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The update of this guideline was an important step to define standards for the use of sialendoscopy and other emerging minimally invasive techniques for the therapy of sialolithiasis and other obstructive salivary gland diseases. The current actualization was necessary to adapt the diagnostic and therapeutic algorithms to the current scientific knowledge. In this article they are presented in a shortened version with a focus on conservative therapeutic measures which are especially relevant for daily practice.Die Aktualisierung der Leitlinie war ein wichtiger Schritt, um mit zunehmender Verbreitung der Sialendoskopie und anderer minimalinvasiver Verfahren Behandlungsstandards zur Therapie der Sialolithiasis und der Speichelgangstenosen zu definieren. Im Rahmen der Aktualisierung wurden die diagnostischen und therapeutischen Algorithmen dem aktuellen Wissensstand angepasst. Sie werden in diesem Artikel in verkürzter Form mit Betonung der praxisrelevanten konservativen Therapieoptionen wiedergegeben.

The success of sialendoscopy depends on several factors. The 2008 introduced lithiasis-stenosis-dilatation (LSD) classification intended to describe more precise the stone-duct system. We investigated whether the LSD classification and additional pre- and intraoperative parameters could be used as prognostic factors for success.We retrospectively assessed patients with primary sialendoscopy for sialolithiasis between September 2018 und March 2020. Among others, the outcome variables were the stone size, location and LSD classification.We included 37 patients. The success group included 12/37 (32 %) patients. The median stone size was 3.7 millimeters (mm) in the success group and 10.0 mm in the failure group (Mann-Whitney test; p 0.0001). In the success group, 11/12 stones were distal in contrast to the failure group (13/25 stones proximal; Pearson's chi-square test; p = 0.010). We noted 10 L1S0D0 stones in the success group in contrast to the failure group (15 L3aS0D0 stones; Pearson chi-square test; p = 0.001). For distal stones smaller than 5 mm, the success rate was 100 % and for proximal stones larger than 4 mm, it was 0 %. For stones free in the duct lumen (L1S0D0), the success rate was 60-100 %.The distal stone location and the smaller stone size in a normal duct should be beneficial prognostic factors for success. Future studies should focus on the LSD classification, stone volume, stone duct orientation and stone distance from the papilla.Der Erfolg der Sialendoskopie hängt von mehreren Faktoren ab. Im Jahr 2008 wurde die Lithiasis-Stenosis-Dilatation (LSD) -Klassifikation zur genaueren Beschreibung des Stein-Gang-Verhältnisses eingeführt. Neben dem Nutzen der LSD-Klassifikation untersuchten wir weitere prä- und intraoperativ erhobene Einflussfaktoren auf den Erfolg der Sialendoskopie bei Sialolithiasis.PatientInnen mit Sialolithiasis der Glandula submandibularis und Glandula parotis, die zwischen September 2018 und März 2020 eine primäre Sialendoskopie erhielten, wurden retrospektiv untersucht. Die Steingröße, Steinlokalisation und LSD-Klassifikation wurden unter anderem als prognostische Einflussfaktoren untersucht.Insgesamt wurden 37 PatientInnen retrospektiv untersucht. Eine erfolgreiche Steinextraktion wurde bei 12/37 (32 %) PatientInnen durchgeführt. Bei Erfolg betrug die mediane Steingröße 3,7 mm, verglichen mit 10 mm bei Misserfolg (Mann-Whitney-Test; p 0,0001). Bei Erfolg waren 11/12 Steine distal lokalisiert, verglichen mit 13/25 proximal lokalisierten Steinen bei Misserfolg (Pearson-Chi-Quadrat-Test; p = 0,010). Bei Erfolg wurden 10/12 Steine als L1S0D0 klassifiziert, während 15/25 bei Misserfolg als L3aS0D0-Steine klassifiziert wurden (Pearson-Chi-Quadrat-Test; p = 0,001). Für distal lokalisierte Steine, die kleiner als 5 mm waren, lag die Erfolgsrate bei 100 %. Für proximal lokalisierte Steine, die größer als 4 mm waren, lag die Erfolgsrate bei 0 %. Für die als L1S0D0 klassifizierten Steine betrug die Erfolgsrate 60–100 %.Distal lokalisierte Steine und Steine kleiner als 5 mm in einem ansonsten unauffälligen Gangsystem können als prognostisch günstige Faktoren angesehen werden. Zukünftige Studien sollten anhand größerer Datenmengen die LSD-Klassifikation, das Volumen der Steine und deren Gangorientierung bzw. deren Abstand von der Papille untersuchen.

