Sialendoscopy-assisted transfacial removal of parotid sialoliths: A systematic review and meta-analysis

Predictive factors for outcomes of sialoendoscopy

OBJECTIVES

We evaluated the epidemiological and clinical factors related to the complications and failure of sialoendoscopy.

METHODS

This retrospective study analyzed the medical records of patients who underwent sialoendoscopy between 2010 and 2019.

RESULTS

Of the 174 sialoendoscopies analyzed, 125 (71.8%) were performed in women, and 114 (65.5%), in the parotid gland. The most prevalent complications described were false path (4.59%) and restenosis (2.30%). Complications in the submandibular gland were 3.43 times more common than those in the parotid gland and procedures in that gland were less successful (86.7% vs. 91.2%). Sialolithiasis treatment was most strongly associated with complications and failure then the other groups.

CONCLUSION

Sialoendoscopy has uncommon and limited complications. Procedures in the submandibular gland and for sialolithiasis treatment were more likely to result in complications and recurrences.

LEVEL OF EVIDENCE: 4

CT Navigation-Assisted Transfacial Removal of Parotid Stones: Does It Work?

Background/Objectives: The failure rate of minimally invasive surgical approaches to parotid stones is about 10%, primarily due to the presence of large, impacted, or unpalpable deep stones. When stones are palpable and exceed 7 mm in size, a combined transfacial and sialendoscopic approach offers a safe and effective surgical option, while unpalpable and impacted stones located in the parenchyma, not visible or accessible through sialendoscopy, can be treated with a CT-guided transfacial approach. Methods: Twenty-two patients (three females, mean age 53 years, range 32-73 years) underwent CT navigation-assisted transfacial removal of unpalpable and impacted parotid stones at the Department of Otolaryngology and Head and Neck Surgery of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico of Milan between 2017 and 2024. Results: The mean size of the stones was 7.4 mm (range 4-14 mm), while the mean depth of stones, calculated as the distance from the skin surface, was 8.7 mm (range 4-14 mm). Stones were removed successfully in all but five patients (77% success rate). Failure of the procedure was significantly associated (p < 0.05) with the depth of the stone (>12 mm); in all these cases, patients were treated immediately by means of traditional parotidectomy. Conclusions: The CT-navigation-assisted transfacial approach can be considered a safe, reliable, and efficacious option for the treatment of difficult unpalpable parotid stones, impacted and deeply located in the gland parenchyma. Stones deeper than 10 mm can be more effectively treated by means of traditional parotidectomy if extracorporeal lithotripsy is not available.

Parotid sialolithiasis - Long term follow-up analyzing surgical approaches

Objectives

Present follow-up data comparing transoral and transfacial parotid gland procedures for stone removal to offer insight addressing technical considerations and complications.

Methods

Retrospective study of a consecutive series of surgical treatments for parotid sialolithiasis from 2013 to 2018 at an academic institution by one surgeon provided review of 16 transoral and 10 transfacial procedures supplemented by long-term follow-up through telephone or mail. Clinical and radiographic parameters, additional treatment, and persistence of symptoms were evaluated.

Results

Four of 10 patients treated with the transfacial approach had parotid-cutaneous fistulas addressed with transdermal scopolamine patches and pressure dressings (one also with intraductal steroid infusion) with closure at a median of 12.5 days. A fifth fistula failed to resolve at 23 days and was addressed with parotidectomy. All 8 patients who were contacted (median: 106 months) reported complete resolution of symptoms. None had facial weakness.Six of 16 patients treated by a transoral approach had persistent stone fragments at the conclusion of operation. Four of these 6 patients underwent subsequent procedures (two transoral, one transfacial, one parotidectomy). Among the 11 patients who responded to long-term follow-up (median: 107 months), one reported mild symptoms insufficient to request treatment. Larger stone size coupled with proximal location correlated with the conversion from transoral to include transfacial approach.

Conclusion

Patients with retained stone remnants at the conclusion of transoral stone removal are more likely to require additional procedures that result in long-term favorable results. The transfacial approach to stone removal offers long-term favorable results following the common short-term complication of salivary fistula.

Level of Evidence

OCEBM Level 4.

Prophylactic antibiotics in sialendoscopy: a randomized clinical trial

OBJECTIVE

Antibiotics have been prescribed routinely in sialendoscopy procedures to reduce the risk of postoperative infection, despite the limited evidence supporting this practice. Being necessary to assess the need for antibiotics in Sialendoscopy, aiming to provide evidence-based guidance to clinicians regarding antibiotic administration in this procedure.

MATERIALS & METHOD

A prospective, randomized, double-blind, controlled clinical trial to evaluate the of prophylactic antibiotics in Sialendoscopy was designed.

