Results of Minimally Invasive Gland-Preserving Treatment in Different Types of Parotid Duct Stenosis

ORIGINAL ARTICLE

ONLINE FIRST Results of Minimally Invasive Gland-Preserving Treatment in Different Types of Parotid Duct Stenosis

Michael Koch, MD, PhD; Heinrich Iro, MD; Nils Klintworth, MD; Georgios Psychogios, MD; Johannes Zenk, MD

Objective: To assess differences in minimally invasive all cases). Interventional sialendoscopy with instrumen- treatment in various types of Stensen duct stenoses, be- tal dilation was successful in 47.1% of cases of type 2 ste- cause sparse data have been published concerning this. nosis and 70.5% of cases of type 3 stenosis (59.2% of all patients). Interventional sialendoscopy combined with Design: Retrospective study. transoral duct surgery was successful in 72.7% of cases of type 3 stenosis (8.6% of all cases). Glands could be Setting: Tertiary reference center, level of evidence: 2b. preserved in 96.4% of cases.

Patients: Ninety-three patients with stenoses. Conclusions: Stenoses that can be differentiated using sialendoscopy seem to require different minimally inva- Methods: Treatment of 111 parotid duct stenoses was sive treatment. Sialendoscopy-guided rinsing with cor- evaluated with particular attention to which treatment tisone is an important basic anti-inflammatory treat- strategies were successful in various types of stenoses (type ment, particularly in inflammatory stenoses. Interventional 1, inflammatory; type 2, web-associated fibrous; and type sialendoscopy with instrumental dilation, transoral duc- 3, fibrous). Minimally invasive treatment consisted of sialendoscopy-guided rinsing with cortisone (all cases) and tal surgery or a combination of both are the first choice interventional sialendoscopy with instrumental dila- in fibrous stenoses. tion alone or combined with transoral ductal surgery. Arch Otolaryngol Head Neck Surg. 2012;138(9):804-810. Results: Sialendoscopy-guided rinsing with cortisone was Published online August 20, 2012. sufficient in 73.0% of cases of type 1 stenosis (21.5% of doi:10.1001/archoto.2012.1618

PTO75% OF STENOSES OF and also hypoechoic parenchymal changes, the salivary ducts are lo- as signs of obstruction of the gland.6 cated in the parotid duct, Stenoses can be directly and safely vi- and these cause approxi- sualized using sialendoscopy, which al- mately 15% to 25% of all lows assessment of the characteristics of the 1,2 unclearU salivary gland diseases. Chronic tissue and the extent of the stenosis.6,7 Si- parotitis is the major cause of this type of alendoscopy also allows precise evalua- tion and classification of the stenosis. Three CME available online at different types of stenoses have been de- www.jamaarchivescme.com scribed: inflammatory (type 1); fibrous, as- and questions on page 802 sociated with intraductal circular or web- like inclusions, often with only a moderate stenosis, but associations with allergic, in- degree of luminal narrowing (type 2); and fectious, granulomatous, and autoim- fibrous, involving the entire ductal wall, al- mune diseases, as well as status after ra- most always with high-grade to complete diotherapy or radioiodine therapy, have also obstruction (type 3).5 Parotid duct steno- been reported.3-5 Ultrasonography is cur- ses are difficult to treat, and the results have Author Affiliations: rently the diagnostic method of choice in so far been unsatisfactory in most cases. Author Affil Department of our department. Ultrasonographic imaging Only a few publications have described the Department Otorhinolaryngology–Head 6-10 Otorhinolary and Neck Surgery, University of parotid gland stenosis shows a hy- treatment of these stenoses. By con- and Neck Su of Erlangen-Nuremberg, poechoic band on the masseter muscle, as trast, there have been numerous reports on of Erlangen- Erlangen, Germany. evidence of dilation of the ductal system, the treatment of chronic parotitis, experi- Erlangen, Ge

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Figure 1. Type 1 stenosis. Before treatment (A) and 3 months after treatment (B). Treatment consisted of dilation by the endoscope itself and intraductal cortisone therapy during and after the intervention.

