British Journal of Oral and Maxillofacial Surgery 46 (2008) 4649

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Selective management of obstructivesubmandibular sialadenitisC.-Q. Yu , C. Yang, L.-Y. Zheng, D.-M. Wu, J. Zhang, B. YDepartment o hai JiaMedical Colle

Accepted 26 JAvailable onl

Abstract

We aimed to diagnosialadenitis.Methods: B structiventional sia if theThe obstruction was treated by operation or interventional sialoendoscopy depending on the size, shape, site, and quality of the sialolith.Results: Forty-nine patients had sialoliths shown radiographically, and the features of 19 were found endoscopically and were of three types:radiolucent (n = 6), in the branch (n = 3), mucus plug (n = 3), and stenotic (n = 7). Twenty-seven obstructions were successfully removedsurgically, giving a success rate of 27/31 (87%). Twenty-seven patients were treated by interventional sialoendoscopy, and in 22 cases thesialoliths weConclusion: 2007 The

Keywords: Si

Introducti

Obstructivesialolith, istion of the sduring meplain radioand scintigthe site of tapproach.

The aetian anatom

Corresponfax: +86 21 6

E-mail ayangchi63@h(L.-Y. Zheng)Zhangjun756

0266-4356/$ doi:10.1016/jre removed directly by sialoendoscopy (22/27, 81%). Obstructive symptoms were relieved in 9 of 10 cases without stones.Operation or sialoendoscopy can be used to treat the obstruction in the submandibular gland.British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

alolith; Sialoendoscopy; Obstructive sialoadenitis; Submandibular gland

on

submandibular sialadenitis, with or without acommon. Sialoliths are the main cause of obstruc-ubmandibular gland, and cause repetitive swellingals. The traditional diagnostic methods includegraphs (occlusal film), sialography, ultrasound,raphy.1 The conventional treatment depends onhe stone, and can be either by intraoral or external

ological factors are still unknown, but have mainlyical and a salivary component. The anatomical

ding author. Tel.: +86 21 63138341x5204/5218;3136956.ddresses: ycq616@hotmail.com (C.-Q. Yu),otmail.com (C. Yang), zhenglingyan73@163.com, qingzhe98@sina.com (D.-M. Wu),28@sohu.com (J. Zhang), yun823@hotmail.com (B. Yun).

structure of the submandibular duct was first described byWharton in the 17th century, and the first attempts to visu-alise the duct with an endoscope were reported in the early1990s.24 During the past 10 years, with the rapid devel-opment in endoscopic techniques and the introduction ofsialoendoscopy, diagnosing and explorating the submandibu-lar gland directly has improved, and also permits minimallyinvasive surgical treatment to deal with the obstruction.

We report here our experience with the diagnosis and treat-ment of obstructive submandibular sialadenitis by differentmethods: classic and sialoendoscopic, and we particularlydescribe the outcome of sialoendoscopic diagnosis and treat-ment of patients with obstructed submandibular glands.

Patients and methods

Between January 2004 and June 2006, 68 patients werediagnosed with obstructive submandibular sialadenitis in

see front matter 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved..bjoms.2007.06.008f Oral and Maxillofacial Surgery, Shanghai Ninth Peoples Hospital, Shangge, 639 Zhi-zao-ju Road, Shanghai 200011, P.R. Chinaune 2007

ine 20 August 2007

describe the effect of our surgical and sialoendoscopic technique for

etween January 2004 and June 2006, 68 patients presented with obloendoscopy or excision. The patients all had radiographs and then,un

o-tong University

sis and treatment of chronic obstructive submandibular

ve symptoms and were diagnosed and treated by inter-sialolith could not be found, diagnostic sialoendoscopy.

C.-Q. Yu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 4649 47

Fig. 1. Diagnostic algorithm.

Shanghai Ninth Peoples Hospital, with symptoms of inter-mittent sweSome discroutine exaradiographhad diagnothe duct po

There arsalivary stotional sialodepends onstones.

The enddiagnosticdilator, forelectrohydr

The prothesia acco

the patient. Local anaesthesia is by nerve block (the lingual) and

rifice.f 0.9%s the vccasioe dev

or byct, aneter. Tuctal shen aentios, partly byed byhen son dilalling of the gland that was aggravated by eating.harged pus. No other diseases were found onmination. All patients were evaluated by plain

s (occlusal film). If no sialolith was found, theystic sialoendscopy, which was also used to detectstoperatively (Fig. 1).e three ways in which we can treat patients withnes: removal through the oral cavity, interven-

endoscopy, and resection of the gland. Our choicethe site, size, shape, number, and quality of the

oscopic system (Karl Storz, Germany) includesand interventional sialoendoscopy, a papillary

ceps, grasping wire basket (3 or 6 wires), and anaulic lithotripter (no. 27080B).cedure can be done under local or general anaes-rding to the site of the stone and the wishes of

nerve

the otion ocleanand o

Thductof dudiamthe d

Wintervstonedirecment

WballoFig. 2. Therapeutic algorithm.perfusion of 2% lignocaine into the duct throughThe endoscope is rinsed intermittently with a solu-

sodium chloride. This slightly dilates the duct,iew of the endoscopist, and removes pus, debris,nally blood.ice is inserted through the orifice of Whartons

a mini-incision into the orifice or the anterior partd the papilla is dilated with dilators of increasinghe first procedure is diagnostic, and can exploreystem thoroughly.stone is located or a ductal disorder identified,

nal sialoendoscopy is required. The small, roundticularly one floating in the duct, can be removedwires or forceps. Larger stones should be frag-

and then removed by wires or forceps (Fig. 2).tenosis is the problem, the patients are treated bytation and continuous irrigation through the endo-

