Eur Arch Otorhinolaryngol DOI 10.1007/s00405-015-3500-5
HEAD AND NECK
Post-sialendoscopy ductoplasty by salivary duct stent placements Chin-Hui Su • Kuo-Sheng Lee • Te-Ming Tseng Shih-Han Hung
•
Received: 9 December 2014 / Accepted: 3 January 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract With damage to a duct or papilla after sialendoscopy, a stent may be necessary to prevent re-stenosis and for maintaining the salivary duct open after complete sialendoscopy. However factors affecting outcomes and complications after stent placement remain unclear. This study aimed to report preliminary experiences in salivary duct stent placement after sialendoscopy. Data from 35 procedures in 33 patients who received sialendoscopy with salivary duct stent placements at Mackay Memorial Hospital between October 2013 and June 2014 were recorded and compared for clinical data, as well as procedural techniques, findings, and outcomes. In the 35 stent placement procedures, the hypospadias silastic stent tubes were used in 27 and the Fr. 5 pediatric feeding tubes were used in the remaining eight. When the hypospadias silastic stent tubes were used for stenting, the stent obstruction and irritation rates were higher compared to those who used the Fr. 5 pediatric feeding tube (100 vs. 0 % and 67 vs. 33 %, respectively). None of the stents secured by a 5-0 nylon suture were complicated by dislocation but when the stents were secured by 6-0 nylon sutures, the dislocation rate went as high as 47.4 %. The duration needed for salivary duct stent placement might be potentially shortened to only
C.-H. Su K.-S. Lee Department of Otorhinolaryngology, Mackay Memorial Hospital, New Taipei City, Taiwan C.-H. Su S.-H. Hung Department of Otolaryngology, School of Medicine, Taipei Medical University, Taipei, Taiwan T.-M. Tseng S.-H. Hung (&) Department of Otolaryngology, Taipei Medical University Hospital, No. 252, Wu-Hsing Street, Taipei 110, Taiwan e-mail: [email protected]
2 weeks. If a salivary duct stent is intended to be placed for a certain period before its scheduled removal, a suture strength equivalent or stronger than the 5-0 nylon suture should be considered for stent fixation. Keywords Sialendoscopy Stent Outcome Complication
Introduction Sialendoscopy has become an increasing trend for the treatment and diagnosis of obstructive salivary gland disease [1]. The most common obstructive salivary gland disease is sialolith, while other etiologies include strictures, mucoid plug, and anatomic ductal abnormalities [2]. Mobile stones of size \5 mm, especially those located at the distal duct position, are generally considered to be removable by simple sialendoscopy without the interference of the original salivary duct structures [3]. In some difficult conditions like in larger stones ([5 mm), a combined sialendoscopic approach that includes ductal incision, may be necessary to remove the stone [4]. Recently, laser surgical technique (especially the Holmium YAG laser) combined sialendoscopy has made it possible to treat large ([1 cm) or multiple sialoliths [5]. In the more invasive procedures, the salivary ducts are unlikely to remain completely intact. During the sialendoscopic procedures, the salivary duct papilla often needs to be dilated with probes to increase the diameter. However, papilla dilation has a 20 % failure rate and papillotomy is sometimes necessary [6]. Limited distal sialodochotomy is usually required when the papilla is tight, making the procedure fairly difficult to perform [7]. Once a duct or papilla is damaged or cut, the risk of
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developing papilla stenosis and secondary iatrogenic obstruction is increased [8]. In such circumstances, a stent may be necessary to prevent re-stenosis and maintain the salivary duct open after complete sialendoscopy. Stent placements may also be helpful in the regeneration of ductal defect(s) and in keeping a wide luminal diameter after the duct wall(s) are primarily closed from incision(s). While these are generally accepted indications for stent placement after sialendoscopy, factors affecting outcomes and complications after stent placement remain unclear [9]. The purpose of this study is to report preliminary experience in salivary duct stent placement after sialendoscopy.
the duct without resistance before the guide wire was removed. Two types of stents were used, including Fr. 5 pediatric feeding tube (O.D. 1.7 mm) and hypospadias silastic stent tube (O.D. 2 mm; I.D. 1.65 mm) (Fig. 1). The duct defect was primary closure by Dexon absorbable sutures. The distal ends of the stent were fixed by 6-0 or 5-0 Nylon sutures. After the stent was in position, methylprednisolone 40 mg diluted with normal saline was instilled into the duct. All of the patients were given prophylactic antibiotics and analgesics for 7 days post-operatively and were followed-up for at least 1 month after the stent was removed. Bacterial culture of the stent was done after removal.
