Sialendoscopy: Experience With the First 60 Glands

in Turkey and a Literature Review

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Erhun Serbetci, MD; Gani Atilla Sengor, MD

Objectives: We performed a retrospective analysis to contribute to the increasing number of reports on sialendoscopy in the literature and give basic concepts for beginners at the same time. Methods: Between 2004 and 2009, 83 patients with symptoms of ductal obstruction of the major salivary glands were admitted to our clinic. Diagnostic and/or interventional sialendoscopy was applied to 60 glands (33 submandibular and 27 parotid) of 54 patients. A holmium:yttrium-aluminum-garnet laser or a pneumatic lithotripter was used for intraductal stone fragmentation. Results: Sialendoscopy revealed no disorder in 2 cases, and in 38 glands (28 submandibular and 10 parotid) sialolithiasis was the underlying disease. Fifteen glands (5 submandibular and 10 parotid) were found to have other main disorders such as stenosis, synechia, or kink formation. Other findings included sialodochitis in 6 glands (2 submandibular and 4 parotid), a polyp in 1 parotid gland, mucus plugs in 21 glands (6 submandibular and 15 parotid), ductal ectasia in 4 glands (2 submandibular and 2 parotid), and ductal collapse in 1 parotid gland. The overall interventional success rate was 83% of all cases, and no complications occurred. Conclusions: The success rate of the interventional sialendoscopy performed in the current study shows consistency with the results given in the related medical literature. In the age of sialendoscopy, the adjunctive intraoral surgeries can be argued to be safer, easier, and more successful than before. Sialendoscopy may be considered to be the best practice not only in sialolithiasis, but also in other treatments of obstructive ductal disorders.Key Words: salivary duct, sialadenitis, sialendoscopy, sialolithiasis.

Annals of Otology, Rhinology & Laryngology 119(3):155-164.© 2010 Annals Publishing Company.

INTRODUCTION

The current surgical philosophy advocates mini-mally invasive approaches from the point of view of both the physician and the patient. Thus, since 1990, the technique of sialendoscopy has been applied in obstructive diseases of major salivary gland ducts in order to avoid gland resection. The main approach in this technique is to enter into the salivary gland ducts, visually observe the disorder, and decide on the treatment. At the beginning of the sialendoscopy era, the approach had limited applications and was considered inappropriate for most cases because of technical shortcomings. However, with the develop-ment of advanced optical systems, it has become the routine procedure for many cases.1,2 The state-of-the-art sialendoscopes present ever-increasing vi-sual quality that widens their scope of applications. The articles published in the medical literature and the presentations made at the seminars and conven-tions held in recent years have resulted in the popu-larization of this technique worldwide. Currently, interventional sialendoscopy has an average success rate of 80% (Table 11,3-11).When sialendoscopy fails to produce an effective treatment on its own, it can be combined with addi-tional methods such as lithotripsy techniques, mini-mal intraoral surgery, or external approaches. The success rate then generally rises to above 80% (Table 1). Such success rates, based on a large number of patients, indicate that sialendoscopic approaches should be considered as the primary alternative ap-proach to traditional gland excisions in ductal dis-orders.Although sialendoscopy was initially considered for sialolithiasis treatment, it has now become a vi-able option for treatment of other diseases, such as stenoses, polyps, juvenile recurrent parotitis, and ra-diation sialadenitis. Therefore, its application areas have multiplied and have been reported in detail. As a result of successful treatments, the following in-dications have currently been added: all stones in salivary ducts that are considered to be removable by intraductal lithotripsy; stones with a diameter under 7 mm in Wharton’s duct, and stones under 5 mm in Stensen’s duct; cases in which detection of residual calculi is required; and conditions revealed by sialography and ultrasonography that are associ-ated with ductal dilatation or stenosis.12-15

