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.

Sialolithiasis: mineralogical composition, crystalline structure, calculus site, and epidemiological features.

The purpose of this paper was to describe the characteristics of salivary calculi and their relationship to epidemiological factors, through a cross-sectional study. We analysed 100 calculi obtained in 2017-2021. Patient data including age, time since onset of symptoms, gland involved, and site of location in the salivary system were studied. The calculi were studied to determine their morphological features using scanning electron microscopy and energy dispersive plain radiographic analysis. Most of the calculi had formed in the submandibular gland (SG) (82%). The mean age of patients at onset was 45.83 years; patients presenting parotid gland (PG) stones were somewhat older (p = 0.031). The mean time since the onset of symptoms was longer in PG calculi (p = 0.038). The most common lithiasis site was the main duct (74%), followed by the hilum (22%). Hilar stones were the largest (p < 0.05) and heaviest (p = 0.028). Octacalcium phosphate (OCP) was the most common crystalline phase (Cp) founded, followed by hydroxyapatite (HA) and whitlockite (WH). Specifically, OCP had a higher presence in PG calculi (p = 0.029) and WH was the most common phase in SG calculi (p = 0.017). The most prevalent site of lithiasis was the main duct, and the largest and heaviest calculi were found in the SG. PG stones were associated with a longer history of symptoms and older age. OCP was the most frequent Cp of the calculi studied, and the main Cp in PG stones. WH was the predominant Cp in SG stones. The Cp of the calculi was not influenced by location, patient age, or time of symptoms.

Giant submandibular sialolith: a case report.

Introduction: Salivary glands lithiasis (Sialolithiasis) is defined as calcified concretions in the salivary glands. Most common localization is in submandibular gland. Usually, submandibular stones are mainly located in Wharton's duct, whereas parotid stones are more often located in the gland parenchyma. Sialoliths are usually 5-10 mm in size, and stones more than 10 mm are unusual sizes. Exact etiology of sialolith formation is still unknown. Case Report: We discuss a case of a 70-year-old patient, presenting painful swelling and a giant submandibular gland sialolith successfully treated with open surgery. Conclusions: A careful anamnesis and physical examination of the patient are important in the diagnosis of sialolithiasis. In addition, several imaging techniques, such as panoramic X-rays and Ultrasound, can be applied. The management can be both medical and surgical.

Sialolito gigante do ducto da glândula submandibular: relato de caso / Giant sialolith of submandibular gland duct: case report

Introdução: A sialolitíase é um distúrbio da glândula salivar que afeta 12 em cada 1.000 indivíduos adultos. É caracterizada pela deposição de minerais dentro de seu ducto ou parênquima, sendo a glândula submandibular a mais afetada. Os sialolitos têm tamanhos variados, quando maiores que 15 mm são raros e relatados como sialolitos gigantes. Sialolitos gigantes dentro do parênquima glandular ou porção proximal do ducto são geralmente tratados de forma invasiva por via extraoral com excisão da glândula associada. Relato de caso: Este estudo relata um caso incomum de um paciente diagnosticado com sialolito salivar gigante localizado na porção proximal de um ducto da glândula submandibular, assintomática, tratado por remoção cirúrgica por via intraoral, minimizando riscos potenciais e obtendo sucesso no tratamento. Considerações finais: Mesmo sialolitos localizados em regiões mais profundas do ducto submandibular, o acesso intraoral pode ser uma alternativa viável e de menor risco... (AU)

Introduction: Sialolithiasis is a disorder of the salivary gland that affects 12 out of 1,000 adult individuals. It is characterized by the deposition of minerals within its duct or parenchyma, with the submandibular gland being the most affected. Sialolites have varying sizes, when larger than 15 mm they are rare and reported as giant sialolites. Giant sialoliths within the glandular parenchyma or proximal portion of the duct are usually treated invasively by the extraoral route with excision of the associated gland. Case report: This study reports an unusual case of a patient diagnosed with giant salivary sialolith located in the proximal portion of a submandibular gland duct, asymptomatic, treated by intraoral surgical removal, minimizing potential risks and achieving treatment success. Final considerations: Even sialoliths located in deeper regions of the submandibular duct, intraoral access can be a viable and less risky alternative... (AU)

Combined sialendoscopic/mini-preauricular microscopic approach for large proximal parotid sialolithiasis.

