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Sialendoscopy-assisted transfacial surgical removal of parotid stones
Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1964e1969
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Sialendoscopy-assisted transfacial surgical removal of parotid stones Pasquale Capaccio a, c, *, Gaffuri Michele a, Pignataro Lorenzo a, b Granda Ospedale Maggiore Policlinico, Milan, Italy Otolaryngology Department, Fondazione IRCCS Ca Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy c Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 February 2014 Accepted 27 August 2014 Available online 7 September 2014
Minimally invasive surgical approaches to parotid stones (such as extra-corporeal shockwave lithotripsy and sialendoscopy) have proved to be effective in a high percentage of cases, although success depends on factors such as the localisation of the stone, its size and its mobility. The failure rate of 10% is largely due to large and impacted stones and, in such cases, a combined external and sialendoscopic approach can be used to avoid morbidity and the risks of more invasive superficial parotidectomy. We treated eight patients with large parotid stones (>7 mm) using a sialendoscopy-assisted transfacial surgical approach that was effective in all but one case, which was successfully solved by combining this procedure with extra-corporeal lithotripsy and operative sialendoscopy. Our results confirm that the combined approach is a valid alternative to parotidectomy for large parotid stones and should be added to other minimally invasive techniques aimed at restoring the function of the affected parotid gland. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Parotid stones Minimally invasive technique Endoscopy assisted Sialolithiasis
1. Introduction About 20% of symptomatic stones are located in Stensen's duct, also called the parotid duct (Iro et al., 1998; Zenk et al., 2012). The symptoms are gland swelling during main meals, recurrent infections, and sometimes trismus (Overton et al., 2012), and a diagnosis can be made clinically or radiologically by means of ultrasound, occlusal view radiography, computed tomography (CT), contrast sialography, magnetic resonance (MR) sialography, or cone beam computed tomography (CBCT) (Abdel-Wahed et al., 2013; Dreiseidler et al., 2010). A remarkable percentage of parotid stones remain undetected by conventional imaging techniques (Nahlieli and Baruchin, 2000); in this regard sialendoscopy has a major role as a diagnostic tool for all causes of salivary obstruction (Nahlieli et al., 2006; Liu et al., 2009). The traditional management of parotid stones is based on sialadenectomy (Capaccio et al., 2009) in the case of main duct and intraparenchymal stones, and sialolithectomy (Witt et al., 2012) in the case of distal duct stones. However, both have well-known
Abbreviations: MR, magnetic resonance; CT, computed tomography; ESWL, extra-corporeal shockwave lithotripsy. * Corresponding author. Otolaryngology Department, Fondazione IRCCS C a Granda Ospedale Maggiore Policlinico, Via F Sforza 35, 20122 Milano, Italy. Tel.: þ39 0250320245; fax: þ 39 0250320248. E-mail address: [email protected] (P. Capaccio).
untoward effects (Overton et al., 2012; Torretta et al., 2012) and, over the last 20 years, various conservative and minimally invasive techniques have been developed, including extra-corporeal shockwave lithotripsy (ESWL) (Capaccio et al., 2004; Escudier et al., 2010; Desmots et al., 2014); operative sialendoscopy (Zenk et al., 2012); interventional radiology (Kelly and Dick, 1991; Drage et al., 2000); and sialendoscopy-assisted surgery (McGurk et al., 2006); the choice of which depends on the size, location (distal, proximal, intraparenchymal), and the number and mobility of the stones (Capaccio et al., 2009; Escudier et al., 2010; McGurk et al., 2006). Operative sialoendoscopy and ESWL (Zenk et al., 2012, 2013) are both highly successful means of treating parotid calculi: the former is better in the case of stones of <4 mm, whereas the latter is effective for stones of 4e7 mm. However, it has been demonstrated that minimally invasive techniques such as interventional sialendoscopy fail in 10% of cases (especially those involving palpable, impacted stones of >7 mm) (McGurk et al., 2006). To fill the gap, a new technique combining external and endoscopic surgery has recently been proposed as a less invasive alternative to traditional parotidectomy. Baurmash and Dechiara, 1991 described the first extra-oral sialolitothomy without parotidectomy supported by plain radiographs and high definition ultrasound. Nahlieli et al. (2002) similarly located stones by means of ultrasonography and/or sialendoscopy, and then removed them using a vertical skin incision. In 2006, McGurk et al. described a modified combined approach that involves locating the
http://dx.doi.org/10.1016/j.jcms.2014.08.009 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
P. Capaccio et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1964e1969
1965
Table 1 Clinical findings and details of parotid stones. mm: millimetre; Fr: French. Patient
Age
Sex
Side
Location
Stone size (mm)
Stent
1 2 3 4 5 6 7 8
60 67 37 72 81 75 56 73
f f m m m m f m
left right left left left right left left
intraparenchymal ductal ductal intraparenchymal intraparenchymal intraparenchymal ductal ductal
10 18 8 8 20 15 10 12
yes yes yes no no no yes yes
stone with a salivary endoscope and its subsequent surgical removal by means of a pre-auricular skin incision. The aim of this paper is to describe our own initial experience of using a combined sialendoscopic and surgical approach to treat eight patients with large parotid stones.
Stent size (Fr)
Follow up (months)
Seldicath Seldicath Seldicath
5 5 3
Seldicath Seldicath
3 4
12 3 6 45 32 25 11 18
meals. The exclusion criterion was the presence of a complete distal stenosis of Stensen's duct as assessed by means of a clinical evaluation and MR sialography. All of the patients underwent salivary gland ultrasonography (Hitachi H21, 7.5 MHz, Hitachi HighTechnologies Corporation Ltd., Tokyo, Japan) to confirm the clinical suspicion of a stone.