There is plethora of treatment options for surgeons dealing with salivary stones. During recent decades, emphasis has been laid on gland-preserving minimally invasive techniques for stone removal. In this context, visualization of salivary ducts with semirigid endoscopes for diagnostic and therapeutic purposes, the so-called sialendoscopy, has become increasingly important. This article gives an overview of indications for sialendoscopy and how the procedure is performed. Furthermore, sialendoscopy is discussed in the context of other modalities for salivary stone treatment.Zur Behandlung von Speichelsteinen steht dem behandelnden Arzt eine Vielzahl von Behandlungsmodalitäten zur Verfügung, wobei in den vergangenen Jahrzehnten zusehends mehr Augenmerk auf drüsenerhaltende, minimal-invasive Techniken der Steinentfernung gelegt wurde. Einen großen Stellenwert hierbei hat die Sialendoskopie, also die zu diagnostischen und therapeutischen Zwecken einsetzbare Visualisierung der Speichelgänge mit semirigiden Endoskopen. Der vorliegende Artikel gibt einen Überblick über Indikationen und Durchführung der Sialendoskopie und bettet diese Behandlungsoption in den Gesamtkontext der übrigen therapeutischen Maßnahmen zur Steinextraktion ein.

Sialolithiasis is one of the most common salivary gland diseases. The main symptom is acute swelling of a major salivary gland after food intake, whereby the submandibular gland is significantly more frequently affected compared to the parotid gland. In the course of the disease, recurrent sialadenitis occurs in many cases. In addition to submandibulectomy, there is currently not only the possibility of improved diagnostics but also of gland-preserving therapy, for example by means of miniature endoscopy (sialendoscopy).Die Sialolithiasis als eine der häufigsten Speicheldrüsenerkrankungen betrifft die Glandula submandibularis im Vergleich zur Glandula parotis deutlich häufiger. Im Verlauf der Erkrankung kommt es in vielen Fällen zu rezidivierenden Sialadenitiden. Durch verbesserte Diagnostik besteht neben der Submandibulektomie auch die Möglichkeit einer drüsenerhaltenden Therapie, z. B. mittels Miniaturendoskopie (Sialendoskopie).

This is the first population-based analysis of inpatient salivary gland surgery across Germany.Nationwide Diagnosis-Related Groups (DRG) statistics for 2007 to 2011 were analyzed regarding indications for salivary gland surgery based on ICD-10 codes. Age specific surgery rates were calculated for both sexes.Inpatient salivary gland surgical rates in 2007-2011 amounted for incisions (OPS [Classification of Operations and Procedures] code 5-260) 1.43 per 100 000 population, for excisions (5-261) 2.06 per 100 000, for salivary gland resections (5-262) 2.06 per 100 000, and for external incisions (5-270) 0.43 per 100 000. Regarding the mentioned four OPS codes, the surgical rates for benign tumors accounted to 10.08 per 100 000, for sialadenitis (without sialoliths) to 4.00 per 100 000, for malignant tumors to 3.90 per 100 000, and for sialolithiasis to 2.09 per 100 000. The increase of surgical rates from 2007 to 2011 was significant for malignant and benign tumors as well as for salivary stones. The surgical rates were highest for patients60 years.Especially surgery for malignant tumors was more frequent than expected. In spite of the introduction of minimal invasive technique the rates for salivary gland resections in case of sialadenitis or sialolithiasis still seem to be high.

Our research was conducted to determine the algorithm changes during the treatment of submandibular sialolithiasis. Two time periods were compared between 2004–2008 and 2009–2012. The turning point was December 2008, when sialendoscopy procedure was introduced. In the first period, 48 patients were treated: 31 outpatient duct incisions with stone evacuation and 17 surgical excision of submandibular gland. In the second period, 207 sialendoscopy procedures were performed on 197 patients. Out of this particular group, 158 patients were diagnosed with pathological obstruction of salivary glands and 64 of them were confirmed to have sialolithiasis of submandibular gland. Deposits of calcifications in 40 individuals (62.5 %) affected by sialolithiasis were removed endoscopically; however, in 21 patients, due to the increased circumference of the stone, the intimate association of deposits within the wall of the duct along with its presence inside the deep portions of the gland, double approach (incision of the floor of the mouth in hilar area and sialendoscopy) was performed. Three individuals had their salivary glands totally removed due to the presence of calcified deposits within the glandular parenchyma. Our results allow us to affirm that sialendoscopy is the current treatment of choice for submandibular glands affected by sialoliths. Indication for a complete removal of the gland is becoming uncommon as a first line treatment although still indispensable in chosen cases.

