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Endoscopy: a minimally invasive procedure for diagnosis and treatment of diseases of the salivary glands
British Journal of Oral and Maxillofacial Surgery (2004) 42, 1—7
Endoscopy: a minimally invasive procedure for diagnosis and treatment of diseases of the salivary glands Six years of practical experience C.M. Ziegler*, H. Steveling, M. Seubert, J. Mühling Department of Oral and Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany Received 5 May 2003; accepted 14 September 2003
KEYWORDS Sialoendoscopy; Calculi; Salivary glands; Sialolithiasis; Sialadenitis
Summary During a 6-year period we did a total of 72 videoendoscopies of the salivary glands and their associated ductal systems. This minimally invasive procedure is associated with little morbidity and discomfort. The main indication was sialolithiasis of the submandibular and parotid glands. Sialoendoscopy was used not only for diagnosis of radiolucent calculi but also for simultaneous removal of calculi. Sialoendoscopy was also of benefit in the diagnosis and treatment of other diseases of the salivary glands. Even patients with chronic sialadenitis could be helped with endoscopic dilatation of the causative sialostenosis, thereby enabling us to conserve the gland. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1. Introduction Minimally invasive techniques offer a wide range of different options, including videoendoscopy for the diagnosis and treatment of nephrolithiasis and cystolithiasis. Comparable techniques and instruments may be used with corresponding modifications for the major salivary glands of the head and neck.1—3 Videoendoscopy is able to supplement and improve current diagnostic techniques for salivary gland diseases with pathological changes of the ductal system. As well as conventional radiographs (such as a pantomogram) these options can include sonography,4—6 scintiscanning, sialography,7,8 and *Corresponding author. Tel.: +49-622-141-9213; fax: +49-622-141-9256. E-mail address: [email protected] (C.M. Ziegler).
also computed tomography (CT) and magnetic resonance imaging (MRI).5,7,9 In contrast to these endoscopy in the form of videomonitoring can be used not only for diagnosis, but also concurrently for treatment. An example is the imaging and removal of salivary stones.
2. Patients and methods During the 6-year period 1996—2001 inclusive, a total of 72 endoscopies of the parotid and submandibular glands were done. Thirty-nine male and 33 female patients, age range 12—74 years, underwent 24 endoscopic procedures on the parotid gland and duct and 48 procedures on the submandibular duct. Two groups of patients were identified: those in whom a calculus was suspected preoperatively (n = 54), and those with inflammatory symptoms
0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-4356(03)00188-8
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C.M. Ziegler et al.
Figure 1 Occlusal radiograph of the mandible showing two large opacities in the area of the left Stensen’s duct.
of unknown origin (n = 18). The median follow-up was 19 months (range 4—49 months). The patients had a largely standardised endoscopic procedures.1,9,10 As well clinical examination and preoperative radiographs (Fig. 1) those suggestive of sialadenitis also had a sonogram. Scintiscanning was indicated for those patients with appreciably reduced excretory function, as proof of a non-functioning gland is a potential contraindication for endoscopy. In addition we also used sonography for follow-up. A total of 68 outpatient endoscopies were done under local anaesthesia. General anaesthesia was required only for patients unable to cooperate fully (severe gag reflex or fear) or who had a calculus distal to the posterior border of the mylohyoid muscle (n = 4). Different procedures and instruments were used depending on the existing intraductal disease: in the case of small concrements dilatation of the duct and irrigation was usually sufficient to wash out the concrements. However, in some grasping instruments were also used to deal with larger stones (more than about 4 mm in diameter) (Figs. 2—4). Most were extracted after previous pulverisation with microforceps. Other intraluminal conditions such as adenoids and adhesions (Fig. 5) with coexisting salivary stasis could also be removed by grasping instruments under direct vision. At the end of the intervention a flexible cannula was temporarily fixed in the duct to avoid postoperative strictures. Antibiotics were given prophylactically only to patients with severe generalised disease, and were continued until the ductal stent was removed. In acute inflammatory episodes, endoscopic interventions were avoided. Further clinical and sonographic controls were done after 6 weeks and after 6 months. In addition to the follow-up a scintiscan was done after a min-
Figure 2
Figure 3
Endoscopic intraductal view of the sialolith.
Two large calculi removed endoscopically.