2. Materials and methods 2.2. Surgical techniques 2.1. Patients and indications Eight patients (three female, five male; mean age 65 years, range 37e81) with recurrent obstructive parotid gland disease due to a large stone (>7 mm), and no previous surgical intervention, were enrolled at the University of Milan's Department of Otolaryngology between July 2009 and May 2013 (Table 1). All of the patients underwent the sialendoscopy-assisted transfacial surgical removal of the parotid stone using McGurk's technique (McGurk et al., 2006) under general anaesthesia (six patients) or Nahlieli's technique (Nahlieli et al., 2002) under sedation (two patients). The inclusion criteria were the presence of a palpable parotid stone of >7 mm located in the main parotid duct or in a secondary parenchymal branch of the ductal system and the recurrence of symptoms and signs such as pain and parotid swelling during
Regardless of the technique used, the surgery always begins with an endoscopic exploration of the ductal system of the affected parotid gland using a dedicated salivary endoscope (0.8 mm, Nahlieli sialoendoscope, Karl Storz Co., GmbH, Tuttlingen, Germany). Its insertion through the opening valve of Stensen's duct is preceded by appropriate dilatation with lacrimal duct probes (Bowman probes, Karl Storz, Tuttlingen, Germany) (Capaccio et al., 2007). Once the surgeon can visualise the stone, the high-powered light at the tip of the endoscope allows its exact location to be marked on the facial skin (Fig. 1a, black arrow). Subsequently: 2.2.1. McGurk's technique A Redon pre-auricular incision is made (Fig. 1a, violet line) and the subcutaneous layers are gently dissected (Fig. 1b). The skin flap
Fig. 1. (a) Stone localisation on the skin surface (black arrow) and drawing of the preauricular incision (violet line). After gentle dissection of the subcutaneous layers (b), a skin flap is raised (c), and the dissection is continued through the parotid fascia in order to expose the parotid gland and the proximal tract of Stensen's duct (d).
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P. Capaccio et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1964e1969
Fig. 2. The buccal branch of the facial nerve (black arrows) is close to the duct (a), and its function is carefully checked using a nerve stimulator (b). The position of the stone is confirmed by means of salivary endoscopy (c) using the high-powered light at the tip of the endoscope (d). In this case, the stone is located intraparenchymally, in the proximal tract of Stensen's duct (e).
is raised and the dissection continues (Fig. 1c), involving the parotid fascia in order to expose the parotid gland in front of the stone and the proximal tract of Stensen's duct (Fig. 1d). During the blunt dissection, the buccal branch of the facial nerve close to the duct surgery is identified (Fig. 2a). The preparation of the best operative field, with complete exposure of the site in which the stone is located, requires the use of a neurostimulator (Neuro-Pulse®, Bovie Medical Corporation, Clearwater, FL, USA) to check the functioning of the buccal and other possible branches of the VII cranial nerve met during dissection (Fig. 2b). The light at the tip of the endoscope allows the exact position of the stone to be located (Fig. 2cee), and the main duct or its secondary parenchymal branch is incised over the stone and parallel to its direction using a size 11 scalpel; after gentle dissection using dedicated instruments, the stone is grasped with pincers, and then removed (Fig. 3aec). The duct is then irrigated with saline (Fig. 4a) and an endoscopic search is made for any
residual stones or debris (Fig. 4b). Subsequently, a Seldinger arterial ter Arte riel, Promed, Le Plessiscatheter (Seldicath® PU Cathe Bouchard, France) is usually placed as a stent through the ductal opening, and secured to the buccal mucosa with a 2-0 silk stitch (Fig. 4c). The duct wall is then sutured with a 6-0 polyglactin (Vicryl®, Johnson & Johnson International, Brussels, Belgium) stitch and the parotid fascia is closed. A Redon drainage system is placed for 48e72 h and peri-operative antibiotic prophylaxis is given. 2.2.2. Nahlieli's technique A 1 cm incision is made over the marked and lighted (by the sialendoscope) region of the cheek upon the stone, according to the facial lines; the stone is then identified after gentle and blunt dissection. The parotid fascia is opened using a size 11 blade, and the stone is removed by means of dedicated elevators. The sialoendoscope is used to check the cavity and remove any residual
Fig. 3. After incising the duct and making a gentle dissection, the stone is held by pincers and removed (aec).
P. Capaccio et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1964e1969
1967
Fig. 4. The duct is irrigated with saline solution in order to remove debris and blood (a). The ductal system is endoscopically explored in a search for any other stones (b). A Seldinger catheter is placed in Stensen's duct to prevent stenosis (c). The aesthetic scar in a female patient 15 days after surgery (d).