ence with which therefore also needs to be taken into ultrasonography. In addition to direct visualization, this al- account.3,11 lowed pretherapeutic assessment of the stenosis.5 The endos- Conservative anti-inflammatory treatment can im- copy set used currently includes 3 sialendoscopes with outer prove the symptoms in approximately 50% of cases,3 and diameters of 0.8 to 1.6 mm. The most important instruments it may include adjuvant measures, such as rinsing with for treatment with direct endoscopic guidance were baskets, 12,13 miniature forceps, microdrills, and balloons (with diameters saline or contrast medium during sialography, as well 2,6,23 12,14 ranging from 0.38 to 0.78 mm). as intraductal administration of various drugs. More The treatment was mainly based on the sialendoscopic find- invasive measures, which are necessary in approxi- 3,11 ings. The basic treatment performed in all patients consisted mately 40% to 50% of cases, include ligation of the ef- of endoscopically guided conservative therapy, with rinsing of ferent duct and various surgical procedures in the distal the ductal system using Ringer solution mixed with predniso- ductal system.3,11,15-17 Even in more recent publications, lone, 250 mg. Treatment for the stenosis was performed in ac- however, parotidectomy is still considered to be unavoid- cordance with the tissue quality and grade of luminal narrow- able in up to 40% of cases.3,11,18-20 ing. The various diameters of the sialendoscopes were used to The development of miniaturized instruments and new assess the degree of stenosis. Low-grade stenoses were pass- treatment methods has led to a fundamental change in able with the 1.1-mm endoscope but not with the 1.6-mm en- treatment approaches during the past 10 years. New meth- doscope; moderate stenoses easily passable with the 0.8-mm ods include radiographically and sialographically con- endoscope and with forced power by the 1.1-mm endoscope; trolled balloon dilation, which has been performed with and high-grade (filiform or complete) stenoses were not pass- a success rate of approximately 80%.9,10,21 Sialendos- able with the 0.8-mm endoscope. Stenoses with slight to moderate luminal constriction, and inflammatory stenoses in par- copy allows endoscopically guided treatment of patho- ticular, which could still be passed with the endoscope under logic changes in the ductal system with direct visualiza- slight pressure, did not represent an indication for further in- tion, after the introduction of miniaturized surgical strumental dilation (Figure 1). By contrast, interventional si- 7,8,21-23 instruments through the working channel. alendoscopy with instrumental dilation was always indicated After categorizing 111 symptomatic stenoses of the pa- for high-grade filiform to complete stenoses. rotid duct in 93 patients,5 this retrospective study re- The stenoses were dilated under direct vision until the lu- ports on our experiences in the treatment of these ste- men was wide enough (ie, Ͼ1 mm) to be passed with the 1.1-mm noses in the same group of patients, with special attention sialendoscope and unobstructed salivary flow was possible. Di- to the value of various treatment procedures in relation lation with the miniature basket is a proven technique here for to the various types of stenoses. atraumatic bougienage of inflammatory or fibrous stenoses (Figure 2). The basket and microdrill allowed cicatricial filiform or complete stenoses to be opened or reamed to restore METHODS a patent ductal lumen (Figure 3). In papillary or distal ductal stenoses, in which insertion of A total of 111 stenoses of the parotid duct in 93 patients were the sialendoscope or interventional sialendoscopy was not pos- treated during the period from 2001 to 2006. Forty-three per- sible, minimally invasive transoral ductal surgery was per- cent of the patients were men (40 of 93). The patients’ aver- formed (papillotomy, distal ductal incision, ductal resection, age age was 49 years (range, 15-75 years; median, 49 years). and reinsertion), with sialendoscopically guided stent place- Isolated stenoses were present in 87.1% of cases (bilateral in ment where appropriate. The extent or length of complete dis- 6.57%), and in 12.9% these were also associated with sialoli- tal papillary or ductal stenosis was previously measured pre- thiasis. cisely using ultrasonography. The threshold at which transoral All of the patients were examined using high-resolution ul- ductal surgery treatment was indicated was a maximum length trasonography (Sonoline Elegra, 7.5 MHz; Siemens Medical So- of 1.0 to 1.5 cm.6 lutions USA Inc). Sialendoscopy was performed after the sus- Combined treatment for stenoses with interventional si- pected diagnosis had been made clinically and on alendoscopy and an open transcutaneous access route has been

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C D

Figure 2. A type 2 stenosis before treatment. This fibrous stenosis shows moderate obstruction (white arrow). A, The parotid duct is massively dilated, creating a megaduct (Ͼ10 mm). B, The stenosis is also visible externally (black arrows). C, Treatment consisted of basket dilation and intraductal cortisone therapy during and after the intervention. D, Status 3 months after treatment.