Extracorporeal shock wave lithotripsy (ESWL) is now judged alongside other therapeutic alternatives like salivary gland endoscopy (SGE). The present analysis investigates the significance of ESWL within the scope of a defined treatment algorithm.A retrospective analysis of data obtained between 2003 and 2009. The results were analysed according to the therapeutic modality used. Successful treatment was defined as an absence of symptoms or stones at follow-up examination.During the period studied, 206 patients with parotid stones and 736 with submandibular stones underwent treatment. Among the latter group, 5 % were treated exclusively by SGE, 92 % underwent transoral stone removal and 3 % received ESWL. The long-term success rates were 93 %, 90 % and 94 %, respectively. Patients with parotid stones were treated in 78 % of cases by ESWL and 22 % underwent SGE exclusively. The overall long-term success rates here were 85 % and 98 %, respectively.ESWL remains an important therapeutic tool in the management of sialolithiasis. The method is particularly important as a gland-preserving tool in the therapy of parotid stones and selected cases of submandibular stones, even though it is not available in the US due to the lack of official equipment approval.

The treatment of stenoses and non-stone-related obstructive diseases of the major salivary glands has undergone significant changes due to the development of minimally invasive treatment modalities. Correct diagnosis can often not be established in detail with all diagnostic tools except sialendoscopy, which is necessary for gland-preserving therapy. Over the last 10 years a range of minimally invasive treatment approaches aimed at preserving gland function have been developed. In addition to sialography-controlled therapy, interventional sialendoscopy plays a central role, representing the treatment of first choice in all stenoses and non-stone-related obstructions of the salivary duct system and with a success rate of about 85%-90%. By combining sialendoscopy with other minimally invasive surgical procedures, the function of the gland can be preserved in more than 95%. Thus sialendoscopy plays a crucial role in the treatment of non-stone-related obstructive diseases of the major salivary glands. In stenoses of the salivary gland ducts extirpation of the gland should be considered only as a last step.

Sialoliths are the underlying cause of salivary gland obstructive disease in 60%-70% of cases. Modern minimally invasive techniques have enabled accurate diagnosis and findings-specific therapy with the aim of full gland-function preservation. This article provides an overview of the current diagnostic measures for and therapy of sialolithaisis. Ultrasound is the investigation of first choice and is able to recognize stones in well over 90% of cases. Sialendoscopy is a directly visualizing technique which is superior to all other diagnostic measures for the assessment of pathologic changes in the salivary duct system and the detection of stones. Treatment was significantly improved with the introduction of extracorporal shock wave lithotripsy (ESWL), sialographic-controlled techniques, surgical procedures of the duct system and in particular by interventional sialendoscopy. Interventional sialendoscopy, especially when combined with other treatment modalities, has a success rate of 85%-95%. Cases which respond poorly to therapy can be treated successfully with the endoscopic transcutaneous approach in about 90% of cases. When sialendoscopy is performed in combination with other minimally invasive treatment options the gland can be preserved in 95%-98% of all cases.

Panoramic radiography is a basic diagnostic tool in the dental field where calcifications are seen occasionally in the lateral parts of the x-ray. The differential diagnosis are carotid artery atheromas, calcified submandibular lymphnodes and sialoliths of the submandibular gland. 4007 panoramic radiographs (100%) from patients40 years were scanned retrospectively. Special emphasis was given to the carotid artery territory (CAT). 225 soft tissue calcifications were found (5.6%). 144 patients had calcifications in the CAT (3.6%), 73 showed calcified submandibular lymphnodes (1.8%), and 8 (0.2%) sialoliths. The female to male ratio was 54.7%:45.3%. Pneumatic diseases were beside hypertension and smoking a risk factor for CAT calcification. Carotid artery atheromas are the main risk for cerebrovascular insults. Dentists can help to detect patients at risk for stroke. Their patients can be referred for further diagnostics (ultrasound).

Mechanisms of secretion transport through the parotid duct (stenon's duct) and their influence on diseases of the parotid gland have not been investigated sufficiently until today.According to this background we performed histologic and scanning electron microscopical investigations of 23 parotid ducts in order to investigate the arrangement of fibrillar structures of the duct as well as get deeper insights into the physiology of secretion transport mechanisms.The subepithelial soft tissue of the parotid duct could be divided into two layers. The inner layer measured about 100-200 microm and consisted of collagen and elastic fibres running in a spiral arrangement. The outer layer varied in its thickness and was composed of collageous fibres, which were mostly arranged longitudinally.The arrangement of collagen fibrils in the wall of the parotid duct seems to influence secretion transport. Due to the spiral organization of collagen fibrils, distension of the duct is likely to be associated with a "wring-out" mechanism leading to unidirectional transport of saliva into the oral cavity. A muscular sphincter at the outlet of the parotid duct did not exist. The duct pierced the buccinatory muscle. Here, it was surrounded by sceletal muscle fibres that lead to a functional closure during contraction. Our results indicate that an active transport of saliva through the parotid duct--as so far assumed--is unlikely.