fragments. After the withdrawal of the sialendoscope, the capsule is sutured with 4-0 polyglactin (Vicryl, Johnson & Johnson International, Brussels, Belgium), a blood-clot-inducing material net (Tabotamp®, Johnson & Johnson Medical Limited, Gargrave, Skipton, UK) is positioned between the parotid fascia and the skin, and the skin is sutured with 6-0 nylon. 2.3. Post-operative follow-up The patients were clinically re-examined after one week, two weeks, one month and six months in order to evaluate the course of wound healing and the presence of a clear secretory flow from the papilla after gland massage. Ultrasonography was used six months after surgery in order to check the echogenicity of the glandular parenchyma and ascertain any dilation of the ductal system. All of the patients were interviewed telephonically in order to verify the clinical course and check any recurrence of symptoms. 3. Results Eight patients with large stones (mean size 12.6 mm; range 8e20 mm) in the main parotid duct (4 patients) or its secondary parenchymal branch (4 patients) underwent combined sialendoscopic and transfacial surgery (Table 1). McGurk's technique was used under general anaesthesia to treat six of the patients; the remaining two were elderly patients with systemic comorbidities who were treated under sedation using Nahlieli's technique. Sialendoscopy-assisted surgery was successful in terms of stone removal in all but one patient. The failure occurred in a patient with a stone located in a secondary parenchymal branch of the ductal system who was treated using McGurk's technique. In this case, the stone moved deeply forward into the parenchyma, and could no longer be located by means of sialendoscopy or finger palpation. This patient successfully
underwent three sessions of extracorporeal shockwave lithotripsy and subsequent operative sialoendoscopy with complete clinical, endoscopic and ultrasonographic stone clearance. No major complications (in particular, no facial or auricular nerve damage) occurred in any of the patients. Mild-to-moderate gland swelling was observed in all cases, but this spontaneously and completely disappeared within 15 days. No postoperative ductal stenosis, sialoceles, or fistulas were observed after the spontaneous elimination or removal of the ductal stent (10e14 days after surgery). No ductal stent was used in the patients treated using Nahlieli's technique because of the superficial and parenchymal location of the stone. All of the patients were satisfied with their facial scars (Fig. 4d). Restored secretory flow after gland massage was observed in all of the patients, and post-operative ultrasonography showed normal echogenicity of the glandular parenchyma; mild duct dilation was observed in two patients proximal to the previous stone location but had no clinical consequences. All of the patients are currently symptom free after a mean follow-up of 19 months (range 6e45). 4. Discussion The advent of minimally invasive surgical techniques for the management of parotid gland stones has been fundamental in allowing a conservative and gland sparing approach to be adopted rather than the previous gold standard of major surgery by means of parotidectomy. According to our experience, and that of other authors' (Gillespie et al., 2011; Zenk et al., 2012; Witt et al., 2012), interventional sialendoscopy is successful for mobile stones and stones less than 5 mm; fixed stones and stones larger than 5 mm can be managed by ESWL. Notwithstanding the use of these techniques about 10% of patients still remain symptomatic thus needing surgery. The combined endoscopic and surgical approach to parotid
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P. Capaccio et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1964e1969
stones has been recently proposed as a successful technique (Koch et al., 2013). In our experience, stones with a diameter of 7 mm are at the upper limit for successful results after ESWL (Capaccio et al., 2004); therefore palpable stones larger than 7 mm were enrolled for the study. A successful result was obtained in all but one of our patients in terms of stone removal and, after a mean follow-up of 19 months, they are free from symptoms and pain; and ultrasonography and clinical evidence of clear salivary secretory flow from the papilla of Stensen's indicate restored glandular function. Our results are in line with those reported by others (Overton et al., 2012; Koch et al., 2013); the success rate of the combined approach, in terms of symptoms and absence of stones, is between 75 and 94% (Koch et al., 2013). On the basis of our and their experience, the main limitation of the procedure is represented by impalpable intraparenchymal stones that cannot be reached by means of sialoendoscopy (McGurk et al., 2006; Nahlieli et al., 2002). The only surgical failure was successfully treated by means of three sessions of ESWL and subsequent sialendoscopy. We previously demonstrated, in a large series of patients with a long-term clinical follow up, that parotid stones were associated with a favourable outcome on multivariate statistical analysis (Capaccio et al., 2004). At the time that treatment decisions were being made, the patient was informed about two possible therapeutic pathways: a cycle of ESWL followed by interventional sialendoscopy or sialendoscopyassisted transfacial removal of the stone. The patient decided to directly undergo sialendoscopy-assisted surgery, because it was a single stage and time-preserving procedure. The combination of sialendoscopy-induced ductal dilation and ESWL in this patient may have favoured the fragmentation and delivery of the stone from the ductal system. An alternative to this approach (especially in countries such as the USA, where ESWL is not available) may be the transfacial ultrasound-guided removal of parotid stones recently proposed by Carroll (Carrol et al., 2013). No major complications occurred. Nerve monitoring to avoid the risk of facial nerve injury is essential, especially in the case of stones located in the middle and distal thirds of Stensen's duct where the nerve is uncovered; the risk is less in the case of intraparenchymal or proximal duct stones because the nerve is protected by gland tissue. No sialoceles or salivary fistulas occurred in our patients, although it has been reported that such complications affected 10% of the patients in McGurk's series (Overton et al., 2012). We have observed one sialocele in a patient who was treated using McGurk's technique to remove a stone trapped in a broken basket wire in Stensen's duct (data not shown): the affected gland completely recovered after two consecutive sessions of botulin toxin type A injections. Botulinum toxin therapy is nowadays considered a treatment option for sialoceles or salivary fistulas, together with conservative procedures such as pressure dressing for one week and surgical procedures, mainly represented by closure of the ductal system or sialadenectomy. The incidence of side effects reported in the literature in the post-surgical management of salivary disorders (Capaccio et al., 2008; Pantel et al., 2013; Kruegel et al., 2010) justifies its use in patients after failure with a new surgical procedure. The placement and type of stent to use during McGurk's procedure is still a matter of debate (McGurk et al., 2006; Nahlieli et al., 2002), although stenting Stensen's duct is essential in order to prevent stenoses, fistulas and sialoceles. We used a Seldinger arterial catheter that was well tolerated by the patients. No stent was used in the case of the patients treated using Nahlieli's technique as the stone was completely intraparenchymal. Scarring was minimal; in order to avoid a poor aesthetic result, we made the incision in a skin fold when using McGurk's technique, and used a small facial incision when using Nahlieli's technique.
