Diagnosis and Treatment of Radioactive Iodine-Induced Sialadenitis: A 10-Year Endoscopic Experience

OBJECTIVES

The aim of this study was to explore the endoscopic characteristics of radioactive iodine-induced sialadenitis (RAIS), and to evaluate the treatment outcomes of endoscopic intervention for RAIS.

STUDY DESIGN

Retrospective case series.

METHODS

Eighty-two consecutive patients (11 males and 71 females) diagnosed as RAIS from Nov. 2012 to Sep. 2023 were retrospectively included. All patients underwent endoscopic exploration and intervention of the affected glands. The endoscopic features were collected, and treatment outcomes were followed-up and evaluated through post to pre-operative comparisons of gland status.

RESULTS

Overall, endoscopic procedures were undertaken for 162 parotid glands (PGs) and 62 submandibular glands (SMGs). Endoscopy showed severe lumen stricture (49.3%) and ductal atresia (23.5%) in PGs, as well as severe stenosis of the anterior duct and ectasia of the proximal duct (59.7%) in SMGs. During a median six months' follow-up, the treatment outcomes of PGs were evaluated as "improvement" in 23.4%，"lesion maintenance" in 45.1% and "lesion aggravation" in 31.5% of the glands. As for SMGs, the treatment outcomes were scored as "improvement"in 29.0%，"lesion maintenance"in 54.8%, and"lesion aggravation"in 16.1% of the glands. No significant differences of treatment outcomes were found relative to RAI treatment sessions and cumulative dosage.

CONCLUSION

RAIS is characteristic of severe lumen stricture and ductal atresia in PGs, and stenosis of the distal duct and ectasia of the proximal duct in SMGs. Endoscopy can alleviate clinical symptoms of RAIS and help to preserve the gland function.

LEVEL OF EVIDENCE

4 Laryngoscope, 2024.

Ultrasound and Sialendoscopy Findings in Radioactive Iodine-Induced Sialadenitis: Comparative Analysis and Possible Impact on Management

BACKGROUND

To assess the correlation/association between ultrasound and sialendoscopy findings in radioactive iodine therapy-induced sialadenitis (RAIS).

METHODS

Patients presenting with RAIS were investigated with ultrasound and sialendoscopy. Four pathologic ultrasound parameters and seven pathologic sialendoscopy parameters were retrospectively assessed. Correlations/associations between ultrasound and sialendoscopy findings and associations between the changes between the first and last ultrasound and sialendoscopy findings were assessed separately for the parotid (PG) and submandibular glands (SMG).

RESULTS

Sixty-seven patients were included. In the first examination, 107 glands were investigated (PGs 88.8%, SMGs 11.21%), and in the last examination, 64 glands were investigated (90.6% PGs, 9.4% SMGs). Highly significant positive associations were observed between the severity or category of ultrasound and sialendoscopy findings for first and last examinations for PGs (both p = 0.0001) and SMGs (p = 0.002; p = 0.037). Duct dilation had a significant negative association with the sialendoscopy findings for PGs in the first and last examinations (both p = 0.0001), but not for SMGs. Comparison of changes in the ultrasound and sialendoscopy findings between the first and last examinations showed a significant positive association for PGs (p = 0.0001) but not for SMGs.

CONCLUSIONS

Ultrasound and sialendoscopy findings for the parenchyma and duct system in RAIS showed significant associations/correlations and can be useful for effective management in RAIS.

Recurrent obstructive salivary disease after sialendoscopy. A narrative literature review

Over the last 20 years, interventional sialendoscopy has become the therapy of choice for the management of obstructive salivary disorders, favouring a significant reduction in the number of patients undergoing traditional sialadenectomy. The overall success rate of sialendoscopy is around 90% as reported by the largest case series published; recurrence is expected in about 10% of cases, and the patient should be informed about the possibility to undergo further conservative procedures to improve symptoms. Adequate pre-operative assessment, based on ultrasonography, cone beam 3D CT and MR-sialography, is mandatory to reduce the risk of unsuccessful procedures and, therefore, recurrence of obstructive sialadenitis; moreover, in case of recurrence, the surgeon should be experienced enough to manage these cases and be able to perform additional interventions, such as transoral/transfacial sialendoscopy-assisted procedures and imaging-assisted procedures in case of difficult anatomical situations. Botulinum toxin injection and traditional sialadenectomy would be considered as possible salvage treatments in case of failure of all conservative approaches.

Sialadenitis as a complication of radioiodine therapy in patients with thyroid cancer: where do we stand?

PURPOSE

This study aims to elaborate on the current knowledge concerning the mechanism, frequency, clinical manifestations, diagnostic procedures, prevention, and management of radioactive iodine (RAI)-induced sialadenitis in patients receiving treatment for differentiated thyroid cancer (DTC).

METHODS

A review of the literature was carried out through the " www.ncbi.nlm.nih.gov/pubmed " database focusing on the results of the past decade.

