Sialendoscopy increases saliva secretion and reduces xerostomia up to 60 weeks in Sjögren's syndrome patients: a randomized controlled study

Connecting salivary gland inflammation to specific symptoms in Sjögren's disease

INTRODUCTION

The complex nature of Sjögren's Disease (SjD) necessitates a comprehensive and patient-centered approach in both diagnosis and management. This narrative review emphasizes the need for a holistic understanding of the connection between salivary gland inflammation and oral symptoms in SjD.

AREAS COVERED

The intricate relationship between salivary gland inflammation and dry mouth is explored, highlighting the variability in associations reported in studies. The association of the severity of xerostomia and degree of inflammation is also discussed. The frequent presence of recurrent sialadenitis in SjD further accentuates the connection of compromised salivary gland function and inflammation. The review additionally discusses local inflammatory factors assessed through salivary gland biopsies, which could potentially serve as predictors for lymphoma development in SjD. Insights into compromised quality of life and hypercoagulable state and their association with salivary gland inflammations are provided. Advancements in noninvasive imaging techniques, particularly salivary gland ultrasonography and color Doppler ultrasound, offer promising avenues for noninvasive assessment of inflammation.

EXPERT OPINION

There is a need for longitudinal studies to unravel the connections between salivary gland inflammation and oral symptoms. This will enhance management strategies and optimize treatment outcomes for SjD patients.

The minimally important difference for the Xerostomia Inventory among Sjögren's disease patients

OBJECTIVE

Until now, the clinically relevant improvement for the Xerostomia Inventory (XI) has not been defined. Therefore, our aim was to determine the Minimally Important Difference (MID) of the XI for improvement in dry-mouth symptoms in SjD patients.

METHOD

The study recruited 34 SjD patients who underwent sialendoscopy of major salivary glands and 15 SjD patients in a nonintervention control group. XI scores were assessed at several time points. The MID was determined from the mean difference in XI scores between the groups with and without improvement.

RESULTS

In the control group, no significant XI score changes were seen. In the sialendoscopy group, a clinically relevant XI score change of four scale points was identified after 1 week. For a prolonged duration (≥16 weeks), a minimum reduction of seven scale points in the XI score was required to indicate clinically relevant improvement.

CONCLUSION

In SjD patients, a minimum change of four points in the XI score indicates a clinically relevant improvement for evaluating short-term effects. For prolonged effects, a clinically relevant improvement requires a MID of seven points. The determination of the MID in XI could assist in future studies that evaluate changes in xerostomia.

Efficacy of Office-Based Salivary Ductal Steroid Irrigation for Managing Post-Irradiation Xerostomia in Head and Neck Cancer Patients: A Retrospective Study

Post-irradiation xerostomia remains a significant quality of life concern for patients with head and neck cancers. Conventional therapies offer limited effectiveness. This study aims to investigate the therapeutic potential of office-based salivary ductal steroid irrigation in patients with post-irradiation xerostomia. This single-center observational study recruited 147 head and neck cancer patients suffering from post-irradiation xerostomia between November 2020 and October 2022. All included subjects received at least one round of successful salivary ductal cannulation and irrigation. The primary measure of efficacy was improvement in subjective xerostomia and objective salivary amylase levels. A logistic regression was employed to evaluate factors affecting treatment responsiveness. The response rate among nasopharyngeal cancer (NPC) patients was 74.8%, and that among non-NPC cancer was 65.6%, without significant intergroup differences. The statistical analysis revealed no significant influence of age, gender, or disease stage on treatment responsiveness. Post-treatment salivary amylase levels were significantly higher in responsive non-NPC patients. In conclusion, salivary ductal steroid irrigation emerged as a promising therapeutic modality for the management of post-irradiation xerostomia in head and neck cancer patients. While no explicit factors were predictive of responsiveness, the high rate of symptom improvement suggests that this therapy may be a viable alternative for patients that are refractory to standard treatments.

Integrated therapy of intraductal irrigations and sialoendoscopies of salivary glands to improve mouth dryness

OBJECTIVE

To assess the combination of salivary gland intraductal irrigations (IG) followed by sialoendoscopy irrigations (SI) of the parotid gland on the improvement of salivary gland secretory dysfunction (SGSD).

