Sialendoscopy and Sialendoscopically-assisted

Operations in the Treatment of Lithiasis of the

Submandibular and Parotid Glands : Our experience of
239 cases
By :
dr. Elvita Nora Susana

Supervisor:
dr. Benny Kurnia, Sp. THT-KL (K), FICS
INTRODUCTION
Sialolithiasis is the most common cause of inflammatory disease of the large salivary glands, and
its quoted prevalence is 1.2%, as stated in Rauch’s monograph from 1949.

Stones are more common in the submandibular gland (87%) then in the parotid (13%) or the
sublingual (7%) glands.

The introduction of sialendoscopy has therefore significantly reduced the number of

submandibular glands that have had to be removed for sialolithiasis. The use of lithotripsy is
effective in 75%, and allows for the complete retrieval of stones in half of all cases.
Sialolithiasis cannot be treated successfully Complete removal
using minimally invasive techniques,if
of the
- a stone is too large *
- there is a history of recurrent inflammation * submandibular or
parotid gland is
NB : * That leads to impaction into the wall of
essential
the efferent duct
 The aim of this study was to analyse our results of treatment of symptomatic
submandibular and parotid sialolithiasis between 2009-2013, with a special focus on
sialendoscopy.
PATIENTS AND METHODS
 This is a prospective study of 397 consecutive 239 stones and 158 stenoses

patients who were treated for obstructive

diseases of major salivary at a tertiary university
centre (Otolaryngology, Head and Neck livary
by 470 sialendoscopies and
Surgery Department,Pozna´n Medical
sialendoscopy-assisted
University)
procedures
Real-time B-mode ultrasonography
for pre-operative diagnosis in all The sialoendoscopic procedure was
patients
done under local anaesthesia after
premedication with midazolam 7.5
mg.
CT was required for 16 patients.
 incision of the floor of the mouth at the
Stone in the submandibular hilum
level of the submandibular hilum +
> 6-7 mm
sialendoscopy

general anaesthesia + facial nerve monitoring

Stone were located in the proximal and middle
leads from the area of the marginal branch
part of the duct + diameter > 6-7 mm (case of
around the mouth+ incision of Stensen’s duct +
the parotid )
sialendoscopy.

ESWL or to remove the gland (mostly in the

the stone was primarily in the parenchyma
submandibular,rare in the parotid).
 Probabilities of
Data of were
Student T test & chi less than 0.05
exported to
square were accepted as
Microsoft Excel
significant

Results were analysed using

STATISTICA 7 (StatSoft Inc., Tulsa, OK,
USA).
RESULTS
- There were no significant differences in age or duration of complaints in either group.
- Coexisting conditions were not associated with rates of sialendoscopic removal of stones.
- Endoscopic removal of stones was significantly dependent on the duration of complaints in both groups:
a history of more than five years doubled the risk of failure (df = 1, p = 0.004).
SUBMANDIBULAR GLAND

175 patients with 191 stones 149 patients (85%) being free of
endoscopic retrieval or surgical stones.
release - Sialoencoscopy alone n = 82
- Together with operation n = 67

Sialendoscopy and operation

Sialoendoscopy alone
- Size of the stones ranged between 7-12 mm
- Stones were located in the lumen of Wharton’s duct
- They were mostly in the region of the hilum
- Their size ranged between2-6 mm, and they were not
(n = 51) and in the middle and distal parts of
fixed .
the duct(n = 16).
SUBMANDIBULAR GLAND
- Twenty patients (11%) had
175 patients with 191 stones
residual stones
endoscopic retrieval or surgical - Six patients (4%) had the gland
release
removed

Residual Stones
Removal was not possible. They were within
- the parenchyma (n = 6) or Gland Removal
- there was ductal stenosis (n = 11). Six patients had the submandibular
gland removed because :
- Calcified deposits within the
glandular parenchyma
- Recurrent painful episodes of
inflammation
Stones were not palpable along Wharton’s
duct so we either adopted a “wait and see”
policy, or sent them for ESWL
SUBMANDIBULAR GLAND

• We found a strong correlation between the age of the patient and the need to
use the double approach: in patients over 45 years old the probability of this
approach being used was significantly higher (df = 182, p = 0.002).

• There was also a strong correlation between sex and the need for the double
approach,as women were significantly less likely to need it than men (df = 1, p
= 0.001).
PAROTID GLAND
64 patients with 71 stones endoscopic
retrieval or surgical release

43 patients (67%) being free of stones :

- Sialendoscopy alone n = 25
- Together with operationn = 18

Sialendoscopy Sialendoscopy and operation,

- Stones were located in the lumen of - The sizes ranged from 7-11 mm,
Stensen’s duct without impaction - They were mainly in the proximal
- Their sizes ranged from 2-6 mm part of the duct, and fixed in all cases.
PAROTID GLAND
64 patients with 71 stones endoscopic
retrieval or surgical release

Twenty patients (31%) had residual

stones, and 1 patient (2%) had the gland
removed

Residual Stones
Removal Gland
Removal was not possible because they were
Only one case required total removal of
within the parenchyma and causing ductal
the gland because of recurrent episodes
stenosis (n = 7). This group of patients was
of inflammation
treated by ESWL,
PAROTID GLAND

Neither sex nor age had any significant influence on

the type of operation.
DISCUSSION
• The diagnosis of sialolithasis is based on its clinical presentation and symptoms. Rapidly
increasing salivary pain is common, particularly during meals, and it may be present
without any mechanical obstruction.

• Real time, high-resolution ultrasonography seems to be first line diagnostic method to

visualise the calcified deposits and exclude the presence of a tumour. However, it is
important to emphasise that false positive results are possible if there is excessive
hyperaemia as a result of inflammation.

• On these occasions sialendoscopy is considered superior

High Resolution
Ultrasonography
Sialendoscopy
CT
The use of endoscopic and minimally invasive techniques allows for
better preservation of the main salivary glands in cases of sialolithiasis.

According to published data, 80%-90% of patients with sialolithiasis of

the parotid gland can be treated using minimally invasive techniques
such as sialendoscopy and ESWL.

After ESWL, larger stones (more than 8-10 mm in diameter) can be

fragmented and then removed with a sialendoscope
 - Sialoendoscopy and release was effective in 85% of the submandibular group and 67%
of the parotid group.
- In those patients who were cured by endoscopic extraction of stones alone, it was
effective was 87% and 85%, respectively

The reported efficacy of endoscopic removal of stones ranges from 61% (Luers et al), to 67%
(Ianovski et al), 82% (Nahieli and Baruchin), 85% (Kroll et al) up to 90% (Lari et al).
 Six patients with submandibular, and one with parotid,lithiasis had
their glands excised because of persistent symptoms and a long history
of inflammation

Submandibular lithiasis
1. Strong correlation between the age of the patient and the needfor the
double approach. Patients over 45 years old were significantly more likely to
need a double approach (df = 182,p = 0.002).
2. Strong correlation between sex and the double approach in that women
were less likely to require the double approach than men (df = 1, p = 0.001).

NB : These correlations were not found in the parotid group.

According to the learning curve of each centre, results of sialendoscopic
treatment of salivary gland stenosis and sialolithiasis have improved
progressively. The development of sialoendoscopy allows us to treat our
patients with minimally invasive procedures.

• Sialendoscopy is safe, and can be done in almost any case (a part from
definite contraindications) without causing the patient discomfort,
pain, or an unpleasant experience.
The double approach is advised if the stones are large and fixed. If there is limited access to ESWL,
a double approach seems to be the alternative treatment for both types of gland.
THANK YOU