JADA Continuing Education
Sialoendoscopy
A new approach to salivary gland obstructive pathology
Oded Nahlieli, DMD,
Liat Hecht Nakar, DMD,
Yaron Nazarian, DMD and
Michael D. Turner, DDS, MD
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ABSTRACT
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Background. During the last 13 years, there has been a growing interest in and use of minimally invasive treatment techniques. Salivary gland endoscopes provide an accurate means of diagnosing and providing minimally invasive surgical treatment for salivary gland diseases.
Methods. The authors review the relevant literature and provide the history of sialoendoscopy. They also report on the treatment methods they use, including instruments and techniques, and their experiences.
Results. The authors’ overall success rate for parotid endoscopic sialolithotomy is 86 percent, and their overall success rate for submandibular endoscopic sialolithotomy is 89 percent. Their success rate for treating strictures is 81 percent.
Clinical Implications. The endoscopic technique opens new horizons in the field of salivary gland diseases. Salivary gland stones and sialadenitis no longer are absolute indications for sialadenectomy. Owing to growing experience and surgical skills, new endoscopic techniques are in clinical use, and there is constant improvement in endoscopic treatment success rates.
Conclusions. Sialoendoscopy is a promising new method for use in the diagnosis, treatment and postoperative management of sialadenitis, sialolithiasis and other obstructive salivary gland diseases.
Key Words: Minimally invasive techniques; endoscopy; sialoendoscopy; sialolithiasis; sialadenitis; strictures
Effective treatment of salivary gland disorders requires accurate diagnosis of the specific disease and determination of the exact location of the obstruction. Salivary gland sialolithiasis is one of the major causes of sialadenitis. Calculi in the salivary glands can be found in 1.2 percent of the general population.1 Other common salivary gland pathologies (other than tumors) are sialadenitis, strictures and kinks. Sialoendoscopy is an efficient yet simple mode of treatment for major salivary gland obstructions, strictures and sialoliths, and it is conducted under local anesthesia in an outpatient clinic. Sialoendoscopy effectively treats salivary gland infections. Advancements in endoscopic equipment, mainly miniaturization, have resulted in major progress in the field.
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HISTORY OF SALIVARY GLAND ENDOSCOPY
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Konigsberger and colleagues2 introduced their first successful application of endoscopically controlled intracorporeal lithotripsy of salivary gland stones in 1990. Also in 1990, Gundlach and colleagues3 published their experiences with using similar equipment. Katz4 described his experience in 1991 in which he used a 0.8-millimeter flexible endoscope in a blind technique to diagnose sialolithiasis and mechanically remove sialoliths from major salivary glands. In 1993, Konigsberger and colleagues5 introduced the use of a combined flexible miniendoscope and intracorporeal lithotriptor for sialolith fragmentation. In 1994, Arzoz and colleagues6 introduced a 2.1-mm rigid miniurethroscope with a working channel of 1 mm. They used an intracorporeal pneumoballistic lithotriptor or a laser lithotriptor with the miniurethroscope to hit the calculus and fragment it. In 1994, Nahlieli and colleagues7 used a rigid miniendoscope to diagnose and treat major salivary gland obstructions, and in 1997, they described their three years’ experience with this new technique.8 In 2000, Marchal and colleagues9 reported having a similar experience with sialoendoscopic techniques. In 2004, Zenk and colleagues10 reported their initial experiences with using a new highly flexible, semirigid sialoendoscope with high-quality imaging (6,000 pixels), an external diameter of 1.1 mm and a working channel of 0.4 mm. In 2005, Koch and colleagues11 published their experiences with cases of indistinct swelling of the major salivary glands.
Until recently, the main use of sialoendoscopy was to confirm the diagnosis of obstructions and strictures and to remove sialoliths by different techniques. In 2004, Nahlieli and colleagues described the endoscopic treatment of juvenile recurrent parotitis12 and chronic recurrent parotitis.13 In 2006, Nahlieli and Nazarian14 reported the results of a preliminary study of endoscopic treatment of radioactive iodine sialadenitis.