Materials and methods Results The Institutional Review Board of Mackay Memorial Hospital approved the study protocol. Data from 33 patients receiving sialendoscopy for obstructive sialoadenitis in the Department of Otorhinolaryngology between October 2013 and June 2014 were recorded and reviewed. All of the procedures were done under general anesthesia. Thirty-three patients received intra-ductal stent placement after sialendoscopy and all of the procedures were done by the senior author. The data collected included patient details, nature of presentation, and clinical outcome. All of the procedures were done using the Miniature Straight Forward Telescope with a direct view at 0° (All in one Karl StorzÒ, Germany). The semi-rigid scope had a working length of 12 cm and an outer diameter of 1.3 mm (model 11575A). A 0.65 mm working channel and an irrigation channel of diameter 0.25 mm were further attached. Another interventional set used was a Miniature Straight Forward Telescope with a direct view at 0° (Interventional Karl StorzÒ, Germany), with a semi-rigid scope with a working length of 16 cm and an outer diameter of 1 mm (model 11577KE). An operation sheath with a 1.15 mm working channel and a telescope channel of same diameter were further attached. Laser lithotripsy was done by Holmium:YAG laser generated through the VersaPulseÒ PowerSuiteTM system (LumenisÒ, Israel) and used during sialendoscopy to achieve stone fragmentations. The Holmium:YAG laser was used with a power of 6 W, rate of 10 Hz, and energy delivery of 0.6 J. Stent placements were done after complete removal of the obstructive lesion by sialendoscopy. The length was measured by scope from the papilla to the 1st bifurcation, and the stent length was 0.5–1 cm longer than the length of the main duct (papilla-1st bifurcation). The guide wire was placed via the working channel to confirm the intra-ductal position. After proper dilatation, the stent was placed into
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Thirty-five stenting procedures were performed after sialendoscopy in 33 patients (23 female, 10 male) with symptoms of obstructive sialoadenitis (Table 1). The initial diagnosis for sialendoscopy included sialolithiasis (23 patients), sialoadenitis (7), sialoectasis (1), ductal stenosis (1), and mucocoele (1). The inserted salivary ducts were 18 left Wharton’s duct, 11 right Wharton’s duct, 4 left Stenson’s duct, and 2 right Stenson’s duct. Of the 35 stent placement procedures, 27 used the hypospadias silastic stent tubes and 8 used the Fr. 5 pediatric feeding tubes. The duration of stent placement ranged from 4 to 21 days. Seventeen stents were scheduled for removal after an average duration of 13.9 days. Three stents was removed because of blocked tube after an average duration of 8 days. Five patients complained strongly of stent irritation and had early removal after an average duration of 9.4 days. Nine cases had accidental stent dislocation and were removed after an average duration of 7.4 days. Overall, the duration for the non-
Fig. 1 Two types of stents. Above is the Fr. 5 pediatric feeding tube (tail is cut to fit the photo) and below is the hypospadias silastic stent tube (O.D. 2 mm; I.D. 1.65 mm)
Eur Arch Otorhinolaryngol Table 1 Patient data Patient
Sex
Age
Diagnosis
Inserted duct
Indication for stent placement
Stent type
Duration
Fixed suture
Symptom remission
1
M
47
Stone 4 mm
R’t Wharton’s
Combined approach
5 Fr
8 days dislocated
6-0 nylon
?
2
F
20
Stone 3 mm
L’t Wharton’s
Combined approach
Hypo
8 days dislocated
6-0 nylon
?
3
F
25
Stone 1 mm
R’t Wharton’s
Retro-papillar incision
Hypo
6-0 nylon
?
4
M
25
Stone 3 mm
R’t Wharton’s
Combined approach
Hypo
8 days removed due to blockage 8 days removed due to blockage
6-0 nylon
?
5
M
16
Stone 5 mm
R’t Wharton’s
Combined approach
Hypo
10 days dislocated
6-0 nylon
?
6
F
21
Stone 3 mm
R’t Wharton’s
LASER
Hypo
5 days dislocated
6-0 nylon
?
7
M
38
Stone 8 mm
L’t Wharton’s
LASER
Hypo
11 days scheduled removed
6-0 nylon
?
8
M
38
Stenosis
L’t Stenson’s
LASER
5 Fr
8 days removed due to irritation
5-0 nylon
?
9
M
42
Stone 9, 13, 5 mm
L’t Wharton’s
LASER
Hypo
12 days dislocated
6-0 nylon
?
10
F
29
Stone 3 mm
L’t Stenson’s
Retro-papillar incision
5 Fr
21 days scheduled removed
5-0 nylon
?
11
F
38
Mucocele
L’t Wharton’s
Mucocele dissection
5 Fr
12 days scheduled removed
6-0 nylon
?
12
F
50
Stone 1.75 cm
L’t Wharton’s
Combined approach
Hypo
14 days scheduled removed
5-0 nylon
?
13
F
56
Sialoectasis
Bil Wharton’s
Decompression
Hypo
14 days scheduled removed
6-0 nylon
Persisted
14
F
33
Stone 4, 6, 1 mm
R’t Wharton’s
LASER
Hypo
4 days dislocated
6-0 nylon
Persisted
15
F
68
Sialoadenitis
L’t Stenson’s
Dilation
5 Fr
7 days removed due to irritation
5-0 nylon
Persisted
16
F
52
Sialoadenitis
Bil Stenson’s
Dilation
Hypo
8 days removed due to irritation
5-0 nylon
Persisted
17
F
52
Stone 1 cm 6, 2 mm
R’t Wharton’s
Combined approach
Hypo
6 days dislocated
6-0 nylon
?
18
F
14
Stone 6, 5 mm
L’t Wharton’s
Retro-papillar incision
5 Fr
10 days scheduled removed
6-0 nylon
?
19
F
47
Sialoadenitis
L’t Wharton’s
Dilation
Hypo
8 days removed due to blockage
6-0 nylon
Persisted
20
F
47
Sialoadenitis
R’t Stenson’s
Dilation
Hypo
14 days schedule removed
6-0 nylon
?
