US-guided percutaneous microwave ablation (MWA) of submandibular gland: A new minimal invasive and effective treatment for refractory sialorrhea and treatment response evaluation with contrast-enhanced imaging techniques.

A 33 years' old male complained of excessive salivation with frequent swallowing and spitting, which resulted in communication disturbance, reduced quality of life, and social embarrassment for 19 years. He had been diagnosed as sialorrhea and submandibular gland hyperfunction by stomatologist, then had unilateral submandibular gland resection 13 years ago, but the symptom relief was not satisfactory. After that, he had been treated with glycopyrrolate for less than a year, which was withdrawn because of the short duration of symptomatic control after each tablet take-in and intolerable side effects. With the wish to receive a new treatment with long term effectiveness, low re-operation risk and normal preserved saliva secretion function, the patient was subject to MWA for the right submandibular gland. After systematic clinical evaluation, US-guided percutaneous MWA was successfully performed with an uneventful post-operative course. The volume of the right submandibular gland and ablated area were measured precisely by an ablation planning software system with automatic volume measurement function based on three-dimensional reconstruction of the pre-operative and post-operative enhanced magnetic resonance imaging (MRI) raw data. Finally, the ablated volume was calculated as 62.2% of the whole right submandibular gland. The patient was discharged 1 day after the operation, with symptoms relieved significantly, the mean value of whole saliva flow rate (SFR) decreased from 11 ml to 7.5 ml per 15 minutes. During the follow up by phone three months after operation, the patient reported that the treatment effect was satisfactory, whereas the SFR value became stable as 7 ml per 15 minutes, drooling frequency and drooling severity (DFDS) score decreased from 6 to 5, drooling impact scale (DIS) score decreased from 43 to 26. US-guided percutaneous MWA of submandibular gland seems to be an alternative, minimal invasive, and effective treatment for refractory sialorrhea.We described a patient with refractory sialorrhea treated successfully with ultrasound (US) guided percutaneous microwave ablation (MWA).

3D 4K VITOM-assisted transoral removal of distal stone in the Wharton's duct.

BACKGROUND: The aim of this study was to describe the potential advantages of the transoral 3D 4K exoscope-assisted removal of calculus of the Wharton's duct. METHODS: A 24-year-old female with swelling in the left oral pelvis was diagnosed of sialolithiasis of distal Wharton's duct. A CT scan confirmed the lithiasic formation and a transoral removal in local anesthesia was planned through the 3D 4K exoscope (VITOM 3D, Karl Storz). RESULTS: A high-quality magnification of the oral pelvis was obtained, with an easy identification of the entrance of the left submandibular gland's duct and the calculus. After blunt dissection the Wharton's duct was incised and the calculus removed. An angiocatheter (20G) was carefully inserted in the duct and removed after 3 days. No postoperative complications occurred. At 7 days post-operative follow-up the patient had developed a neo-ostium 5 mm from the papilla. The exoscope provided a better involvement in the surgery and more interactions of all operating room personnel, residents and students, that had access to the same field of view of the first surgeon with the perception of the depth of the surgical field with 3D technology. CONCLUSIONS: The exoscope could represent a valid option for transoral removal of calculi, allowing for precise surgical dissection of the oral floor, thus reducing the risks for iatrogenic lesion of the lingual nerve. It showed also a high potential for training and educational purposes.

The Efficacy and Safety of Submandibular Transcatheter Perfusion Anesthesia in Submandibular Gland Surgery.

