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Classic Approaches to Sialoendoscopy for Treatment of Sialolithiasis ODED NAHLIELI

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Classic Approaches to Sialoendoscopy for Treatment of Sialolithiasis ODED NAHLIELI 7 Classic Approaches to Sialoendoscopy for Treatment of Sialolithiasis ODED NAHLIELI Obstructive sialadenitis, with or without sialolithiasis, sialoadenitis. These data do not include patients who represents the main inflammatory disorder of the major were treated as ambulatory (outpatient) cases. salivary glands. The diagnosis and treatment of obstruc- There is a male preponderance,5 and the peak tions and inflammations of these glands can be proble- incidence is between the ages of 30 and 60.5 Sialoliths matic due to the limitations of standard imaging grow by deposition and range in size from 0.1 to techniques. Satisfactory treatment depends on our 30 mm.6 Presentation is typically with a painful swelling ability to reach a precise diagnosis and, in the case of of the gland at meal times, when the obstruction caused sialoliths, to accurately locate the obstruction. Until by the calculus becomes most acute.7 recently many of these glands required complete During the past decade, with the introduction of removal under general anesthesia. salivary gland endoscopy there has been a major step Sialolithiasis is a common finding, accounting for forward, not only in providing an accurate means of 50% of major salivary gland disease.1,2 The subman- diagnosing and locating intraductal obstructions, but dibular gland is the most prone to sialolithiasis. In also in permitting minimally invasive surgical treatment various studies it was found that Â/80% of all sialo- that can successfully manage those blockages that are lithiasis cases are in the submandibular glands, 19% not accessible intraorally.8 Á20 occur in the parotid gland, and Â/1% are found in the sublingual gland. Sialolithiasis is most often found in j adults, but it may be diagnosed in children.3 Clinical Presentation Sialoliths may vary in size, shape, texture, and consis- tency. They may occur as a solitary stone or as multiple See Chapter 5 for a full discussion of the clinical stones. Bilateral submandibular stones are a rare condi- presentation of sialoliths. tion (5% of submandibular sialolithiasis cases). Sialoli- thiasis of submandibular and parotid gland together has j Diagnostic Methods not been reported in the literature. The amount of symptomatic and nonsymptomatic sialolithiasis cases is Clinical Evaluation 1% of the population, found in autopsy material.4 The symptomatic group of patients admitted to the Visual scanning of submandibular, preauricular, and hospital each year has been estimated as 57 cases per postauricular regions is the first step in assessing million per annum in the British population, represent- swelling and erythema (see Chapter 5). This is followed ing 3420 patients per annum.1 If this incidence is ap- by intraoral examination. Surgical magnification loops plied to the European or the American population (300 (2.5Á/3.5) are very useful in improving visualization of million), then Â/17,100 patients per annum will require the orifice of Wharton’s and Stensen’s ducts. The orifice hospital treatment for sialolithiasis and its complication may be red and edematous and appear as a papilla. 79 80 CHAPTER 7 j Classic Approaches to Sialoendoscopy for Treatment of Sialolithiasis Plaques or whitish secretions from the duct may represent frank infection. Sometimes a small stone can be found in the orifice; occasionally, the white-yellow color of a stone can be seen through the translucent mucosa. Bimanual palpation is particularly important when examining the submandibular gland and duct. It helps to differentiate the gland from adjacent lymph nodes, inferior to the gland, and to ascertain the presence of any firm mass in the take-off of Wharton’s duct from the hilum of the gland. For the parotid gland, manual palpation allows the surgeon to determine the consistency of the gland. One should also massage the gland to milk and inspect the saliva. Salivary Imaging FIGURE 7 /1 Panoramic dental x-ray, demonstrating large sialolith in theÁ left submandibular gland. Although there are a variety of newly available imaging methods, in this section we focus on those techniques it is the only method that can give the possibility to most suitable for patients suffering from salivary gland examine the ductal system with reasonable cost. Redu- obstructions (See also Chapter 2). The most effective cing the discomfort during sialography may be achieved imaging methods for inflammatory conditions of the by applying topical anesthesia to duct papilla and/or by submandibular and parotid glands are plain x-rays lavaging the gland through the orifice with 2% lidocaine (occlusal, occlusal oblique, panoramic), sialography, prior to the injection of the water-soluble dye. ultrasound, and computed tomography (CT). Scintigra- Sialography provides images of the morphology of the phy will be included in this chapter because of its ductal system and allows the diagnosis of strictures, unique ability to evaluate the gland