classic approaches to sialoendoscopy for … classic approaches to sialoendoscopy for treatment of...

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Classic Approaches to Sialoendoscopyfor Treatment of Sialolithiasis

ODED NAHLIELI

Obstructive sialadenitis, with or without sialolithiasis,represents the main inflammatory disorder of the majorsalivary glands. The diagnosis and treatment of obstruc-tions and inflammations of these glands can be proble-matic due to the limitations of standard imagingtechniques. Satisfactory treatment depends on ourability to reach a precise diagnosis and, in the case ofsialoliths, to accurately locate the obstruction. Untilrecently many of these glands required completeremoval under general anesthesia.

Sialolithiasis is a common finding, accounting for50% of major salivary gland disease.1,2 The subman-dibular gland is the most prone to sialolithiasis. Invarious studies it was found that �/80% of all sialo-lithiasis cases are in the submandibular glands, 19%occur in the parotid gland, and �/1% are found in thesublingual gland. Sialolithiasis is most often found inadults, but it may be diagnosed in children.3

Sialoliths may vary in size, shape, texture, and consis-tency. They may occur as a solitary stone or as multiplestones. Bilateral submandibular stones are a rare condi-tion (5% of submandibular sialolithiasis cases). Sialoli-thiasis of submandibular and parotid gland together hasnot been reported in the literature. The amount ofsymptomatic and nonsymptomatic sialolithiasis cases is1% of the population, found in autopsy material.4

The symptomatic group of patients admitted to thehospital each year has been estimated as 57 cases permillion per annum in the British population, represent-ing 3420 patients per annum.1 If this incidence is ap-plied to the European or the American population (300million), then �/17,100 patients per annum will requirehospital treatment for sialolithiasis and its complication

sialoadenitis. These data do not include patients whowere treated as ambulatory (outpatient) cases.

There is a male preponderance,5 and the peakincidence is between the ages of 30 and 60.5 Sialolithsgrow by deposition and range in size from 0.1 to30 mm.6 Presentation is typically with a painful swellingof the gland at meal times, when the obstruction causedby the calculus becomes most acute.7

During the past decade, with the introduction ofsalivary gland endoscopy there has been a major stepforward, not only in providing an accurate means ofdiagnosing and locating intraductal obstructions, butalso in permitting minimally invasive surgical treatmentthat can successfully manage those blockages that arenot accessible intraorally.8�20

j Clinical Presentation

See Chapter 5 for a full discussion of the clinicalpresentation of sialoliths.

j Diagnostic Methods

Clinical Evaluation

Visual scanning of submandibular, preauricular, andpostauricular regions is the first step in assessingswelling and erythema (see Chapter 5). This is followedby intraoral examination. Surgical magnification loops(2.5�/3.5) are very useful in improving visualization ofthe orifice of Wharton’s and Stensen’s ducts. The orificemay be red and edematous and appear as a papilla.

79

Plaques or whitish secretions from the duct mayrepresent frank infection. Sometimes a small stone canbe found in the orifice; occasionally, the white-yellowcolor of a stone can be seen through the translucentmucosa. Bimanual palpation is particularly importantwhen examining the submandibular gland and duct. Ithelps to differentiate the gland from adjacent lymphnodes, inferior to the gland, and to ascertain thepresence of any firm mass in the take-off of Wharton’sduct from the hilum of the gland.

For the parotid gland, manual palpation allows thesurgeon to determine the consistency of the gland. Oneshould also massage the gland to milk and inspectthe saliva.

Salivary Imaging

Although there are a variety of newly available imagingmethods, in this section we focus on those techniquesmost suitable for patients suffering from salivary glandobstructions (See also Chapter 2). The most effectiveimaging methods for inflammatory conditions of thesubmandibular and parotid glands are plain x-rays(occlusal, occlusal oblique, panoramic), sialography,ultrasound, and computed tomography (CT). Scintigra-phy will be included in this chapter because of itsunique ability to evaluate the gland function. Sialoendo-scopy is a newly developed technique that is useful forimaging and treatment. It will be discussed separately.

Plain X-ray

Traditionally, plain radiographs are often used as asimple first-line investigation. Occlusal, occlusal oblique,and panoramic x-rays are excellent for ruling out anycalcification in the submandibular region (Fig. 7�/1).These will not demonstrate radiolucent calculi, whichaccount for 20 to 43% of submandibular stones.21,22 Forparotid stones, panorex and anteroposterior viewsdirected to the parotid region are recommended. Thepractitioner has to remember that plain x-rays haveminimal value in parotid stones because of the amountof radiolucent stones (60�/70%). The plain x-ray givesno information on the condition of the affected gland.It is therefore necessary to supplement or supplant plainradiography with another diagnostic modality.

Sialography

Sialography is one of the oldest salivary gland imagingtechniques. The first contrast agents used in the earlytwentieth century were pure mercury. The dye that heused was pure mercury. Nowadays we have better dyeoptions. Although there is a need to penetrate to theductal system with a catheter through the ductal papilla,

it is the only method that can give the possibility toexamine the ductal system with reasonable cost. Redu-cing the discomfort during sialography may be achievedby applying topical anesthesia to duct papilla and/or bylavaging the gland through the orifice with 2% lidocaineprior to the injection of the water-soluble dye.

Sialography provides images of the morphology of theductal system and allows the diagnosis of strictures,dilatations, and filling defects. This technique alsoprovides information on glandular function (Fig. 7�/2A).