described,24 but this was not indicated in the group of patients tal stenoses (4 of 93; all type 3 stenoses and treated by treated in the present study. transoral ductal surgery) (Table). After the intervention, all patients received naproxen so- ϫ Multiple sialendoscopic examinations (a maximum dium (Proxen), 2 500 mg/d, for further anti-inflammatory of 4) were performed in 27.9% of the patients (26 of 93). therapy. If there were marked inflammatory changes, an antibiotic was prescribed; for example, roxithromycin (Rulid), Both glands were examined endoscopically in 6 pa- 1ϫ300 mg/d, or ampicillin with sulbactam (Unacid), 3ϫ1 g/d. tients, and bilateral interventional sialendoscopy was per- Regular daily gland massage after stimulation of gland secre- formed in 3 cases. Sialendoscopy plus cortisone therapy tion with sialogoga (eg, ascorbic acid) was recommended, which (CT) was performed in 22.5% of the patients (21 of 93), should be continued also after cessation of the symptoms. and this treatment alone was sufficient in 21.5% (20 of 93) Intraductal administration of single doses of prednisolone, (Figure 1). 50 mg, was also performed after every intervention (current In 74.2% of the patients (69 of 93), attempts were made scheme: once a week for 8 weeks, twice a week for 4 weeks, and once a week for a further 4 weeks; total treatment time, 4 to dilate the stenosis using interventional sialendoscopy months). (with a total of 85 procedures; up to 3 procedures in 10 Parotidectomy was recommended as the treatment of last patients, bilateral in 3). Interventional sialendoscopy was resort if symptoms persisted. The mean follow-up period was the only treatment modality performed on 65.6% of the 27.2 months (range, 3.0-80.0 months; median, 23.5 months). patients (61 of 93), in whom 76 sialendoscopy procedures were performed, 88.2% of which (67 of 76) were RESULTS successful. In all, 59.2% of the patients (55 of 93) were successfully treated with interventional sialendoscopy Sialendoscopy was performed with local anesthesia in 92 (Figure 2 and Figure 3). patients (98.9%). No complications occurred either dur- Minimally invasive transoral ductal surgery was per- ing the procedures or during the subsequent course. formed in 11.8% of the patients (11 of 93), all with type In 4.3% of the patients, insertion of the endoscope was 3 stenosis (4 patients with cicatricial complete papillary possible only after surgical opening of the papilla or dis- stenosis, 5 with extensive scarring and complete oblit- tal ductal system in patients with papillary or distal duc- eration of the duct just after the papilla, and 2 patients

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D E F

Figure 3. A type 3 stenosis in the middle area of the duct before treatment. A, Stenosis showing almost complete fibrous obstruction. B, A basket was inserted to dilate the fibrotic tissue step by step. C, A microdrill (white arrow) was used to cut the fibrous tissue and the stenosis was further opened. D, After instrumental dilation, severely macerated ductal epithelium at a length of 1.5 cm with fibrotic tissue involving more than 50% of the circumference was observable indicating a high risk for recurrence. E, Endoscopically guided stent implantation was performed: a polyurethane stent, 4.5F, 60 mm, was inserted in the healthy proximal duct system (black arrow). F, Two months later control sialendoscopy was performed: after removal of the stent, an epithelialized duct system was observable, which was wide enough to allow unhindered passage with the 1.1-mm endoscope.

Table. Parotid Duct Stenoses: Characteristics, Number, Treatment, and Course in 93 Patients With 111 Stenosesa

Type 1, Course Type 2, Course Type 3, Course Successfully Unsuccessful/ Successfully Unsuccessful/ Successfully Unsuccessful/ Therapy Treated Symptomatic Treated Symptomatic Treated Symptomatic SE ϩ CT 60.0 (9 of 15) 6.7 (1 of 15) 47.1 (8 of 17) 0 (0 of 17) 4.9 (3 of 61) 0 (0 of 61) IntervSE 26.7 (4 of 15) 6.6 (1 of 15) 47.1 (8 of 17) 5.9 (1 of 17) 70.5 (43 of 61) 6.6 (4 of 61)b TDS ± intervSE 13.1 (8 of 61) 4.9 (3 of 61)c

Abbreviations: CT, intraductal cortisone therapy; intervSE, interventional sialendoscopy; SE, sialendoscopy; TDS, transoral ductal surgery. a Data are given as percentage (number/total number). Type 1 is inflammatory; type 2, fibrous and web associated; type 3, fibrous, without webs. b Parotidectomy in 2 patients. c Parotidectomy in 1 patient.

