Removal of stones from the superficial lobe of the submandibular gland (SMG) via an intraoral endoscopy-assisted sialolithotomy.

OBJECTIVES: Sialolithiasis is the most common cause of chronic sialadenitis of the submandibular gland (SMG). Symptomatic superficial lobe stones are often treated by submandibulectomy. A gland preserving operation allows for transoral stone removal through endoscopically assisted sialolithotomy. Herein, we provide clinical and sonographical follow-up data in patients who underwent sialolithotomy under general anesthesia. MATERIALS AND METHODS: Sixty patients treated at the Department of Oral and Maxillofacial Surgery at Düsseldorf University Hospital for superficial lobe sialolithiasis of SMG were included in this study. All received transoral sialolithotomy under general anesthesia. Follow-up was conducted via standardized patient questionnaires, clinical examination, and B-mode and color Doppler sonography. RESULTS: Mean patient age was 48.9 years. 56.6% of right and 43.4% of left SMG were affected. Mean follow-up was 45 months. Fifty-five of 59 detected stones could be removed. Mean operation time was 71 min. 3.3% of patients reported recurrent episodes of postoperative pain and 10% felt recurrent episodes of gland swelling. Persistent postoperative lingual nerve hypesthesia was described in one patient. No facial nerve damages occurred. Salivary flow rates remained reduced in most of the affected glands upon stone removal. Sonographical follow-up data of the previously affected SMG after intraoral endoscopy-assisted sialolithotomy showed a regular gland size in 70.8% of cases, a parenchyma free of inflammation in 93.8%, and without signs of fibrosis in 72.9% of cases. 68.7% of patients showed a regular structure of Wharton's duct at time of follow-up. In total, 89.6% of patients were diagnosed stone-free within both glands on follow-up. No case required subsequent submandibulectomy. CONCLUSIONS: Sialolithotomy of Wharton's duct for removal of stones from the SMG's superficial lobe is a promising alternative to submandibulectomy. CLINICAL RELEVANCE: Reduction of postoperative morbidity through endoscopically assisted sialolithotomy for removal of superficial lobe stones from SMG. TRIAL REGISTRATION: Ethics Committee of Heinrich-Heine-University Düsseldorf (no. 5586).

Intraoral Microscopic Versus Robot-Assisted Sialolithotomy and Sialendoscopy for Submandibular Stones.

OBJECTIVE: Sialendoscopy has remained the standard of treatment for sialolithiasis; however, large stones impacted in the submandibular gland hilum often require an intra-oral combined approach. METHODS: Patients treated for submandibular hilar sialolithiasis from 2015 to 2021 at two tertiary centers were stratified into two groups based on the surgical technique: Intraoral Microscopic-Assisted Sialolithotomy (IMAS) versus Robot-Assisted Sialolithotomy and Sialendoscopy (RASS). We compared the characteristics of retrieved stones, surgical success rate, operative time, and post-operative complications in both techniques. True surgical success was defined as successful stone extraction without reoccurrence within 12 months. RESULTS: The RASS technique was attempted in 60 patients and successful in 56 (93.3%) cases whereas the IMAS technique was performed in 52 patients and successful in 48 (92.3%) cases. The longest dimension of the predominant retrieved calculi was 9.6 ± 3.1 mm (range, 5-18 mm) for the robotic technique and 10 ± 4.8 mm (range, 5-30 mm) for the microscopic technique. The operative time for the robotic technique excluding robot setup time was 70.6 ± 24.8 min compared to 61.9 ± 42.4 min for microscopic technique (p = 0.018). No major adverse outcomes were reported; however, temporary lingual paresthesia was found in ten robotic (16.7%) and five microscopic (9.6%) cases. CONCLUSION: The two techniques were comparable in terms of efficacy and safety for large stones. The robot has the advantage of intraoral high dynamic maneuverability and improved surgeon posture while the microscopic technique has the advantage of intraoral tactile feedback. The procedure was significantly shorter in duration with the microscope. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2170-2176, 2024.