Sialolithiasis as a cause of sialadenitis within Wharton's duct accounts for more than 80% of all cases. In the past extirpation of the gland was carried out in nearly all cases. Gland-preserving therapies such as transoral removal have so far been seldom examined.In 683 patients suffering from submandibular lithiasis with a mean age of 45 years (8-87 years) transoral removal of the stones were carried out. The follow-up period was 1-7 years. The stone location was distal to the edge of the mylohyoid muscle in 283 cases and more proximal to the gland within the hilum in 296 patients (single concrements). Fifty-nine patients had two separate stones, one within the area of the hilum and other smaller ones proximal within the gland.All patients with distal stone location, 89% of patients with single stones of the perihilar region, and 63% of the patients with two separate stones in the hilum and parenchyma were free of stones. Another 8 and 23%, respectively, had small residual concrements without any complaints. Recurrence of lithiasis or damage of the lingual nerve remained below 1%.Transoral removal in palpable sialoliths should be considered as the treatment of choice in patients suffering from submandibular stones located within the floor of the mouth or within the perihilar region of the gland. Ultrasound imaging is important for exact location of the stones.

A brief, schematic summary of a workshop held in Davos 2003 is presented. Sonography of the head and neck has been carried out successfully since the beginning of the sonographical era, as this region is readily accessible to the transducer head and the superficial position of the organ can be very well visualized. The prerequisites are a high-resolution transducer-head (around 7.5 MHz), operator experience and good knowledge of the relevant anatomy. The type of transducer selected--linear or mechanical wobbler--plays a subordinate role, and color Doppler technology is not mandatory. This brief presentation will not address the thyroid gland, the cervical vessels, the paranasal sinuses, the facial soft tissue or the pharynx.

Diagnostic importance of sonography has improved significantly in the last ten years. Nowadays, sonography is the most common form of imaging technologies in medicine. Innovations like "Tissue Harmonic Imaging" provides higher contrast in deeper tissue layers. By use of sonographical panorama imaging techniques the documentation of topodiagnostic could be improved. Even three-dimensional-sonography has been possible for some years. With the development of "SonoCT trade mark Real-time Compound Imaging", a new technique has been developed to acquire more tissue information for clinicians. Multiple coplanar, tomographic images from different viewing angels are obtained. In real-time frame rates this results in an single compound image.In this study, seven patients with tumors or other pathologies of the head and neck region were examined using the fundamental mode versus the "SonoCT trade mark Real-time Compound Imaging" mode. Image resolution and subjective quality of these sonographic images were compared.In all cases the results were improved by use of the "SonoCT trade mark Real-time Compound Imaging" mode. The contrast was better and the image resolution was higher compared to "fundamental" mode."SonoCT trade mark Real-time Compound Imaging" has been developed to acquire and to process ultrasound images in a new and different way. This new method provides increased image contrast, a reduction of inherent artifacts of conventional ultrasound and overall gain of quality within sonographical imaging.

Following the clinical introduction of extracorporeal shockwave lithotripsy in the 1980s for the treatment of sialolithiasis of salivary glands this method has been widely used and replaced surgical interventions in selected patients.Between 1/1995 and 1/1999 35 patients were treated by extracorporeal shockwave lithotripsy (ESWL) with the "Minilith SL-1" lithotripter on an outpatient basis. Radiography and sonography were performed to verify sialolithiasis and scintigraphic investigation was done to control sufficient gland function. Treatment was performed in a fractionated manner with up to 3000 shockwaves per session, normally without anesthesia or analgosedation.After treatment 45.4 % of the patients with sialolithiasis of the parotid gland (n = 11) were stone-free and in 36.3 % an adequate desintegration of the stones was achieved. These patients underwent 2.6 sessions on average for sufficient stone-destruction. 41.6 % of the patients with sialolithiasis of the submandibular gland (n = 24) were stone-free and 3.1 sessions were necessary on average. Desintegration of the stones was achieved in 25 %. Mild pain, swelling, bleeding out of the intraoral orifice of the affected gland and skin petechia were the only complications. All patients were symptom-free after lithotripsy, although fragmented stones persisted in the parotid gland (18.3 %) and the submandibular gland (33.4 %).The advantages of ESWL are the relatively painless treatment and the elimination of the need for an operation with its surgical risks.

Extracorporeal shock wave lithotripsy for salivary gland stones was not introduced until 1989 as a new treatment modality. Follow-up studies years after treatment are lacking.Follow-up study from February to March 2000 of 71 (91%) of all 78 patients who had extracorporeal shock wave lithotripsy for salivary gland stones at our clinic between March 1996 and November 1998.Over 2 years after treatment (mean 27 months, range 12-48 months), 13 (48%) of 27 patients with parotid stones are free of stones and symptoms and 17 (63%) are free of symptoms. In 44 patients with submandibular stones, 13 (29%) are free of stones and symptoms and 23 (52%) are free of symptoms. For residual symptoms, 9 (20%) patients had submandibulectomy whereas no parotidectomy had to be performed. 5 patients with residual stones after treatment showed increased stone size in sonography, and one patient with a stone-free interval for 3 years had a local recurrence.Extracorporeal shock wave lithotripsy is often the treatment of choice for parotid stones and the recommended conservative treatment option for smaller submandibular stones. Limitation to the common, larger submandibular stones diminishes the general value of this modality, which needs to be established in comparison with endoscopic techniques in further studies. Residual stones after treatment may cause new symptoms over time, but only in one case was renewed stone formation observed.

