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A Newly Developed Interventional Sialendoscope for a Completely Nonsurgical Sialolithectomy Using Intracorporeal Electrohydraulic Lithotripsy
TECHNICAL NOTES J Oral Maxillofac Surg 65:1402-1405, 2007
A Newly Developed Interventional Sialendoscope for a Completely Nonsurgical Sialolithectomy Using Intracorporeal Electrohydraulic Lithotripsy Eiji Nakayama, DDS, PhD,* Kazutoshi Okamura, DDS, PhD,† Takeshi Mitsuyasu, DDS, PhD,‡ Toshiyuki Kawazu, DDS,§ Norifumi Nakamura, DDS, PhD,㛳 Seiji Nakamura, DDS, PhD,¶ and Kazunori Yoshiura, DDS, PhD# Interventional sialendoscopy using the lithotripsy technique has been progressively improved over the last 15 years.1-11 Almost all previously reported procedures needed an incision of the papilla or duct wall of the salivary gland to insert the therapeutic sialendoscope. However, we consider that we should avoid any surgical procedures, including a minimal incision of the papilla or duct during interventional sialendoscopy, to make the maximum use of the minimally invasive characteristics of endoscopic treatment. We therefore developed a fine sialendoscope, which allows us to insert the scope without any incision into the papilla or duct wall of the salivary gland in order to perform both diagnostic and therapeutic sialendoscopy. Moreover, this sialendoscope
Received from Kyushu University Hospital, Fukuoka, Japan. *Associate Professor, Department of Oral and Maxillofacial Radiology. †Instructor, Department of Oral and Maxillofacial Radiology. ‡Instructor, Department of Oral and Maxillofacial Surgery. §Instructor, Department of Oral and Maxillofacial Radiology. 㛳Assistant Professor, Department of Oral and Maxillofacial Surgery. ¶Professor, Department of Oral and Maxillofacial Surgery. #Professor, Department of Oral and Maxillofacial Radiology. Address correspondence and reprint requests to Dr Nakayama: Department of Oral and Maxillofacial Radiology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; e-mail: [email protected] © 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6507-0027$32.00/0 doi:10.1016/j.joms.2005.11.087
was designed to have a working channel with a 0.8-mm inner diameter so that a 1.9-Fr probe of an electrohydraulic lithotripter can be inserted into the working channel. Using this newly developed sialendoscopy system for intracorporeal electrohydraulic lithotripsy, we were able to successfully remove a sialolith of the submandibular gland safely and without any surgical intervention. The aims of this article are to introduce this newly developed interventional sialendoscopy system and describe a successful case of a completely nonsurgical sialolithectomy of the submandibular gland using this sialendoscopy system.
Method We developed a new fine rigid sialendoscope (Salivascope T PD-ZS-2002, Polydiagnost GmbH, Pfaffenhofen, Germany) with a 1.35-mm outer diameter in 2004 (Fig 1A). The sialendoscope has 3,000pixel optic fibers, a working channel, and an irrigation channel. The working channel has a 0.8-mm inner diameter so that a 1.9-Fr probe of an electrohydraulic lithotripter can be inserted into the working channel. Both diagnostic and interventional sialendoscopy can thus be performed using the above-mentioned sialendoscope, an electrohydraulic lithotripter, Autolith (Northgate Technologies Inc, Elgin, IL) (Fig 1B), and a 1.9-Fr probe, Micro II (Northgate Technologies Inc) (Fig 1A, B). The operating voltage of the Autolith ranges from 3,000 to 6,000 V, and the shotrepetition frequency ranges from 1 to 30 Hz. The operating voltage and the shot-repetition frequency can be changed in increments of 10% and 1 Hz,
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1403
respectively. The number of shock waves that can be given in a single procedure can also be selected from 1 to 60. The sialoscopic view can be observed with a conventional peripheral endoscopy system (a light source and a CCD camera, monitor, video recorder, etc).
