Partial facial paralysis induced by sialolithiasis of the parotid gland: a case report.

BACKGROUND: Facial paralysis due to parotid sialolithiasis-induced parotitis is a unusual clinical phenomenon that has not been reported in prior literature. This scenario can present a diagnostic challenge due to its rarity and complex symptomatology, particularly if a patient has other potential contributing factors such as facial trauma or bilateral forehead botox injections as in this patient. This case report elucidates such a complex presentation, aiming to increase awareness and promote timely recognition among clinicians. CASE PRESENTATION: A 56-year-old male, with a medical history significant for hyperlipidemia, recurrent parotitis secondary to parotid sialolithiasis, and recent bilateral forehead cosmetic Botox injections presented to the emergency department with right lower facial drooping. This onset was about an hour after waking up and was of 4 h duration. The patient also had a history of a recent ground level fall four days prior that resulted in facial trauma to his right eyebrow without any evident neurological deficits in the region of the injury. A thorough neurological exam revealed sensory and motor deficits across the entirety of the right face, indicating a potential lesion affecting the buccal and marginal mandibular branches of the facial nerve (CN VII). Several differential diagnoses were considered for the lower motor neuron lesion, including soft tissue trauma or swelling from the recent fall, compression due to the known parotid stone, stroke, and complex migraines. An MRI of the brain was conducted to rule out a stroke, with no significant findings. A subsequent CT scan of the neck revealed an obstructed and dilated right Stensen's duct with a noticeably larger and anteriorly displaced sialolith and evidence of parotid gland inflammation. A final diagnosis of facial palsy due to parotitis secondary to sialolithiasis was made. The patient was discharged and later scheduled for a procedure to remove the sialolith which resolved his facial paralysis. CONCLUSIONS: This case emphasizes the need for a comprehensive approach to the differential diagnosis in presentations of facial palsy. It underscores the potential involvement of parotid sialolithiasis, particularly in patients with a history of recurrent parotitis or facial trauma. Prompt recognition of such uncommon presentations can prevent undue interventions, aid in timely appropriate management, and significantly contribute to the patient's recovery and prevention of long-term complications.

The Role of Metal Nanoparticles in the Pathogenesis of Stone Formation.

The process of stone formation in the human body remains incompletely understood, which requires clinical and laboratory studies and the formulation of a new endogenous, nanotechnological concept of the mechanism of origin and formation of crystallization centers. Previously, the mechanism of sialolithiasis was considered a congenital disease associated with the pathology of the ducts in the structure of the glands themselves. To date, such morphological changes of congenital nature can be considered from the position of the intrauterine formation of endogenous bacterial infections complicated by the migration of antigenic structures initiating the formation of crystallization centers. The present work is devoted to the study of the morphology and composition of stones obtained as a result of surgical interventions for sialolithiasis. Presumably, nanoparticles of metals and other chemical compounds can be structural components of crystallization centers or incorporated into the conditions of chronic endogenous inflammation and the composition of antigenic structures, in complexes with protein and bacterial components. X-ray microtomography, X-ray fluorescence analysis, scanning transmission electron microscopy and microanalysis, mass spectrometry, and Raman spectroscopy were used to study the pathogenesis of stone formation. Immunoglobulins (Igs) of classes A and G, as well as nanoparticles of metals Pb, Fe, Cr, and Mo, were found in the internal structure of the stones. The complex of antigenic structures was an ovoid calcified layered matrix of polyvid microbial biofilms, with the inclusion of metal nanoparticles and chemical elements, as well as immunoglobulins. The obtained results of clinical and laboratory studies allow us to broaden the view on the pathogenesis of stone formation and suggest that the occurrence of the calcification of antigenic structures may be associated with the formation of IgG4-associated disease.

Comparative analysis of approaches to the Wharton's duct during surgery of the submandibular gland: A retrospective case-control study.

