Combined interventional sialendoscopy and intraductal steroid therapy for recurrent sialadenitis in Sjögren's syndrome: Results of a pilot monocentric trial.

OBJECTIVES: To evaluate the effectiveness of interventional sialendoscopy alone or combined with outpatient intraductal steroid irrigations in patients with sialadenitis due to Sjögren's syndrome (SS). DESIGN: A pilot therapeutic study. SETTING: ENT Clinics, Universities of Milan and Pavia. STUDY POPULATION: We included 22 patients with SS of whom 12 underwent interventional sialendoscopy followed by intraductal steroid irrigations (group A), and 10 interventional sialendoscopy alone (group B). OUTCOMES MEASURES: The following outcome measures were considered and recorded before and after the therapeutic intervention: (i) number of episodes of glandular swelling, (ii) cumulative prevalence of patients with glandular swelling assessed by the specific domain, the EULAR SS Disease Activity Index (ESSDAI), (iii) severity of pain by means of a 0-10 pain visual analogue scale (VAS), (iv) severity of xerostomia and other disease symptoms assessed by the EULAR SS Patient Reported Index (ESSPRI) and the Xerostomia Inventory questionnaire. RESULTS: The postoperative reduction in the mean number of episodes of glandular swelling was 87% (95% CI: 77-93) and 75% (95% CI: 47%-88%) in the groups A and B, respectively. The percentage of patients with glandular swelling decreased from 41.7% to 0.0% in the group A and from 30.0% to 0.0% in the group B, respectively. Most of the patients experienced a subjective clinical improvement documented by the statistically significant reductions in the postoperative mean pain VAS (group A P<.001; group B P=.004), Xerostomia Inventory (P<.001 and P=.003) and ESSPRI scores (P<.001 and P=.008). Interventional sialendoscopy followed by outpatient intraductal steroid irrigations was more effective than interventional sialendoscopy alone, when pain VAS, Xerostomia Inventory and ESSPRI scores before and after treatment were analysed together using the multivariate Hotelling T2 test (P=.0173). CONCLUSIONS: This pilot study confirms that interventional sialendoscopy with steroid duct irrigation significantly reduces the number of painful episodes of sialadenitis and improves the subjective sensation of oral dryness and other disease symptoms in patients with SS. The study results also suggest that the improvement is greater when interventional sialendoscopy is combined with a cycle of outpatient steroid ductal irrigations. Larger controlled randomised studies are certainly needed to confirm these preliminary data.

The role of interventional sialendoscopy and intraductal steroid therapy in patients with recurrent sine causa sialadenitis: a prospective cross-sectional study.

OBJECTIVES: To verify the role of interventional sialendoscopy and steroidal ductal irrigation in patients with recurrent sialadenitis. DESIGN: A prospective, cross-sectional pilot study. SETTING: University of Milan. PARTICIPANTS: Fifty-four patients with sine causa recurrent sialadenitis who underwent interventional sialendoscopy (group A, 36 patients) or interventional sialendoscopy followed by a intraductal steroidal irrigations (group B, 18 patients). MAIN OUTCOMES MEASURES: The number of episodes of sialadenitis three and 6 months before and after sialendoscopy, and their severity assessed by means of a 0-10 pain visual analogue scale. RESULTS: In the population as a whole, a significant post-treatment reduction in the number of episodes of 30.7 ± 5.5 after 3 months and 34.6 ± 10.2 after 6 months (P < 0.001) and a significant reduction in pain visual analogue scale values of 4.7 ± 0.4 after 6 months (P < 0.001) occurred. There was a statistically significant reduction in both parameters at the same time points in both treatment groups (P ≥ 0.001), with no significant between-group difference in pain visual analogue scale values, an albeit non-significant trend in favour of group B in terms of the number of episodes 3 months after therapy that became significant after 6 months (11.0 ± 9.9 versus 20.5 ± 9.5; P = 0.05). CONCLUSIONS: Interventional sialendoscopy is effective for the treatment of recurrent sialadenitis; the addition of intraductal steroidal irrigations seems to increase its value in the medium term. Further studies of larger case series with longer follow-up are needed to establish the possibly primary role of steroid therapy in blocking inflammation.

Nasal nitric oxide in children with recurrent acute otitis media.