The present study aims to evaluate the feasibility, safety, and effects of the combined use of submandibular transcatheter perfusion with lingual nerve block and subcutaneous infiltration for anesthetic purposes during submandibular gland surgery. A total of 38 patients with benign tumors, who had undergone resection by submandibular gland surgery were randomly divided into 2 groups. Patients in group A were administered with submandibular anesthesia through catheter perfusion, lingual nerve block, and subcutaneous infiltration anesthesia. Patients in the group B were only treated with lingual nerve block and subcutaneous infiltration anesthesia. The submandibular gland surgery was performed within 5 minutes following anesthesia administration, after which the numerical rating scale (NRS) was evaluated before surgery, during skin incision (T1), during the pulling process of the submandibular gland (T2), during the removal of the submandibular gland (T3), and at 2, 6, 12, and 24 hours post-surgery. The dosage of analgesic drugs was also measured after surgery. The findings revealed no significant difference in NRS before surgery, at T1, 6, 12, and 24 hours after surgery (P > 0.01) while NRS was much lower in group A patients as observed at T2, T3, and 2 hours after surgery when compared with group B (P < 0.01). The combined application of submandibular transcatheter perfusion with lingual nerve block and subcutaneous infiltration can be used as an effective anesthetic method during submandibular gland surgery.

Susceptibility of partially desalivated rats to erosive tooth wear by calcium-supplemented beverages.

OBJECTIVES: To investigate the susceptibility of partially desalivated rats to erosive tooth wear (ETW); the anti-erosive effect of a calcium-supplemented beverage; and the quantification of ETW by microcomputed tomography (micro-CT). METHODS: The study population consisted of thirty-eight rats, divided into partially desalivated (n = 19) and normal salivary flow (n = 19). They were randomly allocated into three subgroups (n = 6-7): A-diet soda, B-diet soda + calcium, C-water (control). Solutions were provided ad libitum for 28 days, and the rats were euthanized afterwards. Each left hemi-mandible was scanned using micro-CT for enamel volume (three molars) calculation. Visual analysis of photographs of the lingual surface of first molars was performed independently by three blinded examiners. Data were statistically analysed (α = .05). RESULTS: Micro-CT revealed no significant differences between partially desalivated or normal groups. Rats consuming A had more enamel loss than those consuming B or C, which did not differ from each other. For visual analysis, desalivation did not affect ETW. Rats consuming C showed the lowest ETW, followed by B and then A, for both partially desalivated and normal rats. Spearman correlation between the two ETW quantification methods was -.65. CONCLUSIONS: Partial desalivation did not increase ETW. Ca-containing beverage prevented ETW. Micro-CT quantified ETW, although it was not as sensitive as visual analysis.

Endoscopic-assisted gland-preserving therapy for chronic sialadenitis: a German and US comparison.

OBJECTIVE: To determine whether unique patterns of care are evolving in the United States compared with Germany in endoscopic management of chronic sialadenitis. DESIGN: Comparison of consecutive series of patients. SETTING: Academic tertiary salivary referral centers in Germany and the United States. PATIENTS: A total of 446 patients having chronic sialadenitis treated with salivary endoscopy. MAIN OUTCOME MEASURES: To compare practice patterns and outcomes at each location, databases tracking patients having chronic sialadenitis treated with salivary endoscopy were searched for the following variables: age, sex, involved gland, radiographic studies, endoscopic findings, endoscopic-related complications, gland preservation rate, patient symptom control, and techniques for managing salivary stones and intraductal scar tissue. RESULTS: Significantly more patients in the US cohort had chronic sialadenitis of the parotid gland (P = .03) and multiple gland involvement (P < .001). Salivary endoscopy was regularly performed using local anesthesia in Germany and using general anesthesia in the United States (P < .001). Endoscopic-related complication rates were higher (10.9% vs 1.6%) and gland preservation rates lower (85.9% vs 98.4%) among US patients; however, patients with intact glands demonstrated similar rates of symptom control at both centers (92.7% in the United States vs 85.3% in Germany) at the last follow-up visit. The lower rate of gland preservation in the United States is largely because of lack of access to lithotripsy for larger salivary stones. CONCLUSIONS: Different patterns of care are emerging in the endoscopic management of chronic sialadenitis in the United States compared with Germany, where these techniques were largely developed. Nevertheless, patients with chronic sialadenitis at both locations who undergo endoscopic gland-preserving therapy have high rates of gland preservation and symptom control.