METHODS

We retrospectively analyzed the records of SGSD patients who underwent major salivary gland IG followed by SI during 2014-2020. Records included demographics, systemic background, signs, and symptoms. Improvement was assessed by comparing the mean unstimulated and stimulated whole salivary flow rate (UWSF, SWSF) from the baseline point (before IG procedure) to the last point (after SI) using repeated measures. The between-subjects effects of various factors and covariants were analyzed using repeated measures ANCOVA.

RESULTS

One hundred patients were included with an age range of 15-83 years (mean age of 60.1 ± 13.1 years). Improvement was detected on UWSF measurements (p = 0.031, F = 3.83), but not on SWSF measurements (p = 0.165, F = 1.85). The between-subjects effects on UWSF measurements were statistically significant for sex (p = 0.003, F = 9.526) and salivary gland manipulators use (p < 0.001, F = 15.107) and for the interaction between sex and salivary gland manipulators use (p- = 0.002, F = 9.709). Results of long-term follow-up for 10.87 ± 11.79 months after the SI procedure demonstrated sustained improvement in UWSF measurements (p = 0.011, F = 4.91).

CONCLUSIONS

The combination of IG followed by SI increases UWSF salivary secretion in SGSD patients for a relatively extended duration.

Carbon quantum dots as immune modulatory therapy in a Sjögren's syndrome mouse model

OBJECTIVES

The objective of the study was to evaluate the therapeutic effects of carbon quantum dots (CQDs) in immunomodulation on non-obese diabetic (NOD) mice, as the model for Sjögren's syndrome (SS).

METHODS

Carbon quantum dots were generated from Setaria viridis via a hydrothermal process. Their toxic effects were tested by cell viability and blood chemistry analysis, meanwhile therapeutic effects were investigated in NOD mice in the aspects of saliva flow, histology, and immune cell distribution.

RESULTS

Carbon quantum dots, with rich surface chemistry and unique optical properties, showed non-cytotoxicity in vitro or no damage in vivo. Intravenously applied CQDs alleviated inflammation in the submandibular glands in NOD mice after 6-week treatments. The inflammatory area index and focus score were significantly decreased in CQD-treated mice. Besides, the levels of anti-SSA and anti-SSB were decreased in the presence of CQDs. The stimulated saliva flow rates and weight of submandibular glands were significantly increased in CQD-treated mice by reducing the apoptosis of cells. The CD3+ and CD4+ T cells distributed around the ducts of submandibular glands were significantly decreased, while the percentage of Foxp3+ cells was higher in CQD-treated mice than that in the control group.

CONCLUSIONS

Our findings suggest that CQDs may ameliorate the dysregulated immune processes in NOD mice.

Long-term efficacy of sialendoscopy in treating childhood Sjögren's disease with chronological monitoring by salivary gland ultrasonography: A novel approach

BACKGROUND

Childhood Sjögren's Disease (cSjD) is an underdiagnosed phenomenon with clinical and pathophysiological nuances in contrast to Sjögren's Disease (SjD) in the adult population. While adults typically experience sicca symptoms, children with cSjD often present with recurrent parotitis, diverse autoantibody profiles, and renal and neurological manifestations. Diagnosis and classification in pediatric rheumatology remain controversial due to the reliance on adult-focused diagnostic criteria and the lack of standardized treatment and understanding of outcomes. The purpose of the paper is to propose a multimodal treatment plan and demonstrate the effectiveness of sialendoscopy in the management of cSjD.

CASE PRESENTATION

We present the case of a twelve-year-old female diagnosed with cSjD using the 2016 American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) diagnostic criteria for SjD. In addition to medical management, she underwent sialendoscopy with triamcinolone irrigation under sedation and was monitored for progress via salivary gland ultrasonography (SGUS). Over the course of one year, she demonstrated significant improvement in symptoms, with serial SGUS scores gradually decreasing by five points.

CONCLUSIONS

This paper proposes a multimodal treatment plan involving sialendoscopy and medical management as a non-invasive and potentially more effective approach for cSjD. Standardized monitoring through SGUS scoring allows objective and quantifiable measurement of treatment progress, enabling better assessment of glandular tissue status. Recurrence is possible, and each cSjD patient may present differently. Nevertheless, our year-long observation of a patient with cSjD demonstrates that sialendoscopy, as seen in adults, can promote remission of recurrent parotitis in children as well.

