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Sialoendoscopy is a valuable technique for a variety of obstructive and nonobstructive disorders of the major salivary glands. However, the utility of sialoscopes is limited for salivary stones, which frequently required open removal. Transoral sialolithotomy without scopes is an efficient, low-cost alternative with excellent outcomes available for most of the submandibular stones.

Multiple intraglandular sialolithiasis for stones deep in the glandular parenchyma may require submandibulectomies, especially if sialendoscopic facilities are unavailable. We describe a gland-sparing intraoral sialolithotomy approach for both hilar and intraparenchymal multiple sialoliths. Nine patients with obstructive sialadenitis resulting from multiple sialoliths in both the deep hilar region and the submandibular gland parenchyma were selected for this study. Ultrasonography and computer tomography (CT) scans were performed to determine the location, number and sizes of the calculi and the distance between hilar and intraparenchymal sialoliths. All sialoliths were removed via gland-sparing, intraoral sialolithotomy. In all, 27 stones were found in the 9 patients. The hilar and deeper sialoliths were 4.5–11 and 0.8–4.5 mm, respectively, in diameter. The largest distance between the hilar and intraparenchymal sialoliths was 28.3 mm. Sialoliths in the hilar region were excised through an intraoral incision before deeper intraparenchymal stones were eased out of the same incision site. Postoperative follow-up imaging verified complete sialolith removal. Therefore, submandibular gland multiple sialoliths in the hilum and parenchyma can be successfully removed via an intraoral sialolithotomy under general anesthesia, thereby preserving the gland and restoring its secretory function.

Sialolithiasis, the most common salivary gland pathology, is caused by calculi in the gland itself and its duct. While patients with small sialoliths can undergo conservative treatment, those with standard-size or larger sialoliths require sialolithotomy. In the present case study, we removed two sialoliths located beneath the mucosa in the posterior and anterior regions of Wharton's duct, respectively. For the posterior calculus, we performed sialolithotomy via an intra-oral approach; thereafter, the small anterior calculus near the duct orifice was removed by hydraulic power. This method has not previously been reported. There were no complications either during the operation or postoperatively, and the salivary function of the gland remained normal.

A 60-year-old woman was referred to the otolaryngologist for 18 months of left-sided tongue pain and taste changes. Surgeon-performed ultrasound of the submandibular region revealed a hyperechoic mass. Wharton’s duct was dilated proximally and the submandibular gland demonstrated normal vascularity. While these findings were highly suspicious for submandibular gland sialolith, an in-office attempt at sialolithotomy suggested an alternate process or mass. After imaging failed to further elucidate an aetiology, surgical exploration revealed a well-circumscribed submandibular mass associated with the lingual nerve. The mass was removed en-bloc and pathology revealed a schwannoma of the lingual nerve.

Objectives/Hypothesis The objectives of this study were to describe robot-assisted sialolithotomy with sialendoscopy (RASS) for the management of large palpable hilar submandibular gland (SMG) stones and analyze procedural success and lingual nerve damage following RASS in comparison to the combined transoral sialendoscopic approach. Study Design Retrospective chart review. Methods A retrospective chart review was performed on patients with large palpable hilar SMG stones managed with RASS following institutional review board approval. Large stones were defined as ≥5 mm, the upper limit that can be removed via sialendoscopy. Twenty-two patients between January 2012 and June 2014, with mean stone size of 12.3 mm, were identified. Data collected included symptoms of recurrence, postoperative lingual nerve function, and patient satisfaction at a mean follow-up of 14 months. Procedural success was defined as absence of symptom recurrence in conjunction with gland preservation. These measures were compared with the combined approach (CA) outcomes reported in the English literature. Results Procedural success was 100% (22/22) for our cohort. No patients reported symptoms of lingual nerve damage at follow-up, whereas four patients reported transient lingual nerve paresthesia (mean duration, 2.5 weeks). Mean patient satisfaction was 9.9 out of 10. Literature review identified 135 patients in the CA cohort. Procedural success rate for these patients was 75%, and lingual nerve damage was reported in 2% of patients. Conclusions Our study demonstrates the safety and efficacy of RASS in the management of large SMG sialoliths. We attribute this preliminary success of RASS to the enhanced visualization, magnification, and technical advantages of the procedure. Level of Evidence 4 Laryngoscope, 2015