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INSTRUMENTATION
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Miniendoscopes can be divided into three subtypes: flexible, rigid and semirigid. The semirigid endoscope combines the advantages of flexible and rigid miniendoscopes: it has a clear view, a small diameter, stiffness and good "pushability"; hence we believe it may be the best instrument available.
Various types of forceps and other miniaturized surgical tools can be inserted easily into the glands through the rigid and semirigid endoscopes.15 A new line of microendoscopes has been developed recently that includes a diagnostic sialoendoscope (0.8-mm diameter/120-mm length/6,000-pixel port for irrigation) and two multifunctional sialoendoscopes (1.1-mm diameter/120-mm length/6,000 pixels with a 0.5-mm telescope and 0.4-mm sleeve for irrigation and surgical instruments for diagnostic and surgical procedures and 1.6 mm-diameter/120-mm length/6,000 pixels with a 0.5-mm telescope and 0.8-mm sleeve and port for irrigation for surgical procedures) (Figure 1
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Figure 1. A. The new set of diagnostic and multifunctional sialoendoscopes (0.8-millimeter diameter [top right], 1.1-mm diameter [top left] and 1.6-mm diameter [lower right]). The instruments at the lower left are minigrasping forceps. B. Close-up view of the 1.6-mm sialoendoscope with a surgical instrument inside the surgical sleeve. Images of Karl Storz sialoendoscopes reproduced with permission of Karl Storz GmbH, Tuttlingen, Germany.
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Endoscopic techniques.
Endoscopes can be introduced into a gland through its natural orifice (orifice dilatation can be achieved with lacrimal probes and dilator), via a papillotomy procedure, via ductal exploration or through sialolithotomy after sialolith removal from the duct opening (Figure 2).
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Figure 2. Introduction of a sialoendoscope through the orifice of the Wharton’s duct (after dilatation) into the gland. Note the trans illuminating effect.
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In every endoscopic procedure, clinicians need to create an optical cavity, which in sialoendoscopy is achieved by irrigating the gland. The gland cavity is filled with isotonic saline through the duct. The saline lubricates the gland and lets the endoscope move forward in the gland. The entire gland is numbed by an injection of 2 milliliters of lidocaine 2 percent solution through the main duct.
Sialolith removal techniques.
The approach to the sialolith’s removal can be intraductal when the sialolith’s diameter is less than 5 mm. When the sialolith’s diameter is larger than 5 mm, the approach can be extraductal; in this case, oral surgeons should use endoscopically assisted techniques to make such a determination.
In the intraductal approach, the endoscope is moved forward in the main duct until a sialolith is encountered. Then, the surgeon estimates the sialolith’s diameter using the caliber of the endoscope as a reference guide. At this point, the surgeon can use these methods to extract sialoliths in the following order until the extraction is complete:
- – removal in one piece using minigrasping forceps or basket (this is the method of choice because of its simplicity and since it causes minimum complications) (Figure 3);
- – mechanical fragmentation;
- – intracorporeal laser fragmentation (Figure 4);
- – combined use of an intracorporeal laser lithotriptor wire basket and minigrasping forceps.
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Figure 3. A. Endoscopic view of a basket retrieving a sialolith from the submandibular hilum. B. Endoscopic view of a minigrasping forceps retrieving a sialolith from the submandibular hilum.
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Figure 4. Endoscopic view of an intracorporeal lithotripsy of a submandibular sialolith using an erbium:yttrium-aluminum-garnet laser.
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POSTOPERATIVE MANAGEMENT
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After a sialolith is removed from an affected gland, a sialostent is inserted into the duct for two to four weeks for the duration of the healing process of the oral region and until normal function of the gland is restored, which normally takes two to four weeks; to prevent obstruction of the ductal lumen by postoperative edema; and to serve as a passive dilator to prevent future strictures (Figure 5).