OBJECTIVE: To describe and evaluate a combined approach for sialendoscopic stone localization with microscopic mini-preauricular incision external stone extraction as a gland-sparing minimally invasive surgical management in cases of large proximal duct or intraparenchymal parotid gland sialolithiasis. METHODS: A retrospective chart review of a single primary surgeon's patient series of 21 cases operated in a 5-year period in a tertiary care university and private practice hospitals. RESULTS: Study included 16 males and five females, with age range 12-68 years (mean 40.9 ± 14.5). Nineteen out of the 21 patients had their stones completely removed (90.5%), with two not completing the procedure due to inability of intraoperative endoscopic stone visualization. In total 25 stones were extracted with six patients having two stones. Longest diameter of single (or first) stone was 5-16 mm (mean 9.1 ± 2.9) and second was 3-5 mm (mean, 3.9 ± 0.6). Endoscopic findings showed 14/25 stones in the proximal main parotid duct and 11/25 in one of its secondary parenchymal branches. Stents were used in 4/19 cases (21.1%). No major complications occurred. Minor complications included two postoperative conservatively managed seromas. All 19 cases had completely intact facial nerve function, good parotid salivary flow and acceptable esthetic result after median follow-up period of 26 months (range 6-62). CONCLUSION: The combined sialendoscopic/microscopic mini-preauricular approach is a highly effective and safe gland-preserving method for large proximal parotid sialolithiasis management with a main limitation being inability to visualize the stone endoscopically.

Concurrent giant sialoliths within the submandibular gland parenchyma and distal segment of Wharton's duct: Novel case report.

OBJECTIVE: This article discusses the clinical significance of an unusual case of the simultaneous occurrence of 2 giant sialoliths within the ipsilateral submandibular gland and distal aspect of Wharton's duct in a 63-year-old patient. BACKGROUND: The majority of submandibular gland sialoliths are found in Wharton's duct, with fewer within the gland parenchyma. Giant sialoliths (exceeding 15 mm in size) are rare. MATERIALS AND METHODS: An asymptomatic, otherwise healthy older patient sought dental care and underwent a comprehensive oral and radiographic examination. RESULTS: A panoramic radiograph revealed 2 incidental radiopaque structures, representing giant sialoliths within the submandibular gland and along the distal segment of Wharton's duct. This synchronous finding apparently represents the first case reported in the geriatric literature. CONCLUSIONS: The detection of 1 salivary stone should heighten the scrutiny for additional stones. Practitioners should carefully weigh the risk of sialolith removal versus deferment of treatment in older medically compromised patients.

Ultrasound-guided sialo-irrigation for the treatment of chronic sialodochitis with sialolithiasis.

Sialolithiasis is one of the most common causes of salivary duct obstruction. In the last 20 years, minimally invasive procedures like sialendoscopy, extracorporeal lithotripsy, and basket snaring are increasingly being used for the treatment of salivary gland duct stones. Sialo-irrigation of the salivary gland is an effective procedure for treating inflammation and providing symptomatic relief. This procedure can be employed for the treatment of sialolithiasis using the back pressure of instilled saline. Sialo-irrigation under ultrasound (US) guidance allows for dynamic studies showing real-time images during diagnostic or surgical procedure and can be used for the removal of sialoliths. In addition, it can also be used to remove primitive sialoliths and microliths by washing out the ductal system, which prevents the recurrence of sialoliths. The aim of this study was to propose a minimally invasive technique for sialolithiasis using US-guided sialo-irrigation.

The unique characteristics of sialolithiasis following drug-induced hyposalivation.