Objectives/hypothesis Ultrasound is a proven tool for diagnostic and therapeutic purposes for treatment of salivary gland pathology. It is also useful for localization of calculi during submandibular gland transoral sialolithotomy when calculi cannot easily be palpated. Our objective was to determine the efficacy of sialolith localization using ultrasound during submandibular gland sialolithotomy. Study design Retrospective case series. Methods A study performed utilizing data compiled from 2009 through 2016 in a tertiary academic center. Treatment was completed in 164 patients with sialadenitis and sialolithiasis by submandibular gland transoral sialolithotomy in either the office (81%) or the operating room (19%). Ultrasound was used for localization of sialoliths during submandibular gland sialolithotomy. Main treatment outcomes studied were success of the procedure, complications, and follow-up. Results Successful sialolithotomy was performed in (147 patients) 90% of cases. Complications were minimal and included stricture formation, which occurred in 3% (five patients) of cases, followed by ranula formation in 1.8% (three patients) of cases. There were no incidences of lingual nerve injury. Conclusions Ultrasound can be used effectively for precise sialolith localization intraoperatively. Level of evidence 4 Laryngoscope, 129:2716-2720, 2019.

Sialolithiasis rarely occurs in children; it is observed more commonly in adults. We report a case of a 9-year-old girl with a sialolith in ‘the right anterior Wharton's duct' resulting in a submandibular sialadenitis. Under local anaesthesia, the calculus was removed by means of a sialolithotomy. Post-operative recovery was uneventful and follow-up examinations showed recovery of the function of the affected gland.

One of the most common disorders of the salivary glands is sialolithiasis. A history of pain or/and swelling in the salivary glands, especially during meal suggests this diagnosis. For small and accessible stones conservative therapies like milking of ducts with palliative therapy can produce satisfactory results. Surgical management should be considered when the stone/stones are inaccessible or large in size as conservative therapies turned out to be unsatisfactory. In this paper, we present three cases of sialolithiasis in the submandibular gland along with a review of existing literature. The purpose of this paper is to add three more cases to the literature and review the theories of etiology, clinical features, available diagnostic and treatment procedures.

A 35-year-old male was referred to the Department of Oral and Maxillofacial Surgery with a chief complaint of pain and swelling in the floor of the mouth on the left side. He also complained of thick fluid discharge from the floor of the mouth [Table/Fig-1]. History dated back to 4-5yrs when the patient first noticed the swelling. Since two months, the patient experienced an exacerbation of the symptoms along with associated swelling in the left submandibular region during meal times. [Table/Fig-1]: Intraoral photograph showing swelling in the floor of the mouth. Extraorally there was no swelling or asymmetry at the time of examination. Intraorally, bimanual palpation revealed inflammation and a hard stone like structure along the left Wharton’s duct in the premolar region. There was thick turbid fluid discharge from the duct orifice. The left submandibular gland was tender on palpation. Occlusal radiograph revealed a large radiopacity located in the region of left Wharton’s duct [Table/Fig-2]. A diagnosis of sialolithiasis of the left Wharton’s duct was achieved. Under local anaesthesia, transoralsialolithotomy was performed via intraoral approach [Table/Fig-3]. [Table/Fig-2]: Mandibular occlusal view X-ray showing a large radiopaque mass in the left floor of the mouth. [Table/Fig-3]: Sialolith from left Wharton’s duct explored out and removed. Traction suture was placed behind the sialolith to prevent its posterior displacement. An antero-posterior incision was made in the mucosa parallel to the duct extending from the canine to the first molar region on the left side. After reflection of tissue, the large stone became visible and blunt dissection was done around it. The giant sialolith was removed and the surgical wound was thoroughly irrigated and checked for any satellite stones. Sutures were placed at the level of mucosa and no attempt was made to suture the duct lining [Table/Fig-4]. [Table/Fig-4]: Surgical wound sutured with interrupted 3-0 silk. The obtained sialolith was a hard, oval, rough and yellowish mass. It measured 22x16mm and weighed 7gms. The patient was followed up for six months and was asymptomatic [Table/Fig-5]. [Table/Fig-5]: Excised giant sialolith, measuring 22x16mm.