Endoscopy: a minimally invasive procedure
3 symptom-free patient. In cases of retained debris the success was judged to be partial, if the patient was symptom-free. In cases of sialadenitis, we considered an endoscopic intervention as successful if there was clear salivary flow and normal intraoral and extraoral palpation of the gland. If the patient complained of persisting symptoms or required removal of the gland the result was classified as a failure.
3. Results
Figure 4 Endoscopic view without obstruction after removal of the sialoliths and concrements (same site as in Fig. 2).
imum of 2—3 months postoperatively, but this was not routine. The criteria for successful treatment were considered to be elimination of the calculus and a
Figure 5 Intraluminal adhesions between the ductal wall and a sialolith with additional inflammatory changes.
It was not possible to cannulate the salivary duct orifice in four cases because of pre-existing strictures: one of the parotid gland and three of the submandibular gland. In 54 patients, endoscopy (Table 1) was indicated for suspected sialolithiasis, but radio-opaque sialoliths were shown preoperatively in only 41 patients (76%). In the remaining 18 patients, endoscopy was done for chronic sialadenitis with reduced salivation of unknown origin. All patients had similar clinical symptoms with intermittent swelling of the gland and pain on palpation. All interventions were well tolerated by the patients. Apart from a temporary swelling, which was mainly caused by retention of the irrigating fluid and which receded within a few days, there was no operative or postoperative morbidity such as nerve injury, bleeding, or ductal stricture. In 6 of the 72 patients (8%), the clinical symptoms and subjective problems did not improve after endoscopic intervention, so that subsequent removal of the submandibular gland was required. In one case a large sialolith within the substance of the gland could not be removed. In another, chronic sialadenitis with glandular atrophy showed no sign of regeneration. No cases affecting the parotid gland required subsequent removal of the gland (Table 2). In one case of sialoadenitis with intraluminal adhesions removal of the gland was necessary 5 weeks after endoscopy because of persisting inflammatory symptoms. The median follow-up of 19 months included the five patients in whom removal of the gland was required between 3 and 7 months after the intervention. Eleven patients had sialoliths larger than 4 mm and a further six cases had sialoliths up to 10 mm in diameter, usually at the hilum of the gland where intraductal lithotripsy was not possible, resulting in a failure rate of 11% of the 54 patients with sialoliths. However, it was possible to locate the calculus exactly and to remove it through a small transmucosal incision, after which the duct could be
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Table 1 Clinical cases studied: submandibular gland. Case number
Sex/age (years)
Site (left/right)
Cause of complaints sialolith/others
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
M/12 F/17 F/24 M/26 M/27 M/29 F/30 M/32 F/33 M/35 M/35 M/36 F/37 M/38 M/38 M/39 F/40 F/40 M/42 F/42 M/43 M/44 M/45 F/45 M/41 F/47 M/48 M/49 F/50 F/50 M/52 M/53 F/53 M/54 M/54 M/57 M/59 F/59 M/60 F/60 M/62 M/63 F/64 M/64 M/66 F/67 F/69 F/69
Left Right Right Right Left Left Right Left Right Right Left Left Right Right Left Right Right Left Right Right Right Left Right Left Right Left Left Right Left Left Right Right Right Left Right Left Left Right Right Left Right Left Right Right Left Right Right Left
Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sphincter-like obstruction Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Sphincter-like obstruction Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Kinked duct Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Kinked duct Sialolith (radiolucent) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sphincter-like obstruction Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Kinked duct Sialolith (radiolucent) Intraluminal adhesion
The glands of cases 20, 27, 31, 33, 42 and 45 required removal after endoscopy.
reconstructed and sutured under endoscopic control. There were no clinical or sonographic signs of iatrogenic duct strictures during the follow-up of these cases, all of which affected the submandibular gland.
The largest stone within Stensen’s duct was 5 mm. In 7 of the 41 patients (17%) with a radio-opaque sialolith, endoscopy showed further smaller concrements that had not been detected on the
Endoscopy: a minimally invasive procedure
5
Table 2 Clinical cases studied: parotid gland. Case number
Sex/age (years)
Site (left/right)
Cause of complaints sialolith/others
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
F/28 F/31 M/32 M/33 F/34 F/35 M/38 F/43 M/45 F/49 M/51 M/53 F/56 F/57 M/58 F/58 F/60 F/60 M/63 F/65 M/66 M/70 F/71 F/74
Left Left Left Right Left Left Right Left Right Right Left Left Left Right Left Right Right Left Left Left Right Left Left Right
Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radiolucent) Sialolith (radiolucent) Sphincter-like obstruction Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radiolucent) Intraluminal adhesion Sialolith (radiolucent) Intraluminal adhesion Sialolith (radiolucent)
No gland required removal after endoscopy.