Ultrasound

High-resolution ultrasound is a good imaging method toassess the salivary glands. It is noninvasive, and there isno associated discomfort. It is useful to distinguish thesubmandibular gland from surrounding lymph nodesand to locate calculi. The portion of Wharton’s duct thatleads from the hilum of the gland toward the floor ofthe mouth, precisely after the penetration of themylohyoid muscle, is difficult to identify.23 Calculidetection rates vary between 63 and 94%16 and areclose to those for sialography.24 Ultrasound is able todetect radiolucent stones even though the acousticshadow is not as marked. The distal portion of thesubmandibular and parotid ducts can be difficult tovisualize using extraoral ultrasound.25 However, small,high-frequency intraoral probes are now available thatovercome this limitation26 (Figs. 7�/2B, 7�/3).

Computed Tomography

CT scan is especially useful for evaluating inflammatoryconditions of the submandibular and parotid glands.Sialoliths are readily identified on CT imaging. Thestandard images should be 1 mm cuts with three-dimensional reconstruction. In this way the glands andducts can be visualized in all planes, and stones are less

FIGURE 7�/1 Panoramic dental x-ray, demonstrating largesialolith in the left submandibular gland.

80 CHAPTER 7 j Classic Approaches to Sialoendoscopy for Treatment of Sialolithiasis

likely to be missed. The parotid gland and duct are welldemonstrated by CT. Another advantage is the possibi-lity to diagnose and locate intraparenchymal stones andcalcifications that are not connected to the gland(phleboliths, tonsiliths, calcifications in the lymphnodes, etc.) (Fig. 7�/4).

Scintigraphy

In contrast to ultrasound, which depicts architecture,radioisotope imaging of the salivary glands gives somemeasure of the secretory function and allows compa-rison between the major glands. The assessment of

FIGURE 7�/2 (A) Ultrasound and (B) sialogram of the rightsubmandibular region of patient suffering from multipleswellings. Three stones are demonstrated in the sialogram

and in the ultrasound (arrows). The stones appeared ashyperechogenic lesions with acoustic shadow.

FIGURE 7�/3 Ultrasound of pa-rotid gland with multiple hypo-echogenic sialectases (arrows)and dilated Stensen’s duct (S).

Salivary Gland Diseases 81

salivary gland function using a bolus intravenous injec-tion of technetium Tc 99m pertechnetate is easy toperform, reproducible, and well tolerated by thepatient.27 It enables examination of the parenchymalfunction and excretion rate of the salivary gland and hasthe further advantage of a short half-life and lowradiation dose.27

j Surgical Procedures

This section is problematic because of the enormousand rapid development of methods and technology inrecent years. As in other fields of surgery, traditional andmore aggressive techniques are being replaced by organ-preserving methods with the help of minimally invasivetechniques. The reader needs to be familiar with alltechniques. This section includes two parts: traditionaland modern approaches.

Traditional Approaches to SubmandibularSialolithiasis

Traditionally, sialoliths in the submandibular duct andgland were divided into two groups: (1) stones thatcan be removed through intraoral sialolithotomyapproaches, including stones up to the first molar tooth,which can be palpated; and (2) stones that cannot beremoved from the intraoral approach and require

sialadenectomy, including stones posterior to the firstmolar region, or stones in the middle part of theWharton’s duct that cannot be palpated intraorally.

Intraoral SialolithotomyThe first step is to locate the stone exactly. Thistechnique is useful only in stones in the anterior andmiddle part of Wharton’s duct up to the first molartooth. Effectively, only stones that can be palpated easilyfrom the intraoral region are candidates for thistechnique.

Following administration of local anesthesia, twosutures of 3.0 silk are placed posterior to the locationof the stone. The aims of this step are to isolate the stoneand to prevent movement of the stone to the inner partof the duct or hilum of the gland. The next step is to cutthe mucosa above the stone directly on the stone, whichcan be done with a cold blade, electrosurgery, or CO2

laser.28 The advantages of the CO2 laser are thehemostatic effect and the easy identification of thestone. The contact between the stone and the laserbeam creates a spark that can be easily identified.Following incision of the mucosa and the duct, thestone is exposed and extracted with dental curettes.Following the extraction of the stone, the silk sutures areremoved. Milking the gland allows discharge of plaquesand saliva and possibly additional stones. Interrupted4.0 Vicryl sutures are placed to connect the ductal layerto the oral mucosa. The patient is encouraged to

FIGURE 7�/4 Computed tomo-graphy scan of submandibulargland with stone. The sialolith ismarked with arrows.


massage the gland and is treated postoperatively withoral antibiotics for 7 days.

The same procedure of sialolithotomy has beendescribed for the more posterior region. The author isstrongly opposed to this technique because of the highrisk of injury to the lingual nerve and the possibility ofsevere bleeding from lingual vessels. The technique ofextracting such stones is described in the sectionModern Endoscopic Approaches to Sialolithiasis.

Submandibular SialadenectomySee Chapter 15 for a full discussion of submandibularsialadenectomy.

Traditional Approaches to Parotid Sialolithiasis

Traditionally, sialoliths in the parotid duct and glandwere divided into two groups. (1) stones that can beremoved through an intraoral sialolithotomy approach,including stones up to the curvature of Stensen’s ductabove the masseter muscle; and (2) stones that cannotbe removed with an intraoral approach, requiringextirpation of the parotid gland. This would includestones posterior to the curvature of the duct.

