Interventional sialendoscopy: Retrieval of a stone from
salivary duct

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The Last Improvement in the Diagnosis and Treatment of Salivary Gland Diseases: Sialendoscopy.

Salivary glands and their diseases are not very well known publicly. The common symptom of salivary gland diseases is swelling in the affected gland (chick and/or under the jaw). The most common diseases of salivary glands are infections/inflammations and salivary stones. And most of the cases either of them are found together. The public knows about kidney and gall stones, however salivary gland stones are not well known even though they can greatly affect the quality of a patient's life. The current diagnostic and therapeutic modality in salivary gland obstructive diseases is "sialendoscopy" which makes us capable to approach endoscopically to the salivary canals. In this way, it is likely that the need for open surgery will be decreased. Sialendoscopy may be considered as the "Gold Standard" in the management of obstructive diseases of the major salivary glands.

What Are Some of the Diseases that Cause Swelling in the Salivary Glands?

Diseases of the salivary glands cause swelling in the face or neck, especially under the jaw. This swelling occurs during eating, but slowly decreases after the meal. If the salivary duct is completely obstructed, the swelling can be permanent. The swelling can also be painful from time to time. If the salivary gland has become infected, there can be redness and inflammation in the skin above the involved gland. The most common diseases of salivary gland swelling are listed below:

  • Salivary gland stones (sialolithiasis) (this is the most frequent)
  • Narrowing of the salivary duct (stenosis)
  • Mucus plugs in the salivary duct
  • Infections of salivary glands (sialadenitis) (frequent)
  • Anatomic malformations of salivary ducts
  • Recurrent sialadenitis in children (Juvenile Recurrent Parotitis)
  • After radiotherapy for thyroid cancers (radio-iodine ablation) which can cause obstructions and adhesions
  • Foreign objects that obstruct the salivary duct (hair, tea grinds, fish bones)
  • Connective tissue diseases (autoimmune) of adults (Sjogren's Disease, romatoid arthritis, sarcoidosis)
  • Salivary gland tumors

What is the Newest Method to Diagnose and Treat Salivary Gland Diseases?

The newest and most effective method is sialendoscopy, which can be used to visualize the obstruction through the natural channels of the salivary glands and treat it if necessary. With the use of sialendoscopy the need for gland resections by external incisions has decreased.

What are the Symptoms of Salivary Stones?

If the salivary ducts, which carry the saliva into the mouth, are obstructed certain signs will be present. The most frequent sign is painful swelling in the cheek and under the jaw while eating. In this situation acidic foods stimulate saliva production and secretion as well as salivary gland swelling. If the salivary duct is not entirely obstructed, this painful swelling can slowly decrease after the meals. If the swelling does not decrease quickly and if the gland is warm and painful, it means that the gland has become infected.

When Do Salivary Gland Stones Present Symptoms?

If the salivary stones obstruct the saliva draining canal, the salivary gland swells causing discomfort. This occurs especially while eating. Salivary ducts are 2-4 millimeters in diameter and a stone of this size can obstruct the saliva flow. Sometimes the stones can be loose in the canal. Therefore the duct is either open or obstructed and the complaints of the patients are not always present. Salivary gland swelling decreases when the canal is open and the patient is symptom-free. This lasts until the canal becomes obstructed again. However, today it is known that salivary stones increase in size about one millimeter every year, which means that the duct will become obstructed eventually and the painful swelling will not go away by itself.

How Can Salivary Gland Disorders Be Diagnosed?

If a patient presents salivary gland swelling, a basic ENT examination needs to be done. After the initial exam, an ultrasonographic examination of the face and of the jaw area can be requested. Stones of around 3 mm can be observed by ultrasonography, smaller stones cannot be detected, but they can be seen indirectly by observing dilatation in the duct. Sometimes a CT scan can also be requested if necessary. Today we can observe the ducts of the salivary glands with endoscopes, where we can diagnose and treat the pathology. This method is called "sialendoscopy" (Endoscopy of the Salivary Glands).

How Can Salivary Gland Stones Be Treated?

Until recently, the patient was given antibiotics and analgesics if the stone was not completely obstructing the duct, if the stone obstructs the duct completely the gland removal was the traditional surgical suggestion. Today however, with the use of endoscopes, salivary stones can be removed from the duct. This method is called "interventional sialendoscopy". To use this technique, the diameter of the stone should not be excessively larger than the diameter of the duct. Some bigger stones can be fragmented into smaller parts by the use of laser or shock wave lithotripsy devices so that the fragments can be removed from the duct. Very large stones can not be removed using this technique alone, they can however be removed by a combination of intraoral surgery and the endoscopic approach. If these gland-protecting methods are not successful, the last alternative is gland removal surgery with neck incisions.

Stone retrievel from the salivary glant duct with basket
Stone retrieval from the salivary gland duct with wirebasket

In Which Countries Can Endoscopic Diagnosis and Treatment of Salivary Glands be Performed?

This method of salivary gland stones treatment can be performed in innovative countries such as Switzerland, Germany, France and Israel. Currently we are the only center to perform this technique in Turkey and we are among one of the small numbers of experienced centers in the world. Since 2004, Nisantasi ENT Group (Nişantaşı KBB Grubu) has been working on the diagnosis and intervention of salivary gland ductal system pathologies. Because of this we receive patients not only from Turkey but from all over the neighbour countries.

sialendescopically removed stones from the same salivary gland
sialendescopically removed stones from the same salivary gland

What Do We Do For Patients Who Have Salivary Gland Swelling or Who Are Referred to Us With Salivary Stones?