radiographs preoperatively, but which could also be removed (Fig. 6). Allowing for one sialolithiasis with simultaneous removal of the gland and the need for six conven-
Figure 6 Further smaller concrements, which were also found by the endoscopic investigation (and were not detected previously).
tional stone extractions, our overall endoscopic success rate in 54 patients with sialolithiasis was 87%. Apart from the stenoses caused by stones, 11 patients had intraluminal adhesions (seven in Wharton’s duct and four in Stensen’s duct) and four patients had a sphincter-like obstruction (two in Wharton’s duct and two in Stensen’s duct), which were potential causes of salivary obstruction. In all 15 cases, salivary flow was improved intraoperatively. The 11 intraluminal adhesions were treated by endoscopic bouginage with lysis and lavage of the excretory duct. The four sphincter-like obstructions were reopened. With the help of a basket these were disobliterated. Kinking of the duct as a potential cause for salivary stasis was found in three other cases (one in Stensen’s duct and two in Wharton’s duct). Five of the 18 patients with sialadenitis without stones had little improvement in their clinical findings and symptoms at the time of the follow-up. In all cases the submandibular gland was affected. Two patients had intraluminal adhesions and sphincter-like obstructions and one other was associated with kinking of the duct. In these patients we proceeded to remove the gland rather than to a second endoscopy.
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4. Discussion Endoscopy of the salivary glands is a dynamic, minimally invasive diagnostic and therapeutic procedure which causes little morbidity.1,11,12 Often a final diagnosis can be made even in cases in which other imaging methods have not produced clear results. Endoscopy can often rule out other potential differential diagnoses,10,11 and is important, particularly with regard to sialolithiasis of the major salivary glands.13—16 Even radiolucent concrements may be seen. By using endoscopy Nahlieli and Baruchin found sialoliths associated in the region of the submandibular gland in 32% (in 7 of a total of 22 patients) and in the region of the parotid gland in 70% (in 7 of 10 patients) which had not been detected by other imaging methods.3 The number of such cases within our own series was, however, lower. Nevertheless, we are convinced that sialoendoscopy is superior to plain films or even to CT sialography. After sialoliths have been removed from the distal region of the excretory duct (Figs. 2—4) we could sometimes find further concrements endoscopically in the proximal regions of the duct (Fig. 6). These may go undetected using conventional techniques and may cause persisting symptoms. Our own results of 17% are similar to those reported elsewhere of between 15 and 18%.17,18 This is why endoscopic follow-up should also be considered after conventional sialolithotomy.19 Therefore special flexible endoscopes with a small diameter could be used (Fig. 7). Conventional surgery is particularly difficult in the key area of Wharton’s duct and may lead to postoperative complaints and the risk of an iatrogenic lesion of the lingual nerve. Depending on the symptoms, even removal of the gland should be considered as another approach. In comparison sialoendoscopy is a safer therapeutic option. After endoscopic intervention and removal of any mechanical obstruction an atrophic gland will recover in most cases.3,11 At clinical follow-up we noted a clear improvement of symptoms and of the patients’ subjective problems. Possible postoperative strictures can be excluded if palpation and salivation are normal and if the patient is symptom-free. Prognosis for complete resolution of chronic sialadenitis, however, is not possible to predict.3 This is particularly so when sialoliths are larger than 6 mm in diameter and are difficult to crush mechanically. Other options are pulverisation with pulsed laser (CO2 or colour laser),3,20 electro-hydraulic-intracorporeal lithotripsy, or the extracorporeal induction of piezoelectric shock waves.21—23 Fragmentation by shock wave
Figure 7 Flexible endoscope with a diameter of 0.5 mm for diagnostic interventions.