RESULTS

A total of 80 patients were included in this study, including 57 females (71.8%) and 23 males (28.8%). In terms of prophylaxis, 36 patients (45%) received prophylactic treatment, and 44 patients (55%) did not. The occurrence of infectious events was observed in 2 patients (5.6%) with prophylaxis and 4 patients (9.1%) without prophylaxis. However, this difference was not statistically significant (p = 0.556).

CONCLUSION

In conclusion, our prospective, randomized clinical trial aimed to address the debate regarding the use of prophylactic antibiotics in sialendoscopy. Our study's findings suggest that the routine use antibiotics may not be necessary to prevent postoperative infections in sialendoscopy procedures. These results have important implications for clinical practice, potentially reducing the unnecessary use of antibiotics and addressing concerns related to antibiotic resistance and adverse drug reactions.

Success rate of sialendoscopy. A systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis on the efficacy and safety of sialendoscopy in the treatment of obstructive diseases of the major salivary glands.

MATERIALS AND METHODS

We searched four databases for literature. The primary outcome assessed was the success rate. Secondary outcomes included the use of supportive devices, number of sialadenectomies and complications. Risk of bias was assessed. Meta-analyses with subgroup analysis were performed.

RESULTS

In total, 91 studies were included, comprising 8218 patients undergoing 9043 sialendoscopic procedures. The majority of studies had a medium or high risk of bias. The incidence of sialadenectomy varied from 0% to 14%. No major complications were reported. Meta-analysis revealed a weighted pooled success rate of 80.9%. Subgroup analyses showed the weighted pooled success rate in patients with sialoliths (89.6%), stenoses (56.3%), submandibular glands (88.3%), parotid glands (81.2%), patients treated by an endoscopic-assisted transoral removal of a sialolith (86.3%), patients treated by a combined approach of the parotid gland (78.2%), patients with JRP (67.0%) and with RAIS (45.8%).

CONCLUSION

The success rate of sialendoscopy did not considerably change in the last 9 years. Sialendoscopy is an efficient and safe procedure for the treatment of major salivary gland obstructive disease.

Exploring the potential of Chat-GPT as a supportive tool for sialendoscopy clinical decision making and patient information support

INTRODUCTION

Sialendoscopy has emerged in the last decades as a groundbreaking technique, offering a minimally invasive approach for exploring and managing salivary gland disorders. More recently, the advent of chatbots, powered by advanced natural processing language and artificial intelligence algorithms, has revolutionized the way healthcare professionals and patients access and analyze medical information and potentially will support soon the clinical decision-making process.

MATERIALS AND METHODS

A prospective, cross-sectional study was designed to assess the level of agreement between Chat-GPT and 10 expert sialendoscopists aiming the capabilities of Chat-GPT to further improve the management of salivary gland disorders.

RESULTS

The mean level of agreement was 3.4 (SD: 0.69; Min: 2, Max: 4) for Chat-GPT's answers while it was 4.1 (SD: 0.56; Min: 3, Max: 5) for the group of EESS (p < 0.015). The overall Wilcoxon signed-rank test yielded a significance level of p < 0.026 when comparing the level of agreement between Chat-GPT and EESS. The mean number of therapeutic alternatives suggested by Chat-GPT was 3.33 (SD: 1.2; Min: 2, Max: 5), while it was 2.6 (SD: 0.51; Min: 2, Max: 3) for the group of EESS; p = 0.286 (95% CI - 0.385 to 1.320).

CONCLUSION

Chat-GPT represents a promising tool in the clinical decision-making process within the salivary gland clinic, particularly for patients who are candidates for sialendoscopy treatment. Additionally, it serves as a valuable source of information for patients. However, further development is necessary to enhance the reliability of these tools and ensure their safety and optimal use in the clinical setting.

Sialendoscopy for treatment of major salivary glands diseases: a comprehensive analysis of published systematic reviews and meta-analyses

OBJECTIVES

Sialendoscopy is a minimally invasive procedure used to diagnose and treat obstructive salivary gland diseases. Previous studies in the topic have shown mixed results. The present study aimed to evaluate the efficacy and safety of sialendoscopy through previous systematic reviews for different outcomes of several diseases. We also aimed to assess studies' methodological quality and heterogeneity.

METHODS

We conducted a comprehensive systematic literature search of Pubmed, Embase, Lilacs and Cochrane Library. We included systematic reviews and meta-analyses that used sialendoscopy to treat both lithiasic and alithiasic salivary glands diseases. Data extraction included studies' characteristics and results. We assessed studies' methodological quality using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews 2) tool.

RESULTS

13 studies were included in the review, being 9 in adult populations and 4 in pediatric populations. Sialendoscopy proved to be effective at the treatment of different lithiasic and other obstructive diseases, but with important heterogeneity. The technique was also considered highly safe in most studies. However, studies had a critically low quality of evidence.