Report of a Case A 20-year-old woman visited Kyushu University Hospital with the chief complaint of swelling in the right submandibular region at meals. An occlusal intraoral radiograph showed a sialolith in the right submandibular region (Fig 2). The saliva flow from the orifice of the right submandibular gland was good. Sialography showed a sialolith at the hilus of the submandibular gland (Fig 3). The patient was recommended to undergo surgery to remove the sialolith, however, she did not want to have surgery. Therefore, we decided to perform intracorporeal electrohydraulic lithotripsy of the sialolith with the previously mentioned sialen-
FIGURE 2. An occlusal intraoral x-ray radiograph showing a sialolith in the right submandibular region (arrow). Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
doscopy system in order to carry out a nonsurgical sialolithectomy. This sialendoscopy did not require any invasive procedures such as an incision of the papilla. We first performed conduction anesthesia for the right mandibular nerve with 0.9 mL of 2% lidocaine hydrochloride solution. Next, we expanded the diameter of Wharton’s duct at the papilla using a dilatable bougie and then kept the bougie in place for several minutes. After several trials to dilate the papilla and insert the sialendoscope, we were finally able to suc-
FIGURE 1. A, A newly developed sialendoscope. The sialendoscope has a 1.35-mm outer diameter with a working channel measuring 0.8 mm in inner diameter and an irrigation channel. B, An electrohydraulic lithotripter, Autolith, and a 1.9-Fr probe, Micro II. The probe can be inserted into the working channel of the sialendoscope.
FIGURE 3. A sialograph showing a sialolith at the hilus of the submandibular gland (arrows).
Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
1404 cessfully insert the sialendoscope into the duct without any need to incise the papilla or the duct. We then observed the inner surface of the duct under positive pressure by injecting physiologic saline. The sialendoscopic view showed a sialolith in the duct at the hilus of the submandibular gland. We performed an intracorporeal electrohydraulic lithotripsy under sialendoscopic observations. The top of the sialendoscope was put near the sialolith, and then several milliliters of surface anesthetic, consisting of 2% lidocaine hydrochloride solution was administered under pressure through the irrigation channel. This surface anesthesia, combined with conjunction anesthesia for the mandibular nerve, is necessary to completely avoid any pain caused by the stimulation of the electrohydraulic shock wave. We next inserted a 1.9-Fr probe into the working channel and kept the probe tip at least 5 mm from the edge of the sialendoscope to avoid damaging the scope. Furthermore, we maintained a 1- to 2-mm distance between the probe and the sialolith. We then sent shock waves into the sialolith under sialendoscopic observations, while making sure that the shock waves went directly into the stone and not into the duct wall (Fig 4A). We first started to generate the shock waves at a frequency of 10 Hz, a voltage level of 10%, and a shot number of 1, but with this power level, the sialolith could not be destroyed. We therefore increased the voltage level from 10% to 20%, to 30% and finally 40%, and set the shot number at 3. The sialolith could thus be destroyed, and it broke into many pieces after several shots of shock waves while irrigating the area with a sufficient quantity of physiologic saline (Figs 4B,C). We then applied additional shock waves with a voltage level of 30% to each fragment of the sialolith. Each fragment became progressively smaller until they could be washed out from the proximal end of Wharton’s duct. Finally, the fragments were not observed at the hilus of the submandibular gland (Fig 4D). A few times, a slight amount of bleeding was observed on the surface of the duct wall, which later stopped naturally while being irrigated with physiologic saline. At the end of the procedure, irrigation with acrinol solution was performed to prevent any infection, and then the sialendoscope was removed from Wharton’s duct without any complications. The occlusal view taken just after treatment showed numerous fragments of the sialolith along the course of the right Wharton’s duct (Fig 5). The
SIALENDSCOPY USING ELECTROHYDRAULIC LITHOTRIPSY
FIGURE 5. An occlusal view, which was taken just after the treatment, showing numerous fragments of the sialolith along the course of the right Wharton’s duct. Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
fragments were considered to be moved to the anterior part of Wharton’s duct by saline irrigation during the treatment. The patient felt spontaneous pain that increased in intensity when swallowing after the treatment, which was controlled by analgesics. Moreover, she suffered from moderate swelling of the right side of the oral floor and submandibular region, and therefore, she could not comfortably eat or drink due to the swelling for 2 days after treatment. However, these symptoms disappeared completely by 3 days after treatment, and even the swelling of the right submandibular region at meals due to the sialolith also disappeared. We examined the patient 4 and 12 days after the treatment and confirmed the saliva flow to be good from the papilla of the right submandibular gland without any aftereffects. The occlusal view taken 12 days after the treatment showed no fragments of the sialolith on the right side of the oral floor (Fig 6). The fragments were considered to be flushed out from the orifice of Wharton’s duct by hydrostatic pressure of saliva. A follow-up examination was also done at 3 months after the treatment, and she did not have any further symptoms.