The learning curve of sialendoscopy with modular sialendoscopes: a single surgeon's experience.

OBJECTIVE: To assess the learning curve of sialendoscopy with modular endoscopes based on operative parameters and a postoperative performance rating. DESIGN: Prospective study, case series. SETTING: Tertiary referral hospital. PATIENTS: The study included 50 consecutive patients who underwent sialendoscopy by a single surgeon (J.C.L.) between September 2007 and March 2009 at University Hospital of Cologne, Cologne, Germany. The patients were chronologically arranged into 5 groups of 10 patients. INTERVENTIONS: Diagnostic and interventional sialendoscopy using local anesthesia. MAIN OUTCOME MEASURES: Operative parameters and postoperative performance ratings. RESULTS: The average operative time was 39 minutes, with a ratio of diagnostic to interventional sialendoscopy of 62%:38%. There was a significant improvement in the average operative time (P < .001) and in the average performance rating (P = .007) after the first 10 patients and again after the first 30 patients (P = .003 and P = .01, respectively). A continuous decrease in operation time was measurable up to the last patients. Performance ratings reached a level of excellence within the last group of patients. CONCLUSIONS: The performance of sialendoscopy improves with time and experience. With endoscopes of a modular design, the surgeons have a remarkable learning curve. The surgeons' learning curve in this study required 30 cases to reach satisfactory operation times and performance ratings. Both parameters showed continuous improvement and a leveling off after 50 cases.

[Transoral removal of submandibular hilar calculi: 36 cases]. / Exérèse endobuccale des lithiases submandibulaires postérieures: 36 cas.

INTRODUCTION: Proximal submandibular calculi are usually removed by transcervical submandibular sialadenectomy. The aim of this study was to show that intraoral removal of hilar submandibular calculi gives the same results with fewer complications than submandibulectomy. PATIENTS AND METHODS: The surgical indication is assessed by palpability of the stone and confirmed by simple CT scan. The surgical procedure is performed under local or general anaesthesia. At the end of the procedure, the duct is controlled with a sialendoscope to remove remaining concretions. We prospectively followed 36 patients with a mean follow-up of six months (one to 36 months). RESULTS: The transoral removal of calculi was performed in 34 patients without any definitive neurological complication. The procedure failed in two patients with nonpalpable calculi. Two patients had a recurrence of symptoms due to small intraglandular calculi, which were evacuated later. DISCUSSION: The transoral removal of submandibular hilar calculi is a safe and reproducible procedure with less morbidity than submandibulectomy. It should be recommended for posterior palpable submandibular calculi.

[Transoral removal of submandibular hilar calculi]. / Exérèse des lithiases postérieures de la glande submandibulaire par abord endobuccal.

INTRODUCTION: Sialolithiasis is the most common non-neoplastic salivary gland disease, accounting for 1.2% of the autoptic population. More than 80% of salivary calculi are located in the submandibular ductal system. Hilar calculi are usually removed by transcervical submandibular sialadenectomy. However, intra-oral removal of hilum submandibular calculi is an interesting alternative. INDICATIONS: The main criterion for intra-oral removal is the calculi palpability, knowing that calculi under 8mm of diameter are often treated by other techniques (sialendoscopy and lithotripsy). OPERATIVE PROCEDURE: We describe a conservative and gland-preserving transoral surgical technique for hilar submandibular calculi with postoperative sialendoscopic control. The different surgical steps are illustrated. DISCUSSION: Preservation of the submandibular gland has been attempted in the treatment of sialotithiasis by transoral resection of calculi from the hilum of the gland. This technique features a low morbidity and leads to a complete recovery of glandular function.

Management of xerostomia related to radiotherapy for head and neck cancer.