Koch et al12 gave a list of indications based on their experiences: 1) detection of asymptomatic salivary calculi; 2) detection of salivary calculi in the early development period (mucus plug or fibrin plug) and taking preventive steps against the devel-opment of stones; 3) treatment of obstructions and stenoses following inflammation; 4) determination and treatment of anatomic variations or malforma-tions; 5) diagnosing autoimmune diseases associ-ated with salivary glands and investigation of likely obstructive causes; and 6) follow-up and control of treatment success rates.Sialendoscopy can also be used for examining the proximal portion of the duct after marsupialization or ductoplasty in cases with atresia of the ductal ori-fice.16 Moreover, it has been used to diagnose and manage kinks, which are defined as acute angula-tions of the main duct.17 Recently, it has been used for irrigation purposes in chronic sialade nitis or for interventional purposes in sialadenitis following ra-dioiodine therapy.18-20 There is no age limit for this procedure, and successful results have been reported in both sialolithiasis and juvenile recurrent paroti-tis.21-25 A different perspective that we can add to previous experiences is that even in cases in which the use of only sialendoscopy is known to be inade-quate and in cases of all intraoral ductal surgeries, it can be performed as a guiding, supportive, facilita-tive, and complementary method.It is widely known that sialendoscopy has no re-markable contraindication except for acute sial ade-nitis.4,5In this report, we aim to contribute to the growing literature on the use of sialendoscopy by reporting the results of our cases.

MATERIALS AND METHODS

Between 2004 and 2009, 83 patients were admit-ted to our clinic with obstructive major salivary duct symptoms. Particularly at the beginning of our prac-tice of sialendoscopic intervention, we acted very selectively in choosing in which indications to ap-ply the technique. The patients who seemed suitable according to the indications given above and who consented to the procedure underwent sialendosco-py. The patients whose ultrasonographic stone size was more than 1 cm were excluded. We performed diagnostic and/or interventional sialendoscopy on 60 glands in 54 patients, of whom 33 were female and 21 were male. The ages of the patients ranged from 19 to 66 years, and the mean age was 42 years. All patients were subjected to ultrasonographic study before the operation. Since we prefer not to practice in the office, all of the procedures were car-ried out in operating room settings, and most of the

Fig 1. Algorithm for treatment of pa – ro t id sialolithiasis (as per consensus29). uSG — ultrasonography; MR — magnetic resonance. interventional procedures were done under general anesthesia. The classification of the findings was given according to the new LSD (lithiasis, stenosis, dilatation) classification.26 In this classification, L0 = duct free of stones; L1 = floating stone; L2a = fixed stone, totally visible, less than 8 mm; L2b = fixed stone, totally visible, more than 8 mm; L3a = fixed stone, partially visible, palpable; and L3b = fixed stone, partially visible, nonpalpable. The en-doscopic classification of stenosis was as follows: S0 = no stenosis; S1 = intraductal diaphragmatic stenosis (unique or multiple); S2 = unique ductal stenosis (main duct); S3 = multiple or diffuse ductal stenosis (main duct); and S4 = generalized ductal stenosis. The endoscopic classification of dilatation was as follows: D0 = no dilatation; D1 = unique; D2 = multiple; and D3 = generalized.The instruments used are listed below; they were all manufactured by Karl Storz AG, Tuttlingen, Ger-many. For diagnostic sialendoscopy, one of the fol-lowing was used: a semirigid Marchal sialendoscope with a 1.3-mm outer diameter (OD); a semirigid Marchal miniature telescope with a 1-mm diam-eter, for use with a 1.3-mm OD examination sheath; a nahlieli sialendoscope with a 0.89-mm OD; or a miniature nahlieli telescope with a 0.7-mm OD, for use with a 1.1-mm-OD examination sheath. For interventional sialendoscopy, one of the fol-lowing was used: a semirigid miniature telescope with a 1-mm OD (dual-channel Marchal operating sheath with a 0.8 mm/1.3 mm diameter or a dual-channel Marchal operating sheath with a 1.3 mm/1.3 mm diameter); a miniature telescope with a 0.7-mm OD (dual-channel nahlieli operating sheath with a 1.1 mm/1.3 mm diameter or a dual-channel nahlieli operating sheath with a 1.1 mm/0.8 mm diameter); a semiflexible miniature straight-forward telescope with a 1.1-mm OD (Erlangen type); or a semiflex-ible miniature straight-forward telescope with a 1.6-mm OD (Erlangen type).Other materials that we used during sialendos-copy were salivary gland probes, dilators, and bou-gies with increasing diameters. We used bougies and balloon dilators for dilating stenoses or syn-e ch iae. Forceps and wire baskets were among the equipment used for intervention purposes. In order to induce fragmentation of large calculi, we used a holmium:yttrium-aluminum-garnet laser probe of 365-μm diameter (Versapulse Powersuit Slimline, Lumenis, Santa Clara, California) or an intracorpo-real pneumatic lithotripter (Calcusplit, Karl Storz AG). We used the repeated single-shot modality in performing either of these energy-assisted litho-tripsy techniques to avoid the intraluminal injury reported in the literature.27 Lately, we have begun to use instruments such as drills for perforating and fragmenting stones, and brushes for cleaning small particles and collecting cytologic samples. We preferred to use local anesthesia in a limited number of patients and carried out this procedure by administering Xylocaine spray (10% lidocaine), followed by applying 0.5 mL lidocaine hydrochlo-ride–epinephrine solution for infiltration of the area around the papilla. In patients in whom we chose to administer general anesthesia, we infiltrated the area around the papilla. At the beginning of our practice, we performed infiltration as a routine procedure, but later we preferred to apply it only if there was a need for papillotomy. We use a 50/50 mixture of 0.9% sodium chloride and 2% injectable Xylocaine or lidocaine as an irrigation solution. Detailed infor-mation on papilla dilation, insertion into the lumen, and interventional sialendoscopy can be found in many sources.5,6,28 It should be noted that our treatment algorithm for both indications and procedures is consistent with the algorithm accepted at the Paris consensus meeting in 2008 (Figs 1 and 2).29