Recently, reduced Nasal nitric oxide (nNO) nNO levels have been reported in children with adenoidal hypertrophy predisposing to chronic nasosinusal inflammation. Given the strict anatomic and physiopathologic link between the nasopharyngeal and middle ear compartments, and considering the high prevalence of otitis prone children among those affected with chronic adenoiditis, we designed a study aimed to test any possible difference in nNO levels between non-allergic children with and without recurrent acute otitis media (RAOM) associated with chronic adenoiditis. The study involved 54 children with RAOM (44.4% males; mean age= 7.5±3.5 years) and 51 children without RAOM (47.4% males; mean age= 7.0±3.8 years). nNO levels were significantly reduced in children with RAOM compared to children without RAOM (676.9±250.7 ppb vs 831.8±320.4 ppb, respectively; p= 0.02). Our results could be related to reduced NO production by the ciliated paranasal, nasopharyngeal and middle ear epithelium and the impaired sinusal ostial and Eustachian tube patency due to chronic inflammation, and seem to confirm the involvement of NO pathway in recurrent upper airway infections related to impaired ciliated respiratory mucosa.

Serum 25-hydroxyvitamin D levels in children with recurrent tonsillitis living in Milan.

Involvement of 25-hydroxyvitamin D in the etiopathogenesis of tonsillar disease in children is still debated; this study assesses possible differences in serum 25-hydroxyvitamin D levels between 309 Caucasian children (58.1% males; mean age 55.7 ± 31.0 months) living in Milan with a history of recurrent tonsillitis (RT) and healthy controls. Mean serum 25(OH)D levels were significantly reduced in the children with a history of RT (22.0 ± 8.7 ng/mL vs 24.6 ± 7.8 ng/mL; p=0.03), and the proportion of children with insufficient or deficient serum 25(OH)D levels was higher in the RT group (81.5% and 6.5% respectively) than in the control group (75.1% and 3.5%) (not significant). The multivariable model created to test the independent association between serum 25(OH)D levels and a history of RT after adjusting for age and season showed that the association was not significant. Our study failed to find any significant reduction in serum 25(OH)D levels after adjustment for age and season in a case series of children with RT in comparison with healthy controls, which suggests that vitamin D does not play a relevant role in the etiology of pediatric tonsillar infections.

Hypertonic saline is more effective than normal saline in seasonal allergic rhinitis in children.

Allergic rhinitis (AR) is a very common childhood disease that is associated with a significant reduction in the patients' quality of life. Its treatment combines educating the patients and their parents, immunotherapy and drug administration. However, even the best approach does not relieve the symptoms of a number of patients. Alternative therapies are particularly needed for children because the fear of adverse events frequently reduces parental compliance to the prescribed drugs, and immunotherapy is less easy to administer than in adults. In this prospective investigator-blinded study we evaluated whether children, with a documented history of seasonal grass pollen-related AR, benefit from nasal irrigation by assessing the effects on nasal signs and symptoms, on middle ear effusion and on adenoidal hypertrophy. We randomized children aged 5 to 9 years (median age 82 months) to normal saline or hypertonic saline (a 2.7% sodium chloride solution), administered twice-daily using a disposable 20 ml syringe, or no treatment. Nasal symptoms (rhinorrhea, itching, sneezing, nasal obstruction), swelling of turbinates, adenoid hypertrophy or middle ear effusion were assessed at baseline and after 4 weeks of treatment. Two hundred and twenty children (normal saline: 80; hypertonic saline: 80; no treatment: 60) completed the study. After four weeks, all the considered items were significantly reduced in the group receiving hypertonic saline (P < 0.0001), whereas in the group receiving normal saline only rhinorrhea (P = 0.0002) and sneezing (P = 0.002) were significantly reduced. There was no significant change in any of the items in the control group. The duration of oral antihistamines was significantly lower in the children receiving hypertonic saline than in those treated with normal saline or in controls. No adverse events were reported and parental satisfaction and compliance with the procedure were globally very good, regardless of the solution used. Using our procedure, hypertonic saline is effective, inexpensive, safe, well tolerated and easily accepted by children with seasonal grass pollen-related AR and their parents. Our data suggest that nasal irrigation with hypertonic saline might be included in the wide spectrum of therapies recommended for grass-pollen AR.

The piercing-stretching suture technique for the treatment of simple oral floor ranula.

