1

Introduction

Obstructive sialadenitis is a common disease, representing approximately one-half of benign salivary gland diseases . The most common presentation is recurrent, painful, glandular swelling associated with eating, which can be complicated by bacterial superinfection and abscess formation. Sialolithiasis is the main cause of obstructive sialadenitis, affecting up to 1.2% of the general population . The submandibular gland is involved in 80–90% of cases, followed by the parotid (5–10%) and the sublingual glands (< 1%) .

Historically, obstructive sialadenitis was usually managed conservatively, while surgical treatment was reserved for refractory cases, ranging from papillotomy to sialadenectomy . In the case of sialolithiasis, the former usually utilized for distally located calculi and the latter for proximal or intraglandular calculi. Although sialadenectomy is the definitive treatment for obstructive sialadenitis of any etiology, it carries the highest rates of complications, which include permanent nerve damage (facial, hypoglossal or lingual, depending on the gland excised), salivary fistula, sialocele and aesthetic sequela . The introduction of sialendoscopy has changed the diagnosis and management of salivary gland diseases dramatically. Sialendoscopy offers a minimally invasive approach that enables both better visualization and diagnosis of the ductal system and treatment of obstructive sialadenitis with considerably less morbidity . Furthermore, a significant percentage of affected glands had a normal histologic appearance and the gland regained its function after stones were removed . Small size, good mobility, round or oval shape and distal location of the sialolith were found to be positive predictive factors for sialendoscopic removal . For stones not amenable to endoluminal removal via sialendoscopy, a combined approach using a limited intraoral incision under guidance of sialendoscopy can facilitate stone removal with minimal surgical morbidity. A meta-analysis evaluating the efficacy of sialendoscopy determined that the pooled success rate for interventional sialendoscopy alone was 86% and 93% for the combined approach, with a low incidence of major complications and recovery of secretory function .

There is a paucity of published data evaluating the efficacy and safety of the combined approach for the treatment of sialolithiasis. This study reviewed our institution’s experience with combined approach sialendoscopy and evaluated its role in the treatment of sialolithiasis of the submandibular gland.

2

Materials and methods

This retrospective analysis of 49 interventional, combined approach sialendoscopies for the treatment of suspected sialoliths in the submandibular glands was performed from January 2010 through March 2014. The study was approved by the Helsinki Ethics Committee of Meir Medical Center (permit number MMC0007-14), under the supervision of the Israel Ministry of Health. Informed consent was waived as the study was retrospective. All procedures were performed by the senior author (S.G.) at Meir Medical Center, which is a regional referral center for the treatment of salivary gland diseases and sialendoscopy. Patients who had successful sialolith removal via sialendoscopy were excluded from the study. The presence of comorbidities or the use of anticoagulation or antiplatelet treatment was not considered a contraindication for the procedure. Demographics, clinical data, intraoperative findings and postoperative course were collected from the computerized medical records. Demographic data included age, gender, and systemic illness. Clinical data included obstructive symptoms, need for antibiotic or hospitalization, imaging, glands involved and prior procedures. Intraoperative findings, such as the location and characteristics of the calculi were recorded. The success rate was evaluated based on calculi removal, need for further interventions or hospitalizations, complications, and symptom resolution or recurrence on follow-up.

Diagnosis of sialolithiasis was based on symptomatology and either a conformation with imaging (CT or US) or palpation of the floor of the mouth. In our institution, sialendoscopy is performed under local anesthesia. The punctum of the affected gland is serially dilated under magnification using punctum dilators until the sialendoscope (Polydiagnost, Pfaffenhofen, Germany) can be introduced. The duct is visualized with the endoscope throughout its length to assess for pathology, while saline rinsing is performed to keep the duct patent with local anesthetic rinsing. In cases of obstruction, sialolith removal is first attempted without fragmentation using the basket, the Fogarty balloon catheter to pull from behind, irrigation as a mobilization technique or forceps. If a sialolith remains wedged within the duct or is too large to be removed with these techniques, a limited transoral incision is made in order to deliver it using the sialendoscope transillumination to localize and stabilize the sialolith. After its removal, a stent is sutured in the duct and/or hydrocortisone rinsing is performed according to the physician’s discretion. Thereafter, the entire duct is re-explored for remnants. Postoperatively, the patients are prescribed antibiotics and followed-up after two weeks and then serially, as needed.

2

Materials and methods

This retrospective analysis of 49 interventional, combined approach sialendoscopies for the treatment of suspected sialoliths in the submandibular glands was performed from January 2010 through March 2014. The study was approved by the Helsinki Ethics Committee of Meir Medical Center (permit number MMC0007-14), under the supervision of the Israel Ministry of Health. Informed consent was waived as the study was retrospective. All procedures were performed by the senior author (S.G.) at Meir Medical Center, which is a regional referral center for the treatment of salivary gland diseases and sialendoscopy. Patients who had successful sialolith removal via sialendoscopy were excluded from the study. The presence of comorbidities or the use of anticoagulation or antiplatelet treatment was not considered a contraindication for the procedure. Demographics, clinical data, intraoperative findings and postoperative course were collected from the computerized medical records. Demographic data included age, gender, and systemic illness. Clinical data included obstructive symptoms, need for antibiotic or hospitalization, imaging, glands involved and prior procedures. Intraoperative findings, such as the location and characteristics of the calculi were recorded. The success rate was evaluated based on calculi removal, need for further interventions or hospitalizations, complications, and symptom resolution or recurrence on follow-up.

Diagnosis of sialolithiasis was based on symptomatology and either a conformation with imaging (CT or US) or palpation of the floor of the mouth. In our institution, sialendoscopy is performed under local anesthesia. The punctum of the affected gland is serially dilated under magnification using punctum dilators until the sialendoscope (Polydiagnost, Pfaffenhofen, Germany) can be introduced. The duct is visualized with the endoscope throughout its length to assess for pathology, while saline rinsing is performed to keep the duct patent with local anesthetic rinsing. In cases of obstruction, sialolith removal is first attempted without fragmentation using the basket, the Fogarty balloon catheter to pull from behind, irrigation as a mobilization technique or forceps. If a sialolith remains wedged within the duct or is too large to be removed with these techniques, a limited transoral incision is made in order to deliver it using the sialendoscope transillumination to localize and stabilize the sialolith. After its removal, a stent is sutured in the duct and/or hydrocortisone rinsing is performed according to the physician’s discretion. Thereafter, the entire duct is re-explored for remnants. Postoperatively, the patients are prescribed antibiotics and followed-up after two weeks and then serially, as needed.