INTRODUCTION: We investigated complications and recurrence rates after surgical techniques for sialolith removal with intact and resected Wharton's duct of the submandibular gland. METHODS: The retrospective case-control analysis of a series analysed 271 surgical operations (2003-2022) for sialolithiasis performed at a hospital department of Otolaryngology-Head and Neck Surgery. The study compared two approaches: (1) pure endoscopic technique or pinpoint stone removal with Wharton's duct left intact and (2) transoral duct dissection or pinpoint stone removal technique, after which the duct was shortened. While choosing the surgical option, the size of the stone, the location of the stone, and the presence of multiple stones were taken into account. The rates of complications (lingual nerve paraesthesia, duct stenosis, drooling, and sialoadenitis), the incidence of foreign bodies, and the rate of recurrence during follow-up of ≥18 months were compared. RESULTS: 323 sialoliths were removed from 271 patients. Of these 323 calculi, 150 were removed by the first approach and 173 by the second approach. The calculi varied in diameter from 2 to 38 mm with an average diameter of 8.2 mm. For all 271 patients, the rate of recurrence was 4.8%, but 11 recurrent cases (8.7%) appeared after the first approach surgeries and 2 cases (1.4%) after the second approach surgeries (p = .03). Other variables did not show statistically significant differences. CONCLUSIONS: Surgical removal of the submandibular calculi, ending with shortening of Wharton's duct, reduces the recurrence rate for sialolithiasis but does not affect the rate of postsurgical complications.

Submandibular Sialolithiasis Mimicking Ludwig's Angina: A Case Report and Brief Clinical Review.

The "double tongue sign" is a characteristic finding in patients with Ludwig's angina, a potentially life-threatening infection due to airway compromise. Management primarily focuses on early airway protection and antibiotic administration. Submandibular sialolithiasis, on the other hand, could present with the double tongue sign without symptoms suggestive of airway involvement. Unlike Ludwig's angina, conservative treatment is usually the first-line approach for sialolithiasis. The importance of rapidly recognizing and distinguishing between the 2 conditions is emphasized through effective triage and risk stratification, particularly in rural areas where physicians are not readily available.

[A PhD completed. More insight into the origin and composition of salivary stones]. / Serie: Hora est. Meer inzicht in het ontstaan en de samenstelling van speekselstenen.

Salivary stones are hardened, stony calcifications that primarily develop in the drainage duct of a salivary gland. They can lead to obstruction of the saliva flow, resulting in swelling and pain. Since the aetiology of salivary stones remains largely unclear, this was further investigated in this PhD study. A case-control review of patient records showed that systemic diseases and lifestyle factors most likely do not play a role in their occurrence. The biochemical composition of salivary stones removed by oral-maxillofacial surgeons was examined, revealing that large salivary stones have a different inorganic composition than small salivary stones. Several salivary proteins were detected in submandibular salivary stones, including lysozyme, s-IgA, and -amylase. Clumping together of these proteins may play a role in the initial formation of salivary stones.

Lactoferrin and the development of salivary stones: a pilot study.

Salivary stones (sialoliths) are calcified structures located in the ductal system of the major salivary glands. Their exact cause is not clear but in general they are characterized by concentric inorganic (hydroxyapatite) layers. The formation is a slow intermittent process which may result in enlargement of the sialolith causing obstruction of saliva secretion resulting in mealtime related pain and swelling of the affected salivary gland. Various studies reported the presence of organic material such as proteins and lipids in the core of sialoliths. In the present study the protein composition of twenty submandibular sialoliths was analyzed. It was found that proteins contributed on average 5% to the dry weight of submandibular stones whereby small salivary stones contained more extractable proteins than large salivary stones. Using a combination of SDS-PAGE gel electrophoresis and Western blotting, we identified α-amylase (in all stones; 100%), lysozyme (95%), lactoferrin (85%), secretory-IgA (75%), MUC7 (60%), complement C4 (60%) and C-reactive protein (35%). The presence, and the combinations, of lactoferrin, lysozyme, s-IgA and α-amylase in sialoliths was confirmed by ELISA. The gradually increasing size of a sialolith might provoke a local inflammatory response in the duct of the submandibular gland whereby the relatively low concentrations of lactoferrin and lysozyme may originate from neutrophils. The interaction of lactoferrin with s-IgA could contribute to the accumulation of lactoferrin in sialoliths. In summary, these results suggest a new pathophysiological role for lactoferrin, in the formation of sialoliths.

