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Arjun S. Joshi, MD1; Amit Sood, BA1!

The George Washington University – Division of Otolaryngology - Head and Neck Surgery!

INTRODUCTION!

METHODS AND MATERIALS!

CONCLUSIONS!

DISCUSSION!DESCRIPTION OF TECHNIQUE!

REFERENCES!

Figure 1. Left parotid sialolith ! Figure 2. Needle localization with !methylene blue!

ABSTRACT!

CONTACT!

RESULTS!

Chart 2. Surgical details.!

Figure 3. Intraoperative appearance!

Ultrasound-Guided Needle Localization of Parotid Sialolithiasis !– A Novel Technique!

Arjun S. Joshi, MD!The George Washington University – Division of Otolaryngology Head and Neck Surgery !Email: iamaya@mfa.gwu.edu!Phone: 202-741-3417!

Objectives: !1) To describe a novel operative in patients with parotid sialolithiasis!To demonstrate the feasibility of technique and discuss its indications !!Methods:!From August 2009 to January 2012, patients with symptomatic parotid sialolithiasis underwent ultrasound needle localization and open sialolithotomy in a tertiary-level hospital setting. Outcomes included success of delivery, presence of infection, ductal stenosis, loss of glandular function, or facial nerve paralysis. Independent variables included size of and location of sialoliths.! !Results:!Eleven patients were treated using transcutaneous ultrasound guided needle placement and injection of methylene blue prior to external sialolithotomy in the operating room. Patients were chosen if they 1) had fixed calculi, 2) had stones >5mm, and 3) had failed sialendoscopic extraction or localization. Post-operative outcomes and long-term follow-up results were obtained. Follow-up ranged from 6-12 months. Mean operative time from skin incision to closure was 52 minutes (Range 43-85 minutes). All 11/11 (100%) cases were successful for stone retrieval. Stents were placed in 911/11 cases. The average stone size was 8.7 mm. There were no complications of infection, ductal stenosis, loss of glandular function, or permanent buccal facial nerve paralysis. No patients had salvage parotidectomy. !!Conclusion:!After fai l ing a purely endoscopic approach, sialoliths of the parotid gland pose a problem for precise localization and treatment. Ultrasound has been demonstrated to be reliable for identifying sialoliths. We propose a novel technique and assert that ultrasound-guided needle localization is a reliable aid to effective external parotid sialolithotomy. !!

Under general anesthesia, ultrasound of the parotid gland is typically performed in a transverse axis, and the sialolith is visualized. A 3cc syringe with methylene blue and a 25 gauge needle is utilized to localize the stone using ultrasound guidance. Methylene blue is then injected slowly as the needle is withdrawn. Proper identification of the stone is again confirmed.! A Modified Blair incision is made, sub-SMAS flaps are raised, and the parotidomasseteric fascia is exposed. The location of the stone is suggested by the focus of methylene blue (which usually measures 5mm) and intraparotid dissection is performed. Depending on the location of the stone, the buccal branch of the facial nerve is usually encountered and bluntly dissected. The position of the Stensen’s duct is then identified as a punctate area of methylene blue injection and incision through the duct is then performed in the linear/oblique axis of the duct. ! The stone is delivered and Stensen’s duct is usually stented using a 6Fr infant feeding tube over a vascular guide wire. Ultrasound is performed again to confirm the absence of fragmented sialoliths. The duct is closed using a running 5-0 or 6-0 vascular suture, and the wound is closed in layers. The stent is sutured in place intraorally and removed 4 weeks post-operatively. !!

From August 2009 to January 2012, patients with symptomatic parotid swelling were followed and a prospective database was maintained. Diagnostic sialendoscopy and ultrasound was performed in all patients. Patients with parotid sialolithiasis were identified and an attempt was made to treat the condition using a purely endoscopic approach whenever possible. Those patients that failed sialendoscopic treatment underwent ultrasound needle localization and open parotid sialolithotomy in a tertiary-level hospital setting using the senior authors’ technique as described.!!Patients were then followed up with a phone questionnaire for a minimum period of 6 months and outcome data were tabulated. Primary outcome was success stone of delivery. Secondary outcomes included presence of infection, ductal stenosis, loss of glandular function, or facial nerve paralysis. Independent variables included size of and location of sialoliths.!!

