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Specificity of Parotid Sialendoscopy The Laryngoscope Lippincott Williams & Wilkins, Inc., Philadelphia © 2001 The American Laryngological, Rhinological and Otological Society, Inc. Specificity of Parotid Sialendoscopy Francis Marchal, MD; Pavel Dulguerov, MD, PD; Minerva Becker, MD; Gerard Barki; François Disant, MD; Willy Lehmann, MD Objective: To present our initial experience with INTRODUCTION sialendoscopy of the parotid duct. Study Design: An obstructive disease is the usual diagnosis in case of Methods: Diagnostic and interventional sialendos- unilateral diffuse parotid swelling (after exclusion of mumps copy procedures were performed in 79 and 55 cases, parotitis). The classic attitude is an antibiotic and anti- respectively. Diagnostic sialendoscopy was used to inflammatory treatment, followed by radiological studies, classify ductal lesions into sialolithiasis, stenosis, sia- usually sialography,1 which is still considered the gold stan- lodochitis, and polyps. Interventional sialendoscopy dard. Diagnostic sialendoscopy is a recent procedure2,3 al- was used to treat these disorders. The type of endo- scope used, the type of sialolithiasis fragmentation lowing complete visualization of the ductal system and its and/or extraction device used, the total number of diseases and disorders. Major advances in optical technolo- procedures, the type of anesthesia, and the number gies and the development of semirigid sialendoscopes are and size of the sialoliths removed were the dependent responsible for significant progress in salivary gland endos- variables. The outcome variable was the endoscopic copy.4,5 This procedure, by allowing the complete exploration clearing of the ductal tree and resolution of symp- of the salivary ductal system, is positioned to replace sialog- toms. Results: Diagnostic sialendoscopy was possible raphy and other radiological studies6 because of its higher ؎ in all cases, with an average duration of 26 14 min- specificity and cost-effectiveness. utes and no complications. Interventional sialendos- Because sialolithiasis is the main cause of obstructive copy was successful in 85% of cases, with an average disease of the parotid gland, treatment of repeating epi- .(duration of 73 ؎ 43 minutes (؎ standard deviation sodes includes either a parotidectomy or, rarely, marsupi- Multiple procedures were performed in 45% of cases, general anesthesia was used in 24%, and parotidec- alization (sialodochotomy and/or sialodochoplasty) of the tomy in 2%. Multiple sialoliths were found in 58% of initial part of Stensen’s duct, allowing the direct removal ducts and associated with more procedures under of the stone. However, parotidectomy is rarely performed general anesthesia and longer operations. The aver- for inflammatory conditions because it remains a tedious age size of sialoliths was 3.2 ؎ 1.3 mm; larger stones procedure and carries a higher incidence of postoperative were associated with more procedures under general paresis.7,8 While diagnostic sialendoscopy is an evaluation anesthesia, longer and multiple procedures, use of procedure, interventional sialendoscopy must be consid- fragmentation, and sialendoscopy failures. Sialolithi- ered as a valid operation to relieve the obstructive ductal asis fragmentation was required in 10% of cases, with process, alleviating the need for open surgeries. a success rate of 70%. Semirigid sialendoscopes per- Several techniques have been developed since 1990 to formed better than flexible ones. Complications were fragment sialoliths. Extracorporal lithotripsy, popularized mostly minor but were encountered in 12% of cases. 9 Conclusions: Diagnostic sialendoscopy is a new tech- for sialolithiasis by Iro et al., as well as ductal procedures 10,32,33,35–37 11–13 nique for evaluating salivary duct disease, a tech- such as laser, electrohydraulic, and pneu- nique which is associated with low morbidity. Inter- moblastic14 lithotripsy, has been reported, but leave stone ventional sialendoscopy allows the extraction of fragments in the ductal system. The clearance of these sialoliths in most patients, preventing open gland ex- fragments is incomplete and could become the nidus of cision. Key Words: Salivary gland, parotid, sialolithi- recurrent sialolithiasis.15 asis, stones, endoscopy, instruments, surgical tech- The literature on Stensen’s duct sialendoscopy is lim- nique, laser, treatment, outcome. ited (Table I) because most series report on parotid as well Laryngoscope, 111:264–271, 2001 as submandibular sialolithiasis. Probably, the smaller di- ameter of Stensen’s duct16 has made its exploration more challenging and therefore most previous authors17–19 From the Department of Otolaryngology—Head and Neck Surgery have performed an endoscopy, followed by the blind re- (F.M., P.D., W.L.) and the Department of Radiology (M.B.), Geneva University Hospital, Geneva, Switzerland; Karl Storz GMBH (G.B.), Tüttlingen, Ger- trieval of the stone with a Dormia basket, corresponding, many; and the Department of Otolaryngology—Head and Neck Surgery possibly, to a “endoscopically-assisted stone retrieval,” but (F.D.), Edouard Herriot Hospital, Lyon, France. certainly not to the interventional sialendoscopy described Editor’s Note: This Manuscript was accepted for publication October in the present report. 