Sialendoscopy-assisted combined approach for parotid sialolithotomy: Our long-term experience.

OBJECTIVES: To assess the long-term outcome of sialendoscopy-assisted combined approach for parotid sialolithotomy with gland preservation. PATIENTS AND METHODS: A retrospective study of patients treated with a combined sialendoscopic and open approach was conducted between 2011 and 2020. Demographic data of patients such as operative technique, stone size, stone location, complications, and symptom relief were collected. Patients were followed up via clinical examination and questionnaires. RESULTS: Seventy-four patients were included and underwent endoscopy-assisted combined operations for the removal of 98 parotid stones. Of the 98 stones, 92(94%) stones were completely removed and 6(6%) were partially removed. At a mean follow-up of 47.1 ± 35 months, 65 of 74 patients (88%) achieved long-term success. Patients with stone incomplete removal were significantly more often to develop the recurrence of obstructive symptoms (p = 0.000) There were no cases of facial nerve injury or fistula formation. Gland function was preserved in 73 of 74 patients (99%). CONCLUSIONS: The combined approach for parotid stones is a safe and gland-preserving alternative to parotidectomy. The techniques described here show high success rates and good long-term results, and they avoided the need for gland resection in >95% of cases.

Ultrasonographic Evaluation of Soft Tissue Calcifications in the Head and Neck Region Detected on Panoramic Radiographs.

OBJECTIVE: The aim of this study is to present a comparison between panoramic radiographs and USG imaging with a focus on revealing the advantages of USG over radiographs, and to show the distribution of calcifications detected in USG by considering the age and gender. METHODS: A total of 148 patients with soft tissue calcifications as seen on panoramic radiographs were examined with USG imaging. Sialoliths, carotid artery calcifications, tonsilloliths, phleboliths and lymph node calcifications were examined in terms of anatomical localization, distribution and shape. RESULTS: In the USG evaluation of these 148 patients, soft tissue calcifications were observed in 113 (76.4%) patients. The mean age of the patients with calcification was 55.6 ± 13.1 (min: 22-max: 77). Bilateral calcifications were detected in 25 (22.1%) patients, whereas unilateral calcifications were found in 88 (77.9%) patients. While the rates of tonsilloliths, sialoliths, phleboliths, and lymph node calcifications were statistically similar in male and female patients, the rate of carotid artery calcifications was found to be higher in men than in women (P = 0.017). No statistical significance was found between age groups in terms of the formation of soft tissue calcifications (P = 0.117). CONCLUSIONS: Panoramic radiographs may mislead clinicians in the diagnosis and differential diagnosis of soft tissue calcifications in the head and neck region due to the presence of distortion, superpositions, metal artefacts, and ghost images. USG is an important diagnostic tool in determining the localization of soft tissue calcifications that can be confused on two-dimensional radiographs, their relationship with neighboring structures, and defining calcification. It can be used safely in the detection of soft tissue calcifications as it provides dynamic imaging without the use of radiation or contrast material compared to other advanced imaging methods.

Outcome of the Management of Salivary Gland Diseases by Sialendoscopy: A University Hospital's Experience.

PURPOSE: Sialendoscopy is a minimally invasive procedure for the treatment of salivary gland diseases. The purpose of this study was to review a series of the patients undergoing sialendoscopy and to present our experience regarding the management and outcome of obstructive sialadenitis treated by this procedure. METHODS: This study was a case series. We collected data on patients who underwent sialendoscopy in our institute between January 2016 and July 2019. The data included patients' demographics, involved salivary glands, diagnostic investigation, types of anesthesia, endoscopic findings, materials used, complications, adjunctive treatment, duration of follow-up, and therapeutic outcome. Descriptive statistics were used to analyze the surgical findings and outcome. RESULTS: There were 61 patients involving 76 glands (48 submandibular and 29 parotid glands). There were 43 females and 18 males with the median age 45 years at the time of sialendoscopy. The median duration of follow-up was 6 months. The most dominant symptom was pain with swelling (59.20%). The 2 most common sialendoscopic findings were ductal stenosis and sialolithiasis. We observed a success rate in achieving a complete relief of 77.6% at the first procedure and 96.7% at the last follow-up. We did not have any cases with postoperative complication or recurrence. CONCLUSION: Our study supports sialendoscopy as a safe and successful procedure that plays a dual role in diagnostics and in relieving symptoms of patients with obstructive sialadenitis with or without sialolithiasis. It should be advised for patients with non-neoplastic salivary duct obstruction either for diagnosis or therapeutic intervention.