Sialolithiasis is one of the most common diseases of the salivary glands. Within the scope of a retrospective analysis we report on our clinical and diagnostic findings in the largest patient group suffering from sialolithiasis reported in literature.Between 1987 and 1997, data from 635 patient histories and follow-up examinations were systematically collected and analysed to look for typical symptoms of sialolithiasis, locations of stones and possible risk factors.Sialoliths predominated among patients aged 30 and 70 years, with no male/female predilection. A total of 78.9% of all calculi were detected in the submandibular ducts and 21.1% in the ducts of the parotid glands. The sublingual gland and the smaller salivary glands were not affected. A simultaneous stone disease of the urinary tract or the bile duct system occurred by chance (4.3%). Even regular medication in cases of other systemic diseases cannot be considered cofactors in pathogenesis.Diagnosis of sialolithiasis is the result of careful consideration of patient histories demonstrating typical symptoms and clinical examination. Sonography is the first choice of imaging. Pathogenesis of sialolithiasis seems to be based on local factors within the salivary ducts and glands.

To evaluate prospectively the recently developed method of extracorporeal shock-wave treatment of stones of the parotid gland.76 patients with symptomatic, sonographically proven, solitary stones of the parotid gland (36 females, 40 males; aged 2-80 years) were treated with extracorporeal piezoelectric shock-wave lithotripsy (ESWL) after failed conservative management (sialagogues, gland massage, duct bougie dilation).Parotid stones were no longer demonstrable after a mean follow-up time of 48 (6-71) months in 38 of the 76 patients; they were symptom-free and no new stones had formed. A residual, but symptom-free, stone was found in another 20 patients (26%) of whom 13 (17%) reported marked improvement after ESWL. No change from pretreatment symptoms occurred in five patients (7%) so that operative removal had to be performed. The success rate of the lithotripsy was independent of size and site of the stone.ESWL is the method of first choice in the treatment of parotid gland stones after unsuccessful conservative treatment and obviates operative gland removal in most cases.

Since its introduction in 1965 salivary gland scintigraphy has been an established method to simultaneously investigate excretion function in major salivary glands. In order to elucidate parenchymal function of salivary glands, several authors described various quantitative and semiquantitative methods. However, no standardized protocol for quantitative salivary gland scintigraphy has been established so far.Therefore, in this paper we report on a standardized and validated acquisition protocol for salivary gland scintigraphy using 99mTc-pertechnetate.A normal data base for both parenchymal and excretion function is given in detail. In addition, the diagnostic value of salivary gland scintigraphy is reviewed in various clinical settings, such as mild parenchymal damage in beginning Sjögren's syndrome, proof of functional obstruction in sialolithiasis with and without parenchymal damage, and parenchymal damage following radioiodine treatment. In a second part, applications of salivary gland scintigraphy in current clinical research are described, and radiation protection of salivary glands in rabbits and patients treated with high doses of I-131 are discussed.Salivary gland scintigraphy is a study that is easily performed and well tolerated by the patient. It yields quantitative parameters for parenchymal function and excretion fraction.

Newly available minimally invasive methods have changed established treatment of human sialolithiasis during the past several years. After basic in vitro and in vivo investigations, two systems of shockwave treatment proved to be useful for clinical application: extracorporeal shockwave lithotripsy (piezoelectric system) and intracorporeal laser lithotripsy (using a rhodamine-6G dye laser). Following our clinical experiences with these methods a differential scheme for managing sialolithiasis is recommended depending on localization of the calculi and their maximal diameters. Submandibular stones are best treated by extra-corporeal lithotripsy if the stone is located in intraglandular parts or in the gland hilum. Stones of the hilum can also be treated by laser lithotripsy. In the distal parts and near the duct orifice, papillotomy and stone extraction should be tried independent of the stone size. If the stone is located in the intraglandular parts of the duct system or in the hilum and its diameter is over 12 mm, submandibulectomy is necessary. Calculi of the parotid gland should only be treated by extracorporeal lithotripsy, regardless of size and location.