OBJECTIVES: Assess clinical, imaging, operative, and post-operative characteristics of drug-induced vs. non-drug-induced sialolithiasis that are termed 'other etiologies of sialolithiasis.' MATERIALS AND METHODS: Data collected from a retrospective cohort of 96 patients who underwent intra-oral sialolith removal operations were categorized as patient disease characteristics, physical examination results, and imaging and therapeutic features. Patients were divided into two groups based on having drug-induced sialolithiasis (DIS) vs. other etiologies of sialolithiasis (OES). Patients who consumed any medication for chronic conditions were regarded as DIS. Statistical analyses were conducted to elucidate differences and similarities between the two groups. RESULTS: There were 60 patients in the DIS group and 36 in the OES group. DIS patients were significantly older (average age 57.9 vs. 39.8 years, respectively), with no gender predilection. Statins and anti-hypertensive medications were most commonly consumed. Presenting symptoms including number of past swellings, salty tasting saliva, pain, and antibiotic treatment were similar between the groups; mealtime-related swelling of the gland was noted in a higher proportion of OES patients (51.5% vs. 37%, respectively). Analysis of sialolith size and location from fixed anatomical landmarks on the mandible were not different between groups, and the most frequent sialolith location was the hilus gland in DIS vs. intra-glandular in OES patients. Sialolith removal operation time was significantly shorter for DIS patients (45 ± 11.5 vs. 61.1 ± 18.1 minutes). CONCLUSION: Drug-induced sialolithiasis may be regarded as a unique entity with a typical clinical age, presenting symptoms, imaging characteristics, and surgery duration. CLINICAL RELEVANCE: Clinicians should be aware of the above-mentioned differences when treating patients with sialolithiasis and anticipate a more challenging sialolith removal procedure for other etiologies of sialolithiasis, possibly due to underlying anatomical factors of the duct system. When treating drug-induced sialolithiasis, clinicians can expect a shorter operation time with a similar success rate and hospitalization time as with a younger, healthier population with other sialolithiasis etiologies.

In Vivo Accuracy of Ultrasound for Sizing Salivary Ductal Calculi.

OBJECTIVES: The present study was developed to evaluate the accuracy of in vivo ultrasound sizing for parotid and submandibular salivary gland calculi, as compared with ex vivo pathology sizing with a standard plastic ruler after extraction. STUDY DESIGN: Retrospective chart review. SETTING: Ultrasound is frequently used to size salivary calculi and make treatment decisions, but the accuracy of measurements from this modality has not been validated. SUBJECTS AND METHODS: We evaluated and reviewed the charts and ultrasound examinations of 167 patients who underwent procedures for the treatment of sialolithiasis involving the parotid and submandibular glands. US examinations were performed between 2009 and 2016 in a tertiary-level hospital setting by the senior author. Measurements were collected from ultrasound evaluation before sialolithotomy, and pathology measurements were taken after removal. Ultrasound measurements in millimeters were compared with the measurements collected with a ruler. The differences were calculated and compared. RESULTS: A total of 167 calculi measurements were compared. Good concurrent validity between pathology and ultrasound measurements was suggested by a Pearson correlation of 0.92 (95% CI, 0.887-0.937). On Bland-Altman plot, correlation of the difference between US and pathology measurements showed a mean difference of 0.095 mm (95% CI, -0.19 to 0.38 mm) with a limit of agreement ranging from -3.59 mm (95% CI, -3.84 to -3.34 mm) to +3.78 mm (95% CI, +3.53 to +4.03 mm). CONCLUSIONS: Ultrasound is an accurate, relatively precise, and minimally invasive imaging tool for salivary gland sialolithiasis. Preoperative size of calculi can be used to guide management and clinical decision making. LEVEL OF EVIDENCE: 2C.

Classification of submandibular salivary stones based on ultrastructural studies.