CONCLUSIONS

Most studies demonstrated high efficacy and safety of sialendoscopy, but with critically low quality of evidence. We still lack randomized studies in this field, and future systematic reviews on the topic should follow current guidelines to improve conduction and reporting.

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.

Surgical navigation in parotid sialolith extraction

Posterior parotid lithiasis may in some cases require a combined surgical approach associating sialendoscopy to an external intraoral or transfacial approach. This single-center retrospective study describes the surgical technique for parotid lithiasis extraction by a combined external and sialendoscopic approach with the help of CT-navigation. Five patients were included between November 2014 and July 2020. The sialolith was extracted in 100% of cases. Navigation and transillumination localizations matched consistently. No patients showed postoperative facial paresis. At 2 to 21 months' follow-up, there was no recurrence of sialolithiasis. Navigation can be a complement to transillumination, improving surgical comfort and safety, but does not replace first-line sialendoscopy. Visual control is required whenever possible after extraction. In combined procedures, it enables accurate identification of parotid sialoliths. In case of impassable stenosis, it could be a therapeutic alternative to parotidectomy.

Sialendoscopy-assisted combined approach for parotid sialolithotomy: Our long-term experience

OBJECTIVES

To assess the long-term outcome of sialendoscopy-assisted combined approach for parotid sialolithotomy with gland preservation.

PATIENTS AND METHODS

A retrospective study of patients treated with a combined sialendoscopic and open approach was conducted between 2011 and 2020. Demographic data of patients such as operative technique, stone size, stone location, complications, and symptom relief were collected. Patients were followed up via clinical examination and questionnaires.

RESULTS

Seventy-four patients were included and underwent endoscopy-assisted combined operations for the removal of 98 parotid stones. Of the 98 stones, 92(94%) stones were completely removed and 6(6%) were partially removed. At a mean follow-up of 47.1 ± 35 months, 65 of 74 patients (88%) achieved long-term success. Patients with stone incomplete removal were significantly more often to develop the recurrence of obstructive symptoms (p = 0.000) There were no cases of facial nerve injury or fistula formation. Gland function was preserved in 73 of 74 patients (99%).

CONCLUSIONS

The combined approach for parotid stones is a safe and gland-preserving alternative to parotidectomy. The techniques described here show high success rates and good long-term results, and they avoided the need for gland resection in >95% of cases.

Combined sialendoscopic/mini-preauricular microscopic approach for large proximal parotid sialolithiasis

OBJECTIVE

To describe and evaluate a combined approach for sialendoscopic stone localization with microscopic mini-preauricular incision external stone extraction as a gland-sparing minimally invasive surgical management in cases of large proximal duct or intraparenchymal parotid gland sialolithiasis.

METHODS

A retrospective chart review of a single primary surgeon's patient series of 21 cases operated in a 5-year period in a tertiary care university and private practice hospitals.

RESULTS

Study included 16 males and five females, with age range 12-68 years (mean 40.9 ± 14.5). Nineteen out of the 21 patients had their stones completely removed (90.5%), with two not completing the procedure due to inability of intraoperative endoscopic stone visualization. In total 25 stones were extracted with six patients having two stones. Longest diameter of single (or first) stone was 5-16 mm (mean 9.1 ± 2.9) and second was 3-5 mm (mean, 3.9 ± 0.6). Endoscopic findings showed 14/25 stones in the proximal main parotid duct and 11/25 in one of its secondary parenchymal branches. Stents were used in 4/19 cases (21.1%). No major complications occurred. Minor complications included two postoperative conservatively managed seromas. All 19 cases had completely intact facial nerve function, good parotid salivary flow and acceptable esthetic result after median follow-up period of 26 months (range 6-62).

CONCLUSION

The combined sialendoscopic/microscopic mini-preauricular approach is a highly effective and safe gland-preserving method for large proximal parotid sialolithiasis management with a main limitation being inability to visualize the stone endoscopically.

Non-medical interventions for individuals with Rett syndrome: A systematic review

BACKGROUND

Research into Rett syndrome has included various medical interventions. Non-medical interventions are relatively under-researched. Recent technological communication intervention advances have contributed to the evidence base in Rett syndrome.

METHOD

The Embase, PsycINFO and MEDLINE were systematically searched for peer-reviewed papers describing non-medical interventions for Rett syndrome. All identified papers were evaluated for methodological quality.

RESULTS

Thirteen studies of adequate methodological quality were reviewed (across N = 60 participants). Interventions were primarily communication interventions including music, assistive technology, augmentative and alternative communication strategies, attentional training and cognitive rehabilitation training. All studies reported positive outcomes across communication, quality of life, brain stem activity, physical fitness and a reduction in stereotyped behaviour. However, methodological challenges to generalizability, standardization, lack of follow-up and/or small-N samples were common.