Intaoral SialolithotomyThe first step is to locate the stone exactly. Thistechnique is useful only in stones in the anterior partof Stensen’s duct anatomically demarcated by thecurvature of the duct above the masseter muscle asthe duct penetrates the buccinator muscle. Followinglocal anesthesia around the papilla of Stensen’s duct, alacrimal probe is advanced until it reaches the stone.A hemostat holds the papilla and the probe to ensuresafe tract to the stone. An elliptical incision around

the papilla and the probe is indicated preferably witha CO2 laser. Blunt and sharp dissection is performedaround the duct up to the stone location. The ductallayer above the stone is incised and the stone removedwith dental curettes. Following the sialolithotomy,massage of the gland allows release of plaque andsaliva. The ductal layer is sutured with several 4.0Vicryl sutures to the oral mucosa to promote a patentduct.

Superficial and Total ParotidectomySee Chapter 15 for a full discussion of superficialand total parotidectomy. The difference betweenremoval of the parotid gland with stone and benigntumor is the condition of the gland. Scar tissue,inflammation, and fibrosis inside the gland and aroundStensen’s duct make the operation difficult andheighten the risk for facial nerve damage and salivaryfistulae.29�31

Modern Endoscopic Approaches toSialolithiasis

In the past decade, the advent of salivary gland endo-scopy has brought us a major step forward, not only inthat the novel techniques provide an accurate means ofdiagnosing and locating intraductal obstructions, butalso that they permit minimally invasive surgical treat-ment that can successfully manage blockages not amen-able to an intraoral approach.8�20

In 1997 we (Nahlieli and Baruchin11) reported on ourexperience with the use of a mini rigid endoscope toperform sialoendoscopies on 46 major salivary glands.To date we have successfully managed 892 patients withthese endoscopic techniques.

FIGURE 7�/5 Introduction of 1.3 mmdiagnostic unit through the orifice of theWharton’s duct (following dilatation) intothe gland. Note the transilluminationeffect.


IndicationsThe indications for sialoendoscopy are the following:

1. For diagnostic purposes, recurrent episodes ofmajor salivary gland swelling without obviouscause

2. Sialolithotomy: removal of deeply locatedstones (posterior portion of Wharton’s duct(‘‘comma area,’’ because of its proximity to thelingual nerve) or stones in Stensen’s ductposterior to curvature of the duct above themasseter muscle

3. Exploration of the ductal system followingcalculi removal from the anterior or middlepart of the submandibular or parotid ducts

4. Strictures or kinks of the salivary ductal system5. Treatment of submandibular and parotid siala-

denitis6. Pediatric inflammatory and obstructive patho-

logy

Absolute ContraindicationAcute sialadenitis is an absolute contraindication forsialolithiasis.

Pre-endoscopic AssessmentFollowing the clinical evaluation, plain x-rays, whichinclude panorex, occlusal, occlusal oblique, sialogram,and ultrasound, are recommended. In the case of aparotid stone in the middle or posterior parts, a CT scanis indicated.

Introduction of the SialoendoscopeTo determine the feasibility of entering the ductallumen by use of sialoendoscopy, the size of the ductis measured by sialography and ultrasound imaging.

Sialography is used for mapping the ductal system forpossible variations and assessment of its estimateddilatation capacity.

There are four possible methods for introducingthe endoscope into the ductal lumen: (1) introducingthe exploration unit (1.3 mm) through the naturalorifice of the duct; sometimes there is a need fordilatation, which can be done with lacrimal probes(Fig. 7�/5); (2) through a papillotomy procedure,performed with a CO2 laser immediately posterior tothe orifice of the duct, thus enlarging the opening; (3)through ductal exploration (‘‘ductal cutdown’’), whichinvolves surgical dissection and exposure of the ante-rior portion of the duct with a microsurgical technique.The duct is then incised longitudinally to allow theintraluminal insertion of the endoscope. If there areany difficulties in introducing the endoscope in theanterior part (e.g., stricture, too narrow ductallumen), it may be necessary to expose the duct moreposteriorly to arrive at a location where the diameterwill accommodate the endoscope (Figs. 7�/6, 7�/7);and (4) through a sialolithotomy opening; the endo-scope can be inserted through the same opening in theduct where the stone was extracted.

Irrigation during SialoendoscopyIrrigation or inflation is crucial in every endoscopyprocedure to create an optical cavity. The cavity mustbe filled with fluid to allow free movement of theinstrument, and the area needs to be lavaged to permitgood visualization. Isotonic saline is the fluid ofchoice. An intravenous bag containing isotonic salineis connected to the irrigation port, and the endoscopeis moved forward accompanied by a gentle flow ofsaline. Next, 4 cc of 2% lidocaine is injected through

FIGURE 7�/6 Exploration of the Wharton’sduct. Note the diameter of the duct, sufficientfor insertion of the surgical endoscope forinterventional sialoendoscopy. Lacrimalprobe (LP) is in the duct for correct location.Note the position of the endoscope (E) foraccurate insertion.


this port, resulting in the anesthesia of the entire ductalsystem.

ApproachesAn intraductal or extraductal approach is possible. Theintraductal approach is a purely endoscopic technique.The extraductal approach is an endoscopically assistedtechnique (Tables 7�/1 and 7�/2).