with unsuccessful interventional sialendoscopy) (Table). were placed in only 2.2% (2 of 93) after interventional Resection of the papilla and distal duct, followed by cir- sialendoscopy alone (Figure 3). The stents, made of poly- cular reinsertion of the duct into the buccal mucosa, was urethane, are available with various lengths (20-120 mm) performed in 3 patients, in 1 case with stent placement. and diameters (4.5F-6.0F) and fit precisely over the shaft This treatment was successful in all cases. Incision of the of the various endoscopes in the Erlangen endoscopy set papilla and distal duct system was performed in 8 pa- (patented by Sialo Technology Israel Ltd). The stents were tients, and a stent was also placed under endoscopic guid- sutured to the buccal mucosa and left in place for 6 to 8 ance in 6 of these patients (54.5%). Five of the patients weeks. Correct positioning in the ductal system was al- became free of symptoms. The success rate with tran- ways checked intraoperatively by sialendoscopy and also soral ductal surgery was 72.3% (8 of 11) (Table). A fur- postoperatively using ultrasonography. In all, 95.1% of the ther 8.7% of all patients were successfully treated patients with type 3 stenoses needed and received mini- with transoral ductal surgery, with or without interven- mally invasive surgical treatment. tional sialendoscopy. With regard to the individual treatments adminis- Stents were placed in 8.6% of the patients (8 of 93) tered in relation to the different types of stenosis, 73.3% when there was an increased risk of recurrence, but they of type 1 stenoses (11 of 15) were treated with sialen-

