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J Oral Maxillofac Surg65:1865-1868, 2007

Arterial Stents for Access and Protectionof the Parotid and Submandibular Ducts

During SialoendoscopyMaria Papadaki, DMD, MD,* Leonard Kaban, DMD, MD,†

Christopher Kwolek, MD,‡ David Keith, DMD, FDSRCS, BDS,§

and Maria Troulis, DDS, MSc�

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ialoendoscopy has recently gained popularity as ainimally invasive alternative to ablative surgery for

bstructive salivary duct disease resulting from stonesnd strictures. Sialoendoscopy has been performed inumerous patients with a high degree of success.1-3

owever, damage or perforation of the duct duringepeated manipulation of the endoscope and surgicalnstruments is a known complication.1-3 This can re-ult in a false passage that may compromise the suc-ess of the procedure. The purpose of this study waso assess the feasibility of using cardiovascular stentso dilate and maintain access to the parotid and sub-andibular ducts during sialoendoscopy. The hypoth-

sis was that stents would allow for easy instrumen-ation of the ducts with fewer traumatic injuries. To

eceived from the Departments of Oral and Maxillofacial Surgery

nd General Surgery, Massachusetts General Hospital, Boston, MA.

*AO-ASIF/Synthes Fellow in Pediatric Oral and Maxillofacial

urgery.

†Walter C. Guralnick Professor and Chairman, Department of

ral and Maxillofacial Surgery.

‡Assistant Professor, Division of Vascular and Endovascular

urgery.

§Clinical Professor, Department of Oral and Maxillofacial

urgery.

�Associate Professor, Director of Minimally Invasive Surgery Pro-

ram, Director of Residency Program, Department of Oral and

axillofacial Surgery.

This study was presented in part at the 87th AAOMS meeting in

oston, MA, 2005. This study was funded in part by the Massachu-

etts General Hospital Department of Oral and Maxillofacial Surgery

ducation and Research Fund, the AO-ASIF/Synthes Fellowship in

ediatric Oral and Maxillofacial Surgery, and the Hanson Founda-

ion, NIH K23.

Address correspondence and reprint requests to Dr Troulis:

epartment of Oral and Maxillofacial Surgery, Massachusetts Gen-

ral Hospital, 55 Fruit Street, Boston, MA 02114; e-mail: mtroulis@

artners.org

2007 American Association of Oral and Maxillofacial Surgeons

278-2391/07/6509-0036$32.00/0

soi:10.1016/j.joms.2006.04.041

1865

he best of our knowledge, this is the first report onhe use of cardiovascular stents for this purpose.

aterials and Methods

Sialoendoscopy was performed on 10 Yorkshire pigadaver heads. The parotid (n � 20) and submandib-lar (n � 20) ducts were identified and dilated usingalivary gland dilators (Karl Storz GmbH & Co, Tut-lingen, Germany). The submandibular and parotidland ducts in Yorkshire pigs are 4 to 6 cm long and.5 to 2 mm in diameter, similar dimensions to theorresponding human ducts.4

In the experimental group, 10 parotid and 10 sub-andibular ducts, a 28-mm-long Cypher coronary

tent (Cordis Corp, Miami Lakes, FL) was inserted intoach duct (Fig 1). The balloon was inflated with aressure pump to achieve 12 atm of pressure, whichxpanded the stent to a diameter of 3.5 mm (Fig 2).he balloon was then removed, and the stent wasutured in place to maintain the diameter, reinforcehe duct, and maintain access (Figs 3, 4). In theontrol group of 10 parotid and 10 submandibularucts, the endoscope was used without duct stentingFig 5).

A Nahlieli Storz endoscope (Karl Storz, Tuttlingen,ermany) was used to navigate the duct system inoth groups. This is a semirigid endoscope, 1 mm iniameter, with a 2.3-mm sheath for interventionalndoscopy. The sheath has 3 channels: 1 for thecope, 1 for irrigation, and 1 for working instrumentsFig 5). Navigation of the ducts in both the experi-ental and control groups was repeated 5 times to

eplicate the clinical scenario of repeated instrumen-ation.

The experimental technique was evaluated for easef use, surgical time (in minutes), and duct injury. Tovaluate duct injury, the total length of duct (5 cm)as harvested, dissected longitudinally, and photo-

raphed under 5� magnification. A blinded evaluatorcored the harvested ducts according to the followingrading system: score 0, no damage, normal lining;
core 1, fewer than 2 tears, less than 1 mm long; score

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1866 ARTERIAL STENTS IN SIALOENDOSCOPY

, multiple tears (�2) or a tear larger than 1 mm; andcore 3, frank perforation of the duct.

esults

All submandibular (n � 20) and parotid ducts (n �0) were dilated without complications. Insertion andxpansion of the stents was performed without diffi-ulty. Handling of the scope through the stentedalivary ducts was facile, fast, and effortless in allucts. Insertion of the endoscope was successful in all0 control parotid and submandibular ducts but withreater difficulty. Operative time ranged from 15 to0 minutes for both groups.No damage was observed at the stented portions of

he ducts in the experimental group. No perforations

IGURE 1. Insertion of the stent with its guiding wire into Whartonuct.

apadaki et al. Arterial Stents in Sialoendoscopy. J Oral Maxillo-ac Surg 2007.