48 C.-Q. Yu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 4649

scope if the stenosis is located in the middle or distal part orbranch of the duct. Mucus plugs can also be removed byforceps and washed out by continuous lavage through theendoscope.

Patients in whom the stone is located in the anterior partof Whartons duct, particularly if it is solitary or if a large orirregular stone is found distally or at the hilum, removal isdifficult and complicated. If the stenosis is in the orifice oranteriorly, marsupialisation is done simultaneously.

Interventional sialoendoscopy and operation can be usedjointly to treat multiple stones. Excision of the gland is theultimate choice for cases in which no other method is possi-ble.

Our evaluation of the results included whether the stonehad been removed successfully and whether symptoms ofobstruction were relieved.

Results

Sixty-eight patients were treated in our department, 41 menand 27women aged 12 to 65. Duration of symptoms was 2months to 3 years. Stones were confirmed by plain radio-graphs (ocpatients wetified by di

Nineteeunknown,mucus plupatients hadduct; 6 hadduct. Sevenplugs in thr

A singlemultiple stWe categordoscopy ac

Table 1Results of removal of sialoliths surgically and endoscopically

Surgical removal Interventionalsialoendoscopically

Total

Success Failure Success Failure

Anterior 13 0 4 0 17Distal 14 4 16 4 38Branch duct 2 1 3

Total 27 4 22 5 58

part is in front of the first molar and including it; the distalpart is behind the first molar, and there is the branch. Of 58stones, the sialoliths of 17 were located anteriorly, 3 in thebranch duct, and 38 in the distal duct. The most posteriorstone was recorded when there was more than one.

Stones were removed after radiographs and diagnosticsialoendoscopy. Of 58 cases, 27 were treated by interven-tional sialoendoscopy and 5 failed. The failures were causedby the stone being embedded in the ductal wall, unsuccess-ful dilatation of the stenosis, and the stone being located inthe branch duct. Thirty-one were removed by routine exci-sion (Figs.

andthe futo rem.

bstruconesainingaloende dia

res, anmm.

ngualioticsof the

l film. (6) Removal of stone. (7) Salivary stone.clusal film) in 49 patients (72%), and 19 otherre examined and their obstructive problem iden-agnostic sialoendoscopy.n patients, the reasons for whose stones werewere classified into stone (Fig. 3), stenosis andg (Fig. 4), and a combination of the two. Nine

radiolucent stones or stones located in the branchradiolucent stones, and 3 had stones in the branchpatients had stenosed ducts and there were mucusee.stone was diagnosed in 37/58 (64%) cases and

ones in 24 by radiography and sialoendoscopy.ised the three positions by radiography or sialoen-cording to the position of the stone. The anterior

stonethatwas

glandO

no stRemby si

Thceduto 18subliantibfloor

Figs. 37. (3) Stone in the main duct. (4) Mucus plug. (5) Occlusa57) and four failed because of the position of thesevere adhesions (Table 1). The results showedrther back the stone was, the more difficult itove. Failures were treated by resection of the

tive symptoms were relieved in 9/10 cases withby interventional sialoendoscopy and operation.or radiolucent stones were found in seven casesoscopy after operation.

meter of stones was measured after different pro-d the maximum differed greatly, ranging from 2There were six complications: one patient had acyst; five required corticosteroids together withintravenously for severe swelling of the gland andmouth.

C.-Q. Yu et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 4649 49

Discussion

Stones are the main cause of obstructive submandibularsialadenitis. They vary in size, shape, and quality, and eitherfloat in the lumen or attach to the ductal wall. They canbe either single or multiple, and mechanically obstruct thesalivary du

Radiogrtigating thresonance s

it providesthe salivaryexposure tothe inner duin the duct.endoscopicsystem com

Endoscoand used tolar gland.6introducedobstructiveimmediatelin the ductfied as sialoand all progland. Sialstone andobstructionof obstructcases were

of 85%. Bythat 32% odetected bycases in ouvinced thatto magnetiand more d

Convenis in the disto postopelingual nerClassicallybe extractethey are mbecome chfound in 48by resectiothere was nthe histopacannot therloss, and spractical.