The post-operative results were very good in all cases, and all of the patients were highly satisfied. During the follow-up the patients were asked to drink at least 2 L of water per day, to use sialogogues and to perform a regular glandular massage at least 3 times a day, after main meals. 5. Conclusions The sialendoscopy-assisted transfacial surgical approach is a safe, effective and well-tolerated surgical option in the case of palpable and impacted parotid stones of >7 mm located in the main duct or parenchyma. This novel approach forms part of the multimodal management of parotid stones together with operative sialendoscopy and ESWL; the combination of these techniques favours high rates of success in terms of gland preservation and symptom control (Overton et al., 2012; McGurk et al., 2006; Nahlieli et al., 2002; Koch et al., 2013). In this regard it has been recently demonstrated that the lack of all these procedures lead to a higher rate of parotidectomy (Gillespie et al., 2011). Funding source No funding was secured for this study. Financial disclosure All authors have no financial relationships relevant to this article to disclose. Conflict of interest All authors have no conflict of interest to disclose. References Abdel-Wahed N, Amer ME, Abo- Taleb NS: Assessment of the role of cone beam computed sialography in diagnosing salivary gland lesions. Imaging Sci Dent 43(1): 17e23, 2013 Baurmash H, Dechiara SC: Extraoral parotid sialolithotomy. J Oral Maxillofac Surg 49(2): 127e132, 1991 Capaccio P, Ottaviani F, Manzo R, Schindler A, Cesana B: Extracorporeal lithotripsy for salivary calculi: a long-term clinical experience. Laryngoscope 114(6): 1069e1073, 2004 Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L: Modern management of obstructive salivary diseases. Acta Otorhinolaryngol Ital 27(4): 161e172, 2007 Capaccio P, Torretta S, Osio M, Minorati D, Ottaviani F, Sambataro G, et al: Botulinum toxin therapy: a tempting tool in the management of salivary secretory disorders. Am J Otolaryngol 29(5): 333e338, 2008 Capaccio P, Torretta S, Pignataro L: The role of adenectomy for salivary gland obstructions in the era of sialendoscopy and lithotripsy. Otolaryngol Clin North Am 42(6): 1161e1171, 2009 Carrol WW, Walvekar RR, Gillespie MB: Transfacial ultrasound-guided gland-preserving resection of parotid sialoliths. Otolaryngol Head Neck Surg 148(2): 229e234, 2013 Desmots F, Chossegros C, Salles F, Gallucci A, Moulin G, Varoquaux A: Lithotripsy for salivary stones with prospective US assessment on our first 25 consecutive patients. J Craniomaxillofac Surg 42(5): 577e582, 2014 Drage N, Brown JE, Escudier M, McGurk M: Interventional radiology in the removal of salivary calculi. Radiology 214: 139e142, 2000 Dreiseidler T, Ritter L, Rothamel D, Neugebauer J, Scheer M, Mischkowski RA: Salivary calculus diagnosis with 3-dimensional cone-beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110(1): 94e100, 2010 Escudier MP, Brown JE, Putcha V, Capaccio P, McGurk M: Factors influencing the outcome of extracorporeal shock wave lithotripsy in the management of salivary calculi. Laryngoscope 120(8): 1545e1549, 2010 Gillespie MB, Koch M, Iro H, Zenk J: Endoscopic-assisted gland-preserving therapy for chronic sialadenitis: a German and US comparison. Arch Otolaryngol Head Neck Surg 37(9): 903e908, 2011 Iro H, Zenk J, Waldfahrer F, Benzel W, Schneider T, Ell C: Extracorporeal shock wave lithotripsy of parotid stones: results of a prospective clinical trial. Ann Otol Rhinol Laryngol 107: 860e864, 1998 Kelly IMG, Dick R: Technical report. Interventional sialography: dormia basket removal of a Wharton's duct calculus. Clin Radiol 43: 205e206, 1991 Koch M, Iro H, Zenk J: Combined endoscopic-transcutaneous surgery in parotid gland sialolithiasis and other ductal diseases: reporting medium- to long-term objective and patients' subjective outcomes. Eur Arch Otorhinolaryngol 270(6): 1933e1940, 2013
P. Capaccio et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1964e1969 Kruegel J, Winterhoff J, Koehler S, Matthes P, Laskawi R: Botulinum toxin: a noninvasive option for the symptomatic treatment of salivary gland stenosis e a case report. Head Neck 32(7): 959e963, 2010 Liu DG, Zhang ZY, Zhang Y, Zhang L, Yu GY: Diagnosis and management of sialolithiasis with a semirigid endoscope. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108(1): 9e14, 2009 McGurk M, MacBean AD, Fan KF, Sproat C, Darwish C: Endoscopically assisted operative retrieval of parotid stones. Br J Oral Maxillofac Surg 44(2): 157e160, 2006 Nahlieli O, Baruchin AM: Long-term experience with endoscopic diagnosis and treatment of salivary gland inflammatory diseases. Laryngoscope 110: 988, 2000 Nahlieli O, London D, Zagury A, Eliav E: Combined approach to impacted parotid stones. J Oral Maxillofac Surg 60(12): 1418e1423, 2002 Nahlieli O, Nakar LH, Nazarian Y, Turner MD: Sialoendoscopy: a new approach to salivary gland obstructive pathology. J Am Dent Assoc 137(10): 1394e1400, 2006
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Overton A, Combes JM, McGurk M: Outcome after endoscopically assisted surgical retrieval of symptomatic parotid stones. Int J Oral Maxillofac Surg 41: 248e251, 2012 Pantel M, Volk GF, Guntinas-Lichius O, Wittekindt C: Botulinum toxin type b for the treatment of a sialocele after parotidectomy. Head Neck 35(1): E11eE12, 2013 Torretta S, Pignataro L, Capaccio P, Brevi A, Mazzola R: Fat injections for the management of post-parotidectomy Frey syndrome: a technical note. J Craniomaxillofac Surg 40(2): 173e176, 2012 Witt RL, Iro H, Koch M, McGurk M, Nahlieli O, Zenk J: Minimally invasive options for salivary calculi. Laryngoscope 122(6): 1306e1311, 2012 €nig B, Konz K, Gillespie MB, et al: Sialendoscopy in Zenk J, Koch M, Klintworth N, Ko the diagnosis and treatment of sialolithiasis: a study on more than 1000 patients. Otolaryngol Head Neck Surg 147(5): 858e863, 2012 Zenk J, Koch M, Mantsopoulos K, Klintworth N, Schapher M, Iro H: The significance of extracorporeal shock wave lithotripsy in sialolithiasis therapy. HNO 61(4): 306e311, 2013