Intraductal SialolithotomyWhen a sialolith is encountered, its diameter is esti-mated using the caliber of the endoscope as a reference,

and the method of choice for its removal is selectedfrom four possibilities:

. Removal in one piece by use of grasping forceps,wire baskets, graspers, or balloons (Figs. 7�/8,7�/9)

. Crushing the calculus with forceps, then remov-ing the fragments using irrigation

. Fragmentation with laser lithotripter

. Combined use of an intracorporeal laser litho-tripter or extracorporeal shock wave lithotripter(ESWL), wire basket, and grasping forceps

DUCT

MFGMFG

DUCT DUCT DUCT

ENDOSCOPE

ENDOSCOPE

FIGURE 7�/7 Demonstration of insertion of theendoscope (diagnostic unit) and surgical instrument(mini grasping forceps, MGF) into the ductal lumenafter exploration and exposure of the Wharton’sduct.

TABLE 7�/1 Determination of the Appropriate Submandibular Sialoendoscopic Technique

Stone location and diameter Technique used

Sialolith located up to the middle third of the duct Sialolithotomy and diagnostic sialoendoscopySialolithB/ 5 mm, located in the hilum area Grasping forceps

Papillotomy/duct exploration Grasper or wire basket or balloonLithotripsy (do not use lithotripsy in nonfunctional glands;

apply a ductal stretching technique)Sialolith�/ 5 mm located in the hilum area Ductal stretching technique

SialolithotomyDiagnostic sialoendoscopy and removal of residual sialoliths

Secondary ducts, ductal exploration technique Grasping forcepsLithotripsy


The primary goal is to remove the calculus inone piece. If this fails, the second option is crushing,and the ultimate resort would be intracorporeal lithotri-psy. Occasionally, particularly in cases where lithotripsyhas been used or multiple sialoliths were encountered, ithas been necessary to perform a second sialoendoscopyto clear the involved gland of all obstructions.

Extraductal SialolithotomyThe following extraductal approaches are available:

. Intraoral techniques. These techniques can beused for submandibular and parotid stones.

. Extraoral technique. This technique is exclusivelyfor impacted parotid stones.

Intraoral SialolithotomyWe developed the so-called ductal stretching techniqueto overcome sialolith removal that we cannot solve withthe purely endoscopic techniques or a failed attempt toextract the sialolith by purely endoscopic techniques(Fig. 7�/10). In our experience, indications for thistechnique include:

. Large-size calculi in the submandibular andparotid ducts, measuring more than 5 mm

. Narrowness of the duct, which effectively rulesout the option of attempting an intraductalapproach

. Failures of the intraductal techniques

TABLE 7�/2 Determination of Appropriate Parotid Sialoendoscopic Technique

Stone location and diameter Technique used

Sialolith located up to 1 cm from the papilla Sialolithotomy and diagnostic sialolithotomySialolithB/ 5 mm, located up to the posterior third of the duct Grasping forceps

Papillotomy/duct exploration Grasper or wire basket or balloonLithotripsy

Sialolith�/ 5 mm, located up to the posterior third of the duct Ductal stretching techniqueSialolithotomyDiagnostic sialoendoscopy and removal of residual sialoliths

Sialolith�/ 5 mm, located in the middle and up to the posterior thirdof the duct, and dilation and intraductul stone removal failed

Endoscope-assisted extraoral approach

Secondary ducts, ductal exploration technique Grasping forcepsLithotripsy

Strictures of anterior location Balloon dilation (two trials)Endoscope-assisted application of grasping forceps

FIGURE 7�/9 Endoscopic view of mini grasping forcepsretrieval of sialolith from the submandibular hilum.

FIGURE 7�/8 Endoscopic view of basket retrieval of sialolithfrom the submandibular hilum.


The ductal stretching technique involves these steps:

1. Introducing the endoscope for exact locationof the stone lavage and disconnecting the stonefrom the ductal attachment

2. Introducing the lacrimal probe into the ductand making an incision above the duct with aCO2 laser

3. Dissecting and isolating the duct from thesurrounding tissues up to the first molar (sub-mandibular) or the curvature of the duct abovethe masseter muscle (parotid)

4. In submandibular cases, forwarding the glandtoward the mouth with digital pressure fromthe submandibular region

5. Ductal section above the calculus and sialo-lithotomy

6. Endoscopic exploration for removal of addi-tional calculi and lavage

7. Temporary polymeric stent insertion for 4weeks

Extraoral SialolithotomyThis approach is exclusively reserved for removal ofimpacted parotid stones.19 The indications for theextraoral approach are:

. Calculus in the posterior third of the Stensen’sduct with too narrow duct anterior to it

. Obstruction of the posterior or middle third ofthe Stensen’s duct leading to the calculus

. Large-size (�/5 mm) stones in the middle orposterior part of the duct that cannot be dilatedfor intraductal removal

. Intraparenchymal stones

Identification of SialolithThe first step is to identify the exact location of thesialolith. There are two main approaches:

. Sialoendoscopic identification

. Ultrasound identification

The endoscopic approach is indicated when thereis a possibility of introducing the endoscope (NahlieliSialoendoscope, Karl Storz GmbH, Tuttlingen, Ger-many, Diagnostic Unit 1.3 mm) into the duct. Theultrasound identification is indicated when there is nopossibility to penetrate the duct via Stensen’s duct dueto ductal obstruction or severe stenosis.

The Calculus Can Be Identified through the DuctalLumenFollowing infiltration of local anesthesia around theorifice of the Stensen’s duct and irrigation of theStensen’s duct with 2% lidocaine, the diagnostic unitis introduced, and the calculus is identified. The exactlocation on the outer skin is marked with the aid of thetransillumination effect of the sialoendoscope.