RESULTS

The high concentration of RAI in the salivary glands results in high beta radiation exposure of the striated duct cells and stem cells. This exposure leads to acute and/or chronic sialadenitis with obstructive symptoms and progressive loss of salivary gland function and xerostomia, with severe impact on patients' quality of life. No standard diagnostic method has been established. As far as prevention is concerned, many approaches have been proposed, such as sialogogues, local massage, vitamin E, and amifostine administration. Although there is no unanimity as to their effectiveness, the use of sialogogues is recommended. Treatment includes conservative drug therapy and sialendoscopy when necessary.

CONCLUSION

RAI-induced sialadenitis has a major impact on patients' quality of life. Due to the good prognosis of DTC, the reduction of sialadenitis and its prognosis, prevention, and treatment constitute a priority for the overall treatment of these patients. Further studies that will establish a coherent treatment protocol for this condition are necessary.

Differences between radioactive iodine-induced sialadenitis and chronic obstructive parotitis

The purpose of this study was to clarify the differences in the diagnosis and treatment outcomes between radioactive iodine-induced sialadenitis (RAIS) and chronic obstructive parotitis (COP). The study cohort comprised 47 consecutive patients diagnosed with RAIS and 50 patients with COP. All patients were treated by interventional endoscopy. Clinical, sialography, and endoscopy characteristics and treatment outcomes were compared between the two groups. Compared with the COP group, the RAIS group included more females (male:female ratio 1:8.4 vs 1:2.1; P = 0.011) and had a younger onset age (42 vs 50 years; P = 0.001) and shorter disease duration prior to hospital visit (5.4 vs 34.8 months; P < 0.001). In the RAIS group, sialography revealed obliteration of the main duct (20.4% vs 0%; P < 0.001), non-visualization of the main gland (23.7% vs 0%; P < 0.001), and incomplete contrast filling of the main gland (19.4% vs 6.4%; P = 0.008), which were scarcely observed in the COP group. Endoscopy revealed a higher percentage of duct atresia in RAIS compared to COP (20.4% vs 0%; P < 0.001). During follow-up, a higher percentage of RAIS patients had duct atresia and gland atrophy (49.5% vs 1.1%, P < 0.001). Compared with COP, RAIS more commonly involves younger females and has a shorter disease duration. Atresia of the main duct and atrophy of the gland parenchyma occur more often despite the use of interventional endoscopy.

Sialendoscopy in Chronic Obstructive Sialadenitis Without Sialolithiasis: A Prospective Cohort Study

OBJECTIVES

To evaluate long-term chronic sialadenitis symptoms in patients without sialolithiasis following sialendoscopy-assisted salivary duct surgery (SASDS) compared to a control group managed conservatively.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care center.

METHODS

Thirty-six patients (52 glands) with chronic sialadenitis without sialolithiasis completed the Chronic Obstructive Sialadenitis Symptoms (COSS) questionnaire at presentation and at 3-month time intervals thereafter for 1 year. Lower COSS scores represent lower symptom severity. We compared 27 patients who underwent SASDS to 9 control patients who elected conservative management.

RESULTS

COSS gland-specific scores from 38 SASDS-treated glands (cases) and 14 control glands were similar at baseline. At 6 to 12 months (mean, 8.4 months), the surgically treated group had significantly lower scores and a greater score reduction from baseline compared to controls (mean score change [95% confidence interval] cases: 20.7 points [15.7-25.8]; controls: 11.7 points [4.9-18.4]; P = .04). There was a significant difference in scores between the 2 groups over time (P < .001). A greater proportion (72%) of cases reported partial or complete resolution of overall sialadenitis symptoms at 6 to 12 months compared to the controls (22%, P < .05).

CONCLUSION

Compared to patients electing for conservative management, patients with sialadenitis without sialolithasis treated with SASDS had improved symptom scores and a greater reduction of symptom severity after 6 months. With SASDS, patients had higher rates of significant overall symptom improvement. In evaluating chronic sialadenitis, assessment at multiple time points is necessary to capture the intermittent and cyclical pattern of obstructive symptoms.

Salivary and lacrimal dysfunction after radioactive iodine for differentiated thyroid cancer: American Head and Neck Society Endocrine Surgery Section and Salivary Gland Section joint multidisciplinary clinical consensus statement of otolaryngology, ophthalmology, nuclear medicine and endocrinology

BACKGROUND

Postoperative radioactive iodine (RAI) administration is widely utilized in patients with differentiated thyroid cancer. While beneficial in select patients, it is critical to recognize the potential negative sequelae of this treatment. The prevention, diagnosis, and management of the salivary and lacrimal complications of RAI exposure are addressed in this consensus statement.

METHODS

A multidisciplinary panel of experts was convened under the auspices of the American Head and Neck Society Endocrine Surgery and Salivary Gland Sections. Following a comprehensive literature review to assess the current best evidence, this group developed six relevant consensus recommendations.

RESULTS

Consensus recommendations on RAI were made in the areas of patient assessment, optimal utilization, complication prevention, and complication management.