INTRODUCTION: Sialolithiasis remains a clinical problem with unclear etiopathogenesis, lack of prevention methods, and only surgical treatment. MATERIALS AND METHODS: An ultrastructure examination of submandibular sialoliths obtained from patients with chronic sialolithiasis was conducted using a scanning electron microscope and X-ray photoelectron spectroscopy. RESULTS: Based on the results, we divided sialoliths into three types: calcified (CAL), organic/lipid (LIP), and mixed (MIX). The core structure of the CAL and MIX is very similar. The core of the LIP has a prevalence of organic components. The intermediate layers' structure of the CAL is different from LIP and MIX. In LIP and MIX, the organic component begins to increase in intermediate layers rapidly. The structure of the superficial layers for all types of sialoliths is similar. CONCLUSIONS: We introduced a new classification of the submandibular salivary gland stones. Based on the results, it can be said that sialoliths type CAL and LIP have their separate path of origin and development, while MIX is formed as CAL stone, and the further pathway of their growth passes as LIP stones. Organic components were much more than inorganic in all layers of salivary gland stones, which highly prevents their dissolution in the patient's salivary gland duct.

Aplicabilidade da ultrassonografia no diagnóstico de doenças inflamatórias e obstrutivas das glândulas salivares maiores: revisão de escopo / Applicability of ultrasonography in the diagnosis of inflammatory and obstructive diseases of the major salivary glands: scoping review

Alterações em glândulas salivares maiores (GSM) ocorrem em adultos ou crianças. Sialoadenites agudas ou crônicas são alterações inflamatórias que podem estar ou não associadas à infecção. Sialolitíases se caracterizam pela presença de calcificações (sialolitos) nos ductos ou parênquima glandular. Radiografia e tomografia computadorizada (TC) podem detectar sialolitos, mas possuem limitações relacionadas ao grau de mineralização ou para a caracterização de algumas alterações em tecidos moles. A ressonância magnética (RM) detecta alterações em GSM e sialolitos mineralizados ou não, porém possui alto custo e baixa disponibilidade que inviabilizam seu uso na rotina de atendimento. Ultrassonografia (US) é uma alternativa viável de exame para avaliação das GSMs, devido ao baixo custo, facilidade de aquisição de imagem em tempo real, boa resolução, e não utilização de radiação ionizante. O objetivo da presente revisão de escopo foi verificar a aplicabilidade da US na detecção de alterações em GSMs acometidas por sialoadenites ou sialolitíase. Foi realizada busca nas bases de dados eletrônicas PubMed, Web of Science, EMBASE e SCOPUS, que resultaram na seleção de 2277 referências. Após a leitura de títulos e resumos, 92 artigos contemplaram os critérios de elegibilidade desta revisão. Foram coletados dados sobre os autores, data de publicação, tipo de estudo, condição/alteração/patologia avaliada, GSM, valor diagnóstico da US, características ultrassonográficas das lesões, dados clínicos e informações adicionais. US pôde detectar alterações em GSM, com exceção do lobo profundo das parótidas. O Doppler colorido permitiu avaliar o padrão de vascularização dos tecidos alterados, auxiliando no estabelecimento de diagnósticos diferenciais. Sialolitos, únicos ou múltiplos, maiores que 2 mm foram bem detectados, inclusive tampões mucosos não mineralizados. Sialolitos menores que 1 mm foram melhor visualizados utilizando a técnica de sonopalpação e administração de ácido ascórbico ou suco de limão. Alterações glandulares causadas por sialoadenites agudas ou crônicas foram visualizadas através da US. A associação entre características ultrassonográficas e dados clínicos foi útil no estabelecimento de diagnósticos diferenciais. A ultrassonografia foi considerada como o método de escolha para avaliação inicial de alterações em GSM, tanto em adultos como crianças.