A total of 100 milligrams of hydrocortisone solution should be injected intraductally after any procedure. In all submandibular cases, the patient should receive 1.5 grams of amoxicillin per day for seven days. After parotid sialoendoscopy, the patient should receive 1.5 g of amoxicillin clavulanate potassium per day for seven days.
The only absolute contraindication of sialoendoscopy is acute sialadenitis.
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NEW DATA, SUCCESS RATE, FAILURES AND COMPLICATIONS
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Patients.
During the past 13 years, sialoendoscopy has been performed at the Barzilai Medical Center, Ashkelon, Israel, on 1,078 salivary glands with symptoms of obstructive disease in 533 male patients and 545 female patients (age range 2 to 96 years). There were 722 (67 percent) submandibular glands, 347 (32 percent) parotid glands and nine (1 percent) sublingual glands. In addition, 938 (87 percent) glands were diagnosed with obstruction, and 140 (13 percent) were diagnosed with sialadenitis.
The main cause of obstruction was sialolithiasis in 736 (79 percent) glands. Other causes for obstructions were strictures, kinks, polyps, anatomical malformations and foreign bodies.
All patients underwent preoperative and postoperative screening, including routine radiography, sialography and ultrasonography. Postoperative examination was performed routinely one month after the procedure. Some patients were followed up for as long as 40 months postendoscopy. The majority of procedures were performed under local anesthesia on an outpatient basis. The time for the procedure ranged from 30 to 90 minutes.
Success rate.
The success rate for parotid endoscopic sialolithotomy is 86 percent, and the success rate for submandibular endoscopic sialolithotomy is 89 percent.
Failures.
Immediate failures (cases in which the introduction of the miniendoscope into the gland failed or proved not feasible) totaled 1.1 percent (0.8 submandibular glands, 0.3 percent parotid glands). Intraoperative failures (cases in which surgeons were unable to accomplish any of the endoscopic retrieval techniques) totaled 4.4 percent (3 percent parotid glands, 1.4 percent submandibular glands), and late failures (cases in which there were symptomatic glands though the stone had been removed) totaled 4.7 percent (2.6 percent submandibular glands, 2.1 percent parotid glands).
Complications.
Complications included temporary lingual nerve parasthesia (0.4 percent), postoperative infection (1.6 percent; 1 percent submandibular glands, 0.6 percent parotid glands), postoperative bleeding (0.5 percent all of which were submandibular cases), development of traumatic ranula (0.7 percent) and ductal strictures (2.5 percent; 2.2 percent submandibular glands, 0.3 percent parotid glands).
Strictures.
From our data, it seems that strictures are the no. 1 cause of obstruction after sialoliths. Strictures in salivary ducts have been mentioned briefly and anecdotally in the literature.
Most strictures could be seen in the Stensen’s duct (71 occurrences) and mostly in chronic recurrent sialadenitis.
The following technique can be used as a treatment modality. After making a diagnosis and finding the exact location of the obstruction using a sialogram, the surgeon can use the endoscopic method. The first step is anesthetizing and laving the duct with 2 percent lidocaine and saline. If there is no improvement, the surgeon then can insert a Sialoballoon (Sialotechnology, Ashkelon, Israel), which can be inflated up to 3 mm (Figure 6). The pressure created by the inflation can be sufficient to dilate most strictures. Another technique for dilating strictures is to expand the stricture region with minigrasping forceps used as a dilator.
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Figure 6. A. Endoscopic view of stricture in the Stensen’s duct. B. Insertion of high-pressure Sialoballoon (Sialotechnology, Ashkelon, Israel), C. Postoperative view.
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After the procedure, the surgeon should administer an injection of 100 mg hydrocortisone solution either intraductally or directly into the stricture area.
At our center, we treated 111 strictures. Seventy-one of them occurred in the parotid glands (64 percent), and 40 occurred in the submandibular glands (36 percent). The success rate for the treatment was 81 percent; in 15 percent of the cases, a revision of the procedure was needed, and in 4 percent of the cases, the dilatation procedure failed.
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ENDOSCOPIC OBSERVATIONS
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During the past 13 years of sialoendoscopic treatment, we have observed multiple microanatomical and pathophysiological phenomena.