RESULTS

The observations made on the 60 glands (33 sub-mandibular and 27 parotid) of 54 patients are dis-cussed below.Submandibular sialendoscopy revealed no disor-der in 2 cases. Sialolithiasis was found in 38 glands (28 submandibular and 10 parotid). Among them, 16 had multiple stones (10 submandibular and 6 pa-rotid), whereas 22 had a single stone (18 subman-dibular and 4 parotid). The locations of the subman-dibular stones were as follows: 56% main duct, 35% hilum, and 9% intraparenchymatous ductal system. The locations of the parotid stones were as follows: 40% main duct, 30% hilum, and 30% intraparen-chymatous ductal system. According to the LSD classification, 63% of the stones were L1, 10% L2a, 5% L2b, 10% L3a, and 2% L3b.noncalcular obstructive disorders were seen in 15 glands: 5 submandibular and 6 parotid stenoses, 3 parotid radioiodine synechiae, and 1 parotid pol-yp. According to the LSD classification, 21% of the stenoses were S1, 43% S2, 21% S3, and 14% S4. As coexisting disorders, sialodochitis was found in 6 glands (2 submandibular and 4 parotid), a kink was found in 1 parotid gland, mucus plugs were found in 21 glands (6 submandibular and 15 parotid), ductal ectasia was found in 4 glands (2 submandibular and 2 parotid), and ductal collapse was found in 1 parot-id gland. Consequently, 2 coexisting disorders were detected in 9 cases, 3 in 8 cases, and 4 in 1 case.The frequencies of the main disorders seen in the study were as follows: 38 of 60 glands (63.3%) ex-hibited sialolithiasis; in 27 of these cases (71.1%), sialendoscopic removal on its own resulted in total success (Figs 3 and 4). In 5 cases (3 parotid and 2 submandibular) of this sialendoscopically success-ful group, mechanical lithotripsy was used in 2 cases and a holmium:yttrium-aluminum-garnet la-ser (1 case) or pneumatic lithotripsy (2 cases) was used in the rest of them (Fig 5). The stone fragmen-tations were removed endoscopically by a forceps or a wire basket. One case of pneumatic lithotripsy was not successful. In 4 cases of submandibular sialolithiasis, combination intraoral duct dissection was needed, and in 1 case, the stone could not be 158 Serbetci & Sengor, Sialendoscopy 158Fig 2. Algorithm for treatment of sub-mandibular sialolithiasis (as per consen-sus29).Fig 3. Sialendoscopic stone retrieval with forceps (f).

