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Transoral Balloon Sialodochoplasty and
Sialolithotomy: A Minimally-Invasive Option for
Treatment of Recurrent Sialadenitis
Paul Schalch MD, Jonathan Boyd MD, Sepehr Oliaei MD, Marc Rubinstein MD, Jason H. Kim MD
Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine
OBJECTIVES:
The purpose of this study is to present a case of recurrent
parotid sialadenitis secondary to an obstructive sialolith, treated via a
minimally invasive technique that offers a safe alternative to open
management and without the use of endoscopic materials.
INTRODUCTION: Sialolithiasis is a relatively common condition, resulting from
the formation of inorganic crystals within a salivary gland duct. This
causes obstruction to the gland’s flow, leading to swelling, pain, and
the risk of sialadenitis. The submandibular gland is most commonly
affected, representing 80-95% of salivary calculi, whereas the
parotid gland accounts for only 5% to 20%.1 The remaining glands
are rarely affected by stone formation. Approximately 1.2% of the
population experience sialolithiasis with males affected up to twice
as often as females. Untreated obstructing stones may cause a
sialooral fistula creating further morbidity.2
Recent management of salivary stones have turned to
minimally invasive techniques such as sialolithotomy and
endoscopic retrieval. Avoidance of potential open complications,
such as lingual, hypoglossal, and marginal mandibular nerve injuries
from submandibular gland resection or facial nerve injury from
parotid resection have created the need for these less invasive
techniques.
With sialolithotomy and some endoscopic approaches, intraoral
palpation of the stone is required for retrieval. Hilar or intraglandular
based stones may necessitate sialadenectomy or more advanced
endoscopic approaches.3 When palpable, however, endoscopic
setup and even small intraoral incision may be unnecessary in a
truly minimally invasive technique.
Figure 2. Intraoperative image, showing
placement of the Fogarty catheter into the
Parotid Duct.
METHODS:
This case represents a retrospective case of recurrent parotid
sialadentitis with radiographic evidence of salivary duct calculus
treated at a university-affiliated institution. A 46 year old male patient
presented to the emergency room with unilateral acute parotitis of
several days duration. The patient reported a history of multiple
similar episodes each on the left side, which was treated with
conservative measures including local heat, aggressive hydration,
sialogogues, and oral antibiotics. A contrast enhanced computed
tomography scan revealed a 5 mm calculus in the parotid duct, with
proximal dilatation, significant gland edema and inflammation, with
likely phlegmon. The patient was admitted and treated with IV
antibiotics for 48 hour duration. The patient was taken to the
operating room after failure to improve with conservative measures
and repeated imaging confirmed development of enhancing
abscess.
RESULTS:
Intraoperatively, the parotid duct was explored with a lacrimal
probe and a moderate amount of pus was expressed from the gland.
A 4 Fr Fogarty catheter was then introduced into the duct and
advanced past the calculus, which was determined by palpation. The
catheter was slowly inflated and withdrawn and the calculus was
successfully retrieved from the duct. Copious amounts of pus were
then drained from the gland with angiocatheter irrigation. The patient
was subsequently discharged after resolution of the parotitis post-
operative day two. At two month follow-up, the, the patient continues
to do well with normal function of his parotid gland.
CONCLUSION: Transoral, minimally-invasive, balloon sialodocoplasty with
sialolithotomy is an effective, safe alternative to surgical
management of obstructive salivary disease that fails to respond to
conservative measures. Dependent upon palpation, this adds to the
armamentarium of the orofacial surgeon in the treatment of
symptomatic sialolithiasis.
REFERENCES:
1. Lustmann, Regev, and Melamed. Sialolithiasis; A survey on 245 patients and a review of the literature. International Journal of Oral
& Maxillofacial Surgery. vol 9(3)
2. Bodner & Beer-Sheva. Giant salivary gland calculi: Diagnostic imaging and surgical management. Oral Surgery Oral Medicine Oral
Pathology Oral Radiology and Endoscopy. Sept 2002:94:320-3
3. Nahlieli, Shacham, Zagury, Bar, Yoffe. The ductal stretching technique: An endoscopic-assisted technique for removal od
submandibular stones. The Laryngoscope. 117;June 2007:1031-5.
4. Zhang, Escudiet, Brown, Capaccio, Pignataro, and McGurk. Long-term outcome after intraoral remoival of large submandibular
gland calculi. The Laryngoscope:120. May 2010: 964-6.
5. Osailan, Proctor, Carpenter, Paterson, McGurk. Recovery of rat submandibular salivary gland function following removal of
obstruction: a sialometrical and sialochemical study. Inernational Journal of Experimental Pathology.87; 2006:411–23.
Figure 3. 5mm calculus removed from the
Parotid duct
Figure 1. Intraoperative image, showing
evidence of parotitis and catheter
placement
DISCUSSION:
Over the last ten years, sialolithiasis has been progressively
turning toward minimally invasive techniques due to mounting
evidence that salivary gland function may be preserved by
alleviating ductal obstruction, possibly removing the need for
sialadenectomy.4,5 Minimally invasive sialolithotomy maintains
some potential for both neurological and non-neurological sequelae,
as the ductal tract is invaded and surrounding tissue is exposed to
sharp dissection. Additionally, endoscopy can add unnecessary
operative time due to setup and equipment malfunction or operator
inadequacy.
The use of Fogarty catheters have been well respected for
decades in endovascular treatment of emboli and thrombi. Salivary
duct anatomy and obstruction share striking similarities, which may
support similar treatment modalities. When sialoliths are identifiable
via palpation, balloon retrieval presents a minimally invasive
technique that is relatively atraumatic and rapid without the need for
flouroscopy or endoscopy.
Figure 4. Axial CT scan showing the 5mm
calculus inthe Parotid duct