CONCLUSION

Salivary and lacrimal complications secondary to RAI exposure are common and need to be weighed when considering its use. The recommendations included in this statement provide direction for approaches to minimize and manage these complications.

Clinical and Sialographic Imaging Features of 131I Radiation-induced Submandibular Gland Sialadenitis

PURPOSE

¹³¹I radiation-induced sialadenitis is the most frequent complication of ¹³¹I treatment for papillary thyroid carcinoma, but little is known about ¹³¹I radiation-induced submandibular gland sialadenitis. The purpose of this study was to compare and contrast the clinical and sialographic imaging features of ¹³¹I radiation-induced submandibular gland sialadenitis to ¹³¹I radiation-induced parotitis.

PATIENTS AND METHODS

This retrospective cross-sectional study included patients with ¹³¹I radiation-induced submandibular gland sialadenitis and parotitis. Clinical records and sialographic image features were evaluated. The predictor variables included age at the time of diagnosis, gender, course of the disease, site of symptoms, and sialographic image grades. The outcome variable was the location of sialadenitis. A student t-test was conducted to analyze the associations between predictor variables and the outcome.

RESULTS

The sample was composed of 4 patients with submandibular gland sialadenitis (100% female), 28 with parotitis (85.7% female), and 1 with submandibular gland sialadenitis and parotitis (P < .05). The occurrence of bilateral glands dysfunction was less often in submandibular glands (SMG: 1/4; PG: 19/28). The age and course of disease were not different between submandibular gland sialadenitis and parotitis (Age, SMG: 46.00 ± 13.59 years; PG: 50.04 ± 10.71 years, P > .05; Course of the disease, SMG: 11.00 ± 16.69 months; PG: 6.96 ± 11.18 months, P > .05). Radiographically, 7 of 16 patients with parotitis were identified as grade 2 and 9 patients as grade 3. In 3 patients with submandibular gland sialadenitis, 1 patient was identified as grade 2 and 2 patients as grade 3. The postoperative pathological results showed that the proliferation of glandular tissue from the hilum of the submandibular gland caused duct stenosis.

CONCLUSION

The results suggest ¹³¹I radiation-induced submandibular gland sialadenitis has a lower incidence compared with parotitis and ¹³¹I radiation-induced submandibular gland sialadenitis might be related to duct stenosis caused by proliferative glandular tissue after ¹³¹I radiation treatment.

Salivary side effects after radioiodine treatment for differentiated papillary thyroid carcinoma: Long-term study

BACKGROUND

Although many studies focus on short-term side effects of radioiodine therapy, almost none studied long-term side effects. We assessed radioiodine long-term salivary side effects after radioiodine treatment for differentiated papillary thyroid carcinoma and compared it to short-term morbidity within the same population.

METHODS

A standardized self-administrated questionnaire was submitted in 2019 by patients treated with radioiodine between January 2011 and December 2012. These patients had already answered the same questionnaire 6 years before.

RESULTS

Our study showed a significant reduction for salivary side effects: discomfort in submandibular or parotid area, swelling, pain, a bad or salty taste in the mouth, allowing to get back to a "normal" diet.

CONCLUSIONS

Our study suggests that a significant rate of patients will recover from I¹³¹ therapy salivary side effects. As almost 30% of these remissions happened during our late stage follow-up, we highlight the necessity of a long-term follow-up in these patients.

[Inflammation grading and sialoendoscopic treatment of 131I radioiodine-induced sialadenitis]

OBJECTIVE

To investigate the inflammation grading of ¹³¹I radioiodine-induced sialadenitis based upon sialoendoscopic and sialographic appearances, and to evaluate the results of sialoendoscopic intervention.

METHODS

The patients diagnosed with ¹³¹I radioiodine-induced sialadenitis and underwent sialoendoscopic exploration and intervention procedures in Peking University Hospital of Stomatology from Nov. 2012 to Oct. 2018 were included in this study. The appearances of sialogaphy and sialoendoscopy were analyzed and classified. The treatment options included irrigation with saline and dexamethasone and mechanical dilatation by sialoendoscope. The patients were followed up after treatment.

RESULTS

Forty-two patients with ¹³¹I radioiodine-induced sialadenitis were included. There were 5 males and 37 females, with a male-to-female ratio of 1 ∶7.4. Symptoms included recurrent swelling and pain in the parotid glands, and dry mouth. Sialography showed stenosis in the main duct,and in some cases nonvisua-lization of the branches. Sialoendoscopy showed narrowing of the main duct, and the branch duct atresia was seen. The appearances of sialogaphy and sialoendoscopy were analyzed and classified into 3 groups: (1) Mild inflammation: stenosis and ectasia occurred in the main duct, whereas the 0.9 mm sialoendoscope could pass through easily. (2) Moderate inflammation: one point of severe stricture could be seen in the main duct where 0.9 mm sialoendoscope could not be passed through. (3) Severe inflammation: two points or more of severe strictures or diffused strictures occurred in the main duct. Thirty-three patients with 65 affected glands were examined by both sialography and sialoendoscopy. Eight glands were classified as mild inflammation, 23 glands moderate inflammation, and 34 glands severe inflammation. The duration of follow-up ranged from 3-72 months. The clinical results were evaluated as good in 22 glands, fair in 22 glands, and poor in 19 glands, with an overall effective rate of 69.8% (44/63).