21
F
21
Stone 6 mm, 1 cm, 1 mm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
5-0 nylon
?
22 23
F M
41 11
Stone 5 mm Sialoadenitis
L’t Wharton’s L’t Wharton’s
Combined approach Dilation
Hypo Hypo
7 days dislocated 14 days schedule removed
6-0 nylon 5-0 nylon
? ?
24
F
22
Stone 2 mm
L’t Wharton’s
Combined approach
Hypo
12 days scheduled removed
5-0 nylon
?
25
M
36
Stone 6 mm
R’t Wharton’s
Combined approach
Hypo
5-0 nylon
?
26
F
37
Stone 1 mm
R’t Wharton’s
Retro-papillar incision
Fr 5
19 days scheduled removed 12 days scheduled removed
5-0 nylon
?
27
F
49
Sialoadenitis
L’t Wharton’s
Dilation
Hypo
12 days removed due to irritation
5-0 nylon
Persisted
28
F
49
Sialoadenitis
R’t Wharton’s
Dilation
Hypo
12 days removed due to irritation
5-0 nylon
Persisted
29
F
23
Stone 3.5 mm
L’t Wharton’s
LASER
Hypo
7 days dislocated
6-0 nylon
?
30
M
17
Stone 3 mm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
6-0 nylon
?
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Eur Arch Otorhinolaryngol Table 1 continued Patient
Sex
Age
Diagnosis
Inserted duct
Indication for stent placement
Stent type
Duration
Fixed suture
Symptom remission
31
F
63
Stone 1.2 cm
L’t Wharton’s
Combined approach
5 Fr
14 days scheduled removed
5-0 nylon
?
32
F
47
Stone 3 mm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
5-0 nylon
?
33
M
30
Stone 1.3 cm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
5-0 nylon
?
5 Fr Fr. 5 pediatric feeding tube, Hypo Hypospadias silastic stent tube
scheduled stent removal was 8.1 ± 2.2 days, significantly shorter than the scheduled removal duration (13.9 ± 2.6, p \ 0.001, t test) (Fig. 2). Comparing stent-specific complications, when the hypospadias silastic stent tubes were used, the stent obstruction and irritation rates were higher than when using the Fr. 5 pediatric feeding tube (100 vs. 0 %; 67 vs. 33 %, respectively) (Fig. 3). None of the stents secured by 5-0 nylon suture were complicated by dislocation but when the stents were secured by 6-0 nylon sutures, the dislocation rate was as high as 47.4 % (Table 2). Table 3 shows the comparison for stent placement duration according to different type of stent used. While we were not able to perform statistical analysis due to limited case numbers, our result showed limited differences in stent placement durations between the two stents used in our study. All the stents were sent for bacterial culture after removal and the results all showed mixed respiratory microbes without remarkable findings.
Fig. 2 The duration for the non-scheduled removal of the stent was 8.1 ± 2.2 days, significantly shorter than that for the scheduled removal (13.9 ± 2.6, p \ 0.001, t test)
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Discussion This study demonstrates that selecting different stents after sialendoscopy contributes to different risks in developing complications. To ensure a secured fixation of the stent, using sutures with equivalent strength or stronger than the 5-0 nylon may be a reasonable choice. After sialendoscopy, a stent may be necessary to prevent re-stenosis and to maintain the salivary duct open. Although there are no clear guidelines for stent insertion, it is generally agreed that stenting is necessary after stricture dilation or if significant ductal trauma is encountered during stone removal [10]. In practice, stent placement after sialendoscopy is routinely performed for conditions like combined external approach to remove a large stone after ductal wall incision; obvious thermal injury to the ductal wall after laser lithotripsy; dilation of tight papilla or ductal stenosis; and retro-pillar ductal incision required for difficult papilla route. In the future, the indications for stent placement will be further expanded as it may be used not to only prevent salivary duct strictures but also to treat problems like sialectasis, a condition for which a marsupialization procedure is often required [11]. While there seems to be an increasing consensus in determining when to place a stent after sialendoscopy, the question is how long it should be kept. Many researchers report that the duration of the stent placement is usually 2–8 weeks [9, 10, 12]. Pagliuca et al. [13] report that even without ductal repair suture after removal of large stones, there are no complication when the salivary duct stents are removed after 3 weeks. In this series, the duration of stent placement ranged from 4 to 21 days. While the original intent was to remove the stent after 2 weeks, complications such as stent irritation or dislocation resulted in the early removal of the stent in 18 procedures, with a mean duration of only 8.1 days. Interestingly, no complications were found in these procedures despite the unexpectedly short stent placement durations. This finding implies that perhaps the duration needed for salivary duct stent placement may
Eur Arch Otorhinolaryngol Fig. 3 When the hypospadias silastic stent tubes were used for stenting, the stent obstruction and irritation rates were higher than those when using the Fr. 5 pediatric feeding tube (100 vs. 0 % and 67 vs. 33 %, respectively)
Table 2 Comparison for stent dislocations according to different sutures materials used 5-0 Nylon
6-0 Nylon
Total
16
19
Dislocation
0
9
Dislocation rate
0.0 %
47.4 %
Table 3 Comparison for stent placement durations according to different types of stents used Suture
5 Fr
Hypo
7.5
10.7
8
7.5
5-0 Nylon Average duration (days) 6-0 Nylon Average duration (days)
d days, 5 Fr Fr. 5 pediatric feeding tube, Hypo hypospadias silastic stent tube