Contents lists available at ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Sialendoscopy-assisted transfacial surgical removal of parotid stones Pasquale Capaccio a, c, *, Gaffuri Michele a, Pignataro Lorenzo a, b Granda Ospedale Maggiore Policlinico, Milan, Italy Otolaryngology Department, Fondazione IRCCS Ca Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy c Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 24 February 2014 Accepted 27 August 2014 Available online 7 September 2014
Minimally invasive surgical approaches to parotid stones (such as extra-corporeal shockwave lithotripsy and sialendoscopy) have proved to be effective in a high percentage of cases, although success depends on factors such as the localisation of the stone, its size and its mobility. The failure rate of 10% is largely due to large and impacted stones and, in such cases, a combined external and sialendoscopic approach can be used to avoid morbidity and the risks of more invasive superficial parotidectomy. We treated eight patients with large parotid stones (>7 mm) using a sialendoscopy-assisted transfacial surgical approach that was effective in all but one case, which was successfully solved by combining this procedure with extra-corporeal lithotripsy and operative sialendoscopy. Our results confirm that the combined approach is a valid alternative to parotidectomy for large parotid stones and should be added to other minimally invasive techniques aimed at restoring the function of the affected parotid gland. © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Parotid stones Minimally invasive technique Endoscopy assisted Sialolithiasis
1. Introduction About 20% of symptomatic stones are located in Stensen's duct, also called the parotid duct (Iro et al., 1998; Zenk et al., 2012). The symptoms are gland swelling during main meals, recurrent infections, and sometimes trismus (Overton et al., 2012), and a diagnosis can be made clinically or radiologically by means of ultrasound, occlusal view radiography, computed tomography (CT), contrast sialography, magnetic resonance (MR) sialography, or cone beam computed tomography (CBCT) (Abdel-Wahed et al., 2013; Dreiseidler et al., 2010). A remarkable percentage of parotid stones remain undetected by conventional imaging techniques (Nahlieli and Baruchin, 2000); in this regard sialendoscopy has a major role as a diagnostic tool for all causes of salivary obstruction (Nahlieli et al., 2006; Liu et al., 2009). The traditional management of parotid stones is based on sialadenectomy (Capaccio et al., 2009) in the case of main duct and intraparenchymal stones, and sialolithectomy (Witt et al., 2012) in the case of distal duct stones. However, both have well-known
Abbreviations: MR, magnetic resonance; CT, computed tomography; ESWL, extra-corporeal shockwave lithotripsy. * Corresponding author. Otolaryngology Department, Fondazione IRCCS C a Granda Ospedale Maggiore Policlinico, Via F Sforza 35, 20122 Milano, Italy. Tel.: þ39 0250320245; fax: þ 39 0250320248. E-mail address: [email protected] (P. Capaccio).
untoward effects (Overton et al., 2012; Torretta et al., 2012) and, over the last 20 years, various conservative and minimally invasive techniques have been developed, including extra-corporeal shockwave lithotripsy (ESWL) (Capaccio et al., 2004; Escudier et al., 2010; Desmots et al., 2014); operative sialendoscopy (Zenk et al., 2012); interventional radiology (Kelly and Dick, 1991; Drage et al., 2000); and sialendoscopy-assisted surgery (McGurk et al., 2006); the choice of which depends on the size, location (distal, proximal, intraparenchymal), and the number and mobility of the stones (Capaccio et al., 2009; Escudier et al., 2010; McGurk et al., 2006). Operative sialoendoscopy and ESWL (Zenk et al., 2012, 2013) are both highly successful means of treating parotid calculi: the former is better in the case of stones of <4 mm, whereas the latter is effective for stones of 4e7 mm. However, it has been demonstrated that minimally invasive techniques such as interventional sialendoscopy fail in 10% of cases (especially those involving palpable, impacted stones of >7 mm) (McGurk et al., 2006). To fill the gap, a new technique combining external and endoscopic surgery has recently been proposed as a less invasive alternative to traditional parotidectomy. Baurmash and Dechiara, 1991 described the first extra-oral sialolitothomy without parotidectomy supported by plain radiographs and high definition ultrasound. Nahlieli et al. (2002) similarly located stones by means of ultrasonography and/or sialendoscopy, and then removed them using a vertical skin incision. In 2006, McGurk et al. described a modified combined approach that involves locating the
http://dx.doi.org/10.1016/j.jcms.2014.08.009 1010-5182/© 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
P. Capaccio et al. / Journal of Cranio-Maxillo-Facial Surgery 42 (2014) 1964e1969
1965
Table 1 Clinical findings and details of parotid stones. mm: millimetre; Fr: French. Patient
Age
Sex
Side
Location
Stone size (mm)
Stent
1 2 3 4 5 6 7 8
60 67 37 72 81 75 56 73
f f m m m m f m
left right left left left right left left
intraparenchymal ductal ductal intraparenchymal intraparenchymal intraparenchymal ductal ductal
10 18 8 8 20 15 10 12
yes yes yes no no no yes yes
stone with a salivary endoscope and its subsequent surgical removal by means of a pre-auricular skin incision. The aim of this paper is to describe our own initial experience of using a combined sialendoscopic and surgical approach to treat eight patients with large parotid stones.