The use of a new 3D ultrasound system should reduce the drawbacks of former 3D workstations (long image generation time, limited use due to the need for special 3D transducers), so that it is now applicable in daily clinical routine.An ultrasound 3D workstation was used based on a pentium PC platform, employing a magnetoelectronic position detection system for spatial reconstruction of conventional 2D B-scan image sequences.Better assessment of topographico-anatomical spatial relationships was achieved when presenting pathological findings, especially in assessing lymph nodes and salivary stones. Pathological processes in the maxillofacial area occurring during a period of five months were visualised.The method of 3D reconstruction of standard two-dimensional electronic scans, as presented here, is the first method of its kind enabling applicability in daily clinical routine thanks to rapid imaging. The images can be produced with any ultrasound unit or transducer. First clinical results in maxillofacial surgery clearly show improved diagnostic possibilities although there still room for an improvement of the image quality. The possibility of semi-automatic exact volumetry appears meaningful especially in the investigation of lymph nodes. Integration of colour duplex sonography will further enhance the diagnostic value of this method.

Only about 1% of head and neck tumors are neoplasms of the salivary glands. The majority [80%] of these tumors are benign. Pleomorphic adenomas, the most frequent benign tumors of the salivary glands, can transform into malignancy, especially after a long duration. Treatment of salivary gland tumors consists of complete surgical excision by a surgeon experienced in microsurgery of the facial nerve. Acute suppurative and viral sialadenitis is usually treated by the general practitioner either symptomatically or, if possible, specifically. Chronic sialadenitis, sialadenosis, Sjögren's syndrome, and Frey's syndrome often need long-term follow-up and medical treatment, which is also usually delivered by the general practitioner, after the diagnosis has been established. Trauma to the salivary gland with transsection of the duct or facial nerve needs immediate microsurgical repair by an otolaryngologist. Sialolithiasis is also treated surgically in most cases.

Shock wave lithotripsy of salivary gland stones has become more and more efficient in the treatment of sialolithiasis during the last years. We use two different methods in our hospital: Extracorporeal shock wave lithotripsy (ESWL) and endoscopically intracorporeal lithotripsy (EISL). The results of both therapies are compatible; 60-70% could be successfully treated. The indication is different due to the localisation of the salivary gland stone. Stones that are located in the glandula or very proximal in the duct should be fragmented by extracorporeal lithotripsy. Stones located in the duct and multiple intraductal stones should be treated by the intracorporeal method. Clinical experiments showed that some salivary stones do not fragment easily. The reason is still unknown. We examined the ability of fragmentation in relation to the physicochemical analysis of the stone. The stones were examined by infrared spectroscopy. This study revealed that pure carbonate apatite stones are more difficult to destroy than stones containing some protein.

Extracorporeal lithotripsy is now used routinely for the treatment of salivary duct stones. The question arose whether electrohydraulic intracorporeal lithotripsy, which is applied in urology and gastroenterology, might also be useful in the treatment of this disease. Before its possible clinical application the influence of electrohydraulic intracorporeal shock waves on salivary stones in vitro and any influence on the tissue in the head and neck region (in vivo) had to be investigated.In vitro experiments. Fifty-eight salivary stones and 11 extirpated human submandibular glands were treated by three different electrohydraulic devices. Animal experiments. Electrohydraulic shock waves were applied to the dilated Stensen's duct and other tissues (muscle, parotid gland, facial nerve) of six rabbits.Of 58 salivary stones, 53 (91%) were fragmented, 39 (67%) with a remaining size of less than 1.5 mm and 14 (24%) more than 1.5 mm. In 5 cases (9%) no effects were seen at all. Fragmentation occurred independent of the mineralogical components of the stone and independent of the different lithotriptors used. The smaller the probe diameter and the larger the stone, the more shock waves were needed to achieve fragmentation. With the smaller probes the stones could not be fragmented completely. In human submandibular glands, extensive tissue lesions could be evidenced macroscopically and histologically after application of electrohydraulic shock waves in vitro. Application of electrohydraulic shock waves to the dilated parotid gland duct of rabbits led to perforations of the duct after 1-5 single pulses. Lesions of nerves and blood vessels could also be observed within the duct environment. This occurred with all of the different electrohydraulic devices, probe diameters and intensities used. In our opinion the damage produced is probably the result of both the direct effect of the plasma as well as the resultant stress wave.In view of the severe damage caused to different tissues, use of the described method for the treatment of stones in the narrow human salivary ducts should be greatly restricted.