The Calculus Cannot Be Identified through the DuctalLumenThe gland is evaluated with high-resolution ultrasono-graphic examination (ATL-300, Advanced TechnologyLaboratory, Bothell, WA with high resolution 5�/12 MHzlinear probe). The calculus is detected, and its depth,size, and shape are annotated. Skin coordinates aredrawn to the exact surgical location of the stone, anda biopsy wire marker is inserted under ultrasoundcontrol to locate the stone.

Removal of SialolithThe suspected area of the stone is infiltrated with localanesthesia. A 1 cm incision according to the facial linesis performed. Sharp and blunt dissection will lead to thestone. If we have a location difficulty problem duringthe dissection, the ultrasound probe is used.

We reach the capsule or the scar tissue over the ductaround the stone. A No. 11 blade is used to open thecapsule or the fibrosis, and the stone is exposed andremoved with the aid of curettes. A guide is inserted tothe cavity of the stone, and a 1.3 mm Nahlieli endoscopeis inserted to screen the area and to remove additionalparticles. A thorough lavage under direct vision isperformed. After removal of the stone and the additionalparticles, a polyethylene stent is inserted into this region

FIGURE 7�/10 Ductal stretching technique. A 7 mm stone inthe hilum of the submandibular gland with too narrow a duct forpure endoscopic retrieval. D, duct; S, stone.


directed from the location of the stone intraorally. Thestent is fixated with 4.0 silk to the oral buccal mucosa.

In intraparenchymal stones there is no need for stentusage. The capsule is sutured with 4.0 Vicryl suture, skinclosure with 6.0 nylon. Pressure dressing is applied for48 hours. In cases where there is obliteration of theanterior part of the duct and no passage to the oralregion is identified, a 1.7 mm vein line is intro-duced (after removal of the stone) from the locationof the stone to the oral mucosa. The needle is removed,and the shaft is incised. Using a 4.0 silk suture, the veinline is fixated to the oral mucosa.

Antibiotic coverage follows the procedure. The pro-cedure is done with the aid of magnification loops�/3.5.Pressure dressing is applied for 48 hours. The length ofthe procedure is 90 to 120 minutes.

LimitationsThe depth of the stone from the outer skin surfaceshould not exceed 6 mm, and screening of thesurrounding tissue is mandatory for large blood vesselsand for phleboliths. In the presence of deep calculi orclose relation to a large-size blood vessel, we recommendexploring this region using a face-lift approach.

Postoperative Management and CareFollowing interventional sialoendoscopy, a temporarypolymeric stent (sialostent) (Sialotechnology Ltd.,Ashkelon, Israel) is introduced into the duct and keptin place for 4 weeks (Figs. 7�/11A,B). After placement ofthe stent, the surgeon continues in submandibular casesto perform a modified anti-kink procedure to correctthe unfavorable angle of Wharton’s duct (around the

lingual nerve and the mylohyoid muscle). In theauthor’s opinion, this is one of the main causes of theformation of sialoliths.

The aim of this procedure is to prevent recurrence ofnew stones. Ideally, a 4-week period of retention is mostdesirable. Its purposes are bridging the gap between thehealing process of the oral region (the penetrationregion of the endoscope), which normally occurs veryfast, and the restoration of normal function of gland,which normally takes around 2 to 4 weeks, and theprevention of the obstruction of the ductal lumen bypostoperative edema. This also allows any calculus frag-ments to be washed out by the saliva and acts as a stent inan attempt to reduce the possibility of stenosis. Ductalmarsupialization that involves suturing the incised ductalmargins to the overlying incised mucosal margins canact as an adjunctive measure to provide added safety formaintaining patency of the ductal opening. All patientsare treated postoperatively with antibiotics for 7 days.

Outcomes, Success Rate, Failures, and ComplicationsOver the past 11 years (1993�/2004), sialoendoscopy hasbeen performed on 892 salivary glands, with symptomsof obstructive disease. There have been 442 males and450 females, with ages ranging from 2 to 96 years. Therewere 598 submandibular glands, 289 parotid glands,and 5 sublingual glands. Eighty-six percent of theglands were diagnosed with obstruction, and 14% withsialadenitis.

All patients underwent preoperative and postoperativescreening, including routine radiography, sialography,and ultrasound. Postoperative examination was routinelyperformed 1 month following the procedure. Somepatients were followed as much as 40 months postendo-scopy. The majority of procedures were performedunder local anesthesia on an outpatient basis. The timefor the procedure ranged from 30 to 90 minutes.

The success rate for parotid endoscopic sialolitho-tomy was 86%, and the success rate for submandibularendoscopic sialolithotomy was 89%. Immediate failures(introduction of the miniature endoscope failed orproved not feasible) accounted for 1.4% of cases.Intraoperative failures (inability to accomplish any ofthe endoscopic retrieval techniques) were 6%, and latefailures 5%. One patient suffered from temporarylingual nerve parasthesia, 1.7% suffered from post-operative infection, 0.4% suffered from postoperativebleeding, 0.9% developed traumatic ranula, and 2.5%suffered from ductal strictures.

Endoscopic Observations and Treatment in ClinicalPracticeIn clinical practice, several microanatomical and patho-physiological phenomena have been encountered in thecourse of sialoendoscopic procedures.

FIGURE 7�/11 (A) Sialostent in the Wharton’s duct afterendoscopic surgical intervention. (B) Sialostent.