The effectiveness and safety of sialendoscopy for sialolithiasis in children: a systematic review and meta-analysis.

PURPOSE: Sialendoscopy is a new, minimally invasive method that is becoming increasingly more popular than traditional methods for the treatment of sialolithiasis. In this systematic review and meta-analysis, the effectiveness and safety of this method in children with sialolithiasis are investigated. METHODS: Inclusion criteria were children with sialolithiasis. The information sources were databases MEDLINE and PubMed Central (through PubMed), ScienceDirect, Cochrane Central Register of Controlled Trials (CENTRAL), citation indexes Scopus and Google Scholar, trial registries, and "gray literature". The last search was performed on September 18, 2022. The risk of bias in included studies was assessed using ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions). The pooled proportion of weighted means was calculated for the quantitative synthesis of available data. RESULTS: The effectiveness of the method was estimated at 95.5% (95% CI 89.8-99.3%), from 13 studies including 133 cases. The safety was estimated at 97.2% (95% CI 91.8-100%), from 10 studies including 113 cases. CONCLUSION: The limitations of this study, briefly summarized, are the small number of included studies, the fact that they are mostly retrospective, the difficult application of the guidelines suggested by the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and Cochrane handbook due to the nature of this specific condition and intervention, and the difficulty in assessing reporting bias. The results of the current study indicate that sialendoscopy is an effective and safe method for the treatment of sialolithiasis in children and should be implemented in daily clinical practice.

Sialendoscopy for pediatric salivary gland disorders: a study of safety and effect.

PURPOSE: Sialendoscopy has become the preferred modality for managing pediatric salivary gland disorders (PSGD) including juvenile recurrent parotitis (JRP) and sialolithiasis. The literature remains sparse, but several case series have reported good outcomes and few complications. The aim of this study was to investigate the safety and efficacy of sialendoscopy for PSGD in a Danish setting. METHODS: From a national sialendoscopy database, we included records of children who had undergone sialendoscopy for PSGD at our clinic over a 6-year period. Clinical and intraoperative data, follow-up and e-mail surveys after 1, 3 and 5 years were retrieved for analysis. RESULTS: We included 52 procedures on 50 glands (32 parotid, 18 submandibular) in 49 children. Of eligible patients, 90% attended clinical follow-up, 80% answered the survey after 1 year, 80% after 3 years and 60% after 5 years. JRP was diagnosed in 33 cases, obstructive causes in 18 cases. Complications noted were ductal perforation (2%), transient lingual nerve affection (4%) and infection (2%). For JRP patients, overall symptoms had improved for 96% after 3 months, 81% after 1 year and 83% after 3 years. For patients suffering from obstruction, overall symptoms were improved for 93% after 3 months and for 100% after 1 year. CONCLUSION: Sialendoscopy is a safe procedure for PSGD, and effective for sialolithiasis and symptom reduction in JRP.

Transoral removal of submandibular hilar lithiasis: results on the salivary duct system, glandular parenchyma, and quality-of-life recovery.