Carbon dioxide laser is a highly effective tool for numerous intraoral surgical procedures. Its use for sialolithotomy has been well documented in the literature because of its ability to achieve hemostasis at the time of incision of the Wharton’s duct and the painless nature of the procedure requiring just topical anesthesia or local anesthetic nerve block at the most. As carbon dioxide laser has a high absorption coefficient for water, saliva in the oral cavity acts as a substrate and hence the deeper penetration of the beam and subsequent injury to adjacent structures is prevented. We describe a case of a giant sialolith of the Wharton’s duct, which was successfully removed by carbon dioxide laser-assisted sialolithotomy.

Idiopathic sialolithiasis is one of the most common affliction of the salivary glands with the submandibular gland most frequently involved. The article discusses the occurrence and incidence of this condition with a review of different diagnostic and treatment modalities. In light of several advances to diagnose and treat sialolithiasis, a simple sialolithotomy for idiopathic submandibular gland sialolithiasis may prove to be a preferred treatment for selected patients as it remains a cost-effective and simple out-patient department procedure with minimal/no complications and a highly satisfactory outcome. For stones slightly proximal in the Wharton duct, a "dual" approach of milking the gland to bring the stone more distally followed by a sialolithotomy with a scalpel proves to be a quick and effective procedure.

Sialolithiasis is the most common disease of salivary glands. Commonly, sialoliths measure from 5 to 10 mm in size and stones over 10 mm can be reported as sialoliths of unusual size. Giant sialoliths measuring more than 35 mm are extremely rare, with only around 17 cases published in the literature. We report an asymptomatic case of a sialolith in the submandibular duct measuring 62 × 20 mm and weighing 40 gm, highlighting the management aspects and also review the literature.

Objectives/Hypothesis: To report our experience with management of giant salivary stones via a combined approach technique using salivary endoscopy (CA) and results of a review of current literature related to giant salivary stones. Study Design: Retrospective case series. Methods: An institutional review board-approved chart review was performed on patients managed with a CA to treat giant salivary stones (≥15 mm). In addition, we reviewed the English literature from 1942 to 2009. Results: Table 1 consists of 54 stones; 47 of which were identified during the review of literature and 7 from our case series. Of those 47 stones, 23 were hilar in location, 23 were glandular in location, and 1 stone was missing data. The gland preservation rate in the 47 reported stones was 57% (17/30). Among patients where gland resection was reported, the majority of the patients (12/13) had hilar glandular stones. Only one patient with a ductal stone had a gland resection. In our series, CA enabled a gland preservation rate of 86% (6/7). Among these patients, stone location was hilar glandular in six (86%) and ductal in one (14%). The mean size of stones from the literature review was 35 mm and from our series was 19 mm. Conclusions: Our review reflects current treatment recommendations for giant stones, i.e., transoral sialolithotomy for ductal stones and gland resection for hilar glandular stones. Our preliminary experience with CA for giant stones suggests improved gland preservation rates (86% vs. 57%) independent of stone location and with preservation of salivary function. Laryngoscope, 2010

Objectives:(1) Describe robot-assisted sialolithotomy with sialoendoscopy (RASS) for the management of large submandibular gland (SMG) stones. (2) Analyze symptom recurrence and lingual nerve damage following RASS in comparison to the combined transoral sialoendoscopic approach (CTA).Methods:A retrospective case series was performed on patients with large palpable SMG stones managed with RASS. Large stones were defined as >4 mm, the upper limit that can be removed via sialoendoscopy. Fourteen patients who presented between October 2012 and January 2014 with mean stone size of 11.9 mm were identified. Patients were questioned regarding symptom recurrence, symptoms of lingual nerve damage, and procedural satisfaction at mean follow-up of 8 months. Procedural success was defined as absence of symptom recurrence in conjunction with gland preservation. These measures were compared to reported outcomes with CTA in the English literature.Results:Procedural success was 100% (14/14) for our series. No patients rep...