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removed despite the combined approach, because a submandibular calculus was embedded in the hi-lum. Thus, overall, 31 of the 38 cases (81.6%) in the sialolithiasis group were considered a total success. In the remaining 7 cases in this group (including the failed case in which an intraoral approach was at-tempted), 3 subjects with submandibular stones un-derwent gland resection, and the remaining 4 did not give consent to the operation.According to the further observations on the non-calcular obstructive group, 15 of 60 glands (25%) displayed noncalcular disorders, including stenosis, synechiae, or polyps; 10 (66.6%) of those exhib-ited clinical recovery as a result of the application of sialendoscopic intervention alone (Fig 6). In 3 submandibular cases, sialendoscopy was started in combination with intraoral surgery because of the papillary scars that had formed as a result of pre-vious intraoral attempts in other clinics (Figs 7-9). The rate of success in this group thus reached 86.6% (13 cases). The remaining 2 parotid cases had more complicated ductal stenotic and dilated segments, and intraoral surgery was recommended. The polyp 159 Serbetci & Sengor, Sialendoscopy 159Fig 4. Sialendoscopic stone retrieval with wire basket.Fig 5. Sialendoscopic intraductal stone fragmentation with intracorporeal shock wave lithotripter. p — pneu-malithotripter probe.

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Dcase was diagnosed as Sjögren syndrome in later clinical assessment (Fig 10). In this case, there was no obstructed lumen, and we did not attempt to re-move the polyp because of the risk of bleeding.The mucus plugs observed in 21 of 60 glands (35%) were generally associated with other disor-ders. In the current study, disorders such as sialo-do chitis, ductal ectasia, and ductal collapse were generally recorded as secondary to calculi, stenosis, and/or chronic sialadenitis.DISCuSSIOn In recurrent swelling of the salivary glands, par-ticularly in cases in which the underlying reason cannot be diagnosed with conventional methods, most physicians associate the ductal disorder with salivary gland stones and use a conservative treat-ment (including wait-and-see and follow-up). How-ever, it is now known that the stones obstructing salivary gland ducts grow about 1 mm each year. Consequently, the chance of removing the calculi by a sialendoscopic method decreases year by year and paves the way for conventional surgery.21,30 Thus, the current concept of conservative treatment has changed. The modern practice regarding ductal dis-orders of salivary glands is to advocate sialendos-copy as a conservative treatment. In recent years, as a result of the popularization of the minimally inva-sive techniques, coupled with the technical develop-ments in endoscopes, sialendoscopy has become the primary method in surgical treatment of obstructive diseases of the salivary glands, taking the place of the intraoral approaches and gland resection. The conventional techniques can be used in a comple-mentary manner, depending on the type, location, size, shape, and number of the disorders. Moreover, sialendoscopic interventions have turned intraoral surgery into a more reliable, definitive, relatively safe, and easy procedure. Sialendoscopy can be in-dicated in all salivary gland swellings of unknown cause, and it has no significant contraindication ex-cept acute sialadenitis.4,5 In the swelling of major salivary glands, we use sialendoscopy as the primary diagnostic tool after ul-trasonographic examination.31 It is our opinion that diagnostic sialendoscopy is a distinct method that provides accurate diagnoses for all ductal disorders. According to our own cases and the medical litera-ture data, we have rearranged the distribution of the obstructive ductal disorders (Table 21-5,7,8,28).160 Serbetci & Sengor, Sialendoscopy 160Fig 6. Stenosis related to previous intraoral surgery (arrow). Sial en-dos copy A) before and B-D) after dilation. E-H) Proximal duct sial-endoscopic views. I) Stenting.