OBJECTIVE(S): To confirm that hilar transoral submandibular sialolitectomy (TOSL) is the first treatment option for submandibular hilar lithiasis (SHL) in terms of glandular parenchyma recovery, salivary system restoration, and patient quality of life (QoL) improvement. METHODS: Depending on whether the stone was easily palpable, TOSL was carried out with or without sialendoscopy. For the first time in the literature, Magnetic Resonance Sialography (MR-Si) was performed before and after TOSL, to evaluate stone characteristics, glandular parenchyma status, hilum dilation and main duct recanalization. Radiological data was examined independently by two radiologists. COSQ, a recently validated and specific questionnaire, was used to assess associated QoL. RESULTS: Between 2017 and 2022, 29 TOSL patients were examined. With a high interobserver correlation, MR-Si was confirmed as a very useful radiological test in the pre- and post-surgical evaluation of SHL. The salivary main duct was completely recanalized in all cases. The presence of lithiasis was found in 4 patients (13.8%). After surgery, the majority of patients (79.31%) had hilum dilation. There was a statistically significant improvement in parenchyma status, but no significant progression to glandular atrophy. After surgery, COSQ mean values always improved (22.5 to 4.5). CONCLUSIONS: TOSL is the ideal surgical technique for the management of SHL, resulting in improved parenchymal inflammatory changes, recanalization of Wharton's duct, and enhancement patients' QoL. As a result, before removing the submandibular gland, TOSL should be considered as the first treatment option for SHL.

A comparative study of three-dimensional cone-beam CT sialography and MR sialography for the detection of non-tumorous salivary pathologies.

BACKGROUND: Imaging of the salivary ductal system is relevant prior to an endoscopic or a surgical procedure. Various imaging modalities can be used for this purpose. The aim of this study was to compare the diagnostic capability of three-dimensional (3D)-cone-beam computed tomography (CBCT) sialography versus magnetic resonance (MR) sialography in non-tumorous salivary pathologies. METHODS: This prospective, monocenter, pilot study compared both imaging modalities in 46 patients (mean age 50.1 ± 14.9 years) referred for salivary symptoms. The analyses were performed by two independent radiologists and referred to identification of a salivary disease including sialolithiasis, stenosis, or dilatation (primary endpoint). The location and size of an abnormality, the last branch of division of the salivary duct that can be visualized, potential complications, and exposure parameters were also collected (secondary endpoints). RESULTS: Salivary symptoms involved both the submandibular (60.9%) and parotid (39.1%) glands. Sialolithiasis, dilatations, and stenosis were observed in 24, 25, and 9 patients, respectively, with no statistical differences observed between the two imaging modalities in terms of lesion identification (p1 = 0.66, p2 = 0.63, and p3 = 0.24, respectively). The inter-observer agreement was perfect (> 0.90) for lesion identification. MR sialography outperformed 3D-CBCT sialography for visualization of salivary stones and dilatations, as evidenced by higher positive percent agreement (sensitivity) of 0.90 [95% CI 0.70-0.98] vs. 0.82 [95% CI 0.61-0.93], and 0.84 [95% CI 0.62-0.94] vs. 0.70 [95% CI 0.49-0.84], respectively. For the identification of stenosis, the same low positive percent agreement was obtained with both procedures (0.20 [95% CI 0.01-0.62]). There was a good concordance for the location of a stone (Kappa coefficient of 0.62). Catheterization failure was observed in two patients by 3D-CBCT sialography. CONCLUSIONS: Both imaging procedures warrant being part of the diagnostic arsenal of non-tumorous salivary pathologies. However, MR sialography may be more effective than 3D-CBCT sialography for the identification of sialolithiasis and ductal dilatations. TRIAL REGISTRATION: NCT02883140.

[Recent progress in the treatment of intractable sialolithiasis].