In-office Transoral Hilar Sialolithotomy: A Cost-Effective and Patient-Centered Procedure.

Transoral sialolithotomy performed in-office under local anesthesia is routinely performed for distal submandibular stones. We demonstrate the senior author's novel practice of in-office transoral sialolithotomy for hilar and intraglandular stones. A review of cases performed by the senior author revealed similar rates of complication and stone recurrence as those reported in the literature from removal under general anesthesia. Laryngoscope, 134:4042-4044, 2024.

Transoral Robotic Surgery in the Management of Submandibular Gland Sialoliths: A Systematic Review.

This study aimed to systematically review the literature to determine the efficacy and safety of transoral robotic surgery (TORS) in the management of submandibular gland (SMG) sialolithiasis. PubMed, Embase, and Cochrane were searched for English-language articles evaluating TORS in the management of SMG stones published up to 12 September 2022. Nine studies with a total of 99 patients were included. Eight patients underwent TORS followed by sialendoscopy (TS); 11 patients underwent sialendoscopy followed by TORS and sialendoscopy (STS); 4 patients underwent sialendoscopy followed by TORS only (ST); and 4 patients underwent TORS without sialendoscopy (T). The mean operative time amounted to 90.97 min. The mean procedure success rate reached 94.97%, with the highest for ST (100%) and T (100%), followed by the TS (95.04%) and STS (90.91%) variants. The mean follow-up time was 6.81 months. Transient lingual nerve injury occurred in 28 patients (28.3%) and was resolved in all of them within the mean of 1.25 months. No permanent lingual nerve injury was reported. TORS is a safe and effective management modality for hilar and intraparenchymal SMG sialoliths, with high procedural success in terms of successful sialolith removal, SMG preservation, and reduced risk of permanent postoperative lingual nerve damage.

Extremely Large Submandibular Sialolith Removal - A Case Report.

The Rationale: Sialoliths are calcified organic matter that form within the secretory system of the salivary glands. They rarely measure more than 1.5 cm. Giant sialoliths are rare and defined as a size of 3.5 cm or larger. Patient concerns: Patient complained of the pain and swelling in the right submandibular area for two years with increase in size during meals. Diagnosis: Based on the clinical and radiological investigations. Treatment: Sialolith measuring 39 mm and weighing 7.02 g, was removed in a minimally invasive manner through transoral sialolithotomy using diode 810 µm LASER unit under local anaesthesia. Outcomes: Patient was relieved of the preoperative symptoms and was on follow-up for one year. Take-Away Lessons: Various newer treatment modalities are effective alternatives to conventional surgical treatment of sialoliths. However, transoral sialolithotomy remains the mainstay of management.

Transfacial lithotomy approach to intraparenchymal stones in the submandibular gland: our primary exploration.

The article describes our exploration of a sialendoscopy-assisted transfacial sialolithotomy approach to intraparenchymal stones in the submandibular gland with gland preservation. Five patients with large intraparenchymal stones in the submandibular gland were included. Ultrasonography and computed tomograms (CT) were performed to locate the stones. As the large stones failed to be retrieved during endoscopy, patients were treated by a transfacial lithotomy approach with sialendoscopy. The glands were preserved in all cases. This approach can be considered an optional technique for the treatment of large intraparenchymal stones in the submandibular gland that fail to be removed during a transoral procedure.

Bilateral hilar sialoliths in a child: A rare occurrence.

Salivary sialolithiasis is a well-known cause for obstructive disease of the submandibular and parotid glands. However, the condition frequently occurs unilaterally, and it is uncommon to find a patient reporting with stones in both submandibular or parotid glands. Children below the age of 16 years rarely suffer from salivary stones. Thus, bilateral sialoliths in a child are extremely rare, with only four previous cases been reported in the literature. This is an additional case report of bilateral submandibular sialolithiasis occurring in the hilar area in a 13-year-old boy.

Robot-assisted sialolithotomy with sialoendoscopy: a review of safety, efficacy and cost.