be shortened than as previously expected, with comparable results. Nevertheless, if in any conditions a stent must be held in place until its scheduled removal, it is highly recommended that a suture with equivalent strength to or stronger than 5-0 nylon be used to prevent possible premature dislocations, even if some patients feel irritated by the stiffer 5-0 nylon stitches. Another noteworthy issue is the development of stent obstruction by secondary debris (Fig. 4a). A well-functioning stent appears to be very clear (Fig. 4b). Once the stents are found to be obstructed and filled with debris,
these functionless stents are removed earlier. Kopec et al. [9] report the use of dexamethasone irrigation through the stent and believe that this is useful in the presence of fibrotic remodeling and an inflammatory reaction with epithelial edema in the stenotic area. While post-operative stent irrigation can contribute to a reduced risk of stent obstructions, the hypospadias silastic tube, with its larger lumen diameter, is more likely to develop obstructions than the thinner Fr. 5 pediatric feeding tube. This interesting finding suggests that there is still much to be improved regarding the materials for the salivary duct stents in order to make them thinner and softer to maximally reduce irritability while still maintaining not easily obstructed. Many researchers have reported the results using various types of salivary duct stents with different outcomes. Kopec et al. [9] reported the use of vascular radiologic examination catheter as salivary duct stents. Koch et al. [10] used polyurethane stent with different diameters (Fr. 4.5–6.0) based on the size of the scope used in the procedure. The McMaster University team reported the use of commercially available stents specifically made for sialendoscopy (Polymeric Sialo Drain; Sialo Technology Ltd., Ashkelon, Israel) [12]. More recently, the utilization of resorbable shape-memory starch-based stents for the treatment of salivary ducts under sialendoscopic surgery were reported to be successful in a porcine animal model [14]. While it is too early to conclude which stent outperforms the others, the results of this study may provide valuable information for the evaluation and even future design of salivary duct stents.
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diameter, the hypospadias silastic stent will more likely develop obstructions compared to the Fr. 5 pediatric feeding tube.
Conclusions The duration needed for the salivary duct stent placements may be shortened to only 2 weeks. If a salivary duct stent is intended to be place for a certain period before its scheduled removal, a suture strength equivalent or stronger than the 5-0 nylon suture should be considered for stent fixation. Acknowledgments This study is supported by the Taipei Medical University Hospital Research Fund (TMU103-AE1-B05). Conflict of interest
None.
References
Fig. 4 a An obstructed salivary duct stent of the left Stenson’s duct (arrow). b A functioning salivary duct stent of the left Wharton’s duct (arrow). The lumen was clean, with clear saliva flow
This study has several limitations. First, the case number is relatively low and may not be able to fully demonstrate the true outcome of salivary duct stent placements. Second, the patients enrolled in this study vary in their underlying salivary gland diseases and although the underlying problems seem to have limited impact in the development of stent-specific complications, it will be better if patients can be separated in subgroups according to their different salivary gland problems before analysis. Unfortunately, the case number is limited and insufficient for subgroup analysis. Future studies with larger case numbers should be undertaken. Despite these limitations, the results of this study still provide useful information for otolaryngologist. Based on experience, the duration needed for salivary duct stent placements may be shortened to within 2 weeks there are no long-term complications in the cases of premature stent dislocation. If a salivary duct stent is to be place for a certain period of time before scheduled removal, a suture with equivalent strength to or stronger than the 5-0 nylon suture should be considered for fixation. Even with a larger
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1. Maresh A, Kutler DI, Kacker A (2011) Sialoendoscopy in the diagnosis and management of obstructive sialadenitis. Laryngoscope 121(3):495–500. doi:10.1002/lary.21378 2. Nahlieli O, Baruchin AM (2000) Long-term experience with endoscopic diagnosis and treatment of salivary gland inflammatory diseases. Laryngoscope 110(6):988–993. doi:10.1097/00005537200006000-00020 3. Luers JC, Grosheva M, Stenner M, Beutner D (2011) Sialoendoscopy: prognostic factors for endoscopic removal of salivary stones. Arch Otolaryngol Head Neck Surg 137(4):325–329. doi:10.1001/archoto.2010.238 4. Kopec T, Szyfter W, Wierzbicka M (2013) Sialoendoscopy and combined approach for the management of salivary gland stones. Eur Arch Otorhinolaryngol 270(1):219–223. doi:10.1007/s00405012-2145-x 5. Sun Y-T, Lee K-S, Hung S-H, Su C-H (2014) Sialendoscopy with Holmium:YAG Laser treatment for multiple large sialolithiasis of the Wharton’s duct: a case report and literature review. J Oral Maxillofac Surg 72(12):2491–2496 6. Chossegros C, Guyot L, Richard O, Barki G, Marchal F (2006) A technical improvement in sialendoscopy to enter the salivary ducts. Laryngoscope 116(5):842–844. doi:10.1097/01.mlg.00002 14665.74330.96 7. Chang JL, Eisele DW (2013) Limited distal sialodochotomy to facilitate sialendoscopy of the submandibular duct. Laryngoscope 123(5):1163–1167. doi:10.1002/lary.23801 8. Nahlieli O, Baruchin AM (1997) Sialoendoscopy: three years’ experience as a diagnostic and treatment modality. J Oral Maxillofac Surg 55(9):912–918 (discussion 919–920) (pii: S02782391(97)90056-2) 9. Kopec T, Szyfter W, Wierzbicka M, Nealis J (2013) Stenoses of the salivary ducts-sialendoscopy based diagnosis and treatment. Br J Oral Maxillofac Surg 51(7):e174–e177. doi:10.1016/j.bjoms. 2012.08.004 10. Koch M, Iro H, Klintworth N, Psychogios G, Zenk J (2012) Results of minimally invasive gland-preserving treatment in different types of parotid duct stenosis. Arch Otolaryngol Head Neck Surg 138(9):804–810. doi:10.1001/archoto.2012.1618