Sialolithiasis occurs in approximately 0.45% to 1.20% of the general population. The typical clinical symptom manifests as a painful swelling of the affected glands after a meal or upon salivary stimulation, which extremely affects the life quality of the patients. With the development of sialendoscopy and lithotripsy, most sialoliths can be successfully removed with preservation of the gland. However, sialoliths in the deep hilar-parenchymal submandibular ducts and impacted parotid stones located in the proximal ducts continue to pose great challenges. Our research center for salivary gland diseases (in Peking University School and Hospital of Stomatology) has used sialendoscopy for 17 years and treated >2 000 patients with salivary gland calculi. The success rate was approximately 92% for submandibular gland calculi and 95% for parotid calculi. A variety of minimally invasive surgical techniques have been applied and developed, which add substantial improvements in the treatment of refractory sialolithiasis. Further, the radiographic positioning criteria and treatment strategy are proposed for these intractable stones. Most of the hilar-parenchymal submandibular stones are successfully removed by a transoral approach, including transoral duct slitting and intraductal basket grasping, while a small portion of superficial stones can be removed by a mini-incision in submandibular area. Impacted stones located in the distal third of parotid gland ducts are removed via "peri-ostium incision", which is applied to avoid a cicatricial stenosis from a direct ostium incision. Impacted parotid stones located in the middle and proximal third of the Stensen's duct are removed via a direct mini-incision or a peri-auricular flap. A direct transcutaneous mini-incision is commonly performed under local anesthesia with an imperceptible scar, and is indicated for most of impacted stones located in the middle third, hilum and intraglandular ducts. By contrast, a peri-auricular flap is performed under general anesthesia with relatively larger operational injury of the gland parenchyma, and should be best reserved for deeper intraglandular stones. Laser lithotripsy has been applied in the treatment of sialolithiasis in the past decade, and holmium ∶YAG laser is reported to have the best therapeutic effects. During the past 3 years, our research group has performed laser lithotripsy for a few cases with intractable salivary stones. From our experiences, withdrawal of the endoscopic tip 0.5-1.0 cm away from the extremity of the laser fiber, consistent saline irrigation, and careful monitoring of gland swelling are of vital importance for avoidance of injuries of the ductal wall and the vulnerable endoscope lens during lithotripsy. Larger calculi require multiple treatment procedures. The risk of ductal stenosis can be alleviated by endoscopic dilation. In summary, appropriate use of various endoscopy-assisted lithotomy helps preserve the gland function in most of the patients with refractory sialolithiasis. Further studies are needed in the following aspects: Transcervical removal of intraglandular submandibular stones, intraductal laser lithotripsy of impacted parotid stones and deep submandibular stones, evaluation of long-term postoperative function of the affected gland, et al.

Sialendoscopy in treatment of obstructive sialadenitis.

OBJECTIVES: Sialendoscopy is a relatively new mini-invasive method that allows direct visualisation and intervention in the salivary gland ductal system. The aim of the study was to evaluate the results of sialendoscopy in the treatment of obstructive sialadenitis. MATERIALS AND METHODS: This is a 15-year retrospective study analysing the treatment results of patients treated in the period of 2007-2022 at the Department of Oral and Maxillofacial Surgery, Comenius University Bratislava, Slovakia. RESULTS: The total number of performed sialendoscopies was 70, of which 44 (62.9 %) were performed on the submandibular gland and 26 (37.1 %) on the parotid gland; 46 procedures (65.7 %) were performed via natural ductal system opening without the need for surgical assistance while 24 sialendoscopies (34.3 %) required surgical assistance. The most frequent perioperative findings were the sialoliths (37) in quantities ranging from one to four. Non-calculi pathologies (23) included mucous plugs, strictures, plaque, erythema or foreign bodies. No pathology was found on 10 sialendoscopies. In 82 % (n = 55) of patients, sialendoscopy prevented the salivary gland from being excised. In 18 % (n = 12) of cases, sialendoscopy findings indicated that salivary gland excision was needed. CONCLUSION: The study acknowledges the significant benefit of sialendoscopy in the treatment of obstructive sialadenitis (Tab. 3, Fig. 6, Ref. 39). Text in PDF www.elis.sk Keywords: sialendoscopy, sialadenitis, duct obstruction, sialolith, minimally invasive surgery.

IgG4-positive plasma cells in nonspecific sialadenitis and sialolithiasis.