BACKGROUND: Oral floor ranulas are pseudocysts located in the floor of the mouth that result from the extravasation of mucus from a sublingual gland. Historically, there has been little consensus on the ideal first-line treatment. Currently, definitive treatment involves sublingual gland excision, which can injure the lingual nerve and submandibular duct. Minimally invasive surgical techniques have been proposed, but so far have been associated with a high rate of recurrence. METHODS: The so-called piercing-stretching suture technique was performed in 14 naïve adult and paediatric patients (6 females, with a mean age of 20.3 years (range, 7-55 years)). Clinical and ultrasonographic evaluations were performed in all patients; post-operative sialendoscopy was conducted in two paediatric patients. RESULTS: The surgical procedure was successful in all patients, and complete recovery of the ranula was seen in all but one of the patients who underwent suture replacement. No major or minor complications were encountered. CONCLUSION: This minimally invasive procedure may be considered a reliable and first-line treatment for management of simple oral floor ranulas.

Submental dermoid cyst: a rare clinical entity in early pediatric age.

Herein we describe a rare case of exclusive submental dermoid cyst in the first decade of life. The preoperative ultrasonography (US) and magnetic resonance imaging (MRI) diagnosis was confirmed by the results of a histopathological examination. US followed by MRI is the gold standard for the non-invasive diagnostic differentiation of dermoid cysts from other submental swellings and submental excision remains the best surgical option.

Insights into infectious otitis media.

Otitis media is a multifactorial disease. It represents a major public health burden, as it is the most common diagnosis in children and is characterized by both immediate and long-term morbidity. For years the knowledge about risk factors and microbiology of otitis media has been relatively stable. In recent years new data have been gathered regarding different microbiological aspects of otitis media. This new knowledge may contribute toward the development and implementation of therapeutic and preventive strategies.

Burning mouth syndrome: the role of contact hypersensitivity.

BACKGROUND: Burning mouth syndrome is a burning sensation or stinging disorder affecting the oral mucosa in the absence of any clinical signs or mucosal lesions. Some studies have suggested that burning mouth syndrome could be caused by the metals used in dental prostheses, as well as by acrylate monomers, additives and flavouring agents, although others have not found any aetiologic role for hypersensitivity to dental materials. OBJECTIVE: To evaluate the extent and severity of adverse reactions to dental materials in a group of patients with burning mouth syndrome, and investigate the possible role of contact allergy in its pathogenesis. MATERIALS AND METHODS: We prospectively studied 124 consecutive patients with burning mouth syndrome (108 males; mean age 57 years, range 41-83), all of whom underwent allergen patch testing between 2004 and 2007. RESULTS: Sixteen patients (13%) showed positive patch test reactions and were classified as having burning mouth syndrome type 3 or secondary burning mouth syndrome (Lamey's and Scala's classifications). CONCLUSION: Although we did not find any significant association between the patients and positive patch test reactions, it would be advisable to include hypersensitivity to dental components when evaluating patients experiencing intermittent oral burning without any clinical signs.

Transoral robotic surgery for hilo-parenchymal submandibular stones: step-by-step description and reasoned approach.

The conservative transoral approach to hilo-parenchymal submandibular stones has been proposed as an alternative to traditional sialadenectomy. The main purpose is to preserve the gland and eliminate the risk of a cervical scar and damage to the marginal mandibular branch of the facial nerve. The spread of transoral robotic surgery has favoured its application not only in the oropharynx, but also in the anterior oral cavity. This article describes a transoral robotic approach for hilo-parenchymal submandibular stones. In January 2019, two patients with a right and a left hilo-parenchymal submandibular stone of 15mm and 8mm, respectively, underwent removal of the stone with transoral robotic surgery using the Si Da Vinci surgical robot. The procedure was performed successfully and tolerated well, with a one-night hospitalization. There were no complications such as lingual nerve damage, painful gland swelling, infection, or ranula. The patients were followed up clinically and ultrasonographically for the first 3 months to verify symptom relief and persistence of stones; no symptoms or stones were found. The transoral robotic surgical approach seems to be safe and adequate for the conservative management of large hilo-parenchymal submandibular stones. An adequate diagnosis together with proper docking and an appropriate approach to the oral floor is mandatory.

Role of atypical bacteria in children undergoing tonsillectomy because of severely recurrent acute tonsillopharyngitis.