Discussion FIGURE 4. A sialendoscopic view showing a sialolith and a probe of intracorporeal electrohydraulic lithotripter. A, The probe was placed in front of the sialolith so that the shock wave went directly into the sialolith. B, The sialolith was thus destroyed into 3 fragments (F). C, Additional shock waves further broke it down into many small fragments (F) of the sialolith. D, Finally, the fragments were not observed at the hilus of the submandibular gland. Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
Intracorporeal electrohydraulic lithotripsies under endoscopic observations have been developed to remove the sialoliths in a minimally invasive manner.3,7,8,10,11 The diameters of sialendoscopes for intracorporeal electrohydraulic lithotripsy or laser lithotripsy, which were used in previously reported articles, ranged from 1.6 to 2.3 mm.3-8,10,11 However,
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doscopy. According to this concept, we developed a new sialendoscope with a 1.35-mm outer diameter, a working channel of 0.8-mm inner diameter, and 3,000-pixel optic fibers. The image quality of the sialendoscope is excellent and sufficient to perform both diagnostic and therapeutic sialendoscopy (Fig 4). Using this newly developed sialendoscopy system, we successfully performed a completely nonsurgical sialolithectomy under sialendoscopic observations by means of intracorporeal electrohydraulic lithotripsy. Moreover, a laser lithotripsy method1,2,4-7,9-11 can also be easily introduced using our sialendoscopy system because we can insert a laser probe with an outer diameter smaller than 0.8 mm into the working channel. We also plan to perform intracorporeal laser lithotripsy in the future using this sialendoscopy system, when such an opportunity arises. This newly developed fine sialendoscopy system for intracorporeal electrohydraulic lithotripsy allows us to safely and effectively perform true nonsurgical interventional sialendoscopy to remove sialoliths. FIGURE 6. An occlusal view, which was taken 12 days after the treatment, showing no fragments of the sialolith remaining on the right side of the oral floor. Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
all of these methods of lithotripsy using such sialendoscopes usually require an incision of the papilla or the wall of the salivary duct to insert the sialendoscope into the duct, especially in the case of Wharton’s duct, because the diameter of the endoscope tends to be larger than the dilatation limit of the duct.10 Therefore, we decided to develop a fine sialendoscope with a wide working channel so that the sialendoscope can be inserted into the salivary duct without the need to make any incision of the duct, and a 1.9-Fr probe of an electrohydraulic lithotripter can be inserted into the working channel. The adoption of a thin outer diameter of the sialendoscope and the fragmentation method by intracorporeal electrohydraulic lithotripsy enables us to insert the sialendoscope into the duct and then remove the sialolith outside the duct without any incision of the papilla, even if the sialolith’s size is larger than the limits of the dilatation of the duct.12 Hence, the main objective of our new sialendoscopy system for intracorporeal electrohydraulic lithotripsy is to establish a new procedure for completely nonsurgical therapeutic sialen-
