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Comment:
The symptoms of sialoliths and salivary duct stricture are similar: intermittent swelling, tenderness, and pain usually brought on by eating. Infection and sialadenitis are common complications. For a definitive diagnosis, sialography is imperative, especially to diagnose the presence of several calculi or to detect all strictures.
A few cases of balloon-catheter sialodochoplasty and wire-basket removal of caculi have been reported, mainly in foreign journals (ref. 1-3). Also, calculus was removed by an angioplasty balloon catheter (ref. 4).
The most likely surgical management of intraglandular parotid calculi would involve parotidectomy. There does not seem to be a consensus on managing calculi located between the gland hilus and anterior to the masseter muscle. Extraoral parotid sialolithotomy for calculus extraction has been performed under sialographic and ultrasonographic guidance (ref. 5).
The surgical approach to submandibular calculi is influenced by the location of the stone. Palpable stones anterior to the posterior border of the mylohyoid muscle usually are extracted using a transoral incision. When the stone is posterior to the mylohyoid muscle, removal of the entire gland is recommended (ref. 6,7). The complication rate for these procedures and associated anesthesia is not negligible (ref. 8).
In our independent small series during the last 10 years, we have achieved a high success rate. Contrary to other authors' (ref. 5) experience, we did not have difficulty removing parotid calculi located more than 1.5 cm from the papilla, although removal of calculi from the Wharton duct is generally easier than from the Stensen duct. The course and small size of the Stensen duct often makes instrument manipulation difficult. In our 2 cases of failure, the calculi were larger than the ducts and impacted. These ducts had long strictures in their distal segments, which made instrument approach to the calculi and manipulation impossible. A successful removal of this type of calculus was reported with a vascular snare (ref. 9).
Endoscopic laser lithotripsy is unavailable at our institution. Endoscopically controlled laser lithotripsy for removal of a stone in the Stensen duct (ref. 10) and submandibular lithiasis (ref. 11) has been reported. Our 2 cases of failure could have benefited from this method. A success rate of 36% to 53% has been reported for extracorporeal shock wave lithotripsy (ref. 12).
Wehrmann et a1 (ref. 13) developed a miniaturized lithotriptor, and a significantly higher percentage of patients were free of calculi (stone-free rate, 67%) after treatment. The authors did not report whether any case in this series required supplemental mechanical retrieval of calculi.
In conclusion, mechanical removal of calculi and sialodochoplasty by balloon catheter are excellent alternatives to surgery. These procedures are more cost-effective, with reduced risk of morbidity when compared with the surgical alternatives. The long-term outcome following the procedure is excellent. If the mechanical retrieval of calculi fails, laser lithotripsy, extracorporal lithotripsy, or both will improve the success rate.
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