Alterations in major salivary glands (GSM) occur in adults or children. Acute or chronic sialoadenitis are inflammatory alterations associated or not with infections. Sialolithiasis is characterized by the presence of calcifications (sialoliths) in the ducts or glandular parenchyma. Radiography and computed tomography (CT) can detect sialoliths, but they have limitations related to the grade of mineralization or for the characterization of some alterations in soft tissue. Magnetic resonance imaging (MRI) detects alterations in GSM and mineralized or not mineralized sialoliths, but it has a high cost and low availability that make its use in routine care unfeasible. Ultrasonography (US) is a viable alternative exam for evaluating GSMs, due to its low cost, easy real-time image acquisition, good resolution, and no use of ionizing radiation. The objective of this scope review was to verify the applicability of US in detecting alterations in GSMs affected by sialoadenitis or sialolithiasis. A search was performed in the electronic databases PubMed, Web of Science, EMBASE and SCOPUS, which resulted in the selection of 2277 references. After reading the titles and abstracts, 92 articles met the eligibility criteria for this review. Data on authors, publication date, type of study, condition/alteration/pathology evaluated, GSM, diagnostic value of US, ultrasound characteristics of the lesions, clinical data and additional information were collected. US could detect alterations in GSM, with the exception of the deep parotid lobe. Color Doppler allowed us to assess the vascularization pattern of altered tissues, helping to establish differential diagnoses. Single or multiple sialoliths larger than 2 mm were well detected, including non- mineralized mucus plugs. Sialoliths smaller than 1 mm were better visualized using the sonopalpation technique and administration of ascorbic acid or lemon juice. Glandular alterations caused by acute or chronic sialoadenitis were visualized through US. The association between ultrasound characteristics and clinical data was useful in establishing differential diagnoses. Ultrasonography was considered the method of choice for the initial assessment of alterations in GSM, both in adults and children.

Ultrastructural analysis of the submandibular sialoliths: Raman spectroscopy and electron back-scatter studies.

The aim of work was the epidemiological analysis of the occurrence of sialolithiasis of the submandibular gland in adults and the evaluation of the ultrastructure of salivary stones. The study sample consisted of 44 sialoliths. Analysis of the structure and chemical composition of sialoliths was performed using a Scanning Electron Microscope and Raman Spectroscopy. Comparing our results with the literature we can say that the epidemiology of sialolithiasis has not changed significantly over the past 50 years. A wide variety of sialoliths structure was observed. In 75% (33) cases a layered structure of salivary stones was observed, while in 25% (11) - homogeneous structure. The various distribution of organic and inorganic components was observed among all the analyzed sialoliths. Raman spectroscopy allows for preliminary analysis of the sialoliths structure with only a qualitative assessment of their composition, which significantly reduces the research value of this method. The presence of organic and inorganic compounds in the core and inner layers of the salivary glands stones confirms 2 basic theories of the formation of sialoliths: inflammation and deposition of the inorganic component as a result of disruption of saliva flow in the salivary glands.

Treatment strategy of hilar and intraglandular stones in wharton's duct: A 12-year experience.

OBJECTIVES/HYPOTHESIS: To suggest a strategy for transoral removal of hilar and intraparenchymal submandibular stones. STUDY DESIGN: Retrospective case series. METHODS: Retrospective evaluation was performed for 514 consecutive patients with hilar and intraparenchymal submandibular stones treated via endoscopy-assisted surgery from January 2006 to June 2018. Three patients had bilateral stones. The stones were classified as: hilar (type I), posthilar (type II), intraparenchymal (type III), and multiple stones (type IV). RESULTS: The affected glands included 311 with type I, 84 with type II, 65 with type III, and 57 with type IV stones. Stones were successfully removed in 478 glands (92.5%, 478/517). Main treatment techniques included hilum ductotomy in 311 glands, intraparenchymal ductotomy in 68, submandibulotomy in 14, intraductal retrieval in 74, and hilum ductotomy accompanied by intraductal retrieval in 11. At a mean 40-months follow-up of 478 successful cases, clinical outcomes were good in 425, fair in 27, and poor in 26 glands. Postoperative sialograms in 75 stone-free patients were categorized as: type I, normal (n = 6); type II, ectasia or stenosis in the main duct and no persistent contrast on functional films (n = 44); type III, ectasia or stenosis in the main duct and mild contrast retention (n = 15); and type IV, poor shape of the main duct and evident contrast retention (n = 10). Postoperative sialometry of 32 patients revealed no significant differences of the gland function between the two sides. CONCLUSIONS: Appropriate use of various endoscopy-assisted approaches helps preserve the gland and facilitates recovery of gland function in patients with different depths of hilo-parenchymal submandibular stones. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2360-2365, 2020.