References 1. Gundlach P, Scherer H, Hopf J, et al: Die endoskopisch kontrollierte Laserlithotripsie von Speichelsteinen. HNO 38:247, 1990 2. Königsberger R, Feyh J, Goetz A, et al: Die endoskopisch kontrollierte Laserlithotripsie zur Behandlung der Sialolithiasis. Laryngorrhinootologie 69:322, 1990 3. Königsberger R, Feyh J, Goetz A, et al: Endoscopically-controlled electrohydraulic intracorporeal shock wave lithotripsy (EISL) of salivary stones. J Otolaryngol 22:12, 1993 4. Arzoz E, Santiago A, Garatea J, et al: Removal of a stone in Stensen’s duct with endoscopic laser lithotripsy: Report of case. J Oral Maxillofac Surg 52:1329, 1994 5. Iro H, Zenk J, Benzel W: Laser lithotripsy of salivary duct stones, in Rudert H, Werner JA (eds): Lasers in Otorhinolaryngology, and in Head and Neck Surgery. Adv Otorhinolaryngol, vol 49. Basel, Switzerland, Karger, 1995, p 148 6. Iro H, Zenk J, Waldfather F, et al: Current therapy of sialolithiasis. HNO 44:78, 1996 7. Arzoz E, Santiago A, Esnal F, et al: Endoscopic intracorporeal lithotripsy for sialolithiasis. J Oral Maxillofac Surg 54:847, 1996 8. Nahlieli O, Baruchin AM: Endoscopic technique for the diagnosis and treatment of obstructive salivary gland diseases. J Oral Maxillofac Surg 57:1394, 1999 9. Marchal F, Becker M, Dulguerov P, et al: Interventional sialendoscopy. Laryngoscope 110:318, 2000 10. Marchal F, Dulguerov P, Becker M, et al: Specificity of parotid sialendoscopy. Laryngoscope 111:264, 2001 11. Marchal F, Dulguerov P, Becker M, et al: Submandibular diagnostic and interventional sialendoscopy: New procedure for ductal disorders. Ann Otol Rhinol Laryngol 111:27, 2002 12. Nakayama E, Yuasa K, Beppu M, et al: Interventional sialendoscopy: A new procedure for noninvasive insertion and a minimally invasive sialolithectomy. J Oral Maxillofac Surg 61:1233, 2003
A Newly Developed Interventional Sialendoscope for a Completely Nonsurgical Sialolithectomy Using Intracorporeal Electrohydraulic Lithotripsy Eiji Nakayama, DDS, PhD,* Kazutoshi Okamura, DDS, PhD,† Takeshi Mitsuyasu, DDS, PhD,‡ Toshiyuki Kawazu, DDS,§ Norifumi Nakamura, DDS, PhD,㛳 Seiji Nakamura, DDS, PhD,¶ and Kazunori Yoshiura, DDS, PhD# Interventional sialendoscopy using the lithotripsy technique has been progressively improved over the last 15 years.1-11 Almost all previously reported procedures needed an incision of the papilla or duct wall of the salivary gland to insert the therapeutic sialendoscope. However, we consider that we should avoid any surgical procedures, including a minimal incision of the papilla or duct during interventional sialendoscopy, to make the maximum use of the minimally invasive characteristics of endoscopic treatment. We therefore developed a fine sialendoscope, which allows us to insert the scope without any incision into the papilla or duct wall of the salivary gland in order to perform both diagnostic and therapeutic sialendoscopy. Moreover, this sialendoscope
Received from Kyushu University Hospital, Fukuoka, Japan. *Associate Professor, Department of Oral and Maxillofacial Radiology. †Instructor, Department of Oral and Maxillofacial Radiology. ‡Instructor, Department of Oral and Maxillofacial Surgery. §Instructor, Department of Oral and Maxillofacial Radiology. 㛳Assistant Professor, Department of Oral and Maxillofacial Surgery. ¶Professor, Department of Oral and Maxillofacial Surgery. #Professor, Department of Oral and Maxillofacial Radiology. Address correspondence and reprint requests to Dr Nakayama: Department of Oral and Maxillofacial Radiology, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan; e-mail: [email protected] © 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6507-0027$32.00/0 doi:10.1016/j.joms.2005.11.087
was designed to have a working channel with a 0.8-mm inner diameter so that a 1.9-Fr probe of an electrohydraulic lithotripter can be inserted into the working channel. Using this newly developed sialendoscopy system for intracorporeal electrohydraulic lithotripsy, we were able to successfully remove a sialolith of the submandibular gland safely and without any surgical intervention. The aims of this article are to introduce this newly developed interventional sialendoscopy system and describe a successful case of a completely nonsurgical sialolithectomy of the submandibular gland using this sialendoscopy system.
