**Combined Approaches in Sialolithiasis of Major Salivary Glands Salivary Glands**

**Combined Approaches in Sialolithiasis of Major** 

DOI: 10.5772/intechopen.72308

Iordanis Konstantinidis, Angelos Chatziavramidis and Ioannis Iakovou Ioannis Iakovou Additional information is available at the end of the chapter

Iordanis Konstantinidis, Angelos Chatziavramidis and

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72308

#### **Abstract**

[9] Hiraba H, Inoue M, Sato T, Nishimura S, Yamaoka M, Shimano T, Sampei R, Ebihara K, Ishii H, Ueda K. Chapter 14: Optimal vibrotactile stimulation activates the parasympathetic nervous system. In: Advances in Vibration Engineering and Structural Dynamics Francisco Beltran-Carbajal edite. Croatia: InTech; 2012. pp. 335-369. http://www.intechopen.com [10] Hiraba H, Inoue M, Gora K, Sato T, Nishimura S, Yamaoka M, Kumakura A, Ono S, Wakasa H, Nakayama E, Abe K, Ueda K. Facial vibrotactile stimulation activates the parasympathetic nervous system: Study of salivary secretion, heart rate, pupillary reflex, and functional near-infrared spectroscopy activity. BioMed Research International. 2014;**2**:1-9

116 Salivary Glands - New Approaches in Diagnostics and Treatment

Combined (endoscopic-transcutaneous/intraoral) techniques are an effective treatment for large and/or impacted stones of the major salivary glands. This approach results in high rates of symptom improvement and gland preservation. The complication rates are relatively low, further supporting the use of these techniques as an additional tool between the classic sialendoscopy and the external classic procedures of gland removal. In this chapter, we describe the combined approach for the parotid gland and the submandibular gland and finally, the retrograde sialendoscopy through the surgical field of an open approach.

**Keywords:** sialendoscopy, transcutaneous, sialolithiasis, parotid, submandibular

#### **1. Introduction**

Endoscopic techniques in the management of sialolithiasis were introduced since the 1990s and gradually became the standard treatment option, decreasing the external procedures [1]. In our days only 20–25% of all symptomatic cases require an open surgical approach of the gland [1, 2]. The introduction of interventional sialendoscopy with intraductal laser fragmentation did not solve all the problems as some stones were too large to be fragmented, and some others had associated with ductal stenosis which could not be dilated [3].

In order to avoid gland removal with its associated significant morbidity, surgeons developed combined techniques (endoscopic and transcutaneous) as a solution within the frame of a gland-preserving strategy [4–6].

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2017 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

Indications for this combined management are failure of interventional sialendoscopy to treat impacted calculi, stones larger than 8 mm, stones located behind a stenosis which cannot be dilated, and finally a non-successful extra- or intracorporeal lithotripsy [4–8].

In the vast majority of cases, the first two incisions are used with the last one only in very superficial and/or proximal stones especially in aged people where the skin lines can hide a

Combined Approaches in Sialolithiasis of Major Salivary Glands

http://dx.doi.org/10.5772/intechopen.72308

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In cases where a parotid incision approach is required, the skin flap is elevated exposing enough surface of the gland for the stone removal. Transillumination of the sialendoscope's tip into the ductal system helps the precise gland-preserving dissection technique. In superficial stones, a longitudinal incision of the gland parenchyma (1–1.5 cm in length) above the endoscope light is performed (**Figure 2A**). In stones with deeper location (5 mm from the surface of the gland), a mini-flap of the gland parenchyma is prepared above the area of the

Stenting the ductal system is not obligatory. We suggest the use of a stent in cases where an opening of the ductal system larger than 1 cm has been performed and/or other traumatic manipulations in the duct have been done during removal of a polyp or an impacted stone. Usually, when a stent is used, this is placed in a retrograde fashion via the surgical field and secured in buccal mucosa with absorbable sutures (**Figure 3**). The stent can be left for a period of 3–6 weeks. The closure of the parotid duct is carried out using absorbable sutures. Fibrin glue and absorbable sutures are used for the repositioning of the gland flap in cases of nonsuperficial stone location (**Figure 4A** and **B**). A small drainage usually is needed as in parotid tumor surgery which is removed on the first postoperative day. Tight bandage for 4–5 days is proposed to avoid leak of saliva. Patients take broad-spectrum antibiotic treatment for a week

During the first postoperative period (2–3 weeks), patients are advised to avoid nutrition

**Figure 2.** (A) Longitudinal incision of the gland in a superficial stone and (B) ᴨ-shaped mini-flap in a deep-located stone.

relatively small facial scar.

and analgesics if required.

**2.2. Follow-up assessment**

ductal system which is lighted (**Figure 2B**) [9].

which produce excessive saliva (e.g., lemon juice, etc.).

In this chapter, we present approaches that we use in parotid and submandibular sialolithiasis cases in order to avoid gland removal.