Sialolitiasis submandibular gigante, extracción quirúrgica y reparación ductal: reporte de caso / Giant submandibular sialolithiasis, surgical removal and ductal repair: case report

Introducción: la patología litiásica de las glándulas salivales forma parte de un grupo de afecciones que perjudica el sistema de drenaje normal de la saliva hacia la cavidad oral, ocasionando lesiones múltiples sobre la glándula afectada. Se realizó el reporte de un caso clínico con esta patología que, por el tamaño del lito, se considera extremadamente rara en nuestro medio. Método: se realizó el reporte de caso y revisión de la literatura (estudios radiológicos, historia clínica y hallazgos clínicos); además, el paciente firmó el consentimiento para esta publicación. Resultados: un paciente masculino de 38 años remitido de consulta externa con un cuadro clínico de 1 semana de dolor, edema y tumefacción en la región submandibular izquierda asociado con una secreción sialopurulenta por la cavidad oral. En la radiografía (Rx) oclusal estricta y en la tomografía axial computarizada (TAC) de cuello contrastado se evidenció una lesión litiásica de más o menos 4,5 x 1,8 cm de diámetro, de característica radiolúcida, a nivel del conducto de wharton. Se dio un manejo quirúrgico por otorrinolaringología maxilofacial, consistente en sialolitotomía y antibioticote- rapia por 10 días, con las cuales se obtuvieron buenos resultados. Conclusiones: la litiasis gigante a nivel del sistema salival (glándula, conductos) es una patología poco común en nuestro medio y está involucrada en el desarrollo de múltiples patología de tipo inflamatorio recurrente de la glándula involucrada, lo cual afecta la calidad de vida de los pacientes. Por esta razón, el diagnóstico y manejo debe ser oportuno para evitar complicaciones, como una infección profunda del cuello; en nuestro caso, el manejo fue oportuno con una extracción quirúrgica por la vía oral del cálculo y la reparación del conducto de wharton del lado izquierdo.

Introduction: the lithiasic pathology of the salivary glands is part of a group of conditions that harms the normal drainage system of the saliva towards the oral cavity, causing multiple lesions on the affected gland, a report of a clinical case with this pathology was made. Due to the size of the stone it is considered extremely rare in our environment. Method: case report and review of the literature (radiological studies, clinical history, clinical findings) patient consent was signed for this publication. Results: a 38-year-old male patient referred from the outpatient clinic with a 1-week clinical picture of pain, swelling and edema in the left submandibular region associated with sialopurulent secretion from the oral cavity in the strict occlusal Rx and a contrast-enhanced neck CT revealed a lithiasic lesion with more or less 4.5 x 1.8 cm in diameter of radiolucent features at the level of the wharton duct, surgical management was given by maxillofacial ENT, consisting of sialolitotomy and antibiotic therapy for 10 days with good results. Conclusions: the giant lithiasis at the level of the salivary system (gland, ducts) is a rare pathology in our environment, is involved in the development of multiple pathologies of recurrent inflammatory type of the affected gland, affecting the quality of life of patients, so the diagnosis and management should be timely and avoid complications, such as deep neck infection; in our case, the management was timely with oral surgical removal of the calculus and repair of the wharton duct on the left side.

Analysis of efficiency of sialendoscopy in patients with sialolithiasis

The aim of this research was to analyze 106 clinical observations in which sialendoscopy was performed for diagnosis and treatment patients with sialolithiasis. This research showed, that endoscopy of the major salivary gland ductal system allows to obtain information not only on a sialolith, but also on a condition of ductal system. The obtained data define a method of further treatment. Sialendoscopy can be used not only as diagnostic method, but also as an independent method for sialolith removing or as an assistance. The possibility of sialolith removing depends on its mobility, the size of salivary stone, localization and a salivary duct condition.