OBJECTIVE: Review the safety, efficacy and cost of robot-assisted sialolithotomy with sialoendoscopy (RASS) for large submandibular gland hilar sialoliths. STUDY DESIGN: Retrospective case series. METHODS: Patients ≥18 years diagnosed with submandibular hilar sialolithiasis between 1/1/2015 and 7/31/2018 who underwent RASS were identified. Procedure success, post-operative complications, procedure duration, and costs associated with the procedure were reviewed. RESULTS: 33 patients fit inclusion criteria. 94% of patients had successful sialolith removal. Mean sialolith size was 8.9 mm. 15.1% had transient tongue paresthesia. 0% had permanent tongue paresthesia compared to a 2% rate of lingual nerve damage cited in the literature for combined approach sialolithotomy (CAS). The average total cost was $16,921. Insurance paid 100%, 90-99%, 70-89.9%, and 40-69.9% of the expected reimbursement in 43.8%, 18.7%, 18.7% and 12.5% of patients respectively. 6% of patients self-paid. Compared to CAS, the cost of reusable robotic arms and drapes totaled $475, though these costs were included in the standardized operative cost per minute and were not forwarded to the patient. The mean procedure time was 62 minutes. Compared to published mean procedure times for CAS, the reduced operative time may account for a savings of $3332-$6069. CONCLUSION: RASS is a safe modality for submandibular hilar sialolith removal with a high success rate, low risk for temporary tongue paresthesia, and lower rate of permeant lingual nerve damage compared to CAS. Compared with CAS, RASS may result in a net reduction of operative room costs given its shorter procedure time.

Transoral Sialolithotomy Without Endoscopes: An Alternative Approach to Salivary Stones.

Sialoendoscopy is a valuable technique for a variety of obstructive and nonobstructive disorders of the major salivary glands. However, the utility of sialoscopes is limited for salivary stones, which frequently required open removal. Transoral sialolithotomy without scopes is an efficient, low-cost alternative with excellent outcomes available for most of the submandibular stones.

Submandibular sialolithiasis: A series of three case reports with review of literature.

One of the most common disorders of the salivary glands is sialolithiasis. A history of pain or/and swelling in the salivary glands, especially during meal suggests this diagnosis. For small and accessible stones conservative therapies like milking of ducts with palliative therapy can produce satisfactory results. Surgical management should be considered when the stone/stones are inaccessible or large in size as conservative therapies turned out to be unsatisfactory. In this paper, we present three cases of sialolithiasis in the submandibular gland along with a review of existing literature. The purpose of this paper is to add three more cases to the literature and review the theories of etiology, clinical features, available diagnostic and treatment procedures.

Gland-preserving surgery for salivary stones and the utility of sialendoscopes.

BACKGROUND: Sialoendoscopy is the standard treatment for sialolithiasis; however, some patients may be unlikely to benefit from an endoscopic approach. This study assesses predictors of failure in the endoscopic management of sialoliths. METHODS: Patients treated for sialolithiasis from 2012 to 2017 at two centers were stratified into 3 groups: successful interventional sialendoscopy, incisional sialolithotomy, and gland excision. Patient, disease, and surgical factors were compared. RESULTS: Interventional sialendoscopy was attempted in 156 of 206 cases and successful for 42 (27%). Endoscopically retrieved calculi were smaller (4.96 mm) compared to incisional sialolithotomy (7.90 mm). Nonendoscopic approaches were required more often in submandibular cases 87% (P ≤ .005). Palpable stones were present in 74% of incisional sialolithotomies (P < .001). Submandibular location (OR 3.50, 1.53-7.98), palpability (OR 2.74, 1.21-6.18), CT localization (OR 3.05, 1.32-7.10, P = .010), and increased diameter (OR 1.25, 1.09-1.44) were predictive of incisional management. CONCLUSION: Stone size/location, CT-localization, and palpability were predictive of calculi that require an incisional approach. If these factors are recognized, the surgeon can consider proceeding directly to incisional sialolithotomy. LEVEL OF EVIDENCE: III.