Ultrasound-guided needle localization is an effective technique for the treatment of large and/or proximally located parotid stones which are not amenable for endoscopic treatment. Ultrasound technology is rapidly learned, widely applicable, and cost-effective. !!It should be incorporated into the routine treatment algorithm for treatment of obstructive sialolithiasis. !

Parotid sialolithiasis accounts for 10 to 20% of all cases of sialolithiasis involving the head and neck1, and diagnosis can be challenging for a variety of reasons. Recently, sialendoscopy has been used both as a diagnostic and therapeutic tool in the management of parotid sialolithiasis2-4. It has the distinct ability to directly visualize parotid stones and if amenable, extract the offending sialolith through a purely endoscopic approach. ! However, sialendoscopy is limited by its ability to diagnose and treat proximately located parotid stones, as it is unable to visualize those sialoliths impacted in the secondary or tertiary ductal system well. Additionally, the sialendoscope is limited in its ability to treat sialoliths greater than 3-4mm in a purely endoscopic fashion5.! Modalities such as ultrasound, conventional x-ray, and sialography have all been used with variable success in order to help aid identification of parotid sialolithiasis3-10. Ultrasound has been used by myriad other medical specialties to not only visualize, but localize, and biopsy accessible masses. Our specialty has been relatively reticent about adapting this technology, although many of the disease processes that we treat are transcutaneously accessible. ! In this paper, we present ultrasound guided needle localization of parotid sialolithiasis as a novel technique for the diagnosis and treatment of parotid stones that are not amenable to pure endoscopic extraction. !

1.  Marchal F, Dulguerov P, Becker M, Barki G, Disant F, Lehmann W. Submandibular diagnostic and interventional sialendoscopy: new procedure for ductal disorders. Ann Otol Rhinol Laryngol. 2002;111:27–35. !

2.  Zenk J, Koch M, Klintworh N, Konig B, Konz K, Gillespie MB, Iro H. Sialendoscopy in the Diagnosis and Treatment of Sialolithiasis: A study on More than 1000 patients. Otolaryngol Head and Neck Surgery. 2012 Jun 29. !

3.  experience. Laryngoscope. 2009;118:776–9. !4.  Karavidas K, Nahlieli O, Fritsch M, McGurk M. Minimal surgery for parotid stones: a 7-year endoscopic experience. Int J Oral Maxillofac

Surg. 2010 Jan;39(1):1-4. Epub 2009 Nov 7.!5.  Walvekar RR, Razfar A, Carrau RL, Schaitkin B. Sialendoscopy and associated complications: A preliminary Overton A, Combes J,

McGurk M. Outcome after endoscopically assisted surgical retrieval of symptomatic parotid stones. Int J Oral Maxillofac Surg. 2011 Oct 19.!

6.  Koch M, Bozzato A, Iro H, Zenk J. Combined endoscopic and transcutaneous approach for parotid gland sialolithiasis: indications, technique, and results. Otolaryngol Head Neck Surg. 2010 Jan;142(1):98-103.!

7.  Gritzmann N, Rettenbacher T, Hollerweger A, Macheiner P, Hübner E. Sonography of the salivary glands. Eur Radiol. 2003 May;13(5):964-75. Epub 2002 Sep 5. !

8.  Gritzmann N. [Ultrasound of the salivary glands]. Laryngorhinootologie. 2009 Jan;88(1):48-56; quiz 57-9. Epub 2009 Jan 15.!9.  Nitsche N, Waitz G, Iro H. [Imaging of parotid gland diseases with high resolution magnetic resonance tomography]. HNO. 1990 Dec;

38(12):451-6. !10.  Gritzmann N, Hajek P, Karnel F, Fezoulidis J, Türk R. [Sonography in salivary calculi--indications and status]. Rofo. 1985 May;142(5):

559-62. !11.  Szalma J, Olasz L, Tóth M, Acs P, Szabó G. [Diagnostic value of radiographic and ultrasonic examinations in patients with sialoadenitis

and sialolithiasis]. Fogorv Sz. 2007 Apr;100(2):53-8.!12.  Marchal F. A combined endoscopic and external approach for extraction of large stones with preservation of parotid and submandibular

glands. Laryngoscope. 2007 Feb;117(2):373-7.!!

Chart 1. Patient demographics.!Figure 4. External stent placement. !