lithotripsy, however, has to be used with caution as damage to the glandular tissue cannot be excluded,3,17 and nociceptors and proprioceptors might also be damaged. Intracorporeal (intraductal) lithotripsy is therefore to be preferred, which is also more exact than extracorporeal fragmentation. Our experience is limited with an electrohydraulic shock wave generator (‘‘Calcutript’’, Karl Storz Comp., Tuttlingen, Germany), and so we cannot give a recommendations about its’ advantages and disadvantages over other pneumoballistic generators. Although lithotripsy is possible with extracorporeal induction of shock waves there is still the problem of removing the concrements from the duct system. In assessing this procedure one should consider this aspect particularly the frequent adhesions between sialoliths and the inner wall of the duct that may lead to stasis of salivary flow particularly if the sialoliths are large.3 It is not possible to reach and remove intraglandular sialoliths or their fragments with endoscopy, so submandibular sialadenectomy should be the first consideration. Other intraductal conditions can lead to stasis of salivation and consequently to sialoadenitis, but
Endoscopy: a minimally invasive procedure these may also be dealt with endoscopy. Such conditions includes strictures and bends in the ductal system,24 intraductal adenoids, and sphincter-like findings in the duct walls.25 Other examples are sphincter-like ductal systems, intraluminal adenoids, or adhesions.3,11 When ducts were obliterated we used a Fogarty balloon catheter comparable to those used for endarterectomy in vascular surgery. Balloon-tipped catheters were first used for dilatation of the duct but can also be used for stripping. We think that this technique may have advantage of preventing ductal adhesions after revision of inflammatory changes in the duct walls. According to our experience and that of others19,25 regeneration of the ductal wall after endoscopic removal of concrements or adhesions can be expected. Even a revision of kinking of the duct is possible with endoscopic intervention,24 so microsialodochoplasties were not required in our patients. A patulous and dilated, so-called sausage-shaped, form of ductal ectasia that is found in longstanding chronic low grade parotitis can be only partly improved by endoscopy, but is only a minor cause of clinical problems, and we had no case. In general, our own results (overall success rate of 83%) are comparable to those of Arzoz and Nahlieli.1 Because of the many treatment options, together with a low morbidity and minimal discomfort, we routinely use salivary gland endoscopy for diagnosis and treatment of sialolithiasis. Other potential conditions of the ductal system might lead to atrophy of the gland as a result of obstruction of the duct and stasis. However, because these can be detected and treated well endoscopically, we recommend endoscopy for patients with these findings. Endoscopy can be an option of particular value in cases of chronic sialadenitis when the gland may be conserved and an operation avoided.
References 1. Arzoz E, Nahlieili O. Gland endoscopy. In: McGurk M, Renehan A, editors. Controversies in the management of salivary gland disease. Oxford: University Press; 2002. p. 271—84. 2. Katz P. Endoscopie des glandes salivaires. Ann Radiol Paris 1991;34:110—3. 3. Nahlieli O, Baruchin AM. Sialoendoscopy: three years’ experience as a diagnostic and treatment modality. J Oral Maxillofac Surg 1997;55:912—8. 4. Bruneton JN, Mourou MY. Ultrasound in salivary gland disease. J Otorhinolaryngol Relat Spec 1993;55:284—9.
7 5. Weber AL. Imaging of the salivary glands. Curr Opin Radiol 1992;4:117—22. 6. Wittich GB, Scheible WF, Hajek PC. Ultrasonography of the salivary glands. Radiol Clin North Am 1985;23:29—37. 7. Gundlach P, Hopf J, Linnarz M. Introduction of a new diagnostic procedure: salivary duct endoscopy (sialendoscopy), clinical evaluation of sialendoscopy, sialography and X-ray imaging. Endosc Surg Allied Technol 1994;2:294—6. 8. Haug RH, Braduck JP, Indressano AT. Xeroradiography in the diagnosis of nonradiopaque sialoliths. Oral Surg Oral Med Oral Pathol 1989;67:146—8. 9. Carter BL, Karmody CS, Blickman JR, Panders AL. Computed tomography and sialography. 2. Pathology. J Comput Assist Tomogr 1981;5:46—53. 10. Ziegler CM, Mühling J. Die Videoendoskopie der großen Kopfspeicheldrüsen in Diagnostik und Therapie. Endoskopie heute 1998;3:8—12. 11. Ziegler CM, Nahlieli O, Mühling J. Videoendoskopie der großen Kopfspeicheldrüsen. Mund Kiefer Gesichtschir 1999;3:320—4. 