CONCLUSIONS

The review highlights the paucity of high-quality research. Future research is needed to build on current research and improve validity and generalizability of interventions.

The First Clinical Use of Augmented Reality to Treat Salivary Stones

In this study, we report our first experience of applying the concretion visualization method using augmented reality technology. A clinical case of a new surgical intervention on the parotid salivary gland with the localization of salivary stone in its parenchyma is considered. During additional diagnostics, it was found that the size of the concretion exceeds 5 mm which did not allow us to use the endoscopic technologies. That was the reason for the choice of surgical intervention external access using salivary stone visualization with the help of augmented reality. The preoperative procedures included making the upper jaw cast model, fitting the model and individual mouthguard with an X-ray contrast marker and marker slot. In addition to this, computed tomography of the head and neck using a mouthguard was made. During surgery under general anesthesia with nasal intubation, the mouthguard together with the marker is installed in the patient's mouth and the surgeon puts on the glasses to visualize the stone image in place of its localization. This method enables to visualize the salivary stone on all surgery stages no matter what type of approach is used or performing hydropreparation. That is why using the augmented reality appears promising and is to be studied further.

[Augmented reality in the treatment of sialolithiasis]

In a clinical case we report on the primary application of modern methods of visualization using augmented reality in the treatment of patients with sialolithiasis for the localization of salivary stone in the parenchyma of the parotid salivary gland. Impression was taken and individual splint with radiopaque marker and a cutout for a probe was made. The splint was used for spiral CT of the head and neck. In surgical intervention under endotracheal anesthesia with intubation through the nose, the splint was placed in the mouth with a tap and a surgeon visualized the projection of the stone on the skin using glasses. The method allows to visualize salivary stone at all stages of surgery, regardless of the type of access or hydrotreatment. However, this technique does not make it possible to estimate the depth of the stone, as well as if the salivary stone is not fixed in the duct there is a risk of changing its position. In this regard, the use of augmented reality has a promising direction and requires further research.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

Laser-Assisted Lithotripsy With Sialendoscopy: Systematic Review of YO-IFOS Head and Neck Study Group

INTRODUCTION

Sialolithiasis is the most common cause of symptomatic obstructive sialadenitis. Sialendoscopy represent a minimally invasive technique that has evolved significantly in the last 2 decades, with high success rates in managing sialolithiasis and allowing gland preservation. Lithotripsy assisted or not by laser represents the fragmentation of stone or lithiasis within the salivary duct followed immediately by removal of the fragmented pieces. Material and Methods: A systematic review investigating the role of laser-assisted lithotripsy with sialendoscopy (LAS) in the treatment of sialolithiasis was performed.

RESULTS

Sixteen papers meet inclusion criteria. The mean maximum diameter of lithiasis was 7.11 mm (min: 2 mm/max: 17 mm; standard deviation [SD]: 2.33; 95% CI = 1.573-4.463). Success rate described ranging from 71% to 100% with a mean of 87.3% (SD: 7.21; 95% CI: 5.326-11.158) and the gland preservation rate was 97%. Considering only "non retrievable-non floating stones" studies that include both parotid and submandibular stones: Eight clinical retrospectives, nonrandomized studies and 1 prospective, nonrandomized study report results from parotid and submandibular gland lithiasis. According to this, the most common gland involved was the submandibular gland (n = 153; 65.1%), in comparison to the parotid gland (n = 82; 34.8%).

CONCLUSION

The current evidence supports LAS as a conservative, efficient, safe, and gland-preserving alternative technique, in experienced hands, for management of mid-size sialolith removal from major salivary glands, when the indication is appropriate.

A Pilot Study to Assess the Sialendoscopy-Assisted Transfacial Approach in Parotid Gland Sialolithiasis

INTRODUCTION

Twenty percent of the total lithiasis that affect a major salivary gland will be found in the parotid gland. An exclusive sialoendoscopic approach has achieved success rates close to 80%. In a significant percentage of these remaining cases, combined transfacial approaches assisted by sialendoscopy are presented as an option to be taken into account.

PATIENTS AND METHODS

A prospective analysis of cases treated by combined transfacial approach assisted by sialendoscopy for lithiasis of the parotid gland and the impact of the facial nerve stimulator used during surgery.

RESULTS

Five patients were included; all of them operated satisfactorily. In 4 of them, the approach proposed by McGurk and modified by Capaccio was used, and in 1 of them, the approach proposed by Nahlieli was used. We suffered a complication in just case due to the appearance of postoperative sialocele.

CONCLUSION

According to our results and those previously published, the transfacial approach assisted by sialendoscopy can be considered a useful technique. Proper planning ensures an optimal result in the treatment of parotid gland lithiasis. The use of facial nerve stimulator guarantees extra security when working near to a branch of the facial nerve is suspected.