CONCLUSION

The clinical, sialographic and sialoendoscopic appearances of ¹³¹I radioiodine-induced sialadenitis showed their characteristics. We proposed an inflammation grading standard for the ¹³¹I radioiodine-induced sialadenitis based on the appearances of sialography and sialoendoscopy. Sialoendoscopy can significantly alleviate the clinical symptoms, which is an effective therapy, and better for early lesions.

Efficacy of Sialendoscopy in the Management of Noncalculi-Related Sialadenitis

PURPOSE

Sialendoscopy has effectively changed the paradigm for the treatment of sialolithiasis. Its effect on noncalculi-related recurrent sialadenitis is, however, unclear, especially regarding the long-term outcomes. The objectives of the present study were to evaluate the long-term efficacy of sialendoscopy for noncalculi-related recurrent sialadenitis and determine the clinical and intraoperative features that might be prognosticate outcomes.

PATIENTS AND METHODS

We performed a prospective cohort study of 33 consecutive patients who had undergone sialendoscopy for recurrent noncalculi-related sialadenitis by a single surgeon in a tertiary institution from January 2010 to December 2016. The patient-reported outcome measures were used as the primary determinant of treatment efficacy. The clinical features and endoscopic findings were evaluated as variables that might predict the treatment outcomes. The Fischer exact test was used to analyze the descriptive data, and a P value of < .05 was considered to indicate statistical significance.

RESULTS

Of the 33 patients with recurrent noncalculi-related sialadenitis, 1 was lost to follow-up and thus excluded from the analysis. The mean and median follow-up period for the 32 patients was 27 and 21.5 months, respectively. Of the 33 patients, 28 (87.5%) reported symptom improvement, and 19 patients (59.4%) were symptom free after a single sialendoscopic treatment. The chronicity of symptoms, younger patient age, and concurrent autoimmune disease were predictive of recurrent symptoms despite sialendoscopy.

CONCLUSIONS

The use of sialendoscopy achieved sustained long-term improvements or resolution of symptoms for most patients with recurrent noncalculi-related sialadenitis. The data from our study support the benefits of sialendoscopy for patients with recurrent noncalculi-related sialadenitis.

Saliva: An all-rounder of our body

Saliva is a multifaceted bodily fluid that is often taken for granted but is indispensable for oral health and overall well-being in humans. Although mainly comprised of water (99.5%), proteins, ions and enzymes turn saliva into a viscoelastic solution that performs a variety of vital tasks. This review article gives a brief overview of the salivary gland system, as well as the composition, output and functions of saliva. It also addresses the current applications of saliva for diagnostic purposes, the clinical relevance of saliva in oral diseases as well as current treatment options.

Sialendoscopy With Intraductal Steroid Irrigation in Patients With Sialadenitis Without Sialoliths

Sialendoscopy has emerged as a safe, effective and minimally invasive technique for management of obstructive and inflammatory salivary gland disease. The aim of our study was to analyze outcomes of sialendoscopy and steroid irrigation in patients with sialadenitis without sialoliths. We performed a retrospective analysis of patients who underwent interventional sialendoscopy with steroid irrigation from 2013 to 2016, for the treatment of sialadenitis without sialolithiasis. Twenty-two patients underwent interventional sialendoscopy with ductal dilation and steroid irrigation for the treatment of sialadenitis without any evidence of sialolithiasis. Conservative measures had failed in all. Eleven patients had symptoms arising from the parotid gland, 4 patients had symptoms arising from the submandibular gland, while 6 patients had symptoms in both parotid and submandibular glands. One patient complained of only xerostomia without glandular symptoms. The mean age of the study group which included 1 male and 21 females was 44.6 years (range: 3-86 years). Four patients had autoimmune disease, while 7 patients had a history of radioactive iodine therapy. No identifiable cause for sialadenitis was found in the remaining 11 patients. The mean follow-up period was 378.9 days (range: 16-1143 days). All patients underwent sialendoscopy with ductal dilation and steroid irrigation. Twelve patients showed a complete response and 9 patients had a partial response, while 1 patient reported no response. Only 3 patients required repeat sialendoscopy. The combination of sialendoscopy with ductal dilation and steroid irrigation is a safe and effective treatment option for patients with sialadenitis without sialoliths refractory to conservative measures. Prospective studies with a larger case series are needed to establish its role as a definitive treatment option.

Sialadenitis May Be Associated With an Increased Risk for Osteoradionecrosis: A Nationwide Population-Based Cohort Study

PURPOSE

The impact of sialadenitis on osteoradionecrosis (ORN) is controversial. The aim of this study was to determine the association between sialadenitis and ORN.

