Removed with sialendoscopy in a scarless and incisionless fashion
Sialendoscopy: Ushering in a new era in management of salivary gland duct stones and saving the salivary glands
Satyender Khatri, had complaints of recurrent swelling and pain below the left jaw area on food intake since many years. He had been diagnosed to have stones in the left submandibular duct region which kept on recurring for which he had undergone an oral incision and stone removal many times in the past, however, his problem kept recurring with him never having complete relief in between intense episodes. On CT scan he was found to have a large stone mid way in the submandibular duct of size 7mm and multiple small stones present in the junction of gland and duct with the largest being 4mm in size.
Many such patients suffer the agony of recurrent pain on eating and sometimes, even the simple thought of food and drink leads to severe symptoms. In most of the cases the cause is as simple as a stone or narrowing in the salivary gland duct, which causes obstruction to outflow leading to infection.
When we saw the patient in our OPD we found that the left submandibular gland had swollen to twice its size and the ultrasound showed the presence of the stone in the duct situated in the floor of mouth and just a widened duct behind the stone. The normal size of the duct is just 3 to 5 mm in diameter and a 7 mm size stone had stretched the ductal wall causing extreme blockage leading to his problems. However, even though we could feel the stone in the oral cavity and an incision and stone removal is the conventional norm, we thought we should do something to address the problem of recurrences. To better understand his problem of recurrences we also asked for a CT scan of the gland, which revealed multiple stones behind the stone leading from the duct to almost inside the gland. Since we saw multiple stones near the junction of gland and duct, they would have to be addressed as well otherwise recurrence would have been inevitable.
Up until now most of such patients would be managed initially with antibiotics and then treated with excision of the offending gland, which would leave an unsightly scar and, for the unlucky ones even a lower lip paralysis.
Not wanting to go via the conventional approach we counseled the patient for a sialendoscopic approach.
In this technique under full anaesthesia, the normal opening of the duct is identified under magnification and then dilated using a special set of dilators. After the opening is sufficiently wide, a Sialendoscope, which is a miniature endoscope, is introduced and the entire ductal system is visualized and the obstruction can be directly addressed without any incision for small stones.
In this case, the larger stone was first brought to the opening of the duct and then removed. Then the smaller stones present in the back of the duct were addressed and the 4mm stones was removed using microforceps. Check endoscopy revelaed five other smaller stones along with a lot of debris present in the part of the duct, which was almost inside the gland. These stones were also removed using a completely endoscopic approach and the duct was flushed of all debris.
When asked about the level of difficulty Dr Varun Rai, Associate Consultant at Sir Ganga Ram Hospital, New Delhi said “The procedure is relatively simple in experienced hands and with the sialendoscope we are now able to address the smaller stones at the back of the duct which would have inevitably led to them becoming larger with time and causing recurrence. This procedure of sialendoscopy is a relatively new technique in a developing country such as ours with very few centers even offering it at present.“ Dr Varun Rai has received training in this procedure by the pioneer of this technique, Dr Francis Marchal in Geneva, Switzerland and has been successfully performing sialendoscopies in Sir Ganga Ram Hospital since 2015.
The incidence in our country is about 0.5%, so in our country of 1.2 billion we have an estimated 6 million people having stones in the salivary gland duct.
We, at Sir Ganga Ram Hospital have acquired a state of the art sialendoscopy set with which we address the stones in a completely minimally invasive way without any external scar for the submandibular gland. This procedure, though done under full anaesthesia, is a daycare process and the patient is usually discharged the very same evening.
The duct opening in the mouth is gently dilated and a miniature endoscope of size just a few millimeters in diameter is introduced and the small stones in the ducts are visualized and removed using baskets and forceps. Similarly even the ductal narrowing is treated using dilating balloons and stents.
The crucial benefit of this procedure is that it accurately diagnoses and treats the obstruction of saliva in the gland duct, which is the real reason why the gland is enlarged in the first place. Thus, there is no need to remove the gland after such procedures and this maintains the natural function and flow of saliva in the body.
This procedure is completely scar less with very minimal blood loss and a much shorter hospital stay when compared to conventional treatment of gland removal. The conventional treatment of removal of gland is associated with a scar on the neck below the jaw, risk of disfiguring lower lip paralysis, bleeding and a longer hospital stay of up to three days.
Even when the duct stone is visible in the oral cavity, sialendoscopy offers the option to completely examine the duct for any additional stones which might have been missed by a simple stone extraction as was previously advised.
On follow up the patient is fine without any complications and back to a normal diet without having to worry about pain or swelling of the affected gland which has returned to its normal function.