**2. Combined approach in parotid sialolithiasis**

## **2.1. Surgical technique**

This is a procedure performed under general anesthesia. Facial nerve monitoring is mandatory as in the majority of the cases a branch of the nerve is located closely to the main ductal system.

Before the procedure, a diagnostic sialendoscopy is carried out to ensure that endoscopic localization of the stone is possible. The sialendoscope used in surgery has usually a diameter of 1.1 mm. The first step of the procedure is the identification by means of the endoscope of the stone's location in the ductal system. Then, the skin above the stone is marked as the light of the endoscope's tip can be easily detected (**Figure 1**).

The location of the stone (proximal-distal, superficial-deep in the gland) is the factor which affects the surgeon's decision regarding the incision which is required. Three incisions have been described [8]:


**Figure 1.** Transillumination of the parotid area and skin marking before the operation.

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 relatively small facial scar.

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

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 and analgesics if required.

#### **2.2. Follow-up assessment**

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

In this chapter, we present approaches that we use in parotid and submandibular sialolithia-

This is a procedure performed under general anesthesia. Facial nerve monitoring is mandatory as in the majority of the cases a branch of the nerve is located closely to the main ductal system. Before the procedure, a diagnostic sialendoscopy is carried out to ensure that endoscopic localization of the stone is possible. The sialendoscope used in surgery has usually a diameter of 1.1 mm. The first step of the procedure is the identification by means of the endoscope of the stone's location in the ductal system. Then, the skin above the stone is marked as the light

The location of the stone (proximal-distal, superficial-deep in the gland) is the factor which affects the surgeon's decision regarding the incision which is required. Three incisions have

dilated, and finally a non-successful extra- or intracorporeal lithotripsy [4–8].

sis cases in order to avoid gland removal.

118 Salivary Glands - New Approaches in Diagnostics and Treatment

**2.1. Surgical technique**

been described [8]:

**1.** Lazy S

**2. Combined approach in parotid sialolithiasis**

of the endoscope's tip can be easily detected (**Figure 1**).

**2.** Mini parotidectomy incision extended if required to face lift

**Figure 1.** Transillumination of the parotid area and skin marking before the operation.

**3.** Straight, small incision above the stone

During the first postoperative period (2–3 weeks), patients are advised to avoid nutrition which produce excessive saliva (e.g., lemon juice, etc.).

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

these stenotic areas are considered without clinical impact as none of the patients suffered from postoperative swellings. The incision is parallel to the duct axon, and this may decrease the possibility for severe stenosis even in cases with extended opening. In addition stenting with precise intraoperative placement can be helpful to avoid postoperative stenosis. Undoubtedly, further studies are needed to justify the size of the ductal opening which is

Combined Approaches in Sialolithiasis of Major Salivary Glands

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

121

In the same study, scintigraphic evaluation of the operated parotid glands in two phases (baseline and after stimulation) provided an objective functional evaluation 1 year after the procedures [9]. Specifically, a dynamic imaging of the whole anterior head started after a bolus intravenous injection of 99mTc. Fifteen minutes after the initial injection, diluted lemon juice was given per oz. The parameters measured were (1) uptake rate, taken as the value of the initial slope of the time-activity curve and (2) washout fraction, as a relative mobilized radioactivity from each parotid gland after the sialogogue's application. In the vast majority of cases (11/12), the procedure preserved the function of the gland with only one parotid

Extracorporeal and laser intraductal lithotripsy requires expensive devices which are not always available; they are time-consuming and always have a potential risk of leaving residual stone fragments which can be a nidus for new stone formation. Moreover, some patients prefer the described surgical option as a "one shoot" intervention instead of extracorporeal

Contraindication for this procedure is the presence of diffuse ductal stenosis or multiple

A combined approach can be also used for submandibular gland with large and/or impacted

The procedure starts again with a sialendoscopy, and when the endoscope approximates, the

Infiltration of the transilluminated area with xylocaine 2%-adrenalin 1% solution follows. The next step is an incision of the oral mucosa approximately 2 cm in length following the axis of Wharton's duct size just above the lighted area (**Figure 5A** and **B**). Caution should be taken at this point in order to avoid lingual nerve damage as it crosses Wharton's duct and this is the reason why some authors identify and isolate the nerve with a loop from the surgical field [8]. A useful surgical tip is the fact that the floor of the mouth can be pushed upward by external pressure at submandibular triangle below the patient's mandible, giving better access to the

stone then is fixed to the floor of the mouth or can be held steadily by an assistant.

critical regarding postoperative stenosis.

hypofunction in a patient with long-term history of sialolithiasis.

**3. Combined approach in submandibular sialolithiasis**

lithotripsy which may need multiple sessions [10–12].

stones in a similar manner with the parotid gland.

parenchymal stones [8, 9].

**3.1. Surgical technique**

hilum area endorally.

**Figure 3.** Stent placement in a retrograde fashion via the surgical field. The left loop isolates the main duct, and the right the facial nerve branch which run close to the ductal system.

**Figure 4.** (A) Fibrin glue and (B) absorbable sutures are used for the repositioning of the gland flap in cases of nonsuperficial stone location.

Early complications such as hematoma, sialadenitis, wound infection, fistula, and obstructed and/or extruded stent have been rarely published and usually occur within the first postoperative month. In such cases, conservative management and removal of stent if needed are enough measures [9–11].

Initially, one of the surgeons' concerns about the procedure was the potential postoperative stenosis at the site of the ductal incision. This fact is expected and was confirmed in our data, as 7 patients out of 12 had an endoscopically diagnosed postoperative stenosis [9]. However, these stenotic areas are considered without clinical impact as none of the patients suffered from postoperative swellings. The incision is parallel to the duct axon, and this may decrease the possibility for severe stenosis even in cases with extended opening. In addition stenting with precise intraoperative placement can be helpful to avoid postoperative stenosis. Undoubtedly, further studies are needed to justify the size of the ductal opening which is critical regarding postoperative stenosis.

In the same study, scintigraphic evaluation of the operated parotid glands in two phases (baseline and after stimulation) provided an objective functional evaluation 1 year after the procedures [9]. Specifically, a dynamic imaging of the whole anterior head started after a bolus intravenous injection of 99mTc. Fifteen minutes after the initial injection, diluted lemon juice was given per oz. The parameters measured were (1) uptake rate, taken as the value of the initial slope of the time-activity curve and (2) washout fraction, as a relative mobilized radioactivity from each parotid gland after the sialogogue's application. In the vast majority of cases (11/12), the procedure preserved the function of the gland with only one parotid hypofunction in a patient with long-term history of sialolithiasis.

Extracorporeal and laser intraductal lithotripsy requires expensive devices which are not always available; they are time-consuming and always have a potential risk of leaving residual stone fragments which can be a nidus for new stone formation. Moreover, some patients prefer the described surgical option as a "one shoot" intervention instead of extracorporeal lithotripsy which may need multiple sessions [10–12].

Contraindication for this procedure is the presence of diffuse ductal stenosis or multiple parenchymal stones [8, 9].