MATERIALS AND METHODS

Participants were derived from the Taiwanese Longitudinal Health Insurance Database. From January 1, 2000 to December 31, 2008, cases of sialadenitis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 527.2, 527.3, 527.5 to 527.7, 527.9, and 710.2) and ORN (ICD-9-CM codes 526.89, 526.5, 730.0, and 730.1) were identified. Different treatment modalities, including surgery versus medicine, were used to distinguish the severity of sialadenitis. The primary predictor variable was sialadenitis. The secondary predictor variable was severity of sialadenitis. The primary outcome variable was time to developing ORN. Other study variables were grouped for age, gender, risk factor, and medical treatment. Cox proportional hazard regression was used to investigate the associations between sialadenitis and ORN after adjusting for statistical confounders.

RESULTS

The sample was composed of 47,385 patients with a mean age of 46.6 years (standard deviation, 19.9 yr) and 37.2% were men. Twenty percent had a diagnosis of sialadenitis and 1.13% had a diagnosis of ORN. Sialadenitis was associated with an increased risk of ORN (hazard ratio [HR] = 1.93; 95% confidence interval [CI], 1.61-2.31; P < .0001). After adjustment for confounders, sialadenitis was associated with ORN (multivariable HR = 1.83; 95% CI, 1.52-2.19; P < .0001). Severity of sialadenitis was associated with an increased risk of ORN; risks for ORN were 1.79 (95% CI, 1.49-2.16; P < .0001) and 3.52 (95% CI, 1.67-7.44; P < .001) in patients with mild and serious sialadenitis, respectively, compared with the no-sialadenitis cohort. For the joint effect of ORN between sialadenitis and malignancy type, patients with sialadenitis had 11.6-fold risk for ORN (95% CI, 5.58-23.9) compared with patients without malignancy.

CONCLUSIONS

Sialadenitis markedly increased the risk to develop ORN. The severity of sialadenitis was positively correlated with the incidence of ORN.

Initial clinical experience performing sialendoscopy for salivary gland protection in patients undergoing 225Ac-PSMA-617 RLT

PURPOSE

The main side effect of prostate-specific membrane antigen targeting alpha therapy (PSMA TAT) is dry mouth syndrome. Inflammation of the salivary glands and consequent reduced salivary function have been reported in patients after radioiodine therapy. The beneficial effects of sialendoscopy on radiation-induced inflammation in tissue are well known. Thus sialendoscopy with dilatation, saline irrigation and steroid injections (prednisolone) was performed before and after ²²⁵Ac-PSMA-617 TAT to reduce inflammatory effects in the salivary glands and to improve or prevent xerostomia.

METHODS

Eleven men with metastatic castration-resistant prostate cancer (mean age 68.5 years, range 58-80 years) underwent sialendoscopy, dilatation, saline irrigation and steroid injection of both submandibular and both parotid glands before or after every cycle of ²²⁵Ac-PSMA-617 TAT. Sialendoscopy and steroid injection were performed by a senior ENT physician. Quality of life was evaluated using two health-related quality of life (HRQOL) questionnaires, the Xerostomia Questionnaire (XQ) and the Xerostomia Inventory (XI) before and 3 months after the intervention.

RESULTS

In all 11 patients both parotid and both submandibular glands were affected by radiation sialadenitis and sialendoscopy was performed. The patients experienced no complications after sialendoscopy, and showed a significant improvement in HRQOL as measured using the XQ and XI. After sialendoscopy the XQ score decreased significantly from 77.7 ± 13.6 to 42.7 ± 14.8 (p = 0.003) and the XI score decreased from 44.5 ± 6.9 to 25.8 ± 12.8 (p = 0.003). Due to the limited number of patients we only report tendencies.

CONCLUSION

Sialendoscopy with dilatation, saline irrigation and steroid injection had beneficial effects on salivary gland function and HRQOL in patients undergoing ²²⁵Ac-PSMA-617 RLT. However, even with sialadenoscopic support after multiple cycles of TAT, salivary gland function was reduced and xerostomia was present. Therefore, not only inflammation but also the direct effect of radiation is a putative cause of dry mouth. Further research is necessary to determine the main side effects of PSMA TAT.

Interventional sialendoscopy for radioiodine-induced sialadenitis: quo vadis?

Salivary gland toxicity is a common adverse effect of radioactive iodine (¹³¹I) for the treatment of thyroid cancers with a prevalence ranging from 2% to 67% of the ¹³¹I exposed population. Recently, sialendoscopy has been introduced as an attractive diagnostic and therapeutic tool for management of patients with radioiodine-induced sialadenitis that is unresponsive to standard medical treatments. The objective of the current review was to assess the impact of this procedure on outcomes in patients suffering from radioiodine sialadenitis. Overall, eight studies were included and 122 patients underwent 264 sialendoscopic procedures. Duct stenosis and mucous plugs were observed in 85.7% of endoscopic findings, supporting the role of ductal obstruction in the pathophysiology of radioiodine sialadenitis. In total, 89.3% of patients experienced complete or partial resolution of sialadenitis recurrences without any major adverse events, and parotidectomy was advocated in only 1 case. However, outcomes mainly concerned subjective reports and only two clinical experiences evaluated objective measurement with dissimilar results. Limited to few studies, xerostomia and obstructive symptoms responded differently after sialendoscopy. The optimal timing of salivary gland videoendoscopy needs to be further analysed in order to define the best management of radioiodine-induced obstructive sialadenitis.