Eur Arch Otorhinolaryngol 11. Lohia S, Joshi AS (2013) Idiopathic sialectasis of the Stensen’s duct treated with marsupialisation. BMJ Case Rep. doi:10.1136/ bcr-2013-201548 12. Strychowsky JE, Sommer DD, Gupta MK, Cohen N, Nahlieli O (2012) Sialendoscopy for the management of obstructive salivary gland disease: a systematic review and meta-analysis. Arch Otolaryngol Head Neck Surg 138(6):541–547. doi:10.1001/archoto. 2012.856 13. Pagliuca G, Martellucci S, de Vincentiis M, Greco A, Fusconi M, De Virgilio A, Rosato C, Gallo A (2013) Wharton’s duct repair
after combined sialolithectomy: is ductoplasty necessary? Otolaryngol Head Neck Surg 148(5):775–777. doi:10.1177/01945 99813477839 14. Beilvert A, Faure F, Meddahi-Pelle A, Chaunier L, Guilois S, Chaubet F, Lourdin D, Bizeau A (2014) A resorbable shapememory starch-based stent for the treatment of salivary ducts under sialendoscopic surgery. Laryngoscope 124(4):875–881. doi:10.1002/lary.24380
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HEAD AND NECK
Post-sialendoscopy ductoplasty by salivary duct stent placements Chin-Hui Su • Kuo-Sheng Lee • Te-Ming Tseng Shih-Han Hung
•
Received: 9 December 2014 / Accepted: 3 January 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract With damage to a duct or papilla after sialendoscopy, a stent may be necessary to prevent re-stenosis and for maintaining the salivary duct open after complete sialendoscopy. However factors affecting outcomes and complications after stent placement remain unclear. This study aimed to report preliminary experiences in salivary duct stent placement after sialendoscopy. Data from 35 procedures in 33 patients who received sialendoscopy with salivary duct stent placements at Mackay Memorial Hospital between October 2013 and June 2014 were recorded and compared for clinical data, as well as procedural techniques, findings, and outcomes. In the 35 stent placement procedures, the hypospadias silastic stent tubes were used in 27 and the Fr. 5 pediatric feeding tubes were used in the remaining eight. When the hypospadias silastic stent tubes were used for stenting, the stent obstruction and irritation rates were higher compared to those who used the Fr. 5 pediatric feeding tube (100 vs. 0 % and 67 vs. 33 %, respectively). None of the stents secured by a 5-0 nylon suture were complicated by dislocation but when the stents were secured by 6-0 nylon sutures, the dislocation rate went as high as 47.4 %. The duration needed for salivary duct stent placement might be potentially shortened to only
C.-H. Su K.-S. Lee Department of Otorhinolaryngology, Mackay Memorial Hospital, New Taipei City, Taiwan C.-H. Su S.-H. Hung Department of Otolaryngology, School of Medicine, Taipei Medical University, Taipei, Taiwan T.-M. Tseng S.-H. Hung (&) Department of Otolaryngology, Taipei Medical University Hospital, No. 252, Wu-Hsing Street, Taipei 110, Taiwan e-mail: [email protected]
2 weeks. If a salivary duct stent is intended to be placed for a certain period before its scheduled removal, a suture strength equivalent or stronger than the 5-0 nylon suture should be considered for stent fixation. Keywords Sialendoscopy Stent Outcome Complication
Introduction Sialendoscopy has become an increasing trend for the treatment and diagnosis of obstructive salivary gland disease [1]. The most common obstructive salivary gland disease is sialolith, while other etiologies include strictures, mucoid plug, and anatomic ductal abnormalities [2]. Mobile stones of size \5 mm, especially those located at the distal duct position, are generally considered to be removable by simple sialendoscopy without the interference of the original salivary duct structures [3]. In some difficult conditions like in larger stones ([5 mm), a combined sialendoscopic approach that includes ductal incision, may be necessary to remove the stone [4]. Recently, laser surgical technique (especially the Holmium YAG laser) combined sialendoscopy has made it possible to treat large ([1 cm) or multiple sialoliths [5]. In the more invasive procedures, the salivary ducts are unlikely to remain completely intact. During the sialendoscopic procedures, the salivary duct papilla often needs to be dilated with probes to increase the diameter. However, papilla dilation has a 20 % failure rate and papillotomy is sometimes necessary [6]. Limited distal sialodochotomy is usually required when the papilla is tight, making the procedure fairly difficult to perform [7]. Once a duct or papilla is damaged or cut, the risk of
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developing papilla stenosis and secondary iatrogenic obstruction is increased [8]. In such circumstances, a stent may be necessary to prevent re-stenosis and maintain the salivary duct open after complete sialendoscopy. Stent placements may also be helpful in the regeneration of ductal defect(s) and in keeping a wide luminal diameter after the duct wall(s) are primarily closed from incision(s). While these are generally accepted indications for stent placement after sialendoscopy, factors affecting outcomes and complications after stent placement remain unclear [9]. The purpose of this study is to report preliminary experience in salivary duct stent placement after sialendoscopy.