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 doscopy-guided rinsing with cortisone. Some less se- to 50% of cases, even according to the more recent lit- vere stenotic areas were simultaneously dilated in these erature reports.3,11,18-20 cases during introduction of the sialendoscope itself. Mu- Conservative systemic treatment measures3,11,25 and in- cous or fibrinous plaques were removed at the same time tensified local treatments12-14 allow a temporary reduc- if needed. Active dilation by interventional sialendos- tion in clinical symptoms in approximately 50% of copy was performed in 26.7% of these cases (4 of 15). cases.19,20 Intraductal cortisone treatment proved particularly valu- The development of minimally invasive treatment pro- able (Figure 1). Successful minimally invasive treat- tocols has made it possible to relieve the symptoms per- ment was performed in 86.7% of the type 1 stenoses manently with minimal morbidity while preserving the (Table). function of the salivary gland. These methods include ra- Interventional sialendoscopy with instrumental dila- diographically guided dilation of the salivary ducts, with tion was required for adequate dilation in 52.9% of the type success rates higher than 80%.9,10,21 In addition to allow- 2 stenoses (9 of 17), and was successful in 88.9% of these ing assessment of the tissue characteristics in the area of patients, representing 47.1% of type 2 stenoses (Figure 2). the stenosis, sialendoscopy at the same time allows ap- Altogether, successful minimally invasive treatment was propriate therapy, with direct endoscopic guidance, based carried out in 94.2% of the type 2 stenoses (Table). on the sialendoscopic findings. Sialendoscopy thus al- Endoscopically guided instrumental dilation was per- lows both diagnosis and simultaneous treatment with di- formed in 77.1% of the type 3 stenoses (43 of 61), and rect vision. Success rates of more than 90% have been 91.5% of these procedures were successful, represent- reported for endoscopically guided dilation of parotid duct ing 70.5% of all type 3 stenoses (Figure 3). Eighteen per- stenoses.2,5-8,23 cent of the patients received combination treatment Sialendoscopy played a decisive role in the treatment with interventional sialendoscopy and transoral ductal approach used in this study. Precise sialendoscopic char- surgery (11 of 61), and 72.3% of these procedures were acterization of the stenoses was important for planning successful. It was not initially possible to pass the ste- and carrying out the appropriate treatment. With sialen- noses with the endoscope in 4 cases. When a longer ste- doscopy-guided rinsing with cortisone, symptomatic con- nosis was suspected, intraductal cortisone therapy was trol was achieved in 21.5% of the patients through the performed first, which improved the symptoms notice- anti-inflammatory effect alone and the dilatory effect of ably in all cases, so that no further treatment was nec- the endoscope itself. This was seen in 60% of the type 1 essary as far as the patients were concerned. Altogether, stenoses and 47.1% of the type 2 stenoses (Figure 1 and successful treatment was performed in 88.4% of the type Figure 2; Table). Particularly in stenoses in which there 3 stenoses (Table). is a clear inflammatory reaction, an expectant approach Parotidectomy was ultimately necessary in 3.2% of the avoiding or minimizing surgical manipulation seems to patients (3 of 93), including a bilateral procedure in 1 be justified. In addition, progression (eg, from type 1 to patient (after unsuccessful or treatment-resistant inter- type 3 stenosis) is imaginable and can be prevented at ventional sialendoscopy in a primary stenosis in 1 pa- an early stage in this way. tient; owing to complete stenosis after abscess incision While interventional sialendoscopy was performed in due to sialolithiasis in 1 patient; and after distal ductal only in 33.3% of the type 1 stenoses, it was necessary in incision with stent placement in combined stenosis and 52.9% of the type 2 and 77.1% of the type 3 stenoses sialolithiasis in 1 patient). The procedures, including gland (Figures 2 and Figure 3; Table). It was possible to dilate resection, were free of complications in all cases. the stenoses in 88.2% of the interventional sialendosco- Minimally invasive gland-preserving treatment was pos- pies performed, and 59.2% of all patients were success- sible with the various methods in 96.8% of the patients fully treated with this method. These results, as well as (90 of 93), and 92.5% (86 of 93) reported a clear improve- those reported by other research groups,7,8 show that en- ment of their complaints. Among the patients with pre- doscopically guided therapy is the treatment of choice served glands (n = 90), 92.2% (83) had no further signifi- for parotid gland stenosis. cant symptoms, while 7.8% of the patients treated (7) However, a wide range of procedures are needed to reported persistent symptoms that were subjectively un- maximize the numbers of successful treatments. These comfortable but without requesting further treatment. include transoral ductal surgery and, in particular, resection of the distal duct with reinsertion. In combina- COMMENT tion with transoral ductal surgery, as many as 95.1% of cases of type 3 stenoses could be treated. Particularly when interventional sialendoscopy is not possible or is unsuc- Obstructive diseases in the parotid gland are associated cessful, these procedures offer a solution in cases of com- with considerable impairment of the quality of life for plete distal ductal stenosis, which represented as many the patients affected. Stenoses of the parotid duct are found as 11.8% of cases in the present group of patients—all in approximately 20% of cases in patients with obstruc- with type 3 stenosis. Interventional sialendoscopy is re- tive parotid gland disease and represent 70% to 80% of quired to exclude or treat additional pathologic changes all salivary duct stenoses.1,2 Treating these stenoses is of- and to perform the endoscopically guided stent place- ten problematic in everyday practice. Chronic parotitis, ment that is often required (54.5% of cases after trans- which seems to be one of the major causes of duct ste- oral duct surgery in the present study). The success rates nosis,3-8 was reported to be treatable only with more in- in this study (72.3% of all transoral ductal surgery pro- vasive forms of therapy, including parotidectomy, in 40% cedures or 8.6% of all patients) are better than results pre-