Diagnostic and treatment effects of sialendoscopy for patients with swelling of the parotid gland when sialoliths are undetected with computed tomography

Between August 2009 and May 2016, 74 patients underwent sialoendoscopic surgery. 32 patients had parotid gland disease and 9 patients had intermittent swelling of the parotid gland and sialoliths were not detected with CT imaging. 4 patients were diagnosed with idiopathic Stensen's duct stenosis. Sialendoscopy directly confirmed Stensen's duct stenosis in 2 patients. However, the sialendoscope was unable to be inserted in the other 2 patients, who had stenosis of the orifice of the Stensen's duct. Balloon expansion of the duct was performed in these 2 patients and a steroid drug was injected into the duct in one patient. Complete remission was archived in one patient treated with sialendoscopy. Three patients had sialolithiasis. Microsialoliths and/or white floating matter was observed and removed using sialendoscopy. All patients experienced complete remission. In cases of Sjögren syndrome and recurrent parotitis, sialendoscopic surgery was performed, but the symptoms showed no improvement. For patients with microsialoliths, sialendoscopy may be most useful for diagnosis and treatment when the sialoliths are not detected with CT imaging. At present, sialendoscopic surgery have limitation in the treatment of Stensen's duct stenosis and may similarly have limitation in the treatment of Sjögren's syndrome and recurrent parotitis.

Sialendoscopy in the Management of Radioiodine Induced Sialadenitis: A Systematic Review

Objectives:

Salivary gland dysfunction as a consequence of radioiodide ablation is present in as many as two-thirds of patients, and unfortunately, many of these individuals do not respond to conservative measures. Sialendoscopy as a minimally invasive therapeutic modality may have utility in the treatment of radioiodide induced sialadenitis (RAIS). Our aim was to explore whether sialendoscopy resulted in clinical improvement in patients with RAIS.

Methods:

A systematic review of studies on sialendoscopy for RAIS was conducted using MEDLINE database, Embase, and Cochrane Library. The outcomes of interest included the proportion of patients demonstrating clinical improvement after intervention, patient demographics, radiation dose, specific procedural variations, specific salivary gland, failure rate, and recurrence.

Results:

Eight studies met inclusion criteria. Data reviewed showed an increased predilection of parotid sialadenitis relative to submandibular gland sialadenitis. All but 2 studies employed sialendoscopy only after failure of conservative measures. An overall rate of clinical improvement ranging from 75% to 100% was reported.

Conclusion:

This systematic review encompassing 122 patients represents the largest pooled sample to date of patients undergoing sialendoscopy for RAIS. Sialendoscopy represents an invaluable minimally invasive modality that may obviate the need for more invasive surgery as intervention was associated with a high success rate.

Sialoendoscopy combined with an internal stent and postoperative massage as a comprehensive treatment of delayed I131-induced parotitis

A common complication of radioiodine (I¹³¹) treatment of thyroid cancer is parotitis. Here we describe our clinical experience in treating delayed I¹³¹-induced parotitis using sialoendoscopy together with an internal stent and postoperative massage. In this retrospective cohort study we reviewed 32 patients who were treated in that way under general anaesthesia between July 2010 and March 2015. Their age, sex, and the time to development of the parotitis were collected from the hospital's database. All patients were evaluated using a visual analogue scale (VAS), sialography, and computed tomography preoperatively. The analyses of VAS scores were made during postoperative follow-up visits. We used the paired Student's t test and one-way ANOVA to assess the significance of differences, and probabilities of < 0.05 were accepted as significant. The mean (SD) age of the 32 patients was 50 (11) years, and they developed symptoms of delayed parotitis after a mean (SD) of 12 (11) months. The mean time between treatment with I¹³¹ and sialoendoscopy was 26 (10) months. Ductal stenosis was the most common sialoendoscopic feature, together with mucous plugs and fibrosis. Fifty of the 56 ducts were successfully dilated by sialoendoscopy, and VAS scores significantly decreased from a preoperative 7.3 (1.1) to a postoperative 3.3 (2.1) (p=0.000) during follow-up of 3 - 41 months. Sialoendoscopic interventions combined with an internal stent and postoperative massage may be optimal comprehensive treatment for delayed I¹³¹-induced parotitis.

Sialendoscopy for non-stone disorders: The current evidence

OBJECTIVE

Review the current literature on the use of sialendoscopy in the treatment of non-stone disorders of the major salivary glands.