Method We developed a new fine rigid sialendoscope (Salivascope T PD-ZS-2002, Polydiagnost GmbH, Pfaffenhofen, Germany) with a 1.35-mm outer diameter in 2004 (Fig 1A). The sialendoscope has 3,000pixel optic fibers, a working channel, and an irrigation channel. The working channel has a 0.8-mm inner diameter so that a 1.9-Fr probe of an electrohydraulic lithotripter can be inserted into the working channel. Both diagnostic and interventional sialendoscopy can thus be performed using the above-mentioned sialendoscope, an electrohydraulic lithotripter, Autolith (Northgate Technologies Inc, Elgin, IL) (Fig 1B), and a 1.9-Fr probe, Micro II (Northgate Technologies Inc) (Fig 1A, B). The operating voltage of the Autolith ranges from 3,000 to 6,000 V, and the shotrepetition frequency ranges from 1 to 30 Hz. The operating voltage and the shot-repetition frequency can be changed in increments of 10% and 1 Hz,
1402
NAKAYAMA ET AL
1403
respectively. The number of shock waves that can be given in a single procedure can also be selected from 1 to 60. The sialoscopic view can be observed with a conventional peripheral endoscopy system (a light source and a CCD camera, monitor, video recorder, etc).
Report of a Case A 20-year-old woman visited Kyushu University Hospital with the chief complaint of swelling in the right submandibular region at meals. An occlusal intraoral radiograph showed a sialolith in the right submandibular region (Fig 2). The saliva flow from the orifice of the right submandibular gland was good. Sialography showed a sialolith at the hilus of the submandibular gland (Fig 3). The patient was recommended to undergo surgery to remove the sialolith, however, she did not want to have surgery. Therefore, we decided to perform intracorporeal electrohydraulic lithotripsy of the sialolith with the previously mentioned sialen-
FIGURE 2. An occlusal intraoral x-ray radiograph showing a sialolith in the right submandibular region (arrow). Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
doscopy system in order to carry out a nonsurgical sialolithectomy. This sialendoscopy did not require any invasive procedures such as an incision of the papilla. We first performed conduction anesthesia for the right mandibular nerve with 0.9 mL of 2% lidocaine hydrochloride solution. Next, we expanded the diameter of Wharton’s duct at the papilla using a dilatable bougie and then kept the bougie in place for several minutes. After several trials to dilate the papilla and insert the sialendoscope, we were finally able to suc-
FIGURE 1. A, A newly developed sialendoscope. The sialendoscope has a 1.35-mm outer diameter with a working channel measuring 0.8 mm in inner diameter and an irrigation channel. B, An electrohydraulic lithotripter, Autolith, and a 1.9-Fr probe, Micro II. The probe can be inserted into the working channel of the sialendoscope.
FIGURE 3. A sialograph showing a sialolith at the hilus of the submandibular gland (arrows).
Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
1404 cessfully insert the sialendoscope into the duct without any need to incise the papilla or the duct. We then observed the inner surface of the duct under positive pressure by injecting physiologic saline. The sialendoscopic view showed a sialolith in the duct at the hilus of the submandibular gland. We performed an intracorporeal electrohydraulic lithotripsy under sialendoscopic observations. The top of the sialendoscope was put near the sialolith, and then several milliliters of surface anesthetic, consisting of 2% lidocaine hydrochloride solution was administered under pressure through the irrigation channel. This surface anesthesia, combined with conjunction anesthesia for the mandibular nerve, is necessary to completely avoid any pain caused by the stimulation of the electrohydraulic shock wave. We next inserted a 1.9-Fr probe into the working channel and kept the probe tip at least 5 mm from the edge of the sialendoscope to avoid damaging the scope. Furthermore, we maintained a 1- to 2-mm distance between the probe and the sialolith. We then sent shock waves into the sialolith under sialendoscopic observations, while making sure that the shock waves went directly into the stone and not into the duct wall (Fig 4A). We first started to generate the shock waves at a frequency of 10 Hz, a voltage level of 10%, and a shot number of 1, but with this power level, the sialolith could not be destroyed. We therefore increased the voltage level from 10% to 20%, to 30% and finally 40%, and set the shot number at 3. The sialolith could thus be destroyed, and it broke into many pieces after several shots of shock waves while irrigating the area with a sufficient quantity of physiologic saline (Figs 4B,C). We then applied additional shock waves with a voltage level of 30% to each fragment of the sialolith. Each fragment became progressively smaller until they could be washed out from the proximal end of Wharton’s duct. Finally, the fragments were not observed at the hilus of the submandibular gland (Fig 4D). A few times, a slight amount of bleeding was observed on the surface of the duct wall, which later stopped naturally while being irrigated with physiologic saline. At the end of the procedure, irrigation with acrinol solution was performed to prevent any infection, and then the sialendoscope was removed from Wharton’s duct without any complications. The occlusal view taken just after treatment showed numerous fragments of the sialolith along the course of the right Wharton’s duct (Fig 5). The
SIALENDSCOPY USING ELECTROHYDRAULIC LITHOTRIPSY
FIGURE 5. An occlusal view, which was taken just after the treatment, showing numerous fragments of the sialolith along the course of the right Wharton’s duct. Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
fragments were considered to be moved to the anterior part of Wharton’s duct by saline irrigation during the treatment. The patient felt spontaneous pain that increased in intensity when swallowing after the treatment, which was controlled by analgesics. Moreover, she suffered from moderate swelling of the right side of the oral floor and submandibular region, and therefore, she could not comfortably eat or drink due to the swelling for 2 days after treatment. However, these symptoms disappeared completely by 3 days after treatment, and even the swelling of the right submandibular region at meals due to the sialolith also disappeared. We examined the patient 4 and 12 days after the treatment and confirmed the saliva flow to be good from the papilla of the right submandibular gland without any aftereffects. The occlusal view taken 12 days after the treatment showed no fragments of the sialolith on the right side of the oral floor (Fig 6). The fragments were considered to be flushed out from the orifice of Wharton’s duct by hydrostatic pressure of saliva. A follow-up examination was also done at 3 months after the treatment, and she did not have any further symptoms.
Discussion FIGURE 4. A sialendoscopic view showing a sialolith and a probe of intracorporeal electrohydraulic lithotripter. A, The probe was placed in front of the sialolith so that the shock wave went directly into the sialolith. B, The sialolith was thus destroyed into 3 fragments (F). C, Additional shock waves further broke it down into many small fragments (F) of the sialolith. D, Finally, the fragments were not observed at the hilus of the submandibular gland. Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
Intracorporeal electrohydraulic lithotripsies under endoscopic observations have been developed to remove the sialoliths in a minimally invasive manner.3,7,8,10,11 The diameters of sialendoscopes for intracorporeal electrohydraulic lithotripsy or laser lithotripsy, which were used in previously reported articles, ranged from 1.6 to 2.3 mm.3-8,10,11 However,
1405
NAKAYAMA ET AL
doscopy. According to this concept, we developed a new sialendoscope with a 1.35-mm outer diameter, a working channel of 0.8-mm inner diameter, and 3,000-pixel optic fibers. The image quality of the sialendoscope is excellent and sufficient to perform both diagnostic and therapeutic sialendoscopy (Fig 4). Using this newly developed sialendoscopy system, we successfully performed a completely nonsurgical sialolithectomy under sialendoscopic observations by means of intracorporeal electrohydraulic lithotripsy. Moreover, a laser lithotripsy method1,2,4-7,9-11 can also be easily introduced using our sialendoscopy system because we can insert a laser probe with an outer diameter smaller than 0.8 mm into the working channel. We also plan to perform intracorporeal laser lithotripsy in the future using this sialendoscopy system, when such an opportunity arises. This newly developed fine sialendoscopy system for intracorporeal electrohydraulic lithotripsy allows us to safely and effectively perform true nonsurgical interventional sialendoscopy to remove sialoliths. FIGURE 6. An occlusal view, which was taken 12 days after the treatment, showing no fragments of the sialolith remaining on the right side of the oral floor. Nakayama et al. Sialendscopy Using Electrohydraulic Lithotripsy. J Oral Maxillofac Surg 2007.