Use of Cone-Beam Computed Tomography in Performing Submandibular Sialolithotomy.

PURPOSE: Sialolithotomy for submandibular gland lithiasis is a common procedure often performed in the office setting, with the patient under local anesthesia. The location, size, and number of the sialoliths can greatly influence the indication owing to the difficulty of the procedure for hilar and proximal calculi. The purpose of the present study was to report our experience regarding the advantages of using preoperative cone-beam computed tomography (CBCT) to evaluate submandibular gland lithiasis in patients undergoing sialolithotomy for calculi located anywhere in the area of Wharton's duct, with special regard to hilar and proximal calculi. MATERIALS AND METHODS: We performed a retrospective study by reviewing the medical records of patients with a diagnosis of sialolithiasis of the submandibular gland using CBCT performed the day of stone removal by sialolithotomy. We have described the operative technique and the CBCT landmarks used for intraoperative orientation and control. RESULTS: Thirty-two patients with submandibular sialolithiasis were included in the present study. A total of 51 salivary stones were identified using CBCT. Proximal and hilar calculi were encountered in 14 cases. The number of calculi diagnosed using CBCT matched the number of surgically removed calculi in all cases. Transient lingual nerve hypoesthesia was encountered in 2 patients. No obstructive symptoms recurred after surgery. CONCLUSIONS: We found that preoperative CBCT allows for an optimal understanding of the individual stone configuration in relation to the patient's anatomy. It allows for easy identification of the calculi during sialolithotomy, leading to greater confidence in approaching proximal and hilar stones.

Sialendoscopy plus laser lithotripsy in sialolithiasis of the submandibular gland in 64 patients: A simple and safe procedure.

OBJECTIVE: To demonstrate the safety and efficiency of holmium laser-assisted lithotripsy during sialendoscopy of the submandibular gland using a retrospective, interventional consecutive case series. METHODS: We performed 374 sialendoscopies between 2008 and 2015 and evaluated all patients regarding clinical symptoms, clinical findings, therapy and outcome. We performed 109 procedures of holmium laser-assisted lithotripsy in 64 patients whose sialoliths measured 5 mm or more in diameter. In addition to retrospective case note reviews, we performed telephone interviews of all patients in January 2017. RESULTS: We performed 374 consecutive submandibular gland sialendoscopy procedures in 276 patients between 2008 to 2015. Sialolithiasis had either previously been diagnosed, or symptoms highly suggestive of sialolithiasis of the submandibular gland presented in 197 patients. Holmium laser-assisted Laser lithotripsy was performed in 109 cases (64.9%). Smaller mobile concrement was removed directly either by forceps or wire basket, or following marsupialisation of the submandibular duct. This was the case in 88 patients (29.1%). Three patients (0.8%) required surgical removal of the submandibular gland due to early abscess. The majority of patients (n = 374 procedures; 90.1%) remained symptom-free after two or more years following intervention. In the remaining procedures (n = 37 procedures; 9.9%), patients reported discreet postprandial problems but did not seek medical attention. In total, we managed to preserve the submandibular gland and avoid open surgery in 99% of patients through endoscopic management of submandibular concrement and duct stenosis. CONCLUSION: Holmium laser-assisted lithotripsy is a simple, safe, and effective procedure for treating patients with sialolithiasis of the submandibular gland. Removal of the gland is rarely required, and removing the gland without prior sialendoscopy is no longer recommended. It should be offered to all patients with submandibular gland sialolithiasis, or such patients should be referred to the appropriate centre for sialendoscopy before submandibulectomy is considered.

[Clinical study of endoscopy-assisted lithectomy of parotid gland calculi via a transoral approach].