Chronic sclerosing sialadenitis is commonly regarded as a manifestation of IgG4-related disease. We previously found that a high IgG4 expression or IgG4-related disease could accompany nonspecific sialadenitis, whereas chronic sclerosing sialadenitis was not directly associated with IgG4-related disease. Our previous findings lead us to hypothesize that these inflammatory conditions of the submandibular gland signify a continuous progression of disease rather than different disease entities. We, therefore, aimed to determine the presence of IgG4-positivity and genuine IgG4-related disease in a cohort of 165 submandibular gland specimens from patients who underwent surgery due to chronic nonspecific sialadenitis or sialolithiasis. To do so, we re-evaluated histopathological features and divided samples into three groups: (A) nonspecific sialadenitis without known sialolithiasis, (B) sialadenitis with sialolithiasis, and (C) sialolithiasis without sialadenitis. We performed immunohistochemical staining for IgG4, IgG, and CD31, and assessed the Boston consensus statement criteria for IgG4-related disease in IgG4-positive samples. We also reviewed patient records and supplemented follow-up data with a questionnaire among patients with IgG4-positive samples. IgG4-positive plasma cells (range 1-344) were found in 131 samples. Among these, 19 samples were classified as IgG4-positive (≥70 IgG4-positive plasma cells/high-power field). Two IgG4-positive samples were histologically highly suggestive of IgG4-related disease, but only one had a clinically confirmed diagnosis of IgG4-related disease. Our results indicate that patients with sialadenitis and sialolithiasis often present with IgG4-positive lymphoplasmacytic infiltrates, but exceedingly rarely present with genuine IgG4-related disease. In sialolithiasis without sialadenitis, IgG4-positive plasma cells are often absent or appear in small numbers. These results support our hypothesis of a continuum of disease, and indicate that progressive inflammation of the submandibular gland leads to the development of more specific pathological features over time.

The holmium:YAG laser lithotripsy-a non-invasive tool for removal of midsize stones of major salivary glands.

Incorporeal lithotripsy by using holmium:YAG laser has been recently successfully spread and used in the treatment of urolithiasis. Although this method is not as common in salivary gland surgery, it is also recommended for endoscopic treatment of sialolithiasis. In this study, we decided to analyse effectiveness of holmium:YAG laser method among patients with midsize stones as the treatment in this particular population is still not determined and remains in dispute. Thus, the primary aim of the study is a prospective, complex analysis of incorporeal holmium:YAG laser lithotripsy effectiveness and safety in patients suffering from sialolithiasis. The examined group consisted of 32 consecutive patients, 17 female (53%) and 15 male (47%). The average age was 42 (age range 22-70). In our series, sialoendoscopy with intraductal lithotripsy was performed in patients with wide range of stone's diameter (3 to 10 mm). The calculi were removed with foreign body forceps or retrieval basket, after stone fragmentation with holmium:YAG laser. The power of the laser during surgery was set at 2.5 to 3.5 W. One shot energy equalled 0.5-0.7 J with frequency of 5 Hz. The bivariate Pearson Correlation and a point-biserial correlation were used to analyse the data. Total success rate of holmium:YAG laser lithotripsy in this consecutive group was equal to 90% and efficacy in the group with excluded cases when endoscopic approach difficulties were experienced (stone not visible) reached 93%. The long-term follow-up revealed that in 26 patients (84%), complete recovery was achieved. Two patients developed Wharton's duct stenosis and one Stensen's duct orifice stenosis (9.5%), of whom one required reoperation. Two patients eventually underwent total excision of submandibular gland. Sialoendoscopy combined with incorporeal laser-assisted lithotripsy proved to be effective and safe method for treatment of sialothiasis with midsize stones (4-8 mm) in population of clinic. Even taking into account the prevalence of complications associated with holmium:YAG laser, it is still safer alternative compared to open surgery where there is a significant risk of the bleeding, wound infection or injury of the facial nerve.

Impact on quality of life in obstructive sialadenitis predicting outcomes after sialendoscopy.