Stent size (Fr)
Follow up (months)
Seldicath Seldicath Seldicath
5 5 3
Seldicath Seldicath
3 4
12 3 6 45 32 25 11 18
meals. The exclusion criterion was the presence of a complete distal stenosis of Stensen's duct as assessed by means of a clinical evaluation and MR sialography. All of the patients underwent salivary gland ultrasonography (Hitachi H21, 7.5 MHz, Hitachi HighTechnologies Corporation Ltd., Tokyo, Japan) to confirm the clinical suspicion of a stone.
2. Materials and methods 2.2. Surgical techniques 2.1. Patients and indications Eight patients (three female, five male; mean age 65 years, range 37e81) with recurrent obstructive parotid gland disease due to a large stone (>7 mm), and no previous surgical intervention, were enrolled at the University of Milan's Department of Otolaryngology between July 2009 and May 2013 (Table 1). All of the patients underwent the sialendoscopy-assisted transfacial surgical removal of the parotid stone using McGurk's technique (McGurk et al., 2006) under general anaesthesia (six patients) or Nahlieli's technique (Nahlieli et al., 2002) under sedation (two patients). The inclusion criteria were the presence of a palpable parotid stone of >7 mm located in the main parotid duct or in a secondary parenchymal branch of the ductal system and the recurrence of symptoms and signs such as pain and parotid swelling during
Regardless of the technique used, the surgery always begins with an endoscopic exploration of the ductal system of the affected parotid gland using a dedicated salivary endoscope (0.8 mm, Nahlieli sialoendoscope, Karl Storz Co., GmbH, Tuttlingen, Germany). Its insertion through the opening valve of Stensen's duct is preceded by appropriate dilatation with lacrimal duct probes (Bowman probes, Karl Storz, Tuttlingen, Germany) (Capaccio et al., 2007). Once the surgeon can visualise the stone, the high-powered light at the tip of the endoscope allows its exact location to be marked on the facial skin (Fig. 1a, black arrow). Subsequently: 2.2.1. McGurk's technique A Redon pre-auricular incision is made (Fig. 1a, violet line) and the subcutaneous layers are gently dissected (Fig. 1b). The skin flap
Fig. 1. (a) Stone localisation on the skin surface (black arrow) and drawing of the preauricular incision (violet line). After gentle dissection of the subcutaneous layers (b), a skin flap is raised (c), and the dissection is continued through the parotid fascia in order to expose the parotid gland and the proximal tract of Stensen's duct (d).
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Fig. 2. The buccal branch of the facial nerve (black arrows) is close to the duct (a), and its function is carefully checked using a nerve stimulator (b). The position of the stone is confirmed by means of salivary endoscopy (c) using the high-powered light at the tip of the endoscope (d). In this case, the stone is located intraparenchymally, in the proximal tract of Stensen's duct (e).
is raised and the dissection continues (Fig. 1c), involving the parotid fascia in order to expose the parotid gland in front of the stone and the proximal tract of Stensen's duct (Fig. 1d). During the blunt dissection, the buccal branch of the facial nerve close to the duct surgery is identified (Fig. 2a). The preparation of the best operative field, with complete exposure of the site in which the stone is located, requires the use of a neurostimulator (Neuro-Pulse®, Bovie Medical Corporation, Clearwater, FL, USA) to check the functioning of the buccal and other possible branches of the VII cranial nerve met during dissection (Fig. 2b). The light at the tip of the endoscope allows the exact position of the stone to be located (Fig. 2cee), and the main duct or its secondary parenchymal branch is incised over the stone and parallel to its direction using a size 11 scalpel; after gentle dissection using dedicated instruments, the stone is grasped with pincers, and then removed (Fig. 3aec). The duct is then irrigated with saline (Fig. 4a) and an endoscopic search is made for any
residual stones or debris (Fig. 4b). Subsequently, a Seldinger arterial ter Arte riel, Promed, Le Plessiscatheter (Seldicath® PU Cathe Bouchard, France) is usually placed as a stent through the ductal opening, and secured to the buccal mucosa with a 2-0 silk stitch (Fig. 4c). The duct wall is then sutured with a 6-0 polyglactin (Vicryl®, Johnson & Johnson International, Brussels, Belgium) stitch and the parotid fascia is closed. A Redon drainage system is placed for 48e72 h and peri-operative antibiotic prophylaxis is given. 2.2.2. Nahlieli's technique A 1 cm incision is made over the marked and lighted (by the sialendoscope) region of the cheek upon the stone, according to the facial lines; the stone is then identified after gentle and blunt dissection. The parotid fascia is opened using a size 11 blade, and the stone is removed by means of dedicated elevators. The sialoendoscope is used to check the cavity and remove any residual
Fig. 3. After incising the duct and making a gentle dissection, the stone is held by pincers and removed (aec).
