of obstructive symptoms related to parotid gland.

Objective

The aim of this review is to comprehensively understand the scope of practice, the methodology of management, and the techniques for a successful outcome in sialoendoscopy. Anatomy of the salivary glands and the ductal system is reviewed for a successful outcome. Guidance for patient selection, indications, investigations, and preprocedure preparation for sialoendoscopy are discussed. Algorithms and an instrument checklist are provided in table format in the manuscript for clinical utility.

Conclusion

The author simplifies the various systems of sialoendoscopes and the utility of the instruments. The future of transluminal and intraluminal salivary procedures is within the oral and maxillofacial surgical realm with simulators and multidimensional imaging and navigational advances.

Sialendoscopic management of autoimmune sialadenitis: a review of literature

Autoimmune diseases of major salivary glands include Sjögren's syndrome and a complex of disorders classified as immunoglobulin G4-related diseases. These pathologies are characterised by an autoimmune reaction mediated by T-helper lymphocytes that targets the ducts of exocrine glands in Sjögren's syndrome and glandular parenchyma in immunoglobulin G4-related diseases. Immunoglobulin G4-related diseases represent recently introduced multi-organ diseases that also involve the salivary glands. However, the morbid conditions once known as Mikulicz's disease and Kuttner's tumour were recently considered as two variants of immunoglobulin G4-related diseases affecting the major salivary glands ( immunoglobulin G4-related sialadenitis). This review briefly summarises the pathogenesis and clinical features of autoimmune diseases of the major salivary glands, focusing on the diagnostic and therapeutic role of sialendoscopy.

Sialoendoscopy for treatment of juvenile recurrent parotitis: The Brescia experience

OBJECTIVE

To evaluate the role of sialoendoscopy associated with steroid irrigation for juvenile recurrent parotitis (JRP) at a tertiary referral hospital.

METHODS

Clinical records of patients affected by JRP and treated with operative sialoendoscopy between June 2011 and April 2017 were retrospectively reviewed. Data on demographics, number of acute episodes per year before and after surgery, characteristics of the surgical procedure, hospitalization time, and rate of complications were collected. The outcome of the procedure was measured by comparing the number of episodes of parotid swelling before and after salivary endoscopic treatment.

RESULTS

Twenty-three patients for a total of 34 operative sialoendoscopies were included in the study. Before the surgical endoscopic procedure, the mean number of parotid swelling was 10 episodes per year. At sialoendoscopy, typical endoscopic findings such as mucous plugs, stenosis of the duct, intraductal debris, and pale ductal appearance were evident. All patients were discharged on the first postoperative day. A significant decrease in the number of swelling episodes per year was observed compared to the preoperative rate (p = .0004). Complete resolution of the disorder was obtained in 35% of patients.

CONCLUSIONS

Operative sialoendoscopy with steroid irrigation can be considered a valid therapeutic treatment for JRP. The technique is conservative, effective, safe, and, potentially repeatable. Short hospitalization time, rapid recovery, absence of peri-operative complications, and a high rate of good outcomes are the main advantages of this treatment.

Sialoendoscopy, sialography, and ultrasound: a comparison of diagnostic methods

OBJECTIVE

To compare the accuracy of ultrasound, sialography, and sialendoscopy for examining benign salivary gland obstructions.

METHODS

In this prospective study, patients with symptoms of obstruction of the major salivary gland duct system presenting at the ENT Clinic University Hospital, Ostrava, from June 2010 to December 2013 were included. All patients (n=76) underwent ultrasound, sialography, and sialoendoscopy. The signs of sialolithiasis, ductal stenosis, or normal findings were recorded after the examinations. Statistical analysis of the sensitivity and specificity of all the methods was performed, as well as a comparison of the accuracy of each method for different kinds of pathology (sialolithiasis or stenosis).