Mason and Chisholm, in their book published in1975, described the presence of smooth muscle strandsaround the walls of the Wharton’s duct.32 Katz describedthem in his article in 1991.9 We were able to demon-strate this mechanism and publish in 199711 (Figs. 7�/12and 7�/13). Although a search in the literature did notreveal sphincter-like mechanisms in the parotid gland,we were able to observe and document this mechanismin the Stensen’s duct. The difference between thesphincter-like systems in the parotid and submandibulargland is in their location. In the Wharton’s duct, thesphincter-like system begins near the papilla and runsposteriorly. In the Stensen’s duct, it is located poster-iorly in the vicinity of the ramification.

During sialoendoscopies we could identify in few casesthe sublingual duct opening (Bartholin’s duct) in theWharton’s duct. This opening was noted in the anteriorpart of the Wharton’s duct, between 0 and 5 mmposterior to the papilla.

Typical changes in the ductal system during differentstates of health were noted. In chronic sialadenitis orwith long-standing calculi, the lining mucosa of theductal system had a matted appearance, ecchymosis anda small number of blood vessels. In a healthy gland or inpatients with short-term stasis of saliva, there was a shinyappearance of the ductal lining, and proliferation ofblood vessels was noted.

Peculiar connections between calculi and the ductalwall were observed in the submandibular and parotidglands. The connections in the Wharton’s duct werefound posterior to the bifurcation), the point where theduct divides into the inner and the outer lobes, whereas

in the parotid gland, they were posterior to thecurvature. No such connections were detected anteriorto these regions.

Ductal polyps were noted in 12 glands, 8 in theStensen’s duct and 4 in the Wharton’s duct. All polypscaused obstructions; four of them in the parotid glandhad a history of salivary gland surgery before endoscopy,and three were associated with calculi. All the polypsdemonstrated in the sialogram as a filling defect. Theywere not diagnosed on ultrasound. The polyps wereextracted by miniature biopsy forceps or basket.

Intraparenchymal stones located close to the ductalsystem could be seen with the endoscope, and deepercalculi could not be observed.

We could identify seven foreign bodies in the ductalsystem, four in the parotid duct and three in thesubmandibular duct; four of them were hair shafts,and three were parts of a plant most probably (they werewashed out during irrigation). Five of them wereassociated with calculi, and three of them were inchildren. We observed a formation of sialolith arounda hair shaft in two cases.

Due to the more sophisticated equipment and tech-niques we were able now to better identify, diagnose,and treat the obstructive conditions of ductal stricturesand kinks. These malformations were detected in98 cases, 28 kinks (22 submandibular and 6 parotid)and 70 strictures (26 submandibular and 44 parotid).

We identified an anatomical malformation in thesubmandibular hilus, a pelvis-like formation (a basin-like structure) instead of a bifurcation or trifurcation.This pelvis formation caused obstructive phenomena

FIGURE 7�/12 Sphincter-like system of the Wharton’s duct inthe closed position.

FIGURE 7�/13 Open position of the duct; the submandibulargland hilum is observed.


and was demonstrated as a widening of the duct in thehilus region in a sialogram.

We revealed an evagination in a 10-year-old child whosuffered from two sialoliths. The sialoliths were identi-fied in the Wharton’s duct. During extraction of thesecalculi from the duct, the formation of an evaginationwas noted. It obstructed the ductal lumen and wasthe cause, in our opinion, of the calculi formation.We assume that the intraductal evagination is a form ofanatomical malformation.

Instrumentation (Figs. 7�/14, 7�/15)We have now progressed to using a semirigid, moderatelyflexible endoscopic device (Nahlieli Sialoendoscope)specifically designed for salivary gland endoscopy. It is1 mm in diameter, 10,000 pixels, with two facilities: anexploration unit with an outer sleeve of 1.3 mm, and asurgical unit with a sleeve of 2.3 mm�/1.3 mm, withthree channels for introducing a surgical device with adiameter of 1 mm and an irrigation port device.

Another unit is the type 1 endoscope (pistol). Theouter sleeve is 2.3 mm, with a 1 mm (200 mm length)telescope, a sleeve for surgical instruments, connectionfor irrigation pump, and a valve for control. This type ofsurgical unit is for exploration following sialolithotomyof large-size stones. The surgical instruments that can beuseful are instruments from 1 mm or less. The usefultools are grasping forceps, basket, grasper, balloon-likeFogarty or sialoballoon catheter, biopsy forceps, intra-corporeal lithotripter probes, and laser probes. We workunder direct vision, so we can use our instruments withmeticulous observation. If there is a problem of spaceand we cannot insert the multichannel endoscope, wecan insert the diagnostic unit and the surgical endo-scope by its side.

The last option is to work in a semiblind technique, toidentify the obstruction with the 1.3 mm diagnostic unit,to remove the 1 mm telescope, and to insert the working

instrument through the sleeve. This option is indicatedespecially in the narrow Stensen’s duct.

A new innovative line of multifunctional instruments(Karl Storz, GmbH, Tuttlingen, Germany) was deve-loped recently with the advantage of a minimal dia-meter, from 1.1 mm with a channel for irrigation andsurgical instruments, to make the sialoendoscopy pro-cedures easier (Fig. 7�/16).

Choosing the Appropriate InstrumentA calculus that can be bypassed is usually best handledwith the basket. Calculi that cannot be bypassed due tonarrowness of space can be handled with a graspingforceps or grasper. In the author’s opinion, the graspingforceps is well controlled, and the stone can be held andmaneuvered easily by this instrument. Lithotripterprobes are used to fragment the calculus when theother instruments fail. Balloons are good tools, espe-cially for strictures, but also for a soft small calculus.Biopsy forceps are used for ductal polyps.