the duct without resistance before the guide wire was removed. Two types of stents were used, including Fr. 5 pediatric feeding tube (O.D. 1.7 mm) and hypospadias silastic stent tube (O.D. 2 mm; I.D. 1.65 mm) (Fig. 1). The duct defect was primary closure by Dexon absorbable sutures. The distal ends of the stent were fixed by 6-0 or 5-0 Nylon sutures. After the stent was in position, methylprednisolone 40 mg diluted with normal saline was instilled into the duct. All of the patients were given prophylactic antibiotics and analgesics for 7 days post-operatively and were followed-up for at least 1 month after the stent was removed. Bacterial culture of the stent was done after removal.
Materials and methods Results The Institutional Review Board of Mackay Memorial Hospital approved the study protocol. Data from 33 patients receiving sialendoscopy for obstructive sialoadenitis in the Department of Otorhinolaryngology between October 2013 and June 2014 were recorded and reviewed. All of the procedures were done under general anesthesia. Thirty-three patients received intra-ductal stent placement after sialendoscopy and all of the procedures were done by the senior author. The data collected included patient details, nature of presentation, and clinical outcome. All of the procedures were done using the Miniature Straight Forward Telescope with a direct view at 0° (All in one Karl StorzÒ, Germany). The semi-rigid scope had a working length of 12 cm and an outer diameter of 1.3 mm (model 11575A). A 0.65 mm working channel and an irrigation channel of diameter 0.25 mm were further attached. Another interventional set used was a Miniature Straight Forward Telescope with a direct view at 0° (Interventional Karl StorzÒ, Germany), with a semi-rigid scope with a working length of 16 cm and an outer diameter of 1 mm (model 11577KE). An operation sheath with a 1.15 mm working channel and a telescope channel of same diameter were further attached. Laser lithotripsy was done by Holmium:YAG laser generated through the VersaPulseÒ PowerSuiteTM system (LumenisÒ, Israel) and used during sialendoscopy to achieve stone fragmentations. The Holmium:YAG laser was used with a power of 6 W, rate of 10 Hz, and energy delivery of 0.6 J. Stent placements were done after complete removal of the obstructive lesion by sialendoscopy. The length was measured by scope from the papilla to the 1st bifurcation, and the stent length was 0.5–1 cm longer than the length of the main duct (papilla-1st bifurcation). The guide wire was placed via the working channel to confirm the intra-ductal position. After proper dilatation, the stent was placed into
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Thirty-five stenting procedures were performed after sialendoscopy in 33 patients (23 female, 10 male) with symptoms of obstructive sialoadenitis (Table 1). The initial diagnosis for sialendoscopy included sialolithiasis (23 patients), sialoadenitis (7), sialoectasis (1), ductal stenosis (1), and mucocoele (1). The inserted salivary ducts were 18 left Wharton’s duct, 11 right Wharton’s duct, 4 left Stenson’s duct, and 2 right Stenson’s duct. Of the 35 stent placement procedures, 27 used the hypospadias silastic stent tubes and 8 used the Fr. 5 pediatric feeding tubes. The duration of stent placement ranged from 4 to 21 days. Seventeen stents were scheduled for removal after an average duration of 13.9 days. Three stents was removed because of blocked tube after an average duration of 8 days. Five patients complained strongly of stent irritation and had early removal after an average duration of 9.4 days. Nine cases had accidental stent dislocation and were removed after an average duration of 7.4 days. Overall, the duration for the non-
Fig. 1 Two types of stents. Above is the Fr. 5 pediatric feeding tube (tail is cut to fit the photo) and below is the hypospadias silastic stent tube (O.D. 2 mm; I.D. 1.65 mm)
Eur Arch Otorhinolaryngol Table 1 Patient data Patient
Sex
Age
Diagnosis
Inserted duct
Indication for stent placement
Stent type
Duration
Fixed suture
Symptom remission
1
M
47
Stone 4 mm
R’t Wharton’s
Combined approach
5 Fr
8 days dislocated
6-0 nylon
?
2
F
20
Stone 3 mm
L’t Wharton’s
Combined approach
Hypo
8 days dislocated
6-0 nylon
?
3
F
25
Stone 1 mm
R’t Wharton’s
Retro-papillar incision
Hypo
6-0 nylon
?
4
M
25
Stone 3 mm
R’t Wharton’s
Combined approach
Hypo
8 days removed due to blockage 8 days removed due to blockage
6-0 nylon
?
5
M
16
Stone 5 mm
R’t Wharton’s
Combined approach
Hypo
10 days dislocated
6-0 nylon
?
6
F
21
Stone 3 mm
R’t Wharton’s
LASER
Hypo
5 days dislocated
6-0 nylon
?
7
M
38
Stone 8 mm
L’t Wharton’s
LASER
Hypo
11 days scheduled removed
6-0 nylon
?
8
M
38
Stenosis
L’t Stenson’s
LASER
5 Fr
8 days removed due to irritation
5-0 nylon
?