Xerostomia is a permanent and devastating sequela of head and neck irradiation, and its consequences are numerous. Pharmaceutical therapy attempts to preserve or salvage salivary gland function through systemic administration of various protective compounds, most commonly amifostine (Ethyol) or pilocarpine. When these agents are ineffective or the side effects too bothersome, patients often resort to palliative care, for example, with tap water, saline, bicarbonate solutions, mouthwashes, or saliva substitutes. A promising surgical option is the Seikaly-Jha procedure, a method of preserving a single submandibular gland by surgically transferring it to the submental space before radiotherapy. Improved radiation techniques, including intensity-modulated radiotherapy and tomotherapy, allow more selective delivery of radiation to defined targets in the head and neck, preserving normal tissue and the salivary glands. Acupuncture may be another option for patients with xerostomia. All of these therapies need to be further studied to establish the most effective protocol to present to patients before radiotherapy has begun.

[Mucoepidermoid carcinoma of the salivary glands after high dosage radiotherapy]. / Mukoepidermoid-Karzinom der Speicheldrüsen nach hochdosierter Radioiodtherapie.

BACKGROUND: High-dose radioiodine therapy following total thyroidectomy is standard for patients suffering from differentiated thyroid carcinoma and contributes significantly to their favourable prognosis. Due to active iodine accumulation, high focal radiation doses are received by the salivary glands. PATIENTS/RESULT: Report on two patients, who received multiple high-dose radioiodine treatments because of a differentiated metastatic thyroid carcinoma. A few years later, they developed a mucoepidermoid carcinoma of the salivary glands. Due to the high cumulative radiation dose, radiation-induced secondary malignancies following radiation-induced sialadenitis appears likely, although no causal connection could be proven. CONCLUSION: Consistent protection of the salivary glands during radioiodine therapy as well as the follow-up of the many long-term survivors of differentiated thyroid carcinomas is desirable to further lower the salivary gland-related side effects and to detect secondary malignancies as early as possible.

Salivary epidermal growth factor plays a role in protection of ileal mucosal integrity.

The role of salivary epidermal growth factor (EGF) in the maintenance of ileal mucosal integrity was studied by evaluating the effects of sialoadenectomy on luminal EGF levels, ileal tissue resistance (Rt), and unidirectional flux of [51Cr]EDTA. Mice in groups 1 (SLX) and 2 (SLX + EGF) were subjected to sialoadenectomy, while mice in groups 3 (Sham) and 4 (Sham + EGF) underwent a sham procedure. All animals received normal diet and water, except that EGF (100 ng/ml) was added to water for SLX + EGF and Sham + EGF mice. At seven days after surgery, luminal EGF levels in gastrointestinal segments and ileal Rt were significantly reduced by sialoadenectomy, which was prevented by EGF supplementation. Unidirectional flux of [51Cr]EDTA was 6- to 22-fold greater in the ileum of sialoadenectomized mice, which was prevented by EGF administration. Results suggest that salivary EGF may be the major source of intestinal EGF, and it may play a role in maintenance of ileal mucosal integrity.

Evidence of a role for nerve growth factor in the effect of sialoadenectomy on body temperature of parasite-infected mice.

Mice infected with Schistosoma mansoni were used to investigate the role of the submaxillary salivary gland and nerve growth factor (NGF) in temperature response. The results showed that the infection increased (36.5 +/- 0.3 vs 35.7 +/- 0.2), while sialoadenectomy decreased (34.4 +/- 0.2 vs 35.1 +/- 0.2) body temperature. These temperature changes were associated with high or low circulating NGF levels, respectively. It was also found that infection altered the distribution of oxytocin-positive neurones in the hypothalamus and that administration of 20 mu g of purified NGF in normal mice raised (36.1 +/- 0.2 vs 35.1 +/- 0.2) and of NGF antibodies decreased (34.0 +/- 0.2 vs 35.1 +/- 0.2) body temperature. Taken together, these observations suggest that salivary NGF influences the temperature set-point in adult rodents, but the mechanism regulating these events remains to be elucidated.