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Two or more coexisting disorders were detected in 18 of our cases. Sialendoscopic stone removal was carried out successfully in 71.1% (27 of 38) of these cases. With the combination of intraoral sur-gery, the success rate increased to 81.6% (31 of 38). The success rate of interventional sialendoscopy was 66.6% (10 of 15) in noncalcular main disorders such as stenosis, synechia, and kink formation. With the combination of intraoral surgery, this success rate increased to 86.6% (13 of 15; Table 1).It should be noted that we have generally con-sidered mucus plugs and sialodochitis as secondary disorders, because most of our cases coincided with predominant disorders such as sialolithiasis. Accord-ing to our experience, mucus plugs are encountered in patients with stenosis, Sjögren syndrome, radia-tion sialadenitis, and chronic sialadenitis, particu-larly in sialolithiasis cases. Another issue is that kinks may be considered as anatomic variations, but they may sometimes be challenging operative ob-stacles. So-called ductal collapse is an endoscopic observation that can result from dilated ducts that are seen in chronic sialadenitis and/or sialolithia-sis. During sialendoscopic dilation, we faced ductal spasm several times, attributable to a sphincterlike mechanism.4,6 Additionally, a common observation in daily life is a physiologic saliva ejection. There-fore, we assert that the ductal system has a “pump-ing function.”28 This function may be part of the pathophysiology and should be studied further.The sialendoscopic technique, in addition to di-agnosis, can be used for interventional purposes, as well as for treatment of various disorders in the sali-vary gland ducts. The success rates obtained from several series of cases are given in Table 1. From our experience, we can say that the major reasons behind failures of sialendoscopy are as follows: em-bedded calculi in the ductal wall or hilum, anatomic difficulties occurring as a result of previous casual intraoral surgical interventions, and a lack of a va-riety of supportive equipment such as that for intra-corporeal shock wave lithotripsy (electrohydraulic) and extracorporeal shock wave lithotripsy.In addition to the treatment of primary ductal dis-161 Serbetci & Sengor, Sialendoscopy 161Fig 7. Sialendoscopic view of papillary stenosis and prestenotic cystic dilatation of Stensen’s duct.

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D162 Serbetci & Sengor, Sialendoscopy 162Fig 8. A-C) Sialographic images and D-G) operative scene of intraoral marsupialization.Fig 9. A-D) Intraoral ductal dissection and stone removal in severe papillary stenosis related to previous intraoral surgical at-tempt. w — Wharton’s duct; m — mucus plug; s — stone. E) After sialendoscopic control, F) neo-orifice was created (arrow).eases, sialendoscopy can also be used for salivary gland diseases that occur secondary to ductal dis-eases. For example, in inflammatory diseases, the injection of various drug solutions into the ductal system can be achieved by sialendoscopy.12,32 In patients in whom the underlying reason for clinical symptoms cannot be detected even with sialendos-copy, the mere process of sialendoscopic irrigation with saline solution has many treatment benefits.33 We concur with this opinion; in our experience, even

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163 Serbetci & Sengor, Sialendoscopy 163Fig 10. Polyp in Stensen’s duct in case of Sjögren’s syn-drome. TABLE 2. DISTRIBuTIOn OF DuCTAL OBSTRuCTIVEDISORDERS REVIEWED FROM VARIOuS STuDIES,InCLuDInG OuR OWn1-5,7,8,28Disorder %Sialolithiasis 65.5Stenosis 12.2Kink 2.0Anatomic variation 1.6Ductal polyp 1.3Foreign body 0.6

