Transoral Balloon Sialodochoplasty and

Sialolithotomy: A Minimally-Invasive Option for

Treatment of Recurrent Sialadenitis

Paul Schalch MD, Jonathan Boyd MD, Sepehr Oliaei MD, Marc Rubinstein MD, Jason H. Kim MD

Department of Otolaryngology - Head and Neck Surgery, University of California, Irvine

OBJECTIVES:

The purpose of this study is to present a case of recurrent

parotid sialadenitis secondary to an obstructive sialolith, treated via a

minimally invasive technique that offers a safe alternative to open

management and without the use of endoscopic materials.

INTRODUCTION: Sialolithiasis is a relatively common condition, resulting from

the formation of inorganic crystals within a salivary gland duct. This

causes obstruction to the gland’s flow, leading to swelling, pain, and

the risk of sialadenitis. The submandibular gland is most commonly

affected, representing 80-95% of salivary calculi, whereas the

parotid gland accounts for only 5% to 20%.1 The remaining glands

are rarely affected by stone formation. Approximately 1.2% of the

population experience sialolithiasis with males affected up to twice

as often as females. Untreated obstructing stones may cause a

sialooral fistula creating further morbidity.2

Recent management of salivary stones have turned to

minimally invasive techniques such as sialolithotomy and

endoscopic retrieval. Avoidance of potential open complications,

such as lingual, hypoglossal, and marginal mandibular nerve injuries

from submandibular gland resection or facial nerve injury from

parotid resection have created the need for these less invasive

techniques.

With sialolithotomy and some endoscopic approaches, intraoral

palpation of the stone is required for retrieval. Hilar or intraglandular

based stones may necessitate sialadenectomy or more advanced

endoscopic approaches.3 When palpable, however, endoscopic

setup and even small intraoral incision may be unnecessary in a

truly minimally invasive technique.

Figure 2. Intraoperative image, showing

placement of the Fogarty catheter into the

Parotid Duct.

METHODS:

This case represents a retrospective case of recurrent parotid

sialadentitis with radiographic evidence of salivary duct calculus

treated at a university-affiliated institution. A 46 year old male patient

presented to the emergency room with unilateral acute parotitis of

several days duration. The patient reported a history of multiple

similar episodes each on the left side, which was treated with

conservative measures including local heat, aggressive hydration,

sialogogues, and oral antibiotics. A contrast enhanced computed

tomography scan revealed a 5 mm calculus in the parotid duct, with

proximal dilatation, significant gland edema and inflammation, with

likely phlegmon. The patient was admitted and treated with IV

antibiotics for 48 hour duration. The patient was taken to the

operating room after failure to improve with conservative measures

and repeated imaging confirmed development of enhancing

abscess.

RESULTS:

Intraoperatively, the parotid duct was explored with a lacrimal

probe and a moderate amount of pus was expressed from the gland.

A 4 Fr Fogarty catheter was then introduced into the duct and

advanced past the calculus, which was determined by palpation. The

catheter was slowly inflated and withdrawn and the calculus was

successfully retrieved from the duct. Copious amounts of pus were

then drained from the gland with angiocatheter irrigation. The patient

was subsequently discharged after resolution of the parotitis post-

operative day two. At two month follow-up, the, the patient continues

to do well with normal function of his parotid gland.

CONCLUSION: Transoral, minimally-invasive, balloon sialodocoplasty with

sialolithotomy is an effective, safe alternative to surgical

management of obstructive salivary disease that fails to respond to

conservative measures. Dependent upon palpation, this adds to the

armamentarium of the orofacial surgeon in the treatment of

symptomatic sialolithiasis.

REFERENCES:

1. Lustmann, Regev, and Melamed. Sialolithiasis; A survey on 245 patients and a review of the literature. International Journal of Oral

& Maxillofacial Surgery. vol 9(3)

2. Bodner & Beer-Sheva. Giant salivary gland calculi: Diagnostic imaging and surgical management. Oral Surgery Oral Medicine Oral

Pathology Oral Radiology and Endoscopy. Sept 2002:94:320-3

3. Nahlieli, Shacham, Zagury, Bar, Yoffe. The ductal stretching technique: An endoscopic-assisted technique for removal od

submandibular stones. The Laryngoscope. 117;June 2007:1031-5.

4. Zhang, Escudiet, Brown, Capaccio, Pignataro, and McGurk. Long-term outcome after intraoral remoival of large submandibular

gland calculi. The Laryngoscope:120. May 2010: 964-6.

5. Osailan, Proctor, Carpenter, Paterson, McGurk. Recovery of rat submandibular salivary gland function following removal of

obstruction: a sialometrical and sialochemical study. Inernational Journal of Experimental Pathology.87; 2006:411–23.

Figure 3. 5mm calculus removed from the

Parotid duct

Figure 1. Intraoperative image, showing

evidence of parotitis and catheter

placement

DISCUSSION:

Over the last ten years, sialolithiasis has been progressively

turning toward minimally invasive techniques due to mounting

evidence that salivary gland function may be preserved by

alleviating ductal obstruction, possibly removing the need for

sialadenectomy.4,5 Minimally invasive sialolithotomy maintains

some potential for both neurological and non-neurological sequelae,

as the ductal tract is invaded and surrounding tissue is exposed to

sharp dissection. Additionally, endoscopy can add unnecessary

operative time due to setup and equipment malfunction or operator

inadequacy.

The use of Fogarty catheters have been well respected for

decades in endovascular treatment of emboli and thrombi. Salivary

duct anatomy and obstruction share striking similarities, which may

support similar treatment modalities. When sialoliths are identifiable

via palpation, balloon retrieval presents a minimally invasive

technique that is relatively atraumatic and rapid without the need for

flouroscopy or endoscopy.

Figure 4. Axial CT scan showing the 5mm

calculus inthe Parotid duct