The sialoendoscopic system that we have helps us toremove the stone with minimal effort, particularly when itis distal, and our success rate was 82%. Like others1012 ourexperience shows the results of interventional sialoendoscopyto be directly related to the size, shape, and position of thestone. Sialoendoscopy is a minimally invasive technique for

ng oboperat

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m PMand enldiolog

atz P. Eands). Aonigsbelled ele

livary srzoz E,real lit752.

ecker Mct stenmensioquence

CQ, YsearchstructivChine

archal Fandibulr ductalahlieliagnosisscope 2archal. Histopn Otolarchal Fgl J M

ahlieli Ochniquerg 1994

ahlieli Oatment99;57:1egler Cally invlivary grg 2004

hu DW,bmandink J, K

new endcGurklculi. BcGurke mana06;33,ct, causing recurrent swelling during meals.aphs are a practical and simple way of inves-e ductal system. Nowadays, however, magneticialography is a new way to diagnose the problem;5two-dimensional or three-dimensional images of

gland without contrast medium and too muchradiation. These methods do not allow us to see

ct system directly to make sure what is happeningSialoendoscopy was promoted in the 1990s as antechnique,24 and allows us to explore the ductalpletely, mainly because the scopes are so small.py was introduced to our department in 1999,explore obstructed disorders of the submandibu-In 2002, a new sialoendoscopic system was

, which made it possible to diagnose and treatproblems with minimal intervention, directly andy. Using sialoendoscopy we found the inner signsof the salivary gland. Features were mainly classi-lithiasis, sialodochitis, stenosis, and mucus plug,

duce obstructive symptoms in the submandibularoendoscopy enabled us to detect the radiolucentthe stone in the branch and gave us evidence of. Marchal et al. reported7 the finding of 131 casesed Whartons ducts, and 106 by stones. Ninetysuccessfully relieved, with an overall success rateusing endoscopy, Nahlieli and Baruchin8 foundf stones in the submandibular gland were notroutine imaging methods. The number of such

r series was 9/58 (16%). We were therefore con-sialoendoscopy was superior to plain film or even

c resonance imaging, particularly for the smalleristal stones.tional removal is particularly difficult if the stonetal or hilar area of Whartons duct, and may lead

rative complications, particularly damage to theve. In some cases, the gland must be removed., proximal stones close to the papilla can easilyd orally, whereas the gland must be resected ifore distal. A gland in which the sialolithiasis hasronic may change its function. Marchal et al.9patients with sialolithiasis that had been treated

n, half had abnormal histological patterns, ando correlation between the duration of history andthological alterations in the gland. A long historyefore be used to predict the degree of functionalo conservative treatment is both reasonable and

treatiwith

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, Shugar JM, Train JS, Biller HF. Manifestations of parotidargement: radiographic, pathologic, and clinical correlations.y 1981;141:4216.ndoscopie des glands salivaires. (Endoscopy of the salivarynn Radiol Paris 1991;34:1103.

rger R, Feyh J, Goetz A, Kastenbauer E. Endoscopically con-ctrohydraulic intracorporeal shock wave lithotripsy (EISL)of

tones. J Otolaryngol 1993;22:123.Santiago A, Esnal F, Palomero R. Endoscopic intracor-

hotripsy for sialolithiasis. J Oral Maxillofac Surg 1996;54:

, Marchal F, Becker D, et al. Sialolithiasis and salivaryosis: diagnostic accuracy of MR sialography with a three-nal extended phase conjugate symmetry rapid spin echo. Radiology 2000;217:34758.ang C, Qiu WL, Hu BP, Shen N, Zheng LY. The primary

of endoscopic technique for the diagnosis of the chronice sialoadenitis. Chin J Oral Maxillofac Surg 2002;12:1924se)., Dulguerov P, Becker M, Barki G, Disant F, Lehmann W. Sub-ar diagnostic and interventional sialendoscopy: new proceduredisorders. Ann Otol Rhinol Laryngol 2002;111:2735.

O, Baruchin AM. Long-term experience with endoscopicand treatment of salivary gland inflammatory diseases. Laryn-000;110:98893.

F, Kurt AM, Dulguerov P, Becker M, Oedman M, Lehmannathology of submandibular glands removed for sialolithiasis.Rhinol Laryngol 2001;110:4649., Dulguerov P, Lehmann W. Interventional sialendoscopy. N

ed 1999;341:12423., Neder A, Baruchin AM. Salivary gland endoscopy: a newfor diagnosis and treatment of sialolithiasis. JOralMaxillofac;52:12402., Baruchin AM. Endoscopic technique for the diagnosis andof obstructive salivary gland diseases. J Oral Maxillofac Surg394402.M, Steveling H, Seubert M, Muhling J. Endoscopy: a mini-asive procedure for diagnosis and treatment of diseases of thelands. Six years of practical experience. Br J Oral Maxillofac;42:17.Chow TL, Lim BH, Kwok SP. Endoscopic management of

bular sialolithiasis. Surg Endosc 2003;17:8769.och M, Bozzato A, Iro H. Sialoscopy-initial experiences withoscope. Br J Oral Maxillofac Surg 2004;42:2938.

M, Escudier MP, Brown JE. Modern management of salivaryr J Surg 2005;92:10712.M, Escudier MP, Thomas BL, Brown JE. A revolution ingement of obstructive salivary gland disease. Dent Update2830, 336; Erratum: Dent Update 2006; 33:83.

Selective management of obstructive submandibular sialadenitisIntroductionPatients and methodsResultsDiscussionReferences