The aim of this study was to verify the frequency of atypical bacterial infections in children undergoing tonsillectomy because of severely recurrent acute tonsillopharyngitis (AT) and the possible benefit of surgery in cases in which Mycoplasma pneumoniae and Chlamydophila pneumoniae seem to play a role in causing the recurrences. A total of 118 patients (76 males; mean age +/- standard deviation, 6.67 +/- 3.31 years) were enrolled: 59 underwent tonsillectomy because of severely recurrent AT and 59 underwent adenotonsillectomy because of obstructive sleep apnea syndrome (OSAS). The results show, for the first time, that the great majority of children with a history of severely recurrent AT (and, therefore, considered to be eligible for elective tonsillectomy) are infected by atypical bacteria, mainly M. pneumoniae, and that tonsillectomy seems to be effective in reducing the recurrence of both AT and acute respiratory disease during 12 months follow-up postsurgery.

Treatment of iatrogenic submandibular sialocele with botulinum toxin. Case report.

We report the case of a 40-year-old woman with a submandibular sialocele (diagnosed by ultrasonography and magnetic resonance sialography) after sialoadenectomy for sialolithiasis. Type A botulinum toxin was injected percutaneously under colour Doppler ultrasonographic guidance into the sialocele and the residual salivary gland. Five months later the submandibular swelling had gone, and we gave a second injection of botulinum toxin to block any residual secretory activity. There were no side effects. This is, as far as we know, the first published report of the use of botulinum toxin to treat an iatrogenic submandibular sialocele.

Modern management of obstructive salivary diseases.

Over the last fifteen years, increasing public demand for minimally-invasive surgery and recent technological advances have led to the development of a number of conservative options for the therapeutic management of obstructive salivary disorders such as calculi and duct stenosis. These include extracorporeal shock-wave lithotripsy, sialoendoscopy, laser intra-corporeal lithotripsy, interventional radiology, the video-assisted conservative surgical removal of parotid and sub-mandibular calculi and botulinum toxin therapy. Each of these techniques may be used as a single therapeutic modality or in combination with one or more of the above-mentioned options, usually in day case or one-day case under local or general anaesthesia. The multi-modal approach is completely successful in about 80% of patients and reduces the need for gland removal in 3%, thus justifying the combination of, albeit, time-consuming and relatively expensive techniques as part of the modern and functional management of salivary calculi. With regard to the management of salivary duct anomalies, such as strictures and kinkings, interventional radiology with fluoroscopically controlled balloon ductoplasty seems to be the most suitable technique despite the use of radiation. Operative sialoendoscopy alone is the best therapeutic option for all mobile intra-luminal causes of obstruction, such as microliths, mucous plugs or foreign bodies, or for the local treatment of inflammatory conditions such as recurrent chronic parotitis or autoimmune salivary disorders. Finally, in the case of failure of one of the above techniques and regardless of the cause of obstruction, botulinum toxin injection into the parenchyma of the salivary glands using colour Doppler ultrasonographic monitoring should be considered before deciding on surgical gland removal.

Preliminary considerations on the application of the voice handicap index to paediatric dysphonia.

Dysphonia is a common paediatric condition. Adult voices are usually evaluated using a set of minimal basic measurements including: endoscopic examination, aerodynamics, perception, acoustics, and self-assessment by the patient. The Voice Handicap Index is the most widely used self-assessment tool, but its use in the paediatric setting has never been reported. Aim of this study was to report Voice Handicap Index ratings in a group of dysphonic children, multi-modally assessed before and after voice therapy. The study involved 28 children (16 female, 12 male, mean age 10.9 years (range 6-12)) presenting chronic hoarseness due to vocal fold nodules (18 cases), unilateral localised oedema (6 cases) or recurrent laryngeal paralysis (4 cases). All received voice therapy for 5-6 months, and underwent voice assessments based on video-endoscopy ratings (size of nodule/ oedema or glottic closure in the case of recurrent laryngeal paralysis), maximum phonation time, GIRBAS scale, spectrograms and a perturbation analysis. All patients also completed the Voice Handicap Index. Aerodynamic, acoustic, perceptual and self-assessment data, before and after voice therapy, were compared using Wilcoxon's test and Student's t test. Correlations between the Voice Handicap Index domains were measured by means of Pearson's correlation coefficient. Post-treatment measurements showed that the nodules/oedema had decreased in size in 18 children following therapy, and two subjects with recurrent laryngeal paralysis showed improved glottic closure. Mean maximum phonation time increased slightly, but the difference was not significant. There was a general reduction in perceptual severity, but this was only significant for parameters G, B and A. Spectrographic analysis showed no significant improvement and, although the mean perturbation analysis values improved, only the difference in jitter values was significant (p = 0.016). Voice Handicap Index was applicable in all cases, and showed a clear and significant improvement (p = 0.0006). The correlations between the three Voice Handicap Index factors were close; no correlation was found between the functional domain and the physical and emotional domains. The Voice Handicap Index is a useful tool in children with dysphonia, but an adapted version validated for paediatric patients is essential.