12. Marchal F, Dulguerov P, Becker M, Barki G, Disant F, Lehmann W. Specificity of parotid sialendoscopy. Laryngoscope 2001;111:264—71. 13. Katz P. Nouvelle therapeutique des lithiases salivaires. Int J Dent 1991;73:3975—9. 14. Katz P. Nouvelle therapeutique des lithiases salivaires. Rev Laryngol Otol Rhinol 1993;114:379—82. 15. Lustmann I, Regev E, Melamed Y. Sialolithiasis: a survey of 245 patients and review of the literature. Int J Oral Maxillofac Surg 1990;19:135—8. 16. Nahlieli O, Neder A, Baruchin AM. Salivary gland endoscopy: a new technique for diagnosis and treatment of sialolithiasis. J Oral Maxillofac Surg 1994;52:1240—2. 17. Neder A, Nahlieli O. Discussion: endoscopic intracorporeal lithotripsy for sialolithiasis. J Oral Maxillofac Surg 1996;54:851—2. 18. Rice DH. Advances in diagnosis and management of salivary gland diseases. West J Med 1984;140:238—49. 19. Nahlieli O, Baruchin AM. Endoscopic technique for the diagnosis and treatment of obstructive salivary gland diseases. J Oral Maxillofac Surg 1999;57:1394—401. 20. Iro H, Zenk J, Benzel W. Laser lithotripsy of salivary ductstones. Adv Otorhinolaryngol 1995;49:148—52. 21. Arzoz E, Santiago A, Esnal F, Palomero R. Endoscopic intracorporeal lithotripsy for sialolithiasis. J Oral Maxillofac Surg 1996;54:847—52. 22. Gutmann R, Ziegler G, Leunig A, Jakob K, Feyh J. Die endoskopische und extrakorporale Stoßwellen-Lithotripsie von Speichelsteinen. Laryngorhinootology 1995;74:249— 53. 23. Konigsberger R, Feyh J, Goetz A, Kastenbauer E. Endoscopically controlled electrohydraulic intracorporeal shock wave lithotripsy (EISL) of salivary stones. J Otolaryngol 1993;22:12—3. 24. Nahlieli O, Shacham R, Yoffe B, Eliav E. Diagnosis and treatment of strictures and kinks in salivary gland ducts. J Oral Maxillofac Surg 2001;59:484—90. 25. Nahlieli O, Baruchin AM. Long-term experience with endoscopic diagnosis and treatment of salivary gland inflammatory diseases. Laryngoscope 2000;110:988—93.
Endoscopy: a minimally invasive procedure for diagnosis and treatment of diseases of the salivary glands Six years of practical experience C.M. Ziegler*, H. Steveling, M. Seubert, J. Mühling Department of Oral and Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany Received 5 May 2003; accepted 14 September 2003
KEYWORDS Sialoendoscopy; Calculi; Salivary glands; Sialolithiasis; Sialadenitis
Summary During a 6-year period we did a total of 72 videoendoscopies of the salivary glands and their associated ductal systems. This minimally invasive procedure is associated with little morbidity and discomfort. The main indication was sialolithiasis of the submandibular and parotid glands. Sialoendoscopy was used not only for diagnosis of radiolucent calculi but also for simultaneous removal of calculi. Sialoendoscopy was also of benefit in the diagnosis and treatment of other diseases of the salivary glands. Even patients with chronic sialadenitis could be helped with endoscopic dilatation of the causative sialostenosis, thereby enabling us to conserve the gland. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1. Introduction Minimally invasive techniques offer a wide range of different options, including videoendoscopy for the diagnosis and treatment of nephrolithiasis and cystolithiasis. Comparable techniques and instruments may be used with corresponding modifications for the major salivary glands of the head and neck.1—3 Videoendoscopy is able to supplement and improve current diagnostic techniques for salivary gland diseases with pathological changes of the ductal system. As well as conventional radiographs (such as a pantomogram) these options can include sonography,4—6 scintiscanning, sialography,7,8 and *Corresponding author. Tel.: +49-622-141-9213; fax: +49-622-141-9256. E-mail address: [email protected] (C.M. Ziegler).
also computed tomography (CT) and magnetic resonance imaging (MRI).5,7,9 In contrast to these endoscopy in the form of videomonitoring can be used not only for diagnosis, but also concurrently for treatment. An example is the imaging and removal of salivary stones.
2. Patients and methods During the 6-year period 1996—2001 inclusive, a total of 72 endoscopies of the parotid and submandibular glands were done. Thirty-nine male and 33 female patients, age range 12—74 years, underwent 24 endoscopic procedures on the parotid gland and duct and 48 procedures on the submandibular duct. Two groups of patients were identified: those in whom a calculus was suspected preoperatively (n = 54), and those with inflammatory symptoms
0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-4356(03)00188-8
2
C.M. Ziegler et al.