Sialoliths are responsible for the obstruction of the secretion of saliva. They are rarely larger than 15 mm. More than 80% of the salivary gland calculi appear in the submandibular gland, but they can also be located in the glandular parenchyma and more frequently in the excretory duct. We report an asymptomatic large sialolith case in Wharton's duct of a 58-year-old man and its diagnostic imaging, surgical management and outcomes. For these reasons, we considered useful to report our case in the managing of a sialolith 35 mm in length and weighing 6.45 g located inside Wharton's duct and his treatment was by transoral sialolithotomy with preservation of the submandibular gland.

To identify and describe the ultrasound indicators of persistent obstruction following transoral submandibular sialolithotomy and discuss the utility of ultrasound in the immediate postoperative period.We performed a prospective case series with planned data collection of patients who underwent treatment for symptomatic submandibular swelling.A tertiary care center.Thirty-three patients of either sex with known submandibular gland sialoliths who failed endoscopic retrieval of calculi.We performed in-office or operating room-based transoral submandibular gland sialolithotomy followed by immediate postprocedure ultrasound examination for the assessment of residual calculi. All patients underwent mandatory reexploration for suspicious findings.Only the appearance of hyperechogenic foci with posterior shadowing reliably predicted the presence of residual stones following transoral sialolithotomy (P.0001). The presence of hyperechogenic foci without posterior shadowing (P = 1.00), ductal dilatation (P = .23), and intraglandular dilatation (P = 1.00) was not indicative of retained calculi.The presence of hyperechogenic foci with posterior shadowing on immediate postprocedure ultrasound is an accurate indicator of residual stones following transoral submandibular sialolithotomy. Ultrasound examination can be reliably used to identify patients at risk of symptomatic recurrence of sialoliths.

Twelve pediatric patients with parotid or submandibular salivary gland calculi were successfully diagnosed following appropriately aimed imaging methods. The treatment modalities were: secretory stimulation of the gland to induce spontaneous passage, sialolithotomy or sialadenectomy. The treatment of choice was dependent on the size and location of the calculi, as well as on the affected gland and its functional secretory state.

Objective: 1) To demonstrate the utility of ultrasound in the assessment of the submandibular gland after endoscopic-assisted or purely open sialolithotomy. 2) To discuss limitations of using ultrasound for assessment after submandibular sialolithotomy.Method: From August 2009 to January 2012, 22 adult patients with symptomatic submandibular sialolithiasis underwent endoscopic-assisted or purely open sialolithotomy in a tertiary-level clinic setting. Pre- and immediate postprocedure ultrasound was performed. Examinations were analyzed for evidence of persistent obstruction.Results: Twenty patients with symptomatic submandibular sialolithiasis underwent either endoscopic-assisted sialolithotomy or pure open sialolithotomy for proximally located stones. Three of 22 (13%) demonstrated residual stones on ultrasound characterized by acoustic shadowing immediately after sialolithotomy and were retreated in the same setting with success. Fifteen of 22 (68%) demonstrated proximal ductal dilatation after stone rem...

Contrast-enhanced ultrasound (CE-US)-derived intensity-time gradients (ITGs) can be used for noninvasive monitoring of extracorporeal shock wave sialolithotripsy effects in chronic sialolithiasis-related sialadenitis. Aim of this trial was to further validate CE-US as an independent and quantitative diagnostic tool for sialolithotomy efficacy. In this prospective clinical phase II evidence level c study perfusion in patients (n = 10) with unilateral sialolithiasis of the submandibular gland was quantitatively analyzed by CEUS before and after sialolithotomy comparing with the contralateral disease-free gland. A visual analog scale (VAS) scoring clinical complaints was correlated with CE-US-derived ITGs. Furthermore, ITG ratios reflecting values from the contralateral side and the diseased side were calculated. VAS documented significantly reduced clinical complaints after sialolithotomy indicative of a successful treatment. VAS data significantly correlated with CE-US-derived ITGs. In addition, ITG ratios were significantly increased after sialolithotomy. In conclusion, CE-US-derived ITGs and ITG ratios appear as independent and valid quantitative parameters of sialolithotomy efficacy.