DATA SOURCES

Eligible articles that reported on the use of sialendoscopy in the treatment of non-stone disorders were identified using MEDLINE, Embase, and Google Scholar through May 2016. The search used key words sialendoscopy, salivary endoscopy, salivary scope, salivary duct stenosis, salivary duct stricture, Sjogren's disease, radioiodine sialadenitis, salivary duct obstruction, sialadenitis, chronic sialadenitis, juvenile recurrent parotitis, parotitis, and radiation sialadenitis.

REVIEW METHODS

Full-length prospective and retrospective original articles; systemic reviews; and meta-analysis, including adults and children with adequate data for evaluating the sialendoscopy for non-stone disorders, were included. Individual case reports were excluded.

RESULTS

There is an increasing trend for the use of sialendoscopy for salivary obstruction caused by a wide variety of non-stone disorders worldwide. The studies of sialendoscopy for non-stone disorders are often retrospective, of smaller sample size, and more subjective in measurement of patient outcome. The most common indications currently for the procedure are scars, juvenile recurrent parotitis, radioiodine sialadenitis, and Sjögren syndrome, respectively.

CONCLUSION

Although the initial evidence for the use of sialendoscopy for non-stone disorders is not as established as that for stones, it remains a promising gland-preserving tool in the management of non-stone disorders of major salivary glands.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer

BACKGROUND

Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer.

METHODS

The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations for therapeutic interventions. We developed a similarly formatted system to appraise the quality of such studies and resultant recommendations. The guideline panel had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members.

RESULTS

The revised guidelines for the management of thyroid nodules include recommendations regarding initial evaluation, clinical and ultrasound criteria for fine-needle aspiration biopsy, interpretation of fine-needle aspiration biopsy results, use of molecular markers, and management of benign thyroid nodules. Recommendations regarding the initial management of thyroid cancer include those relating to screening for thyroid cancer, staging and risk assessment, surgical management, radioiodine remnant ablation and therapy, and thyrotropin suppression therapy using levothyroxine. Recommendations related to long-term management of differentiated thyroid cancer include those related to surveillance for recurrent disease using imaging and serum thyroglobulin, thyroid hormone therapy, management of recurrent and metastatic disease, consideration for clinical trials and targeted therapy, as well as directions for future research.

CONCLUSIONS

We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid nodules and differentiated thyroid cancer. They represent, in our opinion, contemporary optimal care for patients with these disorders.

Sialendoscopy for Patients with Radioiodine-Induced Sialadenitis and Xerostomia

BACKGROUND

We examined outcomes in patients treated for radioactive iodine-induced sialadenitis (RAIS) and xerostomia with sialendoscopy.

METHODS

Data was prospectively collected for all patients undergoing sialendoscopy for RAIS from a single institution. Interventional details and intraoperative findings were recorded. Qualitative data were obtained through patient examination, telephone interviews, and use of a standard quality of life questionnaire, Xerostomia Questionnaire. Quantitative data were obtained from patients who underwent sialometry.

RESULTS

Twenty-six patients (24 women and 2 men; median age, 43 years; age range, 19-57 years) underwent interventional sialendoscopy after conservative management of symptoms proved unsuccessful. Sialadenitis was present in 25 patients and xerostomia in 22 patients. Mucus plugging in the duct of the gland was the most common finding (22 patients) followed by stenosis (18 patients), inflammation (eight patients), and erythema (eight patients). Median follow-up time was 23.4±12.1 months. Sixteen patients (64%) reported complete resolution; seven (28%), partial resolution; one (4%), no change in symptoms; and one (4%), regression in RAIS-related symptoms. Patients subjectively noted the following regarding their xerostomia symptoms: seven (31.8%) had complete resolution; 10 (45.5%), partial resolution; four (18.2%), no change; and one (4.5%), regression. Statistical analysis of the available sialometry data revealed a statistically significant difference in saliva production at 6 months following sialendoscopy for unstimulated saliva production (p=0.028).

CONCLUSION

Sialendoscopy is an effective treatment option for the management of RAIS and xerostomia refractory to conservative therapy and medical management. Patients in our cohort report durable improvement in symptoms after intervention.

Salivary gland function after sialendoscopy for treatment of chronic radioiodine-induced sialadenitis

BACKGROUND

The purpose of this study was to determine whether sialendoscopy could ameliorate radioactive iodine-induced obstructive sialadenitis and restore the salivary gland dysfunction in recalcitrant radioactive iodine sialadenitis.

METHODS

Ten patients with 15 parotid glands of chronic radioactive iodine sialadenitis who did not respond to medical treatment were enrolled in this prospective study. We assessed subjective symptom scores and evaluated the objective salivary gland functions before and 3 months after sialendoscopy.

RESULTS

The post-sialendoscopic obstructive symptoms were significantly improved relative to pre-sialendoscopy (p = .009). Xerostomia-related symptom scores post-sialendoscopy did not differ significantly from the pre-sialendoscopy scores. Stimulated salivary flow rate post-sialendoscopy tended to increase relative to pre-sialendoscopy. No pre-sialendoscopic parameters associated with salivary uptake and secretion by salivary gland scintigraphy were significantly improved post-sialendoscopy.