Outline of Salivary Gland Pathogenesis of Sjögren's Syndrome and Current Therapeutic Approaches

Sjögren's syndrome (SS) is an autoimmune disease characterized by the involvement of exocrine glands such as the salivary and lacrimal glands. The minor salivary glands, from which tissue samples may be obtained, are important for the diagnosis, evaluation of therapeutic efficacy, and genetic analyses of SS. In the onset of SS, autoantigens derived from the salivary glands are recognized by antigen-presenting dendritic cells, leading to the activation of T and B cells, cytokine production, autoantibody production by plasma cells, the formation of ectopic germinal centers, and the destruction of salivary gland epithelial cells. A recent therapeutic approach with immune checkpoint inhibitors for malignant tumors enhances the anti-tumor activity of cytotoxic effector T cells, but also induces SS-like autoimmune disease as an adverse event. In the treatment of xerostomia, muscarinic agonists and salivary gland duct cleansing procedure, as well as sialendoscopy, are expected to ameliorate symptoms. Clinical trials on biological therapy to attenuate the hyperresponsiveness of B cells in SS patients with systemic organ involvement have progressed. The efficacy of treatment with mesenchymal stem cells and chimeric antigen receptor T cells for SS has also been investigated. In this review, we will provide an overview of the pathogenesis of salivary gland lesions and recent trends in therapeutic approaches for SS.

Intraoperative Visualization and Treatment of Salivary Gland Dysfunction in Sjögren's Syndrome Patients Using Contrast-Enhanced Ultrasound Sialendoscopy (CEUSS)

In sialendoscopy, ducts are dilated and the salivary glands are irrigated with saline. Contrast-enhanced ultrasound sialendoscopy (CEUSS), using microbubbles, may facilitate the monitoring of irrigation solution penetration in the ductal system and parenchyma. It is imperative to test CEUSS for its safety and feasibility in Sjögren's syndrome (SS) patients. CEUSS was performed on 10 SS patients. The primary outcomes were safety, determined by the occurrence of (serious) adverse events ((S)AEs), and feasibility. The secondary outcomes were unstimulated and stimulated whole saliva (UWS and SWS) flow rates, xerostomia inventory (XI), clinical oral dryness score, pain, EULAR Sjögren's syndrome patient reported index (ESSPRI), and gland topographical alterations. CEUSS was technically feasible in all patients. Neither SAEs nor systemic reactions related to the procedure were observed. The main AEs were postoperative pain (two patients) and swelling (two patients). Eight weeks after CEUSS, the median UWS and SWS flow had increased significantly from 0.10 to 0.22 mL/min (p = 0.028) and 0.41 to 0.61 mL/min (p = 0.047), respectively. Sixteen weeks after CEUSS, the mean XI was reduced from 45.2 to 34.2 (p = 0.02). We conclude that CEUSS is a safe and feasible treatment for SS patients. It has the potential to increase salivary secretion and reduce xerostomia, but this needs further investigation.

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.

Management of Chronic Sialadenitis due to Sjogren's Syndrome and Radioactive Iodine Therapy Using Sialendoscopy

INTRODUCTION

Sialendoscopy is a minimally invasive technique for the management of salivary gland disease. This work characterizes its utility for treating chronic sialadenitis due to Sjogren's syndrome and radioactive iodine (RAI) therapy.

METHODS

A single-center, retrospective review of patients undergoing sialendoscopy between March 2013 and May 2019 for the treatment of chronic sialadenitis due to Sjogren's or prior RAI therapy was performed.

RESULTS

Thirty-four patients with Sjogren's and 25 patients who received RAI were identified, undergoing a total of 86 procedures. Median age at presentation was 53 years with mean follow-up time of 14.3 months. Seventy-two procedures were performed on the parotid gland, four on the submandibular gland, and ten on both glands. Corticosteroid injection and duct dilation were performed most commonly. Sixteen patients required repeat procedure. All patients were symptomatically improved at follow-up visit.