In the present study 162 patients with clinically suspected diseases of the major salivary glands were examined via sonography (n = 162), sialography (n = 111) and CT-sialography (n = 49). The reliability of the three radiological procedures was assessed in diagnosing sialoadenitis, sialolithiasis and glandular and extraglandular tumors. Forty-seven patients were examined with all three methods, 64 patients with sonography and sialography, 2 patients with sonography and CT-sialography and 49 patients with only sonography. The results were compared retrospectively with histologically (70%), cytologically (26%) and clinically proven diagnoses. A sialoadenitis was diagnosed via sonography at a sensitivity of 58%. Sialography frequently produced a false diagnosis of "glandular tumor", which resulted in a comparatively lower sensitivity of 54%. This finding contrasted with the experiences of other authors. A glandular tumor was correctly diagnosed by all three methods and had approximately the same sensitivity (sonography 89%, sialograph 91% and CT-sialography 92%). The correct diagnosis of salivary gland tumors was found by sonography and CT-sialography in 76% of cases and by sialography in 83% of cases. CT-sialography was clearly the superior diagnostic method for detecting extraglandular tumors. Sonography proved its worth as the fundamental procedure for special diagnostic testings of the salivary glands. Sialography is necessary for obtaining important additional information, especially in cases with suspect glandular tumors. CT-sialography is indispensable in the diagnosis of tumors, especially if a malignant, extraglandular or medially localized process is suspected.

In the past, management of sialolithiasis required surgical extirpation of the afflicted gland, in case the concrements could not be removed by dilatation or dissection of the glandular duct. The aim of the present study was to investigate the safety and efficiency of extracorporeal shockwave lithotripsy of salivary gland stones in men.51 patients with symptomatic solitary salivary stones which could not be removed by conservative measures received extracorporeal piezoelectric shockwave treatment. The concrements had a median diameter of 8 (4-18) mm and were located in the submandibular gland (69%) and in the parotid gland (31%). A total number of 72 shockwave treatments (maximum 3 treatments per patient) were performed under continuous sonographic monitoring.In 45 patients (88%) complete fragmentation of the concrements was achieved. Piezoelectric shockwave therapy was tolerated without any need for anesthesia, nor administration of sedatives or analgesics. The only untoward effects resulting from therapy were individual localized petechial hemorrhages after 10 out of 72 treatments (13%) and transient swelling of the gland immediately after shockwave application (2/72, (3%)). Twenty weeks after initial treatment 90% of the patients (46/51) were free of discomfort, and 53% of the patients (27/51) were stone free. The stone clearance rates of patients exhibiting concrements of the parotid gland (81%) were significantly higher than those of patients with stones of the submandibular gland (40%, p0.01). Auxiliary measures such as dilatation or dissection of the salivary duct were required only in patients suffering from concrements of the submandibular gland (20%). No long-term damage to the treated salivary gland nor to adjacent tissue structures were noted during the median follow-up period of 9 (1-24) months.Extracorporeal piezoelectric shockwave therapy promises to become a safe, comfortable and effective minimal-invasive, non-surgical treatment of salivary stones.

358 sonographic studies of the salivary glands of 255 patients with proven diagnoses were evaluated retrospectively. Sonography proves to be highly valuable to differentiate between peri- and intraglandular lesions (98%). Superficial neoplasms can be delineated easily. A sharp margin of the tumour is not reliable to predict benignity, therefore biopsy should be performed in all neoplasms of the glands. Deep infiltrating processes require further evaluation by CT or MR. In cases with sialolithiasis the stones can be demonstrated in approx. 2/3 by ultrasound. Inflammatory diseases of the salivary glands have variant sonographic features. Acute infections usually have hypoechogenic parenchyma, chronic inflammations are more likely hyperechogenic.

In a prospective study, results of the extracorporeal shock wave lithotripsy of salivary stones were evaluated. The study was performed with the currently available technical possibilities of electromagnetic systems to get indication criteria for this procedure. Using the Modulith SL 20-lithotripter of Storz Medical AG, 33 concrements in 25 patients were treated in 89 lithotripsy sections. The stone sizes, localized by ultrasound, ranged from 3 to 13 mm diameter (phi 6.9 mm). After application of local anaesthesia, per session on an average 1300 shock waves with raising energy levels were applied, the succession of shocks fixed to 1 MHz. With the help of ultrasound localisation, a therapeutic success with complete emission of the concrement or an adequate disintegration of these stones could be achieved in 82% of the parotid gland stones (n = 11) and in 14% of the submandibular gland stones (n = 22). Since the unhampered functioning of these salivary glands is an inevitable pre-condition for the spontaneous emission of the disintegrated fragments, the status of function of salivary glands should be established by a scintigraphy before performing the ESWL. Even though complete emission of the stone could be achieved in only 4 patients, all patients were clinically free of symptoms after the treatment. In 3 of 25 patients, discrete bleeding of a passing nature occurred coming from the salivary duct. In 2 patients, formation of haematoma of varying dimensions could be visualized by ultrasound. 3 patients showed petechial skin bleeding. The tinnitus aurium which affected one patient eased after 3 days. In our patients collective a facial nerve damage did not occur.2+ longterm prognosis after this procedure.