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Fig. 4. The duct is irrigated with saline solution in order to remove debris and blood (a). The ductal system is endoscopically explored in a search for any other stones (b). A Seldinger catheter is placed in Stensen's duct to prevent stenosis (c). The aesthetic scar in a female patient 15 days after surgery (d).
fragments. After the withdrawal of the sialendoscope, the capsule is sutured with 4-0 polyglactin (Vicryl, Johnson & Johnson International, Brussels, Belgium), a blood-clot-inducing material net (Tabotamp®, Johnson & Johnson Medical Limited, Gargrave, Skipton, UK) is positioned between the parotid fascia and the skin, and the skin is sutured with 6-0 nylon. 2.3. Post-operative follow-up The patients were clinically re-examined after one week, two weeks, one month and six months in order to evaluate the course of wound healing and the presence of a clear secretory flow from the papilla after gland massage. Ultrasonography was used six months after surgery in order to check the echogenicity of the glandular parenchyma and ascertain any dilation of the ductal system. All of the patients were interviewed telephonically in order to verify the clinical course and check any recurrence of symptoms. 3. Results Eight patients with large stones (mean size 12.6 mm; range 8e20 mm) in the main parotid duct (4 patients) or its secondary parenchymal branch (4 patients) underwent combined sialendoscopic and transfacial surgery (Table 1). McGurk's technique was used under general anaesthesia to treat six of the patients; the remaining two were elderly patients with systemic comorbidities who were treated under sedation using Nahlieli's technique. Sialendoscopy-assisted surgery was successful in terms of stone removal in all but one patient. The failure occurred in a patient with a stone located in a secondary parenchymal branch of the ductal system who was treated using McGurk's technique. In this case, the stone moved deeply forward into the parenchyma, and could no longer be located by means of sialendoscopy or finger palpation. This patient successfully
underwent three sessions of extracorporeal shockwave lithotripsy and subsequent operative sialoendoscopy with complete clinical, endoscopic and ultrasonographic stone clearance. No major complications (in particular, no facial or auricular nerve damage) occurred in any of the patients. Mild-to-moderate gland swelling was observed in all cases, but this spontaneously and completely disappeared within 15 days. No postoperative ductal stenosis, sialoceles, or fistulas were observed after the spontaneous elimination or removal of the ductal stent (10e14 days after surgery). No ductal stent was used in the patients treated using Nahlieli's technique because of the superficial and parenchymal location of the stone. All of the patients were satisfied with their facial scars (Fig. 4d). Restored secretory flow after gland massage was observed in all of the patients, and post-operative ultrasonography showed normal echogenicity of the glandular parenchyma; mild duct dilation was observed in two patients proximal to the previous stone location but had no clinical consequences. All of the patients are currently symptom free after a mean follow-up of 19 months (range 6e45). 4. Discussion The advent of minimally invasive surgical techniques for the management of parotid gland stones has been fundamental in allowing a conservative and gland sparing approach to be adopted rather than the previous gold standard of major surgery by means of parotidectomy. According to our experience, and that of other authors' (Gillespie et al., 2011; Zenk et al., 2012; Witt et al., 2012), interventional sialendoscopy is successful for mobile stones and stones less than 5 mm; fixed stones and stones larger than 5 mm can be managed by ESWL. Notwithstanding the use of these techniques about 10% of patients still remain symptomatic thus needing surgery. The combined endoscopic and surgical approach to parotid
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stones has been recently proposed as a successful technique (Koch et al., 2013). In our experience, stones with a diameter of 7 mm are at the upper limit for successful results after ESWL (Capaccio et al., 2004); therefore palpable stones larger than 7 mm were enrolled for the study. A successful result was obtained in all but one of our patients in terms of stone removal and, after a mean follow-up of 19 months, they are free from symptoms and pain; and ultrasonography and clinical evidence of clear salivary secretory flow from the papilla of Stensen's indicate restored glandular function. Our results are in line with those reported by others (Overton et al., 2012; Koch et al., 2013); the success rate of the combined approach, in terms of symptoms and absence of stones, is between 75 and 94% (Koch et al., 2013). On the basis of our and their experience, the main limitation of the procedure is represented by impalpable intraparenchymal stones that cannot be reached by means of sialoendoscopy (McGurk et al., 2006; Nahlieli et al., 2002). The only surgical failure was successfully treated by means of three sessions of ESWL and subsequent sialendoscopy. We previously demonstrated, in a large series of patients with a long-term clinical follow up, that parotid stones were associated with a favourable outcome on multivariate statistical analysis (Capaccio et al., 2004). At the time that treatment decisions were being made, the patient was informed about two possible therapeutic pathways: a cycle of ESWL followed by interventional sialendoscopy or sialendoscopyassisted transfacial removal of the stone. The patient decided to directly undergo sialendoscopy-assisted surgery, because it was a single stage and time-preserving procedure. The combination of sialendoscopy-induced ductal dilation and ESWL in this patient may have favoured the fragmentation and delivery of the stone from the ductal system. An alternative to this approach (especially in countries such as the USA, where ESWL is not available) may be the transfacial ultrasound-guided removal of parotid stones recently proposed by Carroll (Carrol et al., 2013). No major complications occurred. Nerve monitoring to avoid the risk of facial nerve injury is essential, especially in the case of stones located in the middle and distal thirds of Stensen's duct where the nerve is uncovered; the risk is less in the case of intraparenchymal or proximal duct stones because the nerve is protected by gland tissue. No sialoceles or salivary fistulas occurred in our patients, although it has been reported that such complications affected 10% of the patients in McGurk's series (Overton et al., 2012). We have observed one sialocele in a patient who was treated using McGurk's technique to remove a stone trapped in a broken basket wire in Stensen's duct (data not shown): the affected gland completely recovered after two consecutive sessions of botulin toxin type A injections. Botulinum toxin therapy is nowadays considered a treatment option for sialoceles or salivary fistulas, together with conservative procedures such as pressure dressing for one week and surgical procedures, mainly represented by closure of the ductal system or sialadenectomy. The incidence of side effects reported in the literature in the post-surgical management of salivary disorders (Capaccio et al., 2008; Pantel et al., 2013; Kruegel et al., 2010) justifies its use in patients after failure with a new surgical procedure. The placement and type of stent to use during McGurk's procedure is still a matter of debate (McGurk et al., 2006; Nahlieli et al., 2002), although stenting Stensen's duct is essential in order to prevent stenoses, fistulas and sialoceles. We used a Seldinger arterial catheter that was well tolerated by the patients. No stent was used in the case of the patients treated using Nahlieli's technique as the stone was completely intraparenchymal. Scarring was minimal; in order to avoid a poor aesthetic result, we made the incision in a skin fold when using McGurk's technique, and used a small facial incision when using Nahlieli's technique.