DISCUSSION/CONCLUSION

These results support the idea that sialendoscopy offers symptomatic benefit for patients with chronic sialadenitis due to Sjogren's or RAI.

A randomized controlled trial to verify the irrigation of salivary glands in relieving xerostomia in patients with Sjögren's syndrome

OBJECTIVE

To verify the effect of triamcinolone acetonide (TA) and major salivary glands saline irrigation on relieving xerostomia in Sjögren's syndrome (SS) patients.

METHODS

The enrolled 49 SS patients were randomly assigned to the control group (no irrigation, n=16), saline group (irrigation with saline, n=17) and TA group (irrigation with TA, n=16). Fourteen cases of each group were treated differently but received the same examinations. The examinations include unstimulated whole saliva flow (UWS), chewing-stimulated whole saliva flow (SWS), citric acid-stimulated parotid flow (SPF), Clinical Oral Dryness Score (CODS), Xerostomia Inventory (XI) and EULAR SS Patient Reported Index (ESSPRI) of 1 week before irrigation (T0) and 1 week(T1), 8 weeks (T8), 16 weeks (T16) and 24 weeks (T24) after major salivary irrigation.

RESULTS

Each group had 14 cases with completed follow-ups. Both TA and saline irrigation of major salivary glands resulted in higher SWS and SPF of T8, T16 and than those at T0. ESSPRI (oral dryness domain) of T8, T16 and T24 were significantly lower than that at T0, respectively (P < 0.05). SWS and SPF of T8, T16 and T24 in the saline group were significantly higher than in the control group (P< 0.05). XI and ESSPRI (oral dress domain) of T8, T16 and T24 in the saline group were significantly lower than those in the control group, respectively (P< 0.05). SWS and SPF of T16 and T24 in the TA group were significantly higher than in the control group (P< 0.05). All cases with completed follow-up in TA and saline groups were divided into responders and non-responders. Compared with responders, the UWS, SWS, SPF and CODS of T0 in non-responders were significantly increased (P<0.05). Compared with responders, the XI and ESSPRI of T0 in non-responders were significantly decreased (P<0.05).

CONCLUSION

The irrigation of major salivary glands by TA and saline relieve xerostomia in SS patients. Patients with non-severe xerostomia (responders) have better relief after irrigation than patients with severe xerostomia (non-responders).

CLINICAL TRIAL REGISTRATION

www.chictr.org.cn, identifier (ChiCTR210052314).

Therapeutic effects of sialendoscopy for diagnosis and treatment of hyposalivation patients: a retrospective study

Background

Hyposalivation is disease with multiple symptoms. This disease is hard to be diagnosed and to be treated, and there are not enough clinical protocols to cure the disease. In this study, we propose our own treatment protocols which aim not only to cure the disease but also to care for the disease-related symptoms.

Methods

At the 1st visit, we collect patient-related information. This procedure includes an intraoral exam, patient history taking, VAS value and unstimulated whole saliva (UWS) measurement, and salivary buffer test. Following the interview and oral examination, objective results are obtained by radiological image, CT, and sialoscintigraphy. At the 2nd visit, we analyze radiographic images including neck CT and salivary scintigraphy. These images can allow accurate diagnosis and help the patients to better understand the current condition. Depending on the severity of symptoms and patient’s discomfort, we try a surgical approach at the 3rd visit, sialendoscopy.

Results

With treatment, we can manage the discomfort of patients in daily life. The VAS value of hyposalivation patients dropped gradually with the trial of sialendoscopy. In the case of Sjogren’s syndrome patients, the treatment efficacy has been decreased with low reactivity of treatment. The true meaning of this treatment is in not only curing the disease, but also caring for the disrupted patients. Overall, the amount of UWS increased with the progress after the procedure. Especially in the lower UWS at the 1st visit, there was a more significant increase after the procedure.

Conclusion

Although many factors that cause hyposalivation have not been identified, the efficacy of sialendoscopy to relieve discomfort in hyposalivation patients has been observed. However, treatment was more difficult and complicated in the group of patients with systemic disease. This study will not only present a treatment protocol for hyposalivation patients, but also consider methods for diagnosing more precisely and improving treatment efficacy. Hyposalivation is a curable and manageable disease in some cases, so interpretation between the clinician and the patient is important.