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 viously published in the literature. These procedures are In conclusion, these results show that minimally in- reported as failing in up to 70% of cases in some publi- vasive treatment for parotid duct stenosis is possible with cations, particularly owing to a tendency toward scar- a high success rate. Pretherapeutic sialendoscopy al- ring in the papillary region.3,11,14-17,19 Adequate surgical lows precise assessment of the stenoses, and the combi- technique and interventional sialendoscopy with stent im- nation of various treatment modalities that may be needed plantation evidently lead to a substantial reduction in the is decisive for success. However, interventional sialen- risk of recurrent stenosis.7,15 According to Cohen et al,15 doscopy plays by far the most important role here and resection of the stenotic ductal segment and complete cir- should be the treatment of choice. Different measures may cular suturing of the residual duct into the buccal mu- lead to success, depending on the type of stenosis in- cosa and establishing a wide neo-ostium is seen as being volved. It was possible to manage most type 1 stenoses the key to success in these cases. The results of the pres- and approximately 50% of type 2 stenoses using sialen- ent study confirm this: all patients (n = 3) who under- doscopy-guided rinsing with cortisone. Type 3 stenoses went ductal resection with reinsertion became free of had to be treated with interventional sialendoscopy, trans- symptoms. All of the patients who were not free of symp- oral ductal surgery, or a combination of both in over 90% toms (n = 3) were treated with distal ductal incision. In of cases. the latter cases, stent placement may reduce the risk of recurrent stenosis considerably, but it does not exclude it completely.6,7 Submitted for Publication: April 9. 2012; final revision In all patients, repeated intraductal cortisone appli- received June 11, 2012; accepted June 18, 2012. cation was performed. Cortisone is well known to have Published Online: August 20, 2012. doi:10.1001/archoto anti-inflammatory and antiproliferative effects on tis- .2012.1618 sues. In nearly all cases with chronic obstructive paroti- Correspondence: Michael Koch, MD, PhD, Depart- tis in the involved duct systems, a subacute (or acute) ment of Otorhinolaryngology–Head and Neck Surgery, or chronic inflammatory reaction and fibrinoid dis- FAU Medical School, Friedrich-Alexander-University of charge of various amounts and plaques can be observed Erlangen-Nuremberg, Waldstrasse 1, D-91054 Erlan- with the sialendoscope.3-7,25 Plaque formation can cause gen, Germany ([email protected]). repeated duct obstruction, which apparently has proved Author Contributions: All authors had full access to all not to be bacterially induced.3,4,25 As a result of its anti- the data in the study and take responsibility for the in- inflammatory activity, cortisone is supposed to counter- tegrity of the data and the accuracy of the data analysis. act this primary inflammatory activity, and antibiotic treat- Study concept and design: Koch, Iro, and Zenk. Acquisi- ment proved not to be the treatment of choice.3,6,25 tion of data: Koch, Klintworth, Psychogios, and Zenk. However, exacerbation of inflammation can occur as a Analysis and interpretation of data: Koch and Zenk. Draft- result of bacterial superinfection owing to duct obstruc- ing of the manuscript: Koch. Critical revision of the manu- tion indicating antibiotic therapy. Several study groups script for important intellectual content: Koch, Iro, Klint- reported that inflammatory, noninfectious processes were worth, Psychogios, and Zenk. Statistical analysis: also involved in the development of stenoses.3,4,7,25 Ob- Klintworth and Psychogios. Administrative, technical, and structing plaques (eg, a nearby encroachment, duct bend- material support: Koch. Study supervision: Iro and Zenk. ing, or duct division) were observed to induce a local in- Financial Disclosure: None reported. flammatory reaction, causing shrinkage and fibrosis of Previous Presentations: All parts of this study were pre- the duct wall.3,4,25 Our observations point in the same di- sented orally and were available in abstract form in the rection.5,6 The observed effect to reduce the tendency to congress brochure at the Second International Con- develop a primary or recurrent stenosis after cortisone gress on Salivary Gland Diseases, University of Pitts- treatment also was attributed to its anti-inflammatory and burgh; October 18-22, 2007; Pittsburgh, Pennsylvania; antiproliferative, scar-inhibiting effects in retrospective the German Otorhinolaryngology Congress; May 17- analysis.3,6,7,25 This, of course, has to be investigated by 20, 2007; Munich, Germany; and the Collegium Oto- further controlled studies. Rhino-Laryngologicum Amicitiae Sacrum (CORLAS); Gland massage after stimulation of gland secretion with August 22-25, 2010; University of Budapest, Budapest, sialogoga (eg, ascorbic acid) was strongly recom- Hungary. mended all patients in a personal conversation. Daily per- formance of this was intended to clear the fibrinoid dis- REFERENCES charge out of the duct system and reduce or prevent of plaque formation and duct obstruction in the future. 1. Ngu RK, Brown JE, Whaites EJ, Drage NA, Ng SY, Makdissi J. Salivary duct stric- The fact that gland-preserving treatment was pos- tures: nature and incidence in benign salivary obstruction. Dentomaxillofac Radiol. sible in 96.8% of the patients in the present study, with 2007;36(2):63-67. 2. Koch M, Zenk J, Iro H. Diagnostic and interventional sialoscopy in obstructive 92.2% of the patients reporting no relevant symptoms diseases of the salivary glands. HNO. 2008;56(2):139-144. afterward, argues in favor of the treatment regimen de- 3. Baurmash HD. Chronic recurrent parotitis: a closer look at its origin, diagnosis, scribed herein, adapted to the different types of steno- and management. J Oral Maxillofac Surg. 2004;62(8):1010-1018. ses. These results, as well as other published studies,6-8 4. Qi S, Liu X, Wang S. Sialoendoscopic and irrigation findings in chronic obstruc- show that parotidectomy should no longer be regarded tive parotitis. Laryngoscope. 2005;115(3):541-545. 5. Koch M, Iro H, Zenk J. Sialendoscopy-based diagnosis and classification of pa- as part of the routine range of treatments for parotid rotid duct stenoses. Laryngoscope. 2009;119(9):1696-1703. duct stenoses and should be indicated only in indi- 6. Koch M, Iro H, Zenk J. Role of sialoscopy in the treatment of Stensen’s duct vidual cases. strictures. Ann Otol Rhinol Laryngol. 2008;117(4):271-278.