The post-operative results were very good in all cases, and all of the patients were highly satisfied. During the follow-up the patients were asked to drink at least 2 L of water per day, to use sialogogues and to perform a regular glandular massage at least 3 times a day, after main meals. 5. Conclusions The sialendoscopy-assisted transfacial surgical approach is a safe, effective and well-tolerated surgical option in the case of palpable and impacted parotid stones of >7 mm located in the main duct or parenchyma. This novel approach forms part of the multimodal management of parotid stones together with operative sialendoscopy and ESWL; the combination of these techniques favours high rates of success in terms of gland preservation and symptom control (Overton et al., 2012; McGurk et al., 2006; Nahlieli et al., 2002; Koch et al., 2013). In this regard it has been recently demonstrated that the lack of all these procedures lead to a higher rate of parotidectomy (Gillespie et al., 2011). Funding source No funding was secured for this study. Financial disclosure All authors have no financial relationships relevant to this article to disclose. Conflict of interest All authors have no conflict of interest to disclose. References Abdel-Wahed N, Amer ME, Abo- Taleb NS: Assessment of the role of cone beam computed sialography in diagnosing salivary gland lesions. Imaging Sci Dent 43(1): 17e23, 2013 Baurmash H, Dechiara SC: Extraoral parotid sialolithotomy. J Oral Maxillofac Surg 49(2): 127e132, 1991 Capaccio P, Ottaviani F, Manzo R, Schindler A, Cesana B: Extracorporeal lithotripsy for salivary calculi: a long-term clinical experience. Laryngoscope 114(6): 1069e1073, 2004 Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L: Modern management of obstructive salivary diseases. Acta Otorhinolaryngol Ital 27(4): 161e172, 2007 Capaccio P, Torretta S, Osio M, Minorati D, Ottaviani F, Sambataro G, et al: Botulinum toxin therapy: a tempting tool in the management of salivary secretory disorders. Am J Otolaryngol 29(5): 333e338, 2008 Capaccio P, Torretta S, Pignataro L: The role of adenectomy for salivary gland obstructions in the era of sialendoscopy and lithotripsy. Otolaryngol Clin North Am 42(6): 1161e1171, 2009 Carrol WW, Walvekar RR, Gillespie MB: Transfacial ultrasound-guided gland-preserving resection of parotid sialoliths. Otolaryngol Head Neck Surg 148(2): 229e234, 2013 Desmots F, Chossegros C, Salles F, Gallucci A, Moulin G, Varoquaux A: Lithotripsy for salivary stones with prospective US assessment on our first 25 consecutive patients. J Craniomaxillofac Surg 42(5): 577e582, 2014 Drage N, Brown JE, Escudier M, McGurk M: Interventional radiology in the removal of salivary calculi. Radiology 214: 139e142, 2000 Dreiseidler T, Ritter L, Rothamel D, Neugebauer J, Scheer M, Mischkowski RA: Salivary calculus diagnosis with 3-dimensional cone-beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110(1): 94e100, 2010 Escudier MP, Brown JE, Putcha V, Capaccio P, McGurk M: Factors influencing the outcome of extracorporeal shock wave lithotripsy in the management of salivary calculi. Laryngoscope 120(8): 1545e1549, 2010 Gillespie MB, Koch M, Iro H, Zenk J: Endoscopic-assisted gland-preserving therapy for chronic sialadenitis: a German and US comparison. Arch Otolaryngol Head Neck Surg 37(9): 903e908, 2011 Iro H, Zenk J, Waldfahrer F, Benzel W, Schneider T, Ell C: Extracorporeal shock wave lithotripsy of parotid stones: results of a prospective clinical trial. Ann Otol Rhinol Laryngol 107: 860e864, 1998 Kelly IMG, Dick R: Technical report. Interventional sialography: dormia basket removal of a Wharton's duct calculus. Clin Radiol 43: 205e206, 1991 Koch M, Iro H, Zenk J: Combined endoscopic-transcutaneous surgery in parotid gland sialolithiasis and other ductal diseases: reporting medium- to long-term objective and patients' subjective outcomes. Eur Arch Otorhinolaryngol 270(6): 1933e1940, 2013
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