PURPOSE: Sialendoscopy is a minimally invasive procedure considered a paradigm shift in the treatment of obstructive sialadenitis. However, it shows an average need for revision procedure in up to 24% of operated cases. This study analyzed whether patient-related variables could predict the need for a revision during postoperative follow-up. METHODS: From 2012 to 2020, this prospective comparative study analyzed demographic data as well as preoperative responses to the "Manukau Salivary Symptoms Score" (MSSS) questionnaire as predictors of the need for a revision procedure due to symptoms recurrence. RESULTS: 188 sialendoscopies (39.4% for stones/60.6% for stenoses) in 112 parotid (59.6%) and 76 submandibular glands (40.4%) were included in this study. Forty patients (21.3%) required a revision procedure. The variable "Impact on quality of life" in the preoperative period of patients with sialoliths showed that the likelihood of a revision procedure increases by 33.6% with each increase in the 10-point Likert scale presented in the MSSS (p = 0.010, OR = 1336, CI = 1.071 to 1.667). This finding was not influenced by the location of the sialolith in the duct (p = 0.415), size (p = 0.058) or number of stones (P = 0.476). Other demographic variables related to the patient showed no association with the need of a revision procedure. CONCLUSION: Further studies should be performed to exclude the influence of other variables on the results; however, special attention should be given to patients who report a greater pre-operative impact on quality of life due to sialolithiasis. LEVEL OF EVIDENCE: II.

Patient experiences of sialendoscopy with monitored anesthesia care versus general anesthesia.

OBJECTIVE: To compare the experiences of patients who received sialendoscopy under general anesthesia (GA) with those who received monitored anesthesia care (MAC). METHODS: Patients who underwent sialendoscopy for sialadenitis or sialolithiasis from July 1, 2020, to July 31, 2021, were offered inclusion to this prospective observational study. A survey was sent to consenting patients on post-operative day 1 to record aspects of their pre-, intra-, and post-operative experience. The primary outcome was overall satisfaction. Secondary outcomes included pain tolerability and preference for similar anesthetic modality in the future. RESULTS: Seventy-five patients completed the post-operative survey (86% response rate), of which 39 patients received GA and 36 received MAC. Patient overall satisfaction was similar between groups (GA: "Poor/Average/Good" = 23%, "Excellent" = 77%; MAC: "Poor/Average/Good" = 25%, "Excellent" = 75%, p = 1.00). Tolerability of immediate post-operative pain was likewise similar between the GA (82%) and MAC (97%) groups (p = 0.058). Patients who received MAC reported intra-operative pain as "none/tolerable" 72% of the time and "uncomfortable" 28% of the time. Patients who received GA would prefer the same anesthetic in the future more often than in the MAC group (85% versus 61%, respectively, OR 3.50, 95% CI 1.17-10.50, p = 0.035). CONCLUSION: In regard to patient satisfaction, both MAC and GA are acceptable anesthetic choices in sialendoscopy for appropriate cases. Patients report similar overall satisfaction and post-operative pain tolerance under either anesthetic modality. Patients who undergo GA report higher rates of preference for similar anesthetic modality in the future. Further study is needed to determine the most appropriate criteria for anesthesia modality selection.

Cost-analysis of in-office versus operating room sialendoscopy: Comparison of cost burden and outcomes.

PURPOSE: Office-based procedures in otolaryngology are increasingly utilized to increase efficiency, reduce cost, and eliminate risks associated with surgery. Gland-preserving surgical management of sialadenitis and sialolithiasis are often performed in the operating room, although many surgeons are moving this practice to clinic. We aim to determine the difference in patient charges and perioperative outcomes for salivary gland procedures performed in the clinic versus the OR. METHODS: Retrospective series of patients presenting with sialolithiasis, acute or chronic sialadenitis, and stricture between 2010 and 2019. Demographics, perioperative variables, setting, and charge data were collected. RESULTS: 528 patients underwent operative intervention (n = 427 office, n = 101 OR). Cohort demographics were comparable. Sialolithiasis was the most common presenting diagnosis in both cohorts. Both cohorts had similar rates of complete (p = 0.09) and partial (p = 0.97) response to treatment. A higher percentage of patients in the OR group reported no improvement (21.4 vs 12.2%, p = 0.034). Overall complications were similar (p = 0.582). Mean charges were statistically greater in the OR ($5560.35 OR vs $1298.33 office, p < 0.001). Operative time was significantly reduced in the office group (21.8 min vs 60.85 min, p < 0.001). CONCLUSIONS: Appropriately selected patients can be successfully treated in outpatient clinic without compromising patient safety or quality while significantly reducing the financial burden to patients and the healthcare system.