- – Sphincterlike mechanisms. In 1975, Mason and Chisholm16 described strands of smooth muscle around the Wharton’s duct wall. In 1991, Katz4 reported the same observation. Nahlieli and Baruchin8 described the same phenomena in the Stensen’s duct. In the Wharton’s duct, the sphincterlike system is located near the papilla, whereas in the Stensen’s duct it is located posteriorly.
- – Sublingual duct opening. During submandibular sialoendoscopy the sublingual duct opening (known as Bartholin’s duct) has been observed in the anterior part of the Wharton’s duct, up to 5 mm posterior to the papilla.
- – Changes in the ductal system. The lining mucosa of long-standing infected glands has a matted appearance, ecchymosis and a small number of blood vessels (Figure 7).
- – Peculiar connections between calculi and the ductal wall. We observed these in the submandibular and parotid glands. The connections in the Wharton’s duct were found posterior to the bifurcation (the point where the duct divides into the inner and the outer lobes), whereas in the parotid gland, they were posterior to the curvature. We did not detect any such connections anterior to these regions.
- – Ductal polyps. We have observed these in both parotid glands’ and submandibular glands’ main ducts. They appear in sialography as a dye defect and cannot be detected by ultrasonography. They can be removed by miniature biopsy forceps or a basket.
- – Intraparenchymal sialoliths. These are located close to the ductal system and can be observed with the endoscope.
- – Foreign bodies. In a few cases, we observed foreign bodies such as hair or tea leaves inside the lumen of the ductal system.
- – Ductal strictures and kinks.
- – Pelvislike formation. This is an anatomical malformation in the submandibular hilum, which replaces the bifurcation or trifurcation. It is another obstructive condition that is shown as a widening of the duct in the hilum region.
- – Occult radiolucent calculi. During our endoscopic exploration, we found that 32 percent of the submandibular sialoliths and 67 percent of the parotid sialoliths appear radiolucent in radiographs taken without the use of dye or computerized tomography.
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Figure 7. A. Endoscopic appearance of a healthy submandibular gland. Note the shiny lining mucosa and the proliferation of blood vessels in the lining mucosa. B. Endoscopic appearance of chronic sialadenitis of submandibular hilum (the lining mucosa of the ductal system had a matted appearance ecchymosis and a small number of blood vessels). Images of Karl Storz sialoendoscopes reproduced with permission of Karl Storz GmbH, Tuttlingen, Germany.
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CONCLUSION
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Sialoendoscopy is a promising new method for use in diagnosing and treating most inflammatory conditions of the major salivary glands. It is an outpatient procedure, using local anesthetic, and does not have major complications. It appears to be a solution for managing perplexing inflammatory salivary gland pathology. As more oral surgeons become involved with endoscopy, more findings and innovations will be forthcoming, adding to its effectiveness.
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FOOTNOTES
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DISCLOSURE: Dr. Nahlieli is a consultant to Karl Storz GmbH, Tuttlingen, Germany, and to Sialotechnology, Ashkelon, Israel.
Dr. Nahlieli is a professor and the chairman, Oral and Maxillofacial Surgery Department, Barzilai Medical Center, Ashkelon, Israel 78404, e-mail "nahlieli{at}yahoo.com".
Dr. Nakar is a resident, Oral and Maxillofacial Surgery Department, Barzilai Medical Center, Ashkelon, Israel.
Dr. Nazarian is a resident, Oral and Maxillofacial Surgery Department, Barzilai Medical Center, Ashkelon, Israel.
Dr. Turner is an assistant professor, New York University College of Dentistry, Oral and Maxillofacial Surgery, New York City.
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REFERENCES
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- Konigsberger R, Feyh J, Goetz A, Schilling V, Kastenbauer E. Endoscopic controlled laser lithotripsy in the treatment of sialolithiasis [in German]. Laryngorhinootologie 1990;69(6):322–3.[Medline]
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ABSTRACT
HISTORY OF SALIVARY GLAND...