Figure 1 Occlusal radiograph of the mandible showing two large opacities in the area of the left Stensen’s duct.
of unknown origin (n = 18). The median follow-up was 19 months (range 4—49 months). The patients had a largely standardised endoscopic procedures.1,9,10 As well clinical examination and preoperative radiographs (Fig. 1) those suggestive of sialadenitis also had a sonogram. Scintiscanning was indicated for those patients with appreciably reduced excretory function, as proof of a non-functioning gland is a potential contraindication for endoscopy. In addition we also used sonography for follow-up. A total of 68 outpatient endoscopies were done under local anaesthesia. General anaesthesia was required only for patients unable to cooperate fully (severe gag reflex or fear) or who had a calculus distal to the posterior border of the mylohyoid muscle (n = 4). Different procedures and instruments were used depending on the existing intraductal disease: in the case of small concrements dilatation of the duct and irrigation was usually sufficient to wash out the concrements. However, in some grasping instruments were also used to deal with larger stones (more than about 4 mm in diameter) (Figs. 2—4). Most were extracted after previous pulverisation with microforceps. Other intraluminal conditions such as adenoids and adhesions (Fig. 5) with coexisting salivary stasis could also be removed by grasping instruments under direct vision. At the end of the intervention a flexible cannula was temporarily fixed in the duct to avoid postoperative strictures. Antibiotics were given prophylactically only to patients with severe generalised disease, and were continued until the ductal stent was removed. In acute inflammatory episodes, endoscopic interventions were avoided. Further clinical and sonographic controls were done after 6 weeks and after 6 months. In addition to the follow-up a scintiscan was done after a min-
Figure 2
Figure 3
Endoscopic intraductal view of the sialolith.
Two large calculi removed endoscopically.
Endoscopy: a minimally invasive procedure
3 symptom-free patient. In cases of retained debris the success was judged to be partial, if the patient was symptom-free. In cases of sialadenitis, we considered an endoscopic intervention as successful if there was clear salivary flow and normal intraoral and extraoral palpation of the gland. If the patient complained of persisting symptoms or required removal of the gland the result was classified as a failure.
3. Results
Figure 4 Endoscopic view without obstruction after removal of the sialoliths and concrements (same site as in Fig. 2).
imum of 2—3 months postoperatively, but this was not routine. The criteria for successful treatment were considered to be elimination of the calculus and a
Figure 5 Intraluminal adhesions between the ductal wall and a sialolith with additional inflammatory changes.
It was not possible to cannulate the salivary duct orifice in four cases because of pre-existing strictures: one of the parotid gland and three of the submandibular gland. In 54 patients, endoscopy (Table 1) was indicated for suspected sialolithiasis, but radio-opaque sialoliths were shown preoperatively in only 41 patients (76%). In the remaining 18 patients, endoscopy was done for chronic sialadenitis with reduced salivation of unknown origin. All patients had similar clinical symptoms with intermittent swelling of the gland and pain on palpation. All interventions were well tolerated by the patients. Apart from a temporary swelling, which was mainly caused by retention of the irrigating fluid and which receded within a few days, there was no operative or postoperative morbidity such as nerve injury, bleeding, or ductal stricture. In 6 of the 72 patients (8%), the clinical symptoms and subjective problems did not improve after endoscopic intervention, so that subsequent removal of the submandibular gland was required. In one case a large sialolith within the substance of the gland could not be removed. In another, chronic sialadenitis with glandular atrophy showed no sign of regeneration. No cases affecting the parotid gland required subsequent removal of the gland (Table 2). In one case of sialoadenitis with intraluminal adhesions removal of the gland was necessary 5 weeks after endoscopy because of persisting inflammatory symptoms. The median follow-up of 19 months included the five patients in whom removal of the gland was required between 3 and 7 months after the intervention. Eleven patients had sialoliths larger than 4 mm and a further six cases had sialoliths up to 10 mm in diameter, usually at the hilum of the gland where intraductal lithotripsy was not possible, resulting in a failure rate of 11% of the 54 patients with sialoliths. However, it was possible to locate the calculus exactly and to remove it through a small transmucosal incision, after which the duct could be
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C.M. Ziegler et al.