CONCLUSION

These results show that sialendoscopy can improve obstructive symptoms; however, it seems to have some limitations for relief of xerostomia and improvement of salivary gland dysfunctions in recalcitrant chronic radioactive iodine sialadenitis.

Sialendoscopy-assisted treatment for radioiodine-induced sialadenitis

PURPOSE

Chronic sialadenitis is a common complication of radioactive iodine for the treatment of thyroid disease. The aim of this study was to describe the authors' experience with interventional sialendoscopy for the management of radioiodine-induced sialadenitis.

MATERIALS AND METHODS

Twelve patients with radioiodine-induced sialadenitis treated with sialendoscopy from January 2013 through December 2013 at the Department of Oral and Maxillofacial Surgery, School of Stomatology, China Medical University were retrospectively reviewed. Age, gender, and time to development of radioiodine-induced sialadenitis were obtained from the hospital database. All patients were asked to undergo visual analog scale (VAS) and salivary gland scintigraphy (SGS) examinations before and 6 months after surgery. A paired t test was conducted, and a P value less than .05 was considered statistically significant.

RESULTS

Twelve patients (15 parotid glands and 4 submandibular glands) successfully underwent interventional sialendoscopy under local anesthesia. Ductal stenosis was the most common feature identified by endoscopy. Among the 12 patients, swelling occurred in 91.7%. Compared with the preoperative score of 6, the mean VAS score 6 months after sialendoscopy was 3; 15 glands (78.9%) showed improved uptake and excretion by SGS. The postoperative VAS score was significantly lower than the preoperative VAS score (P < .05), and the postoperative SGS result was significantly higher than the preoperative SGS result (P < .05).

CONCLUSIONS

Interventional sialendoscopy could be an effective technique for the treatment of sialadenitis caused by radioactive iodine.

Sialoendoscopy: a viable treatment for I(131) induced sialoadenitis

To evaluate the viability, efficacy, and safety of sialoendoscopy for the diagnosis and management of radioiodine I(131-) related sialoadenitis, we retrospectively reviewed 30 patients referred between September 2007 and July 2013 from the Thyroid Surgery Unit to the Maxillofacial Unit of the Second University of Naples Hospital with persistent sialoadenitis after treatment with I(131). After the affected gland had been isolated, the endoscope was introduced into the duct under local anaesthesia with 2% lignocaine and continuous lavage with isotonic saline, and was advanced until it reached the ductal system. We studied 24 women and 6 men, mean (SD) age 52 (??) years. In 25 patients I(131) was given for papillary (83%), in 3 for medullary (10%), and in 2 for follicular thyroid carcinoma (7%). Stenosis alone was found in 30 glands (40%), mucous plugs alone in 35 (47%), and mucous plugs, stenosis, and kinks in 10 (13%). Of the 75 glands, dilatation of the ducts was successful in 70, and we completely removed all mucous plugs and kinks. We achieved symptomatic improvement in 23 patients (77%) during a follow-up ranging from 2 weeks to 84 months. Sialoendoscopy is a viable technique for the diagnosis of obstructive salivary disease, and is a safe and effective way to treat sialoadenitis, the most common complication of treatment with I(131).

Salivary morbidity and quality of life following radioactive iodine for well-differentiated thyroid cancer

OBJECTIVE

Determine the prevalence of sialadenitis in a group of patients treated with radioactive iodine (RAI) for well-differentiated thyroid cancer and assess whether RAI treatment is associated with a reduction in swallowing-related or global head and neck quality of life.

STUDY DESIGN

Retrospective self-administered questionnaire study.

SETTING

Academic, tertiary care, National Cancer Institute-designated cancer center.

SUBJECTS AND METHODS

Surviving patients seen for well-differentiated thyroid cancer were identified by review of the cancer center registry. Patients were mailed a baseline questionnaire, the M. D. Anderson Dysphagia Inventory (MDADI), the University of Washington Quality of Life Questionnaire (UW-QOL), and the Xerostomia-Related Quality of Life Scale (XeQOLS).

RESULTS

The study included 121 women and 24 men, with a mean age of 52 years. Radioactive iodine exposure was correlated with an increase in sialadenitis and was dose dependent (R (2) = 0.335, P < .001). Sialadenitis was 2.47 times more likely to occur in patients who received greater than 150 mCi when compared with those who received less than 150 mCi (P = .04). Radioactive iodine exposure of over 150 mCi was also associated with a reduction in the recreation domain of the UW-QOL (P = .04), the daily swallowing domain of the MDADI (P = .02), and the psychological/personal, pain, and social domains of the XeQOLS (P = .03, .03, and .04, respectively).

CONCLUSION

Patients treated with RAI exhibited an increased risk for sialadenitis as well as a reduction in swallowing-related and global head and neck quality of life. Our findings suggest these patients should be screened for salivary morbidity and may benefit from both pre-RAI prophylaxis and post-RAI intervention.