RESULTS

The sensitivity of ultrasound, sialography, and sialoendoscopy for sialolithiasis findings were 71.9%, 86.7 %, and 100%, respectively. The sensitivity of sialography and sialoendoscopy for stenosis of the duct was 69.0%, and 100%, respectively. The study showed impossibility of ultrasonic diagnostics of ductal stenosis. The sensitivity of sialoendoscopy for both pathologies was significantly higher than that from ultrasound or sialography (p<0.05). The specificity of sialoendoscopy was significantly higher than that from by ultrasound or sialography (p<0.05).

CONCLUSION

Sialoendoscopy was the most accurate method for examination ductal pathology, with significantly higher sensitivity and specificity than by ultrasound or sialography.

Device failure in sialoendoscopy: Intraoperative practical decision-making

Sialoendoscopy has recently emerged as an alternative to gland excision in management of recurrent sialoadenitis and sialolithiasis. This technique has both diagnostic and therapeutic purposes. We report a case of unusual device failure during removal of a submandibular stone from Wharton's duct, which ultimately led to ductal avulsion. Sialoendoscopy is safe and effective in management of non-neoplastic major salivary gland disorders. Ductal avulsion can happen during mechanical procedures like stone removal or dilation of strictures. Failing to release the stone from the basket is very rare but can be problematic and lead to major complications.

Sialoendoscopy: state of the art, challenges and further perspectives. Round Table, 101(st) SIO National Congress, Catania 2014

This draft of the Official Round Table held during the 101(st) SIO National Congress is an updated review on sialoendoscopy, a technique used for diagnosis and treatment of obstructive pathologies of salivary glands in a minimally invasive fashion. This review treats many aspects of salivary gland endoscopy, starting from anatomy to deal with the more advanced surgical techniques and analyses the main decisional algorithms proposed in the literature. In addition, particular attention was directed to the current limitations of this technique and to the potential developments that sialoendoscopy could have in the near future.

Endoscopic management of salivary gland obstructive diseases in patients with Sjögren's syndrome

PURPOSE

To evaluate, on the basis of our clinical experience, the reliability of an endoscopic approach to the management of obstructive salivary diseases related to Sjögren's syndrome.

MATERIAL AND METHODS

A retrospective review of all patients affected by Sjögren's syndrome who were followed up at the Maxillo-Facial Unit of the Second University of Naples Hospital and referred from the Reumatology Unit of the same hospital from September 2007 to July 2012 for chronic obstructive sialadenitis unresponsive to medical therapy. A total of 34 patients (29 women and 5 men) were recruited for this study. After the detection of the impaired gland, under local anesthesia with lidocaine 2% to the orifice region and a gradual dilation of the duct orifice, the diagnostic unit was introduced into the duct and was advanced forward until reaching the ductal system, with continuous lavage with isotonic saline solution. The plaques were washed out, and any strictures were dilated. Mucus plugs and debris were removed with irrigation or with a forceps if necessary.

RESULTS

Our cohort included 34 patients with a mean age of 51.76 years. A total of 60 parotid glands and 25 submandibular glands were explored and treated. Strictures were found in 38 glands (38 of 85; 45%), mucus plugs in 47 glands (47 of 85; 55%), mucus plugs and strictures together in three glands (3 of 85; 4%), and kinks in two glands (2 of 85; 2%). In 32 parotid glands (32 of 60; 53%) the Stensen duct was affected, in two (2 of 60; 3%) only secondary ducts, and in 18 (18 of 60; 30%) both. In submandibular glands explored, strictures and mucus plugs were mainly observed in Wharton ducts. Symptomatic improvement was achieved in 29 patients (29 of 34; 85%), in a follow-up period ranging from 5 months to 3 years.

CONCLUSIONS

Interventional sialoendoscopy is a viable technique to treat acute symptomatology in patients with obstructive salivary gland diseases related to Sjögren's syndrome and refractory to conventional management.