9
M
42
Stone 9, 13, 5 mm
L’t Wharton’s
LASER
Hypo
12 days dislocated
6-0 nylon
?
10
F
29
Stone 3 mm
L’t Stenson’s
Retro-papillar incision
5 Fr
21 days scheduled removed
5-0 nylon
?
11
F
38
Mucocele
L’t Wharton’s
Mucocele dissection
5 Fr
12 days scheduled removed
6-0 nylon
?
12
F
50
Stone 1.75 cm
L’t Wharton’s
Combined approach
Hypo
14 days scheduled removed
5-0 nylon
?
13
F
56
Sialoectasis
Bil Wharton’s
Decompression
Hypo
14 days scheduled removed
6-0 nylon
Persisted
14
F
33
Stone 4, 6, 1 mm
R’t Wharton’s
LASER
Hypo
4 days dislocated
6-0 nylon
Persisted
15
F
68
Sialoadenitis
L’t Stenson’s
Dilation
5 Fr
7 days removed due to irritation
5-0 nylon
Persisted
16
F
52
Sialoadenitis
Bil Stenson’s
Dilation
Hypo
8 days removed due to irritation
5-0 nylon
Persisted
17
F
52
Stone 1 cm 6, 2 mm
R’t Wharton’s
Combined approach
Hypo
6 days dislocated
6-0 nylon
?
18
F
14
Stone 6, 5 mm
L’t Wharton’s
Retro-papillar incision
5 Fr
10 days scheduled removed
6-0 nylon
?
19
F
47
Sialoadenitis
L’t Wharton’s
Dilation
Hypo
8 days removed due to blockage
6-0 nylon
Persisted
20
F
47
Sialoadenitis
R’t Stenson’s
Dilation
Hypo
14 days schedule removed
6-0 nylon
?
21
F
21
Stone 6 mm, 1 cm, 1 mm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
5-0 nylon
?
22 23
F M
41 11
Stone 5 mm Sialoadenitis
L’t Wharton’s L’t Wharton’s
Combined approach Dilation
Hypo Hypo
7 days dislocated 14 days schedule removed
6-0 nylon 5-0 nylon
? ?
24
F
22
Stone 2 mm
L’t Wharton’s
Combined approach
Hypo
12 days scheduled removed
5-0 nylon
?
25
M
36
Stone 6 mm
R’t Wharton’s
Combined approach
Hypo
5-0 nylon
?
26
F
37
Stone 1 mm
R’t Wharton’s
Retro-papillar incision
Fr 5
19 days scheduled removed 12 days scheduled removed
5-0 nylon
?
27
F
49
Sialoadenitis
L’t Wharton’s
Dilation
Hypo
12 days removed due to irritation
5-0 nylon
Persisted
28
F
49
Sialoadenitis
R’t Wharton’s
Dilation
Hypo
12 days removed due to irritation
5-0 nylon
Persisted
29
F
23
Stone 3.5 mm
L’t Wharton’s
LASER
Hypo
7 days dislocated
6-0 nylon
?
30
M
17
Stone 3 mm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
6-0 nylon
?
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Eur Arch Otorhinolaryngol Table 1 continued Patient
Sex
Age
Diagnosis
Inserted duct
Indication for stent placement
Stent type
Duration
Fixed suture
Symptom remission
31
F
63
Stone 1.2 cm
L’t Wharton’s
Combined approach
5 Fr
14 days scheduled removed
5-0 nylon
?
32
F
47
Stone 3 mm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
5-0 nylon
?
33
M
30
Stone 1.3 cm
L’t Wharton’s
LASER
Hypo
14 days scheduled removed
5-0 nylon
?
5 Fr Fr. 5 pediatric feeding tube, Hypo Hypospadias silastic stent tube
scheduled stent removal was 8.1 ± 2.2 days, significantly shorter than the scheduled removal duration (13.9 ± 2.6, p \ 0.001, t test) (Fig. 2). Comparing stent-specific complications, when the hypospadias silastic stent tubes were used, the stent obstruction and irritation rates were higher than when using the Fr. 5 pediatric feeding tube (100 vs. 0 %; 67 vs. 33 %, respectively) (Fig. 3). None of the stents secured by 5-0 nylon suture were complicated by dislocation but when the stents were secured by 6-0 nylon sutures, the dislocation rate was as high as 47.4 % (Table 2). Table 3 shows the comparison for stent placement duration according to different type of stent used. While we were not able to perform statistical analysis due to limited case numbers, our result showed limited differences in stent placement durations between the two stents used in our study. All the stents were sent for bacterial culture after removal and the results all showed mixed respiratory microbes without remarkable findings.