A model was developed in which high-resolution real-time sonography was compared with radiological examinations for determining their sensitivity in diagnosing salivary gland stones. For this purpose an artificial salivary gland medium was compared with human salivary gland tissue for echogenicity. It was shown that both the artificial and the true salivary gland medium possessed comparable acoustic properties. Forty salivary gland stones were examined ultrasonographically in both media with 5 and 7.5 MHz linear scanners and a 5 MHz sector scanner, following which a plain X-ray was done, while 35 of 40 calculi could be definitely identified with linear scanners in both media, this could be accomplished by X-ray only in 50% (20 of 40 calculi). All salivary gland stones greater than 1-2 mm could be detected ultrasonographically, whereas radiological identification did not correlate with stone size. Mineral composition was found to influence the radiological study but not sonographic pictures of sialoliths. If sialolithiasis is suspect clinically, ultrasonography with a linear scanner must be considered the diagnostic procedure of choice.

Techniques such as orthopantomography and ultrasound are usually employed for examination for submandibular calculi, but we have found transverse scanning of the submandibular gland by ultrasound to be safe and rapid. As the mandible and hyoid bone present a shadow there is a margin for possible error, but this technique enables these areas to be seen and thus checked: a submandibular calculus may be seen as a third shadow between the other two. Comparison showed ultrasound to be superior to orthopantomography. If the ultrasound is negative and there is a strong clinical suspicion of a submandibular calculus orthopantomography is the next step to be employed.

Endoral ultrasound was introduced for imaging of T1 and T2 tumors of the anterior third of the tongue and the floor of the mouth in 1988. Using this method, 100 patients with diseases of the oral cavity and the oropharynx were examined, and the findings were compared with those of transcutaneous ultrasound, CT and MRI. Endoral ultrasound provided valuable additional information in tumors of the tongue base and the middle and dorsal third of the tongue. Tumors of the tonsil were demonstrated very well. MRI proved to be superior for imaging of large lesions. CT was of less value in diagnostic imaging of the oral cavity and the oropharynx due to low soft tissue contrast.

Digital subtraction sialography offers a new technique for the diagnosis of salivary gland disease. The basis of this technique is the removal of superimposed bony structures. Ninety-one patients (4-77 years old) with acute and chronic inflammatory disorders, chronic sialectasis, chronic sialolithiasis and tumours of various types underwent sialography using the digital subtraction technique. In addition, conventional sialography using a 100 mm camera and high resolution ultrasonography was performed. The results were compared with the histopathology and intraoperative findings. The digital subtraction technique is superior in recognition of inflammatory changes and chronic sialolithiasis, whereas ultrasonography is more sensitive in diagnosis and localization of tumours.

Twenty-one patients with tumors or chronic inflammation of the parotid gland were examined both by MRI and ultrasound. The findings of MRI were compared with sonography and with the findings of other imaging methods. In most cases MRI provided valuable additional information about the structure of the gland and the extent of a tumor. Sonography provided a correct estimation of the tumor extent in 11 of 15 patients with tumours, but MRI did so in all cases. In 5 out of 6 patients with stones or chronic inflammation, sonography provided the correct diagnosis; resolution of the gland structure was superior by MRI.

We recorded 45 sialograms on digital screens and discuss the use of a digital recording, processing and screening system for the diagnosis of inflammation, tumours and stones of the major salivary glands. Thirty-three investigations of a total of 33 parotid sialograms and 12 submandibular sialograms were analysed. A ductal examination with small volumes of soluble contrast media, permitting painless examination, was possible in all cases due to excellent homogeneous optical density, satisfactory detail and good contrast.

Piezoelectric lithotripsy was performed in 14 patients with salivary stones. None of the patients required anaesthesia, analgesics or sedatives. All of the salivary stones could be fragmented totally during the first lithotripsy procedure. Three months after treatment with extracorporeal shock waves all the patients were free of symptoms and in 7 out of 14 patients no concrement could be found by sonography. The piezoelectric lithotripsy of salivary stones had caused no serious side effects as proved by clinical, biochemical, sonographic and magnetic resonance imaging examinations. Extracorporeal piezoelectric lithotripsy is a new and promising non-surgical therapy for selected cases of sialolithiasis of the large salivary glands of the neck.

62 inpatients suffering from an acute suppurative sialadenitis of the parotid and submaxillary glands were treated at the ENT clinic of the University of Homburg/Saar between 1982 and 1988. In general, the anamnesis is short. Typical findings are fully elastic, immobile, painful swellings of the inflamed salivary gland. In most cases, staphylococci could be identified by microbiological examination as the causative germs. As therapy, high-dose antibiotic treatment is necessary. In case of an abscess or a phlegmon, incision and drainage has also been performed. Differential diagnosis of an acute purulent sialadenitis is discussed and listed in tabular form.