Table 1 Clinical cases studied: submandibular gland. Case number
Sex/age (years)
Site (left/right)
Cause of complaints sialolith/others
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
M/12 F/17 F/24 M/26 M/27 M/29 F/30 M/32 F/33 M/35 M/35 M/36 F/37 M/38 M/38 M/39 F/40 F/40 M/42 F/42 M/43 M/44 M/45 F/45 M/41 F/47 M/48 M/49 F/50 F/50 M/52 M/53 F/53 M/54 M/54 M/57 M/59 F/59 M/60 F/60 M/62 M/63 F/64 M/64 M/66 F/67 F/69 F/69
Left Right Right Right Left Left Right Left Right Right Left Left Right Right Left Right Right Left Right Right Right Left Right Left Right Left Left Right Left Left Right Right Right Left Right Left Left Right Right Left Right Left Right Right Left Right Right Left
Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sphincter-like obstruction Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Sphincter-like obstruction Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Kinked duct Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Kinked duct Sialolith (radiolucent) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sphincter-like obstruction Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radio-opaque) Kinked duct Sialolith (radiolucent) Intraluminal adhesion
The glands of cases 20, 27, 31, 33, 42 and 45 required removal after endoscopy.
reconstructed and sutured under endoscopic control. There were no clinical or sonographic signs of iatrogenic duct strictures during the follow-up of these cases, all of which affected the submandibular gland.
The largest stone within Stensen’s duct was 5 mm. In 7 of the 41 patients (17%) with a radio-opaque sialolith, endoscopy showed further smaller concrements that had not been detected on the
Endoscopy: a minimally invasive procedure
5
Table 2 Clinical cases studied: parotid gland. Case number
Sex/age (years)
Site (left/right)
Cause of complaints sialolith/others
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
F/28 F/31 M/32 M/33 F/34 F/35 M/38 F/43 M/45 F/49 M/51 M/53 F/56 F/57 M/58 F/58 F/60 F/60 M/63 F/65 M/66 M/70 F/71 F/74
Left Left Left Right Left Left Right Left Right Right Left Left Left Right Left Right Right Left Left Left Right Left Left Right
Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radiolucent) Sialolith (radiolucent) Sphincter-like obstruction Sialolith (radio-opaque) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radiolucent) Sialolith (radio-opaque) Intraluminal adhesion Sialolith (radio-opaque) Sialolith (radiolucent) Intraluminal adhesion Sialolith (radiolucent) Intraluminal adhesion Sialolith (radiolucent)
No gland required removal after endoscopy.
radiographs preoperatively, but which could also be removed (Fig. 6). Allowing for one sialolithiasis with simultaneous removal of the gland and the need for six conven-
Figure 6 Further smaller concrements, which were also found by the endoscopic investigation (and were not detected previously).
tional stone extractions, our overall endoscopic success rate in 54 patients with sialolithiasis was 87%. Apart from the stenoses caused by stones, 11 patients had intraluminal adhesions (seven in Wharton’s duct and four in Stensen’s duct) and four patients had a sphincter-like obstruction (two in Wharton’s duct and two in Stensen’s duct), which were potential causes of salivary obstruction. In all 15 cases, salivary flow was improved intraoperatively. The 11 intraluminal adhesions were treated by endoscopic bouginage with lysis and lavage of the excretory duct. The four sphincter-like obstructions were reopened. With the help of a basket these were disobliterated. Kinking of the duct as a potential cause for salivary stasis was found in three other cases (one in Stensen’s duct and two in Wharton’s duct). Five of the 18 patients with sialadenitis without stones had little improvement in their clinical findings and symptoms at the time of the follow-up. In all cases the submandibular gland was affected. Two patients had intraluminal adhesions and sphincter-like obstructions and one other was associated with kinking of the duct. In these patients we proceeded to remove the gland rather than to a second endoscopy.
6
C.M. Ziegler et al.