FIGURE 2. Inflation of the balloon and expansion of the stent.


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ere encountered in either group. Damage scores ofand 2 were seen in the control group and in the

nstented portions of the ducts in the experimentalroup (Table 1). All stented portions of the experi-ental group (n � 20) had a damage score of 0 (no

njury).

iscussion

In 1991, Katz was the first to perform sialoendos-opy with a flexible endoscope to diagnose sialolithi-sis.5 Because the flexible endoscope did not have annstrumentation port, sialoliths were removed blindly

IGURE 3. The stent maintains the diameter and access to the ductfter the balloon withdrawal. Note that, due to the length of the stent

28 mm), only the distal two thirds of the duct are protected by the stent,hereas the proximal third remains unstented.


IGURE 4. Insertion of the scope (with the sheath) through the stenteduct (Nahlieli Storz endoscope; Karl Storz, Tuttlingen, Germany).


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PAPADAKI ET AL 1867

ith Dormia baskets (Porges; Paliseau Cedex, Salat,rance). In 1994, Nahlieli et al6 reported the use of aigid endoscope for diagnosing and treating obstruc-ive salivary duct disease. In 1999, a new semirigidndoscope (Nahlieli Sialoendoscope; Karl Storz) specif-cally designed for salivary gland interventional endos-opy was introduced; this was the endoscope used inhe present study.7 Currently, smaller-diameter endo-copes with working ports are available: the Marchalialoendoscope (Karl Storz), with a total diameter of.3 mm, and the Sialoview endoscope (Millenniumevices Inc, Islandia, NY), with a diameter of 1.1 mm.Diagnostic sialoendoscopy is superior to conven-

ional techniques (radiography, sialography, and ultra-ound). Sialography is used as the standard imagingethod for diagnosing sialolithiasis in most institu-

ions in Europe. However, the clinician must considerhe risks of allergy to the contrast solution and theossibility of displacing the stone(s) deeper into theuctal system. In addition, the radiation dose for sia-

ography is equivalent to that from approximately 20hest radiographs.8,9 Sialoendoscopy offers the advan-age of direct visualization of the interior of the sali-

FIGURE 5. Insertion of the sheath directly into the duct (no stent).


Table 1. RESULTS

Score

Experimental Group

Submandibular Duct (n � 10) Par

Stented(Distal 28 mm)

Unstented(Proximal 20 mm)

Stented(Distal 28 m

0 10 6 101 - 3 -2 - 1 -3 - - -

core 0, no damage, normal lining; Score 1, tears less than 1 mm inears; Score 3, perforation.

apadaki et al. Arterial Stents in Sialoendoscopy. J Oral Maxillofac Sur

ary ducts and diagnosis of pathological conditionshat cause obstructive salivary gland disease, such asialodochitis, ductal polyps, kinks, foreign bodies, andnatomic malformations.10,11 Other advantages of sia-oendoscopy include the ability to 1) identify smalltones (calcified or radiolucent), 2) differentiate stonesrom projecting ductal polyps and mucous plugs,) visualize and dilate the proximal portion of theuct, and 4) remove stones located near the hilum ofhe gland. Stones less than 3 mm in diameter areemoved with baskets or grasping forceps. Largertones are fragmented with a laser (CO2, dye laser) ory external or internal lithotripsy.3,12-16

Sialoendoscopy results in less postoperative painnd swelling and fewer complications (eg, infection,erve injury, hematoma) compared with traditionalreatments (ie, ablative surgery).2,3,17,18 In addition,ength of hospital stay is reduced, and the patient mayeturn to work more quickly. However, sialoendos-opy is a demanding and technically difficult proce-ure. It is performed with very delicate and fragile

nstruments through an access site only 1 to 4 mm iniameter. A technical limitation is the dilation andaintenance of access to the duct during the proce-

ure. Complications of sialoendoscopy, as a result ofnstrumentation of the duct system, include duct tearsr perforations with subsequent lingual nerve dam-ge, saliva extravasation, ranula formation, and infec-ion. At Massachusetts General Hospital, an angiocath-ter (14 or 16 G) is placed in the duct after dilation torevent tears, perforation, and development of a falseassage; however, the angiocatheter is not expand-ble and does not aid duct dilation.19