23, 2000. Send Correspondence to Francis Marchal, MD, CE, 16 Cours de Rive, The aim of this study is to report our 5-year experi- 1204 Geneva, Switzerland. ence with four successive generations of endoscopes in 77 Laryngoscope 111: February 2001 Marchal et al.: Parotid Sialendoscopy 264 patients who had surgery performed by the first author TABLE I. (F.M.) in two university centers (Geneva University Hos- Interventional Sialendoscopy of the Parotid Gland in pital, Switzerland, and Edouard-Herriot Hospital, Claude the Literature. Bernard University, Lyon, France). No. of Interventional No. of Parotid Author, Year Sialendoscopic Cases Sialendoscopic Cases PATIENTS AND METHODS Ko¨ nigsberger, 199032 11 Patients Gundlach, 199233 73 8 The study population consists of 77 consecutive patients *Gundlach, 199434 240 12 (?) suspected of having a disease or disorder of Stensen’s duct who Iro, 199535 20 0 were seen between November 1995 and March 2000. Two pa- Ito, 199636 15 0 tients having bilateral symptoms, a total of 79 diagnostic sialen- doscopic procedures were attempted. These were followed by a Arzoz, 199637 27 4 therapeutic sialendoscopy in 55 cases. Nahlieli, 199738 46 9 6,20 Because of concomitant study protocols, most of the pa- *Nahlieli, 19995 154 57 tients had a preoperative radiological evaluation including sia- lography, ultrasound, magnetic resonance imaging (MRI) sialog- *Probably including cases of the previous reports. raphy, or, rarely, computed tomography (CT) scan. The observed diseases and disorders of Stensen’s duct were classified as sialolithiasis, stenosis, sialodochitis, and ductal pol- 4. The fourth endoscopic system also includes two different yps. The number of instances of each pathological finding in each devices (reference no. 11.516 KA and KT, Karl Storz AG). ductal system was noted. When there were multiple stones, the The diagnostic sialendoscope resembles the single-lumen largest stone was measured with calipers. diagnostic device described above, with slight modifica- The number of diagnostic and interventional procedures tions (handle with rinsing system). The OD is 1.3 mm, was recorded, as well as the type of anesthesia (local vs. general), and the cross-section area is 1.33 mm2. The interven- the fragmentation and extraction device used (discussed later in tional sialendoscope is a double-lumen device with one this section), the total number of sialendoscopic procedures per- channel of 1.1 mm for the endoscope and a working chan- formed per patient, and the number of parotidectomies per- nel of 0.8 mm diameter, which is used for custom-made formed. “Sialendoscopic success” was considered when the lumen baskets and/or laser fibers (Fig. 1). The overall cross- of all the ductal branches was free of any disease. “Sialendoscopic section is 2.29 mm2. The tip of the instrument has been failure” was considered when sialendoscopy was impossible or beveled and blunted for easier cannulation of the duct. unsuccessful or when a gland resection was performed. Both instruments were slightly bent to facilitate explora- In the last 40 patients, the pain experienced as a result of tion of the ductal tree. sialendoscopy was evaluated using a 10-cm visual analogue scale. Statistical analysis for categorical variables was performed with the ␹2 test; numerical variables were analyzed with the Student t test (two groups) or the Kruskal-Wallis test (three or Other Materials more groups), as implemented by the Statistical Package for the Other materials include a customized papilla dilator (refer- Social Sciences (SPSS) software (version 9.0, Chicago, IL). ence nos. 745910 and 745845–744856, Karl Storz AG) and cus- tomized grasping wire baskets (prototypes not referenced yet). Fragmentation of larger stones was achieved in this study using Endoscopes the following devices: an electrohydraulic lithotriptor with a 0.5 The technology of the endoscopes that were used evolved in mm probe (Calcutript, Karl Storz AG) and a 0.4 mm holmium four generations (free optical fiber, flexible endoscope, and two laser probe (Coherent, Versapulse Select, Santa Clara, CA). generations of semirigid endoscopes device of various diameters), as follows: Surgical Technique 1. Initial trials were performed with free optical fibers
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