4. Discussion Endoscopy of the salivary glands is a dynamic, minimally invasive diagnostic and therapeutic procedure which causes little morbidity.1,11,12 Often a final diagnosis can be made even in cases in which other imaging methods have not produced clear results. Endoscopy can often rule out other potential differential diagnoses,10,11 and is important, particularly with regard to sialolithiasis of the major salivary glands.13—16 Even radiolucent concrements may be seen. By using endoscopy Nahlieli and Baruchin found sialoliths associated in the region of the submandibular gland in 32% (in 7 of a total of 22 patients) and in the region of the parotid gland in 70% (in 7 of 10 patients) which had not been detected by other imaging methods.3 The number of such cases within our own series was, however, lower. Nevertheless, we are convinced that sialoendoscopy is superior to plain films or even to CT sialography. After sialoliths have been removed from the distal region of the excretory duct (Figs. 2—4) we could sometimes find further concrements endoscopically in the proximal regions of the duct (Fig. 6). These may go undetected using conventional techniques and may cause persisting symptoms. Our own results of 17% are similar to those reported elsewhere of between 15 and 18%.17,18 This is why endoscopic follow-up should also be considered after conventional sialolithotomy.19 Therefore special flexible endoscopes with a small diameter could be used (Fig. 7). Conventional surgery is particularly difficult in the key area of Wharton’s duct and may lead to postoperative complaints and the risk of an iatrogenic lesion of the lingual nerve. Depending on the symptoms, even removal of the gland should be considered as another approach. In comparison sialoendoscopy is a safer therapeutic option. After endoscopic intervention and removal of any mechanical obstruction an atrophic gland will recover in most cases.3,11 At clinical follow-up we noted a clear improvement of symptoms and of the patients’ subjective problems. Possible postoperative strictures can be excluded if palpation and salivation are normal and if the patient is symptom-free. Prognosis for complete resolution of chronic sialadenitis, however, is not possible to predict.3 This is particularly so when sialoliths are larger than 6 mm in diameter and are difficult to crush mechanically. Other options are pulverisation with pulsed laser (CO2 or colour laser),3,20 electro-hydraulic-intracorporeal lithotripsy, or the extracorporeal induction of piezoelectric shock waves.21—23 Fragmentation by shock wave
Figure 7 Flexible endoscope with a diameter of 0.5 mm for diagnostic interventions.
lithotripsy, however, has to be used with caution as damage to the glandular tissue cannot be excluded,3,17 and nociceptors and proprioceptors might also be damaged. Intracorporeal (intraductal) lithotripsy is therefore to be preferred, which is also more exact than extracorporeal fragmentation. Our experience is limited with an electrohydraulic shock wave generator (‘‘Calcutript’’, Karl Storz Comp., Tuttlingen, Germany), and so we cannot give a recommendations about its’ advantages and disadvantages over other pneumoballistic generators. Although lithotripsy is possible with extracorporeal induction of shock waves there is still the problem of removing the concrements from the duct system. In assessing this procedure one should consider this aspect particularly the frequent adhesions between sialoliths and the inner wall of the duct that may lead to stasis of salivary flow particularly if the sialoliths are large.3 It is not possible to reach and remove intraglandular sialoliths or their fragments with endoscopy, so submandibular sialadenectomy should be the first consideration. Other intraductal conditions can lead to stasis of salivation and consequently to sialoadenitis, but
Endoscopy: a minimally invasive procedure these may also be dealt with endoscopy. Such conditions includes strictures and bends in the ductal system,24 intraductal adenoids, and sphincter-like findings in the duct walls.25 Other examples are sphincter-like ductal systems, intraluminal adenoids, or adhesions.3,11 When ducts were obliterated we used a Fogarty balloon catheter comparable to those used for endarterectomy in vascular surgery. Balloon-tipped catheters were first used for dilatation of the duct but can also be used for stripping. We think that this technique may have advantage of preventing ductal adhesions after revision of inflammatory changes in the duct walls. According to our experience and that of others19,25 regeneration of the ductal wall after endoscopic removal of concrements or adhesions can be expected. Even a revision of kinking of the duct is possible with endoscopic intervention,24 so microsialodochoplasties were not required in our patients. A patulous and dilated, so-called sausage-shaped, form of ductal ectasia that is found in longstanding chronic low grade parotitis can be only partly improved by endoscopy, but is only a minor cause of clinical problems, and we had no case. In general, our own results (overall success rate of 83%) are comparable to those of Arzoz and Nahlieli.1 Because of the many treatment options, together with a low morbidity and minimal discomfort, we routinely use salivary gland endoscopy for diagnosis and treatment of sialolithiasis. Other potential conditions of the ductal system might lead to atrophy of the gland as a result of obstruction of the duct and stasis. However, because these can be detected and treated well endoscopically, we recommend endoscopy for patients with these findings. Endoscopy can be an option of particular value in cases of chronic sialadenitis when the gland may be conserved and an operation avoided.
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