Sialoendoscopy: a viable treatment for I(131) induced sialoadenitis

To evaluate the viability, efficacy, and safety of sialoendoscopy for the diagnosis and management of radioiodine I(131-) related sialoadenitis, we retrospectively reviewed 30 patients referred between September 2007 and July 2013 from the Thyroid Surgery Unit to the Maxillofacial Unit of the Second University of Naples Hospital with persistent sialoadenitis after treatment with I(131). After the affected gland had been isolated, the endoscope was introduced into the duct under local anaesthesia with 2% lignocaine and continuous lavage with isotonic saline, and was advanced until it reached the ductal system. We studied 24 women and 6 men, mean (SD) age 52 (??) years. In 25 patients I(131) was given for papillary (83%), in 3 for medullary (10%), and in 2 for follicular thyroid carcinoma (7%). Stenosis alone was found in 30 glands (40%), mucous plugs alone in 35 (47%), and mucous plugs, stenosis, and kinks in 10 (13%). Of the 75 glands, dilatation of the ducts was successful in 70, and we completely removed all mucous plugs and kinks. We achieved symptomatic improvement in 23 patients (77%) during a follow-up ranging from 2 weeks to 84 months. Sialoendoscopy is a viable technique for the diagnosis of obstructive salivary disease, and is a safe and effective way to treat sialoadenitis, the most common complication of treatment with I(131).

Deep and unusual sialolithiasis of submandibular duct and gland: a surgical dilemma

Giant solitary submandibular duct calculus and multiple calculi of the gland are extremely rare. This occurrence along with more deep and proximally placed common calculi in submandibular gland may occasionally cause a dilemma in selection of the appropriate surgical approach in the present era of sialoendoscopic surgery. There is a high chance of fracture of the stone in a proximally placed stone in the gland followed by likely dissemination of fragments of the stone into the gland parenchyma during the procedure of sialoendoscopy which is a matter of grave concern. We authors believe that excision of the submandibular gland with the stone in such a situation should still be preferred as the gold standard of treatment leaving the ductal stone for endoscopic removal.

Sialendoscopy in juvenile recurrent parotitis: a review of the literature

Juvenile recurrent parotitis (JRP) is the second most frequent salivary gland disease in childhood, defined as a recurrent non-suppurative and non-obstructive parotid inflammation. The recurring attacks actually represent the most dramatic and serious aspect of this pathology, since they significantly influence the quality of life, and there are no recognized therapies to avoid them. In recent years, there are reports of many international experiences related to the management of JRP by sialendoscopy. In this context, several authors have stressed the striking role of sialendoscopy in the prevention of JRP attacks. The objective of the current review is to overview the existing literature with particular regards to diagnostic and therapeutic outcomes after the application of sialendoscopy in patients suffering from JRP.

A retrospective case series illustrating a possible association between a widened hilum and sialolith formation in the submandibular gland

OBJECTIVE

The purpose of this study was to explore any association between anatomical variances in the ductal system and sialolith formation using sialoendoscopy and acrylic resin replication of the ductal system.

METHODS

A retrospective study of 372 submandibular gland sialoendoscopies was performed to review the findings of the submandibular gland duct anatomy. Using sialoendoscopy and replicated casts, a high rate of hilar widening was noted in patients with submandibular sialolithiasis.

RESULTS

Sialolithiasis was detected in 326 of the patients who presented with obstructive symptoms. Around 67% (285/426) of the stones were located in the distal third of the ducts or at the hilum of the submandibular gland. During the sialoendoscopic procedure, the anatomy of the ductal system was examined and 285/326 (87.4%) of the hilums were noted to be widened like a basin. The anatomy of the duct from the replicated casts demonstrated a treelike structure and the basin-like widening of the hilum was found in all the excised submandibular glands.

CONCLUSION

Using sialoendoscopy, a high number of patients presenting with sialolithiasis in the submandibular gland seem to have an anatomical variance in the hilar region. The reproduced ductal system from excised glands also demonstrated this abnormal widening of the hilum. Although further studies need to be performed, we try and explain why there is such a high prevalence of hilar widening in patients with submandibular sialolithiasis.