Objective: To investigate the indications and long-term outcomes of endoscopy-assisted removal of parotid gland calculi via a transoral approach. Methods: From August 2005 to December 2016, 158 consecutive patients with parotid gland calculi underwent endoscopy-assisted lithectomy transorally. They included 71 males and 87 females, with an age of 5-84 years. The immediate safety and effectiveness were evaluated. After surgery, the patients were followed up, and gland function was analyzed on the basis of clinical manifestations, sialography, scintigraphy and sialometry. Postoperative sialograms were categorized into 2 types: ①type Ⅰ, the main duct was normal or had ectasia and stenosis, but no persistent contrast was seen on the functional film; ②type Ⅱ, the main duct had ectasia or stenosis, with persistent contrast media on the functional film. Results: Under one endoscopic procedure, the stones (or foreign bodies) were completely removed in 134 cases and almost completely removed in 10 cases, with a success rate of 91.1% (144/158). Of the 144 successful cases, the treatment options included direct basket retrieval or forceps grasping in 77 cases, basket entrapment with direct ostium incision in 36, basket capture with perio-ostium incision in 23 and perio-ostium incision in 8 cases with impacted stones. In two of the initial 14 failure cases, the stones were discharged spontaneously 3 months after operation. During 3-120 months' follow-up (mean 36 months) of the 146 patients, one had recurrent stone, two developed ductal obturation, 16 had mild symptoms, and the remaining 127 cases were asymptomatic. Of the postoperative sialograms in 34 stone-free patients 25 were type Ⅰ, 9 were type Ⅱ. Both scintigraphy and saliva flow rate indicated an improvement of the affected gland function in some degree (P<0.05). Conclusions: Transoral endoscopy-assisted removal of parotid gland calculi is a safe and effective technique. It is mainly indicated for mobile stones in the main duct or impacted stones in the anterior third of the Stensen's duct. Sialography, scintigraphy and sialometry show postoperative improvement of gland function in most of the cases.

Evaluation of Parotid Gland Function Before and After Endoscopy-Assisted Stone Removal.

PURPOSE: To quantify gland function before and after endoscopy-assisted lithectomy for patients with parotid stones and to analyze correlations among different evaluation modalities. MATERIALS AND METHODS: This study investigated 58 patients (27 men and 31 women) with a stone larger than 5 mm or multiple parotid stones who underwent successful endoscopy-assisted surgery at the authors' center from August 2007 through September 2017. Meticulous postoperative manipulations were administered routinely for 3 to 6 months to promote functional recovery of the affected gland. Gland function was evaluated preoperatively and 6 to 36 months (mean, 12 months) postoperatively by sialography, scintigraphy, and sialometry. Statistical analyses were conducted to quantify gland function recovery and to distinguish correlations among the 3 objective tests. RESULTS: Preoperative sialograms exhibited ductal ectasia at the stone site with ductal stenosis anterior to the stone (n = 53) or duct interruption at the stone site (n = 5). Postoperative sialograms of 45 patients without stones were categorized as approximately normal (type I; n = 17); showing ectasia or stenosis of the main duct without persistent contrast on the functional film (type II; n = 16); showing ectasia or stenosis of the main duct with mild contrast retention (type III; n = 6); or showing poor ductal shape with evident contrast retention (type IV; n = 6). Scintigraphy of 23 preoperative and 12 postoperative patients and sialometry of 24 preoperative and 12 postoperative patients indicated severe preoperative impairment and postoperative improvement of gland function. Postoperatively, although no relevant differences in saliva flow rate were found between the 2 sides, scintigraphy showed lower function of the affected gland compared with the control side. Statistical data showed positive correlations among the 3 methods. Sialography intuitively reflected the ductal shape, whereas sialometry and scintigraphy were more sensitive for evaluating gland function. CONCLUSION: For patients with parotid stones, minimally invasive endoscopic surgery and meticulous postoperative manipulations help preserve the glands and facilitate recovery of gland function. The 3 evaluating modalities have certain positive correlations.