dilation and irrigation of salivary gland ducts and in-sertion of a stent can be considered as a stand-alone treatment that decreases clinical signs and relieves symptoms of uncertain cause.With the rapid development of technologies and increasing experience, it can be stated that the vari-ety of intraductal interventions will increase and that we will be able to treat the majority of cases with sialendoscopic and combined techniques. Further-more, as a result of sialendoscopy, our knowledge of ductal anatomopathological information is ever increasing. Sialendoscopy may be considered to be the best practice not only in sialolithiasis, but also in other gland diseases such as Sjögren’s disease and radioiodine-induced sialadenitis.REFEREnCES 1. Koch M, Zenk J, Iro H. Diagnostic and interventional sialoscopy in obstructive diseases of the salivary glands [in Ger-man]. HnO 2008;56:139-44. 2. Koch M, Iro H, Zenk J. Sialendoscopy-based diagnosis and classification of parotid duct stenoses. Laryngoscope 2009; 119:1696-703. 3. Katz P. new techniques for the treatment of salivary lith-iasis: sialoendoscopy and extracorporal lithotripsy: 1773 cases [in French]. Ann Otolaryngol Chir Cervicofac 2004;121:123-32. 4. nahlieli O, nakar LH, nazarian Y, Turner MD. Sialoen-doscopy: a new approach to salivary gland obstructive pathol-ogy. J Am Dent Assoc 2006;137:1394-400. 5. Marchal F, Dulguerov P, Becker M, Barki G, Disant F, Lehmann W. Specificity of parotid sialendoscopy. Laryngo-scope 2001;111:264-71. 6. Marchal F, Dulguerov P, Becker M, Barki G, Disant F, Lehmann W. Submandibular diagnostic and interventional sial-endoscopy: new procedure for ductal disorders. Ann Otol Rhi-nol Laryngol 2002;111:27-35. 7. Ziegler CM, Steveling H, Seubert M, Mühling J. En dos-copy: a minimally invasive procedure for diagnosis and treat-ment of diseases of the salivary glands. Six years of practical experience. Br J Oral Maxillofac Surg 2004;42:1-7. 8. Papadaki ME, McCain JP, Kim K, Katz RL, Kaban LB, Troulis MJ. Interventional sialoendoscopy: early clinical re-sults. J Oral Maxillofac Surg 2008;66:954-62. 9. Yu CQ, Yang C, Zheng LY, Wu DM, Zhang J, Yun B. Se-lective management of obstructive submandibular sialadenitis. Br J Oral Maxillofac Surg 2008;46:46-9. 10. Yu C, Zheng L, Yang C, Shen n. Causes of chronic ob-structive parotitis and management by sialoendoscopy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:365-70. 11. Walvekar RR, Razfar A, Carrau RL, Schaitkin B. Sialen-doscopy and associated complications: a preliminary experi-ence. Laryngoscope 2008;118:776-9. 12. Koch M, Zenk J, Bozzato A, Bumm K, Iro H. Sialoscopy in cases of unclear swelling of the major salivary glands. Oto-laryngol Head neck Surg 2005;133:863-8. 13. nahlieli O, Baruchin AM. Long-term experience with en doscopic diagnosis and treatment of salivary gland inflam-matory diseases. Laryngoscope 2000;110:988-93. 14. nahlieli O, Shacham R, Bar T, Eliav E. Endoscopic me-chanical retrieval of sialoliths. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:396-402. 15. Serbetci E, Sengor GA. Diagnostic and interventional sial endoscopy in recurrent salivary gland swellings. Turk Arch Otolaryngol 2007;45:84-90. 16. Capaccio P, Gaini LM, Pagani D, Sambataro G, Pignata-ro L. Videosialoendoscopic assessment of bilateral atresia of the Wharton’s duct orifice in an infant. J Pediatr Surg 2007;42:E5-E7. 17. nahlieli O, Shacham R, Yoffe B, Eliav E. Diagnosis and treatment of strictures and kinks in salivary gland ducts. J Oral Maxillofac Surg 2001;59:484-92. 18. Qi S, Liu X, Wang S. Sialoendoscopic and irrigation find-ings in chronic obstructive parotitis. Laryngoscope 2005;115: 541-5. 19. Kim JW, Han GS, Lee SH, Lee DY, Kim YM. Sialoendo-scopic treatment for radioiodine induced sialadenitis. Laryngo-scope 2007;117:133-6. 20. nahlieli O, nazarian Y. Sialadenitis following radioio-dine therapy — a new diagnostic and treatment modality. Oral Dis 2006;12:476-9. 21. Marchal F, Dulguerov P. Sialolithiasis management: the state of the art. Arch Otolaryngol Head neck Surg 2003;129:951-6.

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