Sialolithiasis Lithotripsy

Lithotripsy for kidney stones was first reported in 1980.The first report on the use of shock waves to fragmentsialoliths was in 1986 by Marmary.33 The problemsinitially were due to the large lithotripsy machine thathad very broad focus. They caused removal of dentalfillings and periosteal irritation. There are three exter-nal lithotripsy methods depending on the system ofgenerating the shock waves: electrohydraulic, electro-magnetic, and piezoelectric. The waves are brought tofocus through acoustic lenses. The shock waves passthrough a water-filled cushion to the sialolith, where two

FIGURE 7�/14 The 1.3 mm diagnostic unit of the sialoendo-scope.

FIGURE 7�/15 The 2.3 mm surgical unit with grasping forcepsin the surgical sleeve.

FIGURE 7�/16 The 1.1 mm multifunctional sialoendoscopewith integrated surgical sleeve and irrigation.


mechanisms, stress and cavitation, act to fragment thecalculus. The soft tissue and the water around the stonedo not interfere with the passage of the shock waves. Acompressive wave is propagated through the stone,subjecting it to stress. The energy from the sialolith�/

water contact results in the formation of expansionwaves, inducing cavitation bubbles.

When the bubbles collapse, a jet of water is projectedthrough the bubbles to the surface of the stone. Thisforce is enough to fragment the stone. Development ofsmaller machines with a more finely focused beam ofwaves led to a few centers in Europe using it. From 1989we can find in the literature articles discussing theresults of ESWL. The technique delivers 1000 to 5000shock waves per session. Usually three sessions areneeded. The location of the stone is identified andtargeted through an inline ultrasound 7.5 MHz probe.

Reviewing the relevant literature34�36 demonstrates asuccess rate from 16 to 63% for stone-free gland provenby ultrasound screening. Most authors have foundelimination of the symptoms is a very significant valueof the technique. Iro and colleagues achieved completestone removal in 50 to 58% of the patients, partialelimination of the stone in 35 to 50%, and alleviation ofsymptoms in 76 to 100%.34 Escudier et al found 38%stone free and 62% with residual fragments.35 They alsofound stone size to be a statistically significant indicatorof success, ESWL being less effective on stones largerthan 7 mm. The morbidity following the lithotripsyprocedures is low and includes ductal bleeding, glandswelling, petechial skin hemorrhage, and secondaryinfection of the affected gland.

Until recently the low success rate and the veryexpensive equipment were the main obstacles prevent-ing more surgeons from using this technique. The rapiddevelopment in miniaturization of the equipment, thereduction in the equipment price, and the combinationwith other minimally invasive techniques gave thislithotripsy technique a place in our armamentarium inthe treatment of sialolithiasis.

In 2004 we (Nahlieli and Hecht-Nakar) developedminiature ESWL (Sialotechnology Ltd., Ashkelon,Israel).37 The diameter of the generator is not biggerthan a computer box, and the therapy head wasreduced dramatically to fit the dimension of the headand neck region. Ultrasound and endoscopy are usedto locate the calculus. The endoscope irrigates andinflates the salivary gland using isotonic saline. Addi-tionally, 2% lidocaine anesthetizes the entire gland andprotects the salivary parenchyma, generating moresubstance to produce the cavitation effect. The successrate of the new lithotripter for complete removal ofthe stone is 63% (37% total elimination, 26% a needfor simple endoscopic intervention). The eliminationof the symptoms is striking: Ninety percent of the

patients were symptom free following the first treat-ment. The endoscopic removal of the residual stonesafter the lithotripsy procedures is easier and lesscomplicated. The shock waves disconnect the stonefrom the ductal wall and reduce the volume of thestone. In the future, as in urology, ESWL will be inmany cases the first line of treatment. This treatment isadjuvant technique for deep stones in the hilum of thesubmandibular and in the posterior parts of theparotid gland.

Intracorporeal LithotripsyIn this technique the lithotripsy energy is delivered tothe target stone through a fine probe. Several methodsused to generate the energy for the lithotripsy proce-dures include the electrohydraulic technique, pneumo-ballistic technique, dye pulsed laser, and holmiumlaser.36,38 The probes are delivered to the location ofthe stone under the supervision of the endoscope.Electrohydraulic and pneumoballistic techniques aremost effective in fragmenting the calculus to smallpieces, although the particles are not always smallenough for free passage through the ductal lumen.The main disadvantage of these energies is the damageof the shock waves to glandular tissues, especially usingthe electrohydraulic technique.38 The holmium laser,which is a gold standard technique in urology, alsocauses severe damage to the surrounding tissues and caneasily cause ductal perforation. Another disadvantage ofthis technology is the high cost of the equipment. A newand promising development in the intracorporeal litho-tripsy field is a new generation of lithotripters designedespecially for the salivary glands based on erbium:yttrium-aluminumgarnet (YAG) laser technology.39

The advantage of this method is the quality of thefragmentation, to a dust that can easily be washed outfrom the gland with minimal collateral damage to thesurrounding tissues. The fragmentation is done underendoscopic supervision and can be done under localanesthetic as an ambulatory procedure. Other impor-tant advantages of this technology are the low cost andthe availability of the instruments (the basic laser unit isthe same as that for dental use).