Fig. 2 The duration for the non-scheduled removal of the stent was 8.1 ± 2.2 days, significantly shorter than that for the scheduled removal (13.9 ± 2.6, p \ 0.001, t test)
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Discussion This study demonstrates that selecting different stents after sialendoscopy contributes to different risks in developing complications. To ensure a secured fixation of the stent, using sutures with equivalent strength or stronger than the 5-0 nylon may be a reasonable choice. After sialendoscopy, a stent may be necessary to prevent re-stenosis and to maintain the salivary duct open. Although there are no clear guidelines for stent insertion, it is generally agreed that stenting is necessary after stricture dilation or if significant ductal trauma is encountered during stone removal [10]. In practice, stent placement after sialendoscopy is routinely performed for conditions like combined external approach to remove a large stone after ductal wall incision; obvious thermal injury to the ductal wall after laser lithotripsy; dilation of tight papilla or ductal stenosis; and retro-pillar ductal incision required for difficult papilla route. In the future, the indications for stent placement will be further expanded as it may be used not to only prevent salivary duct strictures but also to treat problems like sialectasis, a condition for which a marsupialization procedure is often required [11]. While there seems to be an increasing consensus in determining when to place a stent after sialendoscopy, the question is how long it should be kept. Many researchers report that the duration of the stent placement is usually 2–8 weeks [9, 10, 12]. Pagliuca et al. [13] report that even without ductal repair suture after removal of large stones, there are no complication when the salivary duct stents are removed after 3 weeks. In this series, the duration of stent placement ranged from 4 to 21 days. While the original intent was to remove the stent after 2 weeks, complications such as stent irritation or dislocation resulted in the early removal of the stent in 18 procedures, with a mean duration of only 8.1 days. Interestingly, no complications were found in these procedures despite the unexpectedly short stent placement durations. This finding implies that perhaps the duration needed for salivary duct stent placement may
Eur Arch Otorhinolaryngol Fig. 3 When the hypospadias silastic stent tubes were used for stenting, the stent obstruction and irritation rates were higher than those when using the Fr. 5 pediatric feeding tube (100 vs. 0 % and 67 vs. 33 %, respectively)
Table 2 Comparison for stent dislocations according to different sutures materials used 5-0 Nylon
6-0 Nylon
Total
16
19
Dislocation
0
9
Dislocation rate
0.0 %
47.4 %
Table 3 Comparison for stent placement durations according to different types of stents used Suture
5 Fr
Hypo
7.5
10.7
8
7.5
5-0 Nylon Average duration (days) 6-0 Nylon Average duration (days)
d days, 5 Fr Fr. 5 pediatric feeding tube, Hypo hypospadias silastic stent tube
be shortened than as previously expected, with comparable results. Nevertheless, if in any conditions a stent must be held in place until its scheduled removal, it is highly recommended that a suture with equivalent strength to or stronger than 5-0 nylon be used to prevent possible premature dislocations, even if some patients feel irritated by the stiffer 5-0 nylon stitches. Another noteworthy issue is the development of stent obstruction by secondary debris (Fig. 4a). A well-functioning stent appears to be very clear (Fig. 4b). Once the stents are found to be obstructed and filled with debris,
these functionless stents are removed earlier. Kopec et al. [9] report the use of dexamethasone irrigation through the stent and believe that this is useful in the presence of fibrotic remodeling and an inflammatory reaction with epithelial edema in the stenotic area. While post-operative stent irrigation can contribute to a reduced risk of stent obstructions, the hypospadias silastic tube, with its larger lumen diameter, is more likely to develop obstructions than the thinner Fr. 5 pediatric feeding tube. This interesting finding suggests that there is still much to be improved regarding the materials for the salivary duct stents in order to make them thinner and softer to maximally reduce irritability while still maintaining not easily obstructed. Many researchers have reported the results using various types of salivary duct stents with different outcomes. Kopec et al. [9] reported the use of vascular radiologic examination catheter as salivary duct stents. Koch et al. [10] used polyurethane stent with different diameters (Fr. 4.5–6.0) based on the size of the scope used in the procedure. The McMaster University team reported the use of commercially available stents specifically made for sialendoscopy (Polymeric Sialo Drain; Sialo Technology Ltd., Ashkelon, Israel) [12]. More recently, the utilization of resorbable shape-memory starch-based stents for the treatment of salivary ducts under sialendoscopic surgery were reported to be successful in a porcine animal model [14]. While it is too early to conclude which stent outperforms the others, the results of this study may provide valuable information for the evaluation and even future design of salivary duct stents.
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Eur Arch Otorhinolaryngol
diameter, the hypospadias silastic stent will more likely develop obstructions compared to the Fr. 5 pediatric feeding tube.
Conclusions The duration needed for the salivary duct stent placements may be shortened to only 2 weeks. If a salivary duct stent is intended to be place for a certain period before its scheduled removal, a suture strength equivalent or stronger than the 5-0 nylon suture should be considered for stent fixation. Acknowledgments This study is supported by the Taipei Medical University Hospital Research Fund (TMU103-AE1-B05). Conflict of interest
None.
References
Fig. 4 a An obstructed salivary duct stent of the left Stenson’s duct (arrow). b A functioning salivary duct stent of the left Wharton’s duct (arrow). The lumen was clean, with clear saliva flow
This study has several limitations. First, the case number is relatively low and may not be able to fully demonstrate the true outcome of salivary duct stent placements. Second, the patients enrolled in this study vary in their underlying salivary gland diseases and although the underlying problems seem to have limited impact in the development of stent-specific complications, it will be better if patients can be separated in subgroups according to their different salivary gland problems before analysis. Unfortunately, the case number is limited and insufficient for subgroup analysis. Future studies with larger case numbers should be undertaken. Despite these limitations, the results of this study still provide useful information for otolaryngologist. Based on experience, the duration needed for salivary duct stent placements may be shortened to within 2 weeks there are no long-term complications in the cases of premature stent dislocation. If a salivary duct stent is to be place for a certain period of time before scheduled removal, a suture with equivalent strength to or stronger than the 5-0 nylon suture should be considered for fixation. Even with a larger
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