The results of the present study indicate that stentsrotected the covered (“stented”) areas of the ductsTable 1). The use of stents made dilatation and accessonsiderably easier and allowed better manipulationf the scope and instruments. The need for repeatedilatation was eliminated, thus decreasing the risk offalse passage. Stents should be left in the duct for 10

o 30 days postoperatively, to allow salivary flow and

Control Group

uct (n � 10) SubmandibularDuct (n � 10);

Unstented

Parotid Duct(n � 10);Unstented

Unstented(Proximal 20 mm)

5 5 53 3 22 2 3- - -

nd no more than 2 mm; Score 2, tear larger than 1 mm or multiple

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1868 ARTERIAL STENTS IN SIALOENDOSCOPY

o prevent stenosis. Expandable stents have potentialherapeutic value by maintaining duct diameter inreas of strictures and straightening kinks. Stents ofarious dimensions can be used, depending on thendoscope used and the size of the stone.Studies in live animals are currently in progress to

ssess the ideal length for dilating stents and theptimal duration to keep them in place. In addition,e are working with industry to develop cost-effec-

ive stents specifically for sialoendoscopy.

cknowledgments

The authors thank Dr Ik-Kyung Jang, Cardiology Division, Cardi-logy Laboratory of Integrative Physiology and Imaging, Cordisorp for the CYPHER stent, and Karl Storz USA for technicalssistance.

eferences1. Nahlieli O, Baruchin AM: Long-term experience with endo-

scopic diagnosis and treatment of salivary gland inflammatorydiseases. Laryngoscope 110:988, 2000

2. Marchal F, Dulguerov P, Becker M, et al: Submandibular diag-nostic and interventional sialendoscopy: New procedure forductal disorders. Ann Otol Rhinol Laryngol 111:27, 2002

3. Katz P: New techniques for the treatment of salivary lithiasis:Sialoendoscopy and extracorporal lithotripsy: 1773 cases: AnnOtolaryngol Chir Cervicofac 121:123, 2004

4. Zenk J, Hosemann WG, Iro H: Diameters of the main excretoryducts of the adult human submandibular and parotid gland: Ahistologic study. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 85:576, 1998

5. Katz PH: Endoscopy of the salivary glands. Ann Radiol 34:110,
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6. Nahlieli O, Neder A, Baruchin AM: Salivary gland endoscopy: Anew technique for diagnosis and treatment of sialolithiasis.J Oral Maxillofac Surg 52:1240, 1994

7. Nahlieli O, Baruchin AM: Endoscopic technique for the diag-nosis and treatment of obstructive salivary gland diseases.J Oral Maxillofac Surg 57:1394, 1999

8. Marchal F, Dulguerov P, Becker M, et al: Specificity of parotidsialendoscopy. Laryngoscope 111:264, 2001

9. Gundlach P, Hopf J, Linnarz M: Introduction of a new diagnos-tic procedure: Salivary duct endoscopy (sialendoscopy) clinicalevaluation of sialendoscopy, sialography, and x-ray imaging.Endosc Surg Allied Technol 2:294, 1994

0. Nahlieli O, Shacham R, Yoffe B, et al: Diagnosis and treatmentof strictures and kinks in salivary gland ducts. J Oral MaxillofacSurg 59:484, 2001

1. Ziegler CM, Steveling H, Seubert M, et al: Endoscopy: A mini-mally invasive procedure for diagnosis and treatment of dis-eases of the salivary glands. Six years of practical experience.Br J Oral Maxillofac Surg 42:1, 2004

2. Arzoz E, Santiago A, Esnal F, et al: Endoscopic intracorporeallithotripsy for sialolithiasis. J Oral Maxillofac Surg 54:847, 1996

3. Marchal F, Becker M, Dulguerov P, et al: Interventional sialen-doscopy. Laryngoscope 110:318, 2000

4. McGurk M, Escudier MP, Brown E: Modern management ofobstructive salivary gland disease. Ann R Australas Coll DentSurg 17:45, 2004

5. McGurk M, Prince MJ, Jiang ZX, et al: Laser lithotripsy: Apreliminary study on its application for sialolithiasis. Br J OralMaxillofac Surg 32:218, 1994

6. Ito H, Baba S: Pulsed dye laser lithotripsy of submandibulargland salivary calculus. J Laryngol Otol 110:942, 1996

7. Nahlieli O, Shacham R, Bar T, et al: Endoscopic mechanicalretrieval of sialoliths. Oral Surg Oral Med Oral Pathol OralRadiol Endod 95:396, 2003

8. Nahlieli O, Shacham R, Shlesinger M, et al: Juvenile recurrentparotitis: A new method of diagnosis and treatment. Pediatrics114:9, 2004

9. McCain J, Katz R, Kaban L, et al: Interventional sialoendoscopy:Early clinical results. J Oral Maxillofac Surg 63:44, 2005
(suppl 1)

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