Salivary lithotripsy in the era of sialendoscopy.

The traditional management of obstructive salivary disorders has been replaced by minimally-invasive gland-preserving techniques including shock-wave lithotripsy, sialendoscopy, interventional radiology and endoscopically video-assisted trans-oral and cervical stone retrieval, of which sialendoscopy is considered to be the method of first choice. Primary endoscopically controlled stone extraction without prior fragmentation is only possible in 15-20% of cases; in more than 80%, fragmentation is necessary because of the size, impactation and location of the stone, or an alternative treatment such as transoral duct surgery or combined approaches are required. Moreover, about 10-20% of all stones cannot be adequately accessed by means of a sialendoscope or any alternative surgical method and, in such cases, extra-corporeal shock wave lithotripsy (ESWL) is the treatment of choice. However, in endoscopically accessible stones, ESWL is being gradually replaced by endoscopically assisted intra-corporeal techniques, including endoscopically guided laser and pneumatic intracorporeal lithotripsy. We describe the currently most widely used techniques for salivary lithotripsy, including ESWL, and endoscopically guided laser, electrohydraulic, electrokinetic and pneumatic intra-corporeal lithotripsy, and discuss their indications given the widespread use of advanced rehabilitative sialendoscopy and combined therapeutic approaches.

Sialendoscope-assisted transoral removal of hilo-parenchymal sub-mandibular stones: surgical results and subjective scores.

It has been suggested that a conservative trans-oral approach to proximal and hilo-parenchymal submandibular stones (HPSMS) is a valid alternative to the more frequently used sialadenectomy. The aim of this study was to evaluate the surgical, ultrasonographic and patients' subjective outcomes of results of the trans-oral removal of HPSMS. Between January 2003 and September 2015, sialendoscope-assisted trans-oral surgery was used to remove symptomatic, large (> 7 mm), fixed and palpable HPSMS from 479 patients under general anaesthesia. All patients were followed clinically and ultrasonographically to investigate symptom relief and recurrence of stones, and were telephonically interviewed to assess saliva-related subjective outcomes with a questionnaire. Stones were successfully removed from 472 patients (98.5%); the seven failures (1.5%) concerned pure parenchymal stones. One year after the procedure, 408 patients (85.1%) were symptom free, 59 (12.3%) had recurrent obstructive symptoms and 12 (2.6%) had recurrent infections. Of the 54 patients who developed a recurrent stone (11.2%), 52 underwent a second procedure: 29 interventional sialendoscopies, two sialendoscope-assisted intra-corporeal pneumatic lithotripsy, eight secondary transoral surgery to remove residual stones, six a cycle of extra-corporeal lithotripsy and seven submandibular sialadenectomy. Most patients (75.2%) reported mild surgery-related pain. The symptoms of 454 patients (94.8%) improved after adjunctive treatment and, at the end of follow-up, the affected gland was preserved in 98.5% of patients. A sialendoscope-assisted trans-oral removal of large HPSMS is a safe, effective, conservative surgical procedure, and functional preservation of the main duct and parenchyma of the obstructed gland allows sialendoscopic access through the natural ostium in case of recurrence. Combining a trans-oral approach with other minimally invasive, conservative procedures ensures symptomatic relief and salivary duct system clearance in the majority of patients.

Interventional sialendoscopy for radioiodine-induced sialadenitis: quo vadis?