  • It is possible that there is an obstruction of the salivary gland if there is swelling in the face or under the jaw during mealtime.
  • In a patient like this an ENT examination can show that the salivary gland is bigger and becomes firmer than normal.
  • An ultrasonography, CT scan or similar diagnostic methods could have been done on this patient, which may or may not reveal a stone or any alterations in the duct.
  • Sometimes these radiological methods may incorrectly diagnose a stone. Sialendoscopy will show that it is either mucus plugs, stenoses (the narrowing or adhesion of the duct), kinks (bending) or polyps (soft tissue build-up) rather than a salivary stone. Therefore if ultrasonography shows a stone in the duct, it does not always mean that the obstruction is actually caused by a stone. Also, there may be a stone even if it is not shown by ultrasonography. Thus the exact diagnostic method must be for visualization of the inside of the duct by sialendoscopy.
  • In ultrasonography sometimes the size of stone cannot be accurately diagnosed because several stones may accumulate and may give the appearance of a single large stone. There also may be thick secretions around a smaller stone that give the appearance of a large stone.
  • As a result the salivary gland ductal obstructing diseases can be best diagnosed using sialendoscopy where the lumen (salivary canal) can be seen directly by the surgeon.
  • Often general anesthesia is not necessary for sialendoscopy. The technique called "diagnostic sialendoscopy," which is painless, bloodless and does not exceed 30 minutes, can be performed in outpatient office conditions or in the operation room with local anesthesia. When it is used just for diagnosis, the complication rates are extremely low. Very few of the patients experience temporary swelling in the involved gland after the procedure.
  • Sometimes we can continue to use local anesthesia even to treat the diagnosed obstructing pathology, however, if bigger stones need to be fragmented or an intraoral approach or open surgery needs to be used, it is better to work under general anesthesia.
  • If the stone gives signs of swelling it is usually located in the main duct. Ultrasonography and other diagnostic methods can not always detect the exact location of the stones. Especially if there are small and multiple stones because some of them may be located in the duct or in the gland. The smaller stones in the gland and out of the main ducts are usually not symptomatic and do not need to be removed.
  • If a stone is observed, its distance to the opening of the duct, if it obstructs the lumen or not, its movability, its shape, and its hardness or fragility are important factors that must be known in order to remove it safely at the same time of diagnosis. Generally speaking stones under 5 millimeters can be removed easily from the duct.
  • If there is no stone, but rather a narrowing of the duct (stenosis), the duct can be dilated. After recovery of salivary flow, the patient's complaints will decrease.
  • In sialendoscopy, mucus plugs that obstruct the salivary duct can be seen as well as salivary stones. In these patients the symptoms are the same as those patients with sialolithiasis. This causes them to be misdiagnosed as having salivary stone. In these patients sialendoscopy can detect the exact cause of obstruction and can be used to irrigate and clean the duct. This treatment will relieve the patient's symptoms.

Where Can Sialendoscopy Be Used (Indications) ?

  • In recurrent salivary gland swelling (chronic recurrent sialadenitis / Parotitis).
  • In diagnosing and treatment of stones, narrowing (stenosis), polyps, mucus plugs, kinks, foreign objects.
  • In situations where it is dangerous to use the traditional intraoral approach to remove salivary stone.
  • After prior unsuccessful attempts to remove salivary stone where symptoms reoccur sialendoscopy can be used to detect if there are any remaining stone or not.
  • In the detection of hidden stones.
  • In the detection and cleaning of the early build-up period of stones (mucus or fibrn plugs).
  • In the treatment of the narrowing (stenoses) or complete obstruction of salivary ducts following salivary gland infections (sialadenitis) or intraoral surgical attempts.
  • In detection and treatment of anatomical variations and malformations of salivary ducts.
  • In detection and treatment of pathologies in the salivary ducts caused by systemic or rheumatologic disorders.
  • In the dilation and irrigation of salivary gland ducts in patients with chronic sialadenitis.
  • After radiation therapy or radio-iodine ablation of some head and neck cancers which cause dryness in the oral cavity and recurrent infections in the salivary glands, sialendoscopy is the newest and most effective treatment method.
  • Recurrent salivary gland swelling during childhood (Juvenile Recurrent Parotitis).
  • Salivary stones in children.

Instructions for the patients from outside of Turkey

  • Please make an appointment one week before the visit and indicate that you are coming from out of country and you have salivary gland disorder.
  • The examination will be held in the date of appointment. Patients kindly requested to bring all their medical documents with them. If sialendoscopic intervention would be indicated, it will be usually undertaken on the next day of the examination.
  • In acute sialadenitis, which means the signs of acute infection are prominent (redness, pain, regional temparature and swelling on the affected gland area), it is suggested to be seen by a neighbouring otolaryngologist. Just swellings during meals, without or less pain are the usual signs of salivary canal obstructive diseases. In this occasion there is no need to antibiotic treatment and to delay the sialendoscopic intervention.
  • Generally there is no need to stay at night in the hospital. The second day after the sialendoscopic intervention the patient is expected for the postoperative follow up.
  • Information for hotel accomodation in the neighbour area can be taken by e-mail:
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