function. Sialoendo- dilatations, and filling defects. This technique also scopy is a newly developed technique that is useful for provides information on glandular function (Fig. 7Á/2A). imaging and treatment. It will be discussed separately. Ultrasound Plain X-ray High-resolution ultrasound is a good imaging method to assess the salivary glands. It is noninvasive, and there is Traditionally, plain radiographs are often used as a no associated discomfort. It is useful to distinguish the simple first-line investigation. Occlusal, occlusal oblique, submandibular gland from surrounding lymph nodes and panoramic x-rays are excellent for ruling out any and to locate calculi. The portion of Wharton’s duct that calcification in the submandibular region (Fig. 7 /1). leads from the hilum of the gland toward the floor of These will not demonstrate radiolucent calculi, whichÁ 21,22 the mouth, precisely after the penetration of the account for 20 to 43% of submandibular stones. For 23 mylohyoid muscle, is difficult to identify. Calculi parotid stones, panorex and anteroposterior views 16 detection rates vary between 63 and 94% and are directed to the parotid region are recommended. The 24 close to those for sialography. Ultrasound is able to practitioner has to remember that plain x-rays have detect radiolucent stones even though the acoustic minimal value in parotid stones because of the amount shadow is not as marked. The distal portion of the of radiolucent stones (60Á/70%). The plain x-ray gives submandibular and parotid ducts can be difficult to no information on the condition of the affected gland. 25 visualize using extraoral ultrasound. However, small, It is therefore necessary to supplement or supplant plain high-frequency intraoral probes are now available that radiography with another diagnostic modality. 26 overcome this limitation (Figs. 7Á/2B, 7Á/3). Sialography Computed Tomography Sialography is one of the oldest salivary gland imaging CT scan is especially useful for evaluating inflammatory techniques. The first contrast agents used in the early conditions of the submandibular and parotid glands. twentieth century were pure mercury. The dye that he Sialoliths are readily identified on CT imaging. The used was pure mercury. Nowadays we have better dye standard images should be 1 mm cuts with three- options. Although there is a need to penetrate to the dimensional reconstruction. In this way the glands and ductal system with a catheter through the ductal papilla, ducts can be visualized in all planes, and stones are less Salivary Gland Diseases 81 FIGURE 7 /2 (A) Ultrasound and (B) sialogram of the right and in the ultrasound (arrows). The stones appeared as submandibularÁ region of patient suffering from multiple hyperechogenic lesions with acoustic shadow. swellings. Three stones are demonstrated in the sialogram likely to be missed. The parotid gland and duct are well Scintigraphy demonstrated by CT. Another advantage is the possibi- lity to diagnose and locate intraparenchymal stones and In contrast to ultrasound, which depicts architecture, calcifications that are not connected to the gland radioisotope imaging of the salivary glands gives some (phleboliths, tonsiliths, calcifications in the lymph measure of the secretory function and allows compa- nodes, etc.) (Fig. 7Á/4). rison between the major glands. The assessment of FIGURE 7 /3 Ultrasound of pa- rotid glandÁ with multiple hypo- echogenic sialectases (arrows) and dilated Stensen’s duct (S). 82 CHAPTER 7 j Classic Approaches to Sialoendoscopy for Treatment of Sialolithiasis FIGURE 7 /4 Computed tomo- graphy scanÁ of submandibular gland with stone. The sialolith is marked with arrows. salivary gland function using a bolus intravenous injec- sialadenectomy, including stones posterior to the first tion of technetium Tc 99m pertechnetate is easy to molar region, or stones in the middle part of the perform, reproducible, and well tolerated by the Wharton’s duct that cannot be palpated intraorally. patient.27 It enables examination of the parenchymal function and excretion rate of the salivary gland and has Intraoral Sialolithotomy the further advantage of a short half-life and low The first step is to locate the stone exactly. This radiation dose.27 technique is useful only in stones in the anterior and middle part of Wharton’s duct up to the first molar tooth. Effectively, only stones that can be palpated easily j Surgical Procedures from the intraoral region are candidates for this technique. This section is problematic because of the enormous Following administration of local anesthesia, two and rapid development of methods and technology in sutures of 3.0 silk are placed posterior to the location recent years. As in other fields of surgery, traditional and of the stone. The aims of this step are to isolate the stone more aggressive techniques are being replaced by organ- and to prevent movement of the stone to the inner part preserving methods with the help of minimally invasive of the duct or hilum of the gland. The next step is to cut techniques. The reader needs to be familiar with all the mucosa above the stone directly on the stone, which techniques.
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