[The treatment of patients with chronic sialadenitis resulting from salivary outflow disorder]. / Lechenie bol'nykh khronicheskim sialodenitom, voznikaiushchim v rezul'tate narusheniia ottoka sliuny.

The author analyzes the results of treatment of 128 patients with chronic sialadenitis by original surgical and conservative organ-preserving methods. Narrowed orifice of the submandibular duct and excessive curves of the parotid duct in the buccinator were surgically corrected. Conservative therapy included electrophoresis of residues of the Saki Lake therapeutic mud, followed by ultrasonic therapy. These pathogenetically based methods proved to be fairly effective. Removal of stenosed sites of the ducts resulted in alleviation of inflammation symptoms in 103 (80.47%) patients and in clinical remission of the condition.

[A non-exocrine function of the submaxillary gland]. / Une fonction non exocrine de la glande sous-maxillaire.

Emphasizing on the concept of "banalization" and multifactoriality of the signal molecules of the cellular communication, the authors review data of the literature which allow to attribute to some substances synthetized by the submandibular salivary glands (SSG), mainly growth factors as EGF and NGF, an endocrine role. Because of their direct secretion in the oral cavity or their overflow into bloodstream the consequences of the deficit of these growth factors could be correlated with some oral pathologies such as aphthous lesions, puberty and pregnancy gingivitis, which endocrine etiology is often assumed, as well as autoimmune salivary pathologies. Thus, the results obtained after SSG removal furnish a support for envisaging a link between the submandibular salivary glands and the reproductive function (decrease in plasma LH level, ultrastructural changes of the Leydig cells, spontaneous abortion) and with some structures of the central nervous system such as hypothalamus (variation in hypothalamic TRH content) or pineal gland (decrease in pineal cyclic AMP content). Particularly interesting is the possibility that NGF secreted in blood by the SSG during a stress may represent the signal able to stimulate the peripheral immunity cells as well as to inform the central nervous system through a neuronal pathway via the superior cervical ganglia and the pineal gland. This brain afferent information could be associated with an increased hypothalamic NGF synthesis, also observed during stress, whose finality might be to stimulate the secretion of hypophyseal ACTH, the main hormone involved in the interrelationship between endocrine and immune response.

Decrease of hypothalamic TRH levels but not plasmatic TSH levels after ablation of submandibular salivary glands in the rat.

Indirect relationships are thought to exist between submandibular salivary glands (SSG) and the central nervous system (CNS) via superior cervical ganglia (SCG). To study this topic, the concentrations of thyrotropin releasing hormone (THR) and somatostatin (SRIF) were measured in both whole and specific areas of the hypothalamus, as well as plasmatic thyrotropin stimulating hormone (TSH) levels following ablation of SSG. Twenty, forty and fifty days after ablation of SSG, groups of operated and sham-operated animals weighing 230-260 g at the beginning of experimentation, were killed by cervical dislocation. Plasma was taken, frozen and stored for TSH-radioimmunoassay (RIA) and the hypothalami were removed and homogenized in either 0.1 N HCl (for TRH-RIA) or 0.2 N acetic acid (for SRIF-RIA). Twenty days after ablation of SSG in another group, TRH concentrations were measured in both the median eminence (ME) and the paraventricular nucleus (PVN), dissected by the micropunch technique. The results show that twenty days after SSG ablation, the hypothalamic TRH concentrations was significantly lower in operated than in sham-operated animals (295.2 +/- 24.8 vs 226 +/- 11.15 pg/mg hypothalamus respectively p less than 0.01, n = 9). No differences were observed at later intervals. This finding seems to be specific for this peptide since the SRIF level was not modified twenty days after SSG removal. Among the discrete hypothalamic areas examined, only the ME exhibited a significant decrease in TRH content (25.43 +/- 3.02 ng/mg prot. VS. 41.24 +/- 1.33 ng/mg prot., respectively). Despite these results on TRH levels, no modifications in plasmatic TSH levels were observed.(ABSTRACT TRUNCATED AT 250 WORDS)