Acute Sialadenitis Caused by Sialolith

A complete blockage of the salivary duct by stone cancause a saliva collection, and this can easily be infected.The obstruction can be in the hilum region or by a smallfragment of stone that was fractured and moved forwardto the narrowest place in the distal portion of the duct.The infection can be moderate with swelling of thegland itself, but severe infections with spread to adjacentanatomical spaces is well documented in the literature.40

The submandibular gland can cause severe infection


due to its anatomical location and has the potential tocause airway obstruction (see discussion in Chapter 5).

The bacterial cause of parotid and submandibu-lar infection due to sialolith is mainly Staphylococcusaureus .41 During the acute phase, probing of theinvolved duct is indicated. Surgical intervention duringthe acute phase to remove the stone (hot sialolitho-tomy) is documented in the literature, especially withCO2 laser.28 The author’s personal experience is toremove the stone from the duct only if it is in theanterior part of the duct and the sialolithotomy is asimple procedure without a need for dissection.

Another situation in which the patient can benefitfrom hot sialolilithotomy is in severe infections from thesubmandibular gland with a need for incision anddrainage. In all the other cases the author’s preferenceis to ‘‘cool’’ the gland with antibiotic treatment first andto wait with the definitive surgical intervention until thegland is clear from acute infection.

Strictures and Kinks

Following the extensive use of sialoendoscopy, in ourdepartment, we encountered new pathologies that causesalivary gland obstruction. From our past and presentdata, it seems that strictures and kinks are the leadingcause of obstruction after sialoliths. Strictures in salivaryducts have been mentioned briefly and anecdotally inthe literature, whereas, kinks are a new pathology.17

Buckenham et al42 and Brown et al43 were the pio-neers in the use of balloon technique under fluoro-scopic guidance. The endoscopic technique simplifiedthe dilatation techniques, as we can use less complicatedinstruments combined with our ability to work underdirect or semidirect vision.

DiagnosisStrictures were investigated and diagnosed by sialogra-phy and sialoendoscopy. Kinks were diagnosed mainlyby sialography, and sialoendoscopy was used to rule outother pathologies and to locate the kink. Occasionallysialography, demonstrating a kink, revealed storage ofthe contrast dye in the area of the kink. During thepostevacuation phase of the gland, blockage is noted inthe same area. Strictures are quite obvious in sialogram,and they have a typical appearance in sialoendoscopy.

TreatmentTreatment techniques are based on the diagnosticprogress made in identifying and locating pathologieswhen using the sialoendoscope.

DilatationThe treatment of strictures is based, first of all, on diag-nosing and locating the pathologic process. Dilatation

can be accomplished by saline hydrostatic pressureballoons or a mini-forceps expansion maneuver. Thefirst attempt to dilate the stricture is undertaken bysaline pressure irrigation, through the irrigation port,while introducing and advancing the diagnostic sialoen-doscope. If the saline pressure irrigation fails to inducedilatation, the next step is to insert a sialoballoon(Sialotechnology Ltd., Ashkelon, Israel). The sialobal-loon has a high-pressure balloon tip of 2 to 4 mm inlength, and an outer diameter of 2.5 Fr (B/1 mm). It canbe inflated with air up to 4 mm H2O pressure at amaximum of 18 Bar. This pressure is sufficient to dilatemost of the strictures.

The balloon can be inserted in either of two ways:under direct vision, if there is enough space to insertthe sialoendoscope and the balloon; or in a semi-blind approach, through the telescope channel of thediagnostic sialoendocope in a semiblind technique.Another technique for dilatation of strictures is toexpand the involved region with the use of miniaturegrasping forceps. The technique involves the use of thegrasping forceps as a dilator, in that the openedgrasping jaws are gently moved in a retrograde fashionalong the inner wall of the stricture region. Followingthe procedure, we inject 100 mg of hydrocortisonesolution intraductally.

A sialostent can be inserted to assist in preventingre-creation of strictures; the stent is kept in place for4 weeks. All patients are treated postoperatively withamoxicillin 1.5 g per day for 7 days.

Anti-kink ProcedureThe treatment of kinks, as in strictures, is precededby a careful diagnostic workup to provide accuratelocalization of the pathology. In the submandibularkink, a balloon performs contouring of the kink. Thenext step ahead is the advancement ductoplasty. Thisis performed by stripping the duct and removing�/5 mm of the anterior part of the duct, pulling itanteriorly, and inserting a sialostent. The anterior edgeis sutured to the mucosa and periosteum near thelingual side of the anterior teeth with 4.0 Vicryl suture.For additional support, a 3.0 silk suture is insertedthrough the oral mucosa lining and the ductal layerand connected to the anterior teeth. The wholemaneuver means to extend the angle of the kink.The procedure is completed by injecting 100 mghydrocortisone into the kink region through thesialoendoscope.

In the event of a parotid kink, the procedure includesballoon contouring, placement of the polyethylenestent, and hydrocortisone injection. All patients aretreated postoperatively with oral antibiotics for 7 days.All these procedures are performed under local anes-thesia on an outpatient clinic basis.


j Conclusion

Sialoendoscopy is a promising new method for use indiagnosing and treating many inflammatory conditionsof the major salivary glands. It is an outpatient proce-dure, utilizing local anesthesia and without majorcomplications. It appears to be the future solution forthe management of perplexing inflammatory salivarygland pathology. As more surgeons become involvedwith endoscopy, more findings and innovations will beforthcoming, adding to its effectiveness.

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