Sialoliths are responsible for the obstruction of the secretion of saliva. They are rarely larger than 15 mm. A 48-year-old man was referred for the assessment of swelling and pain in the submandibular right region during meals. A hard mass was palpable along the right Wharton duct. A panoramic radiograph showed a single, elongated, radiopaque, 22-mm-long mass in the right submandibular region. A diagnosis of giant sialolith in the right Wharton duct was made. Removal of the giant sialolith and sialodochoplasty were performed via an intraoral approach. Six months after the intervention, salivary flow was normal. Diagnosis and management of sialoliths of a remarkable size are challenging for the clinician. Conservative methods of treatment should be considered as an alternative for surgical excision, in particular for little calculi, but for giant sialoliths, transoral sialolithotomy with sialadenectomy or sialodochoplasty still remains the mainstay of management.

Surgical management of salivary gland diseases has always been challenging because it carries a considerable risk of nerve damage. This study evaluates an innovative ambulatory laser-aided technique that may be an alternative to traditional treatment, and presents our 5-y experience of salivary gland excision.Twenty-five submandibular salivary gland excisions were performed with an 810- to 830-nm diode laser. The diagnosis was sialolithiasis with stones in the salivary gland duct above the glandular hilum. A 320-microm flexible delivery fiber was used in continuous wave mode at 2.5 W power. The procedure consisted of locating the stone, isolating the duct from the surrounding tissues, introducing a button probe, ductal incision above the stone, sialolithotomy, and checking duct patency.The overall success rate was 92%. The largest stone removed was 4.5 cm in size. In 1 patient (4%), an additional undetected stone was diagnosed by endoscopy after removal of the stone from the duct, and in 1 patient (4%), synechiae formed in the duct during healing and duct patency had to be restored with a probe. We had no cases of transient palsy or paresis of the mandibular branch of the facial or lingual nerves.Use of the 810-nm laser is safe for this type of surgical procedure, carries a low complication rate, and is a valid alternative to traditional surgery. It is indicated as the procedure of choice in cases of stones located in the duct above the kink leading into the mylohyoid muscle, and above the glandular hilum.

Clinical results in 76 cases of sialolithiasis of the submandibular gland and a case report of multiple parotid sialoliths are presented. Sialolithiasis of the submandibular gland occurred most frequently in the fourth decade of life. There was no sex prevalence. The submandibular duct was the most common site of involvement (67.2%) and sialoliths were found in two or more of the duct, gland and transitional portion in 9. 2% of the cases. As compared to 24. 9 months in patients with sialoliths in the duct, the period from the onset of symptoms to the initial visit in patients with intraglandular sialoliths was longer (96.7 months). The most common chief complaint was a swelling and/or pain of the submandibular region. In patients with intraductal sialoliths, the main symptoms included swelling and/or pain of the submandibular region or of the mouth floor and they often manifested themselves on eating, whereas sialoliths in the gland and transitional portion were associated less frequently with symptoms of the mouth floor and eating episodes. Sialoliths could not be demonstrated in 9 patients with plain radiographs. Sialoliths were removed by intraoral sialolithotomy in 43 of 51 patients with intraductal sialoliths and 7 of 9 patients with sialoliths in the transitional portion, whereas sialoliths were removed by sialoadenectomy of the submandibulr gland in 8 of 9 patients with intraglandular sialoliths and in 2 patients with sialoliths in the transitional portion. A combination of the two procedures was employed in 5 of 7 patients with sialoliths at more than 2 different sites. Six sialoliths evacuated spontaneously and sialolithotomy was not done in 5 patients because of poor systemic condition, or reluctance to receive a treatment probably due to the absence or disappearance of acute symptoms. Two sialoliths were found in the duct and the gland of parotid with CT.

The extraoral approach to duct surgery for the removal of parotid stones can be a simple procedure once the stone is accurately located in relation to the skin surface. The combination of sialography and sonography can provide this information. A case report demonstrates the step-by-step approach to diagnosis, localization, and surgery for the management of such extraglandular sialoliths.