Sialolithotomy of the submandibular duct using sialendoscopy.

BACKGROUND: Conventionally, indirect radiography has been used to diagnose salivary gland diseases. However, with the development of sialendoscopy, diagnosis and treatment of salivary gland diseases have become more effective. Herein, we report a case of sialolithotomy treated with sialendoscopy and compare it with the existing methods through a literature review. CASE PRESENTATION: Two patients with a foreign body sensation under the tongue and dry mouth visited the Anam Hospital, Korea University. Radiographic examination revealed salivary stones inside the right Wharton duct, and the patients underwent sialolithotomy under local or general anaesthesia. The stones were totally removed, and there were no postoperative complications such as bleeding or pain. CONCLUSION: The development of sialendoscopy has enabled better definitive diagnosis of salivary gland diseases compared with the conventional methods; better treatment outcomes can be obtained when sialendoscopy is used in appropriate cases.

Sonolocation during submandibular sialolithotomy.

OBJECTIVES/HYPOTHESIS: Ultrasound is a proven tool for diagnostic and therapeutic purposes for treatment of salivary gland pathology. It is also useful for localization of calculi during submandibular gland transoral sialolithotomy when calculi cannot easily be palpated. Our objective was to determine the efficacy of sialolith localization using ultrasound during submandibular gland sialolithotomy. STUDY DESIGN: Retrospective case series. METHODS: A study performed utilizing data compiled from 2009 through 2016 in a tertiary academic center. Treatment was completed in 164 patients with sialadenitis and sialolithiasis by submandibular gland transoral sialolithotomy in either the office (81%) or the operating room (19%). Ultrasound was used for localization of sialoliths during submandibular gland sialolithotomy. Main treatment outcomes studied were success of the procedure, complications, and follow-up. RESULTS: Successful sialolithotomy was performed in (147 patients) 90% of cases. Complications were minimal and included stricture formation, which occurred in 3% (five patients) of cases, followed by ranula formation in 1.8% (three patients) of cases. There were no incidences of lingual nerve injury. CONCLUSIONS: Ultrasound can be used effectively for precise sialolith localization intraoperatively. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2716-2720, 2019.

Ultrasound indicators of persistent obstruction after submandibular sialolithotomy.

OBJECTIVE: To identify and describe the ultrasound indicators of persistent obstruction following transoral submandibular sialolithotomy and discuss the utility of ultrasound in the immediate postoperative period. STUDY DESIGN: We performed a prospective case series with planned data collection of patients who underwent treatment for symptomatic submandibular swelling. SETTING: A tertiary care center. SUBJECTS: Thirty-three patients of either sex with known submandibular gland sialoliths who failed endoscopic retrieval of calculi. METHODS: We performed in-office or operating room-based transoral submandibular gland sialolithotomy followed by immediate postprocedure ultrasound examination for the assessment of residual calculi. All patients underwent mandatory reexploration for suspicious findings. RESULTS: Only the appearance of hyperechogenic foci with posterior shadowing reliably predicted the presence of residual stones following transoral sialolithotomy (P < .0001). The presence of hyperechogenic foci without posterior shadowing (P = 1.00), ductal dilatation (P = .23), and intraglandular dilatation (P = 1.00) was not indicative of retained calculi. CONCLUSION: The presence of hyperechogenic foci with posterior shadowing on immediate postprocedure ultrasound is an accurate indicator of residual stones following transoral submandibular sialolithotomy. Ultrasound examination can be reliably used to identify patients at risk of symptomatic recurrence of sialoliths.

A Large Sialolith Perforating the Wharton's Duct: Review of Literature and a Case Report.

Sialolithiasis accounts for the most common cause of diseases of salivary glands. The majority of sialoliths occur in the submandibular gland or the Wharton's duct. This article discusses review of literature, predisposing factors, signs and symptoms, diagnostic methods and various modalities available for the management of sialolithiasis. This case report presents a case of sialolith of a large size in the left Wharton's duct, which was explored and removed via an intra-oral approach.