Between August 2009 and August 2012, eleven patients were treated at the George Washington University Hospital using ultrasound guided needle localization prior to external sialolithotomy in the operating room. Patients were selected if their stone was fixed, >5mm, or could not be visualized during diagnostic sialendoscopy. ! The mean age was 47.2 +/- 16.1 (range 22-72) years. Of the 11 patients, 6 (54.5%) were male, and 5 (45.5%) were female. The mean symptom duration was 33.1 (range 1-86) months. The presenting symptoms were pain, swelling, discharge, peri-prandial, and xerostomia in 9 (81.8%), 10 (90.9%), 6 (54.5%), 6 (54.5), 1 (9.1%) of the patients, respectively. Additional factors were antibiotic usage, smoking, occasional caffeine consumption, moderate caffeine consumption, and heavy caffeine consumption that were present in 8 (72.7%), 6 (54.5%), 5 (45.5%), 5 (45.5%), and 1 (9.1%) of the patients, respectively. ! Seven (63.6%) patients had right-sided disease and 4 (36.4%) presented with left sided disease. Ten (91.9%) patients had stones within the proximal 1/3 of the ductal system. One (9.1%) patient had stones present within both the proximal 1/3 and middle 1/3 of ductal lumen. ! The average surgical time was 53 +/- 10.8 (range 37-73) minutes. The average sialolith length was 7.6 +/- 2 (range 5.7-11) mm. The average sialolith width was 6 +/- 1.9 (range 3-10) mm. Stents were placed in 11 (100%) of the cases. Ten (91.9%) stones were irregularly-shaped, and 1 (9.1%) stone was oval-shaped. ! Post-operative outcomes and long-term follow-up results were obtained. Average follow-up was at 8.9 +/- 2.6 (range 6-14) months. All 11 (100%) of cases were successful for stone retrieval. 10(91.%) patients had complete symptom resolution, and 1 (9.1%) patient had partial resolution of symptoms. 0 (0%) patients had major complications. 3 (27.3%) patients had evidence of minor complications; 1 patient had ductal perforation that developed into a salivary fistula that resolved with pressure dressings; and 2 patients had sialoceles that resolved. There were no complications of infection, ductal stenosis, loss of glandular function, or permanent buccal facial nerve paralysis. No patients had salvage parotidectomy. !

The treatment for parotid sialolithiasis varies mainly on the size and location of the pathology. Ultrasound has been proven effective in the detection7,10 and localization of parotid sialolithiasis, but has largely been ignored for its potential role in the treatment of the same disease process despite the fact that the condition is transcutaneously accessible. ! Sialendoscopy also offers a minimally-invasive approach to the treatment of parotid sialolithiasis, but requires a special set of instrumentation and additional personnel for its effective use. It is limited by its ability to treat large stones and detect stones that are located within the secondary or tertiary parotid ductal system5. Ultrasound-guided needle localization during open sialolithotomy offers a minimally invasive approach to the treatment of most parotid sialoliths, including those that have failed an endoscopic approach. ! Distinct advantages offered by this technique over the so-called combined approach (combination of sialendoscopy for localization and external approach for delivery) include: 1) the ability to accurately localize proximal parotid ductal sialoliths, 2) the avoidance of additional instrumentation which can obscure the surgical field, and 3) maintenance of sterility until the final portion of the case which theoretically may reduce the number of post-operative infections. ! Our preliminary data suggest the technique is applicable to a variety of clinical situations, such as fixed calculi, stones>4-5mm, and also proximally located stones, which are typically missed by routine sialendoscopes. In this study, the average sialolith length was 7.6mm, and average width was 6mm. 10/11 (91.9%) had stones in the proximal 1/3 of the ductal system, and all were fixed in position. ! The technique is safe and complication rates are acceptable. Sialocele was the most common complication encountered in this group of patients (3 cases) and was easily treated with a pressure dressing. There were no cases of permanent facial paralysis. Operative times are acceptable with an average of 53 minutes to skin closure (range 37-73 minutes). ! Additional advantages conferred by the use of ultrasound during external sialolithotomy include the ability to use the same modality of assessment for both pre-op and post-op assessment. Residual stones if present, can be rapidly identified, and mandatory re-exploration can be performed. ! Drawbacks of this technique are few. The use of this technique is user-dependent and advanced training in head and neck ultrasound is a prerequisite. Stones that are small (1 mm) or mobile may be missed during ultrasound examination.!