all of these methods of lithotripsy using such sialendoscopes usually require an incision of the papilla or the wall of the salivary duct to insert the sialendoscope into the duct, especially in the case of Wharton’s duct, because the diameter of the endoscope tends to be larger than the dilatation limit of the duct.10 Therefore, we decided to develop a fine sialendoscope with a wide working channel so that the sialendoscope can be inserted into the salivary duct without the need to make any incision of the duct, and a 1.9-Fr probe of an electrohydraulic lithotripter can be inserted into the working channel. The adoption of a thin outer diameter of the sialendoscope and the fragmentation method by intracorporeal electrohydraulic lithotripsy enables us to insert the sialendoscope into the duct and then remove the sialolith outside the duct without any incision of the papilla, even if the sialolith’s size is larger than the limits of the dilatation of the duct.12 Hence, the main objective of our new sialendoscopy system for intracorporeal electrohydraulic lithotripsy is to establish a new procedure for completely nonsurgical therapeutic sialen-
References 1. Gundlach P, Scherer H, Hopf J, et al: Die endoskopisch kontrollierte Laserlithotripsie von Speichelsteinen. HNO 38:247, 1990 2. Königsberger R, Feyh J, Goetz A, et al: Die endoskopisch kontrollierte Laserlithotripsie zur Behandlung der Sialolithiasis. Laryngorrhinootologie 69:322, 1990 3. Königsberger R, Feyh J, Goetz A, et al: Endoscopically-controlled electrohydraulic intracorporeal shock wave lithotripsy (EISL) of salivary stones. J Otolaryngol 22:12, 1993 4. Arzoz E, Santiago A, Garatea J, et al: Removal of a stone in Stensen’s duct with endoscopic laser lithotripsy: Report of case. J Oral Maxillofac Surg 52:1329, 1994 5. Iro H, Zenk J, Benzel W: Laser lithotripsy of salivary duct stones, in Rudert H, Werner JA (eds): Lasers in Otorhinolaryngology, and in Head and Neck Surgery. Adv Otorhinolaryngol, vol 49. Basel, Switzerland, Karger, 1995, p 148 6. Iro H, Zenk J, Waldfather F, et al: Current therapy of sialolithiasis. HNO 44:78, 1996 7. Arzoz E, Santiago A, Esnal F, et al: Endoscopic intracorporeal lithotripsy for sialolithiasis. J Oral Maxillofac Surg 54:847, 1996 8. Nahlieli O, Baruchin AM: Endoscopic technique for the diagnosis and treatment of obstructive salivary gland diseases. J Oral Maxillofac Surg 57:1394, 1999 9. Marchal F, Becker M, Dulguerov P, et al: Interventional sialendoscopy. Laryngoscope 110:318, 2000 10. Marchal F, Dulguerov P, Becker M, et al: Specificity of parotid sialendoscopy. Laryngoscope 111:264, 2001 11. Marchal F, Dulguerov P, Becker M, et al: Submandibular diagnostic and interventional sialendoscopy: New procedure for ductal disorders. Ann Otol Rhinol Laryngol 111:27, 2002 12. Nakayama E, Yuasa K, Beppu M, et al: Interventional sialendoscopy: A new procedure for noninvasive insertion and a minimally invasive sialolithectomy. J Oral Maxillofac Surg 61:1233, 2003