Salivary gland toxicity is a common adverse effect of radioactive iodine (131I) for the treatment of thyroid cancers with a prevalence ranging from 2% to 67% of the 131I exposed population. Recently, sialendoscopy has been introduced as an attractive diagnostic and therapeutic tool for management of patients with radioiodine-induced sialadenitis that is unresponsive to standard medical treatments. The objective of the current review was to assess the impact of this procedure on outcomes in patients suffering from radioiodine sialadenitis. Overall, eight studies were included and 122 patients underwent 264 sialendoscopic procedures. Duct stenosis and mucous plugs were observed in 85.7% of endoscopic findings, supporting the role of ductal obstruction in the pathophysiology of radioiodine sialadenitis. In total, 89.3% of patients experienced complete or partial resolution of sialadenitis recurrences without any major adverse events, and parotidectomy was advocated in only 1 case. However, outcomes mainly concerned subjective reports and only two clinical experiences evaluated objective measurement with dissimilar results. Limited to few studies, xerostomia and obstructive symptoms responded differently after sialendoscopy. The optimal timing of salivary gland videoendoscopy needs to be further analysed in order to define the best management of radioiodine-induced obstructive sialadenitis.

Modern management of paediatric obstructive salivary disorders: long-term clinical experience.

Recent technological improvements in head and neck field have changed diagnostic and therapeutic strategies for salivary disorders. Diagnosis is now based on colour Doppler ultrasonography (US), magnetic resonance (MR) sialography and cone beam 3D computed tomography (CT), and extra- and intracorporeal lithotripsy, interventional sialendscopy and sialendoscopy-assisted surgery are used as minimally invasive, conservative procedures for functional preservation of the affected gland. We evaluated the results of our long-term experience in the management of paediatric obstructive salivary disorders. The study involved a consecutive series of 66 children (38 females) whose obstructive salivary symptoms caused by juvenile recurrent parotitis (JRP) (n = 32), stones (n = 20), ranula (n = 9) and ductal stenosis (n = 5). 45 patients underwent interventional sialendoscopy for JRP, stones and stenoses, 12 a cycle of extracorporeal shockwave lithotripsy (ESWL), three sialendoscopy-assisted transoral surgery, one drainage, six marsupialisation, and two suturing of a ranula. Three children underwent combined ESWL and interventional sialendoscopy, and seven a secondary procedure. An overall successful result was obtained in 90.9% of cases. None of the patients underwent traditional invasive sialadenectomy notwithstanding persistence of mild obstructive symptoms in six patients. No major complications were observed. Using a diagnostic work-up based on colour Doppler US, MR sialography and cone beam 3D TC, children with obstructive salivary disorders can be effectively treated in a modern minimally-invasive manner by extracorporeal and intracorporeal lithotripsy, interventional sialendoscopy and sialendoscopy-assisted transoral surgery; this approach guarantees a successful result in most patients, thus avoiding the need for invasive sialadenectomy while functionally preserving the gland.

MR Imaging in Sudden Sensorineural Hearing Loss. Time to Talk.

Sudden sensorineural hearing loss is defined as acute hearing loss of the sensorineural type of at least 30 dB over 3 contiguous frequencies that occurs within a 72-hour period. Although many different causative factors have been proposed, sudden sensorineural hearing loss is still considered "idiopathic" in 71%-85% of cases, and treatments are empiric, not based on etiology. MR imaging implemented with a 3D FLAIR sequence has provided new insights into the etiology of sudden sensorineural hearing loss. Herein, we review the current management trends for patients with sudden sensorineural hearing loss, from the initial clinical diagnosis to therapeutic strategies and diagnostic work-up. We focused primarily on MR imaging assessment and discuss the relevance that MR imaging findings might have for patient management, pointing out different perspectives for future clinical research.

Sialendoscopy-assisted transfacial surgery for the removal of an iatrogenic foreign body in Stensen's duct: a stone and broken wire basket.

BACKGROUND: A foreign body is a rare cause of parotid gland obstructive sialadenitis; intra-oral penetration via Stensen's duct is unusual. The relatively recent introduction of interventional sialendoscopy to treat obstructive sialadenitis has allowed surgeons to adopt a gland-sparing approach by means of miniaturised endoscopes and instruments. However, unusual anatomy or pathological conditions can give rise to a risk of intraductal rupture that may lead to a subsequent iatrogenic foreign body. CASE REPORT: This paper describes the case of a patient with a 4 mm stone engaged by a broken wire basket stuck in a secondary branch of Stensen's duct. RESULTS: The iatrogenic foreign body was successfully retrieved by means of sialendoscopy-assisted transfacial surgery. CONCLUSION: This is the first reported case of an intraductal rupture of a miniaturised device during interventional sialendoscopy successfully resolved by means of combined endoscopy and external surgery. This proved to be an effective method of rescuing a foreign body stuck in Stensen's duct.