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©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 7. Nahlieli O, Shacham R, Yoffe B, Eliav E. Diagnosis and treatment of strictures otitis (author’s transl) [in German]. Laryngol Rhinol Otol (Stuttg). 1977;56 and kinks in salivary gland ducts. J Oral Maxillofac Surg. 2001;59(5):484-490. (11):902-906. 8. Ardekian L, Shamir D, Trabelsi M, Peled M. Chronic obstructive parotitis due to 17. Nichols RD. Surgical treatment of chronic suppurative parotitis: a critical review. strictures of Stenson’s duct: our treatment experience with sialoendoscopy. J Oral Laryngoscope. 1977;87(12):2066-2081. Maxillofac Surg. 2010;68(1):83-87. 18. Amin MA, Bailey BM, Patel SR. Clinical and radiological evidence to support su- 9. Brown JE. Interventional sialography and minimally invasive techniques in be- perficial parotidectomy as the treatment of choice for chronic parotid sialadeni- nign salivary gland obstruction. Semin Ultrasound CT MR. 2006;27(6):465- tis: a retrospective study. Br J Oral Maxillofac Surg. 2001;39(5):348-352. 475. 19. Moody AB, Avery CM, Walsh S, Sneddon K, Langdon JD. Surgical management 10. Waldman DL, Westesson PL, Hengerer AS. Balloon dilation of parotid duct stenosis. of chronic parotid disease. Br J Oral Maxillofac Surg. 2000;38(6):620-622. J Vasc Interv Radiol. 1998;9(1, pt 1):167-168. 20. Sadeghi N, Black MJ, Frenkiel S. Parotidectomy for the treatment of chronic re- 11. Motamed M, Laugharne D, Bradley PJ. Management of chronic parotitis: a review. current parotitis. J Otolaryngol. 1996;25(5):305-307. J Laryngol Otol. 2003;117(7):521-526. 21. McGurk M, Escudier MP, Thomas BL, Brown JE. A revolution in the manage- 12. Antoniades D, Harrison JD, Epivatianos A, Papanayotou P. Treatment of chronic ment of obstructive salivary gland disease. Dent Update. 2006;33(1):28-30, sialadenitis by intraductal penicillin or saline. J Oral Maxillofac Surg. 2004; 33-36. 62(4):431-434. 22. Katz P. New method of examination of the salivary glands: the fiberscope. Inf 13. Galili D, Marmary Y. Juvenile recurrent parotitis: clinicoradiologic follow-up study Dent. 1990;72(10):785-786. and the beneficial effect of sialography. Oral Surg Oral Med Oral Pathol. 1986; 23. Koch M, Zenk J, Bozzato A, Bumm K, Iro H. Sialoscopy in cases of unclear swell- 61(6):550-556. ing of the major salivary glands. Otolaryngol Head Neck Surg. 2005;133(6): 14. Bowling DM, Ferry G, Rauch SD, Goodman ML. Intraductal tetracycline therapy 863-868. for the treatment of chronic recurrent parotitis. Ear Nose Throat J. 1994;73 24. Marchal F. A combined endoscopic and external approach for extraction of large (4):262-274. stones with preservation of parotid and submandibular glands. Laryngoscope. 15. Cohen D, Gatt N, Olschwang D, Perez R. Surgery for prolonged parotid duct ob- 2007;117(2):373-377. struction: a case report. Otolaryngol Head Neck Surg. 2003;128(5):753-754. 25. Nahlieli O, Bar T, Shacham R, Eliav E, Hecht-Nakar L. Management of chronic re- 16. Mu¨nzel M, Meister P. On the ligation of Stenson’s duct in chronic-recurrent par- current parotitis: current therapy. J Oral Maxillofac Surg. 2004;62(9):1150-1155.

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