Francis Marchal

Specificity of parotid sialendoscopy

Objective To present our initial experience with sialendoscopy of the parotid duct.

Postparotidectomy facial nerve paralysis: possible etiologic factors and results with routine facial nerve monitoring.

Objective: Analyze the incidence and factors responsible for postparotidectomy facial nerve paralysis when the surgery is performed with the routine use of facial nerve monitoring. Study Design: A prospective, nonrandomized study. Methods: Seventy consecutive patients underwent parotidectomy with intraoperative facial nerve monitoring. Two devices were used: a custom mechanical transducer and a commercial electromyograph‐based apparatus. All patients were analyzed, including those with cancer and those with deliberate or accidental sectioning of facial nerve branches. The outcome variables were the motor facial nerve function according to the House‐Brackmann grading scale (HB) at 1 week (temporary paralysis) and 6 to 12 months (definitive paralysis). Facial nerve grading was performed blindly from reviewing videotapes. Results: The overall incidence of facial paralysis (HB > 1) was 27% for temporary and 4% for permanent deficits. Most of the deficits were partial, most often concerning the marginal mandibular branch. Temporary deficits with HB scores of greater than 2 were only present in patients with parotid cancer or infection. Permanent deficits were present in three patients, including one patient with facial nerve sacrifice. Factors significantly associated with an increased incidence of temporary facial paralysis include the extent of parotidectomy, the intraoperative sectioning of facial nerve branches, the histopathology and the size of the lesion, and the duration of the operation. Conclusions: Despite a stringent accounting of postoperative facial nerve deficits, these data compare favorably to the literature with or without the use of monitoring. An overall incidence of 27% for temporary facial paralysis and 4% for permanent facial paralysis was found. Although the lack of a control group precludes definitive conclusions on the role of electromyograph‐based facial nerve monitoring in routine parotidectomy, the authors found its use very helpful.

Submandibular diagnostic and interventional sialendoscopy: new procedure for ductal disorders

We present our initial experience with submandibular sialendoscopy, a new therapeutic approach for disorders of Whartons duct. We review the sialendoscopes used and discuss their respective merits. We evaluated and treated 129 consecutive patients with suspected ductal disorders. Diagnostic sialendoscopy was used for classifying ductal lesions as sialolithiasis, stenosis, sialodochitis, or polyps. Interventional sialendoscopy was used to treat these disorders. The type of endoscope used, the type of sialolith fragmentation and/or extraction device used, the total number of procedures, the type of anesthesia, and the number and size of the sialoliths removed were the dependent variables. The outcome variable was the endoscopic clearing of the ductal tree and resolution of symptoms. Diagnostic sialendoscopy was possible in 131 of 135 glands (97%), with an average (±SD) duration of 28 ± 15 minutes. Interventional sialendoscopy was attempted in 110 cases, with an average duration of 71 ± 41 minutes, with a success rate of 82%. Multiple sialendoscopies were necessary in 25% of cases. General anesthesia was used in 12% of cases. Submandibular gland resection was performed in 4%. The average size of the stones was 4.9 ± 2.9 mm. Multiple sialoliths were found in 31 cases (29%). Sialolith fragmentation was required in 26%. Larger and multiple stones often required longer and multiple procedures and general anesthesia, and more often resulted in failures. Semirigid endoscopes had a higher success rate (85%) than flexible sialendoscopes (54%). Complications were mostly minor, but were encountered in 10% of cases. Diagnostic sialendoscopy is a new technique for evaluating salivary duct disorders that is associated with low morbidity. Interventional sialendoscopy allows the extraction of sialoliths in most patients, thus preventing open gland excision.

Histopathology of submandibular glands removed for sialolithiasis

A Detailed Description of the Pars Media of the Cricothyroid Muscle GEORGE L CHARPIED CCC MS (presenter); GREGORY A GRILLONE MD FACS; Boston MA Objectives: For proper understanding of the function of the larynx in medicosurgical management of laryngeal pathology, a thorough understanding of its structure is necessary. The pars media is a significant muscle that is poorly understood. This strap-like muscle is thought to be part of the cricothyroid muscle but is seldom mentioned in the literature on laryngeal structure. Our objective was to describe its anatomy, histology, histochemistry, morphometry, and neural innervation, in preparation for EMG studies. Methods: Thirty-six human larynges (72 hemilarynges) obtained from IRB-approved postmortem examinations were cleaned and preserved in formalin. Exposure of the pars media was via either a lateral approach (removal of thyroid lamina) or a medial approach (removal of the vocal folds). Under the guidance of a dissecting microscope, descriptions of muscle attachments and relationships were documented with line drawings and photographs. Hematoxylin and eosin, silver, and Mallorys trichrome staining, as well as computerized morphometry, further documented the pars medias structure. Results: The pars media is a large strap-like muscle with attachments to the thyroid cartilage and cricoid arch. It is innervated by the middle division of the internal branch of the superior laryngeal nerve. Its myoneural junctions are lined up along its longitudinal axis and not diffuse in distribution. In other features it appears similar to other intrinsic laryngeal muscles but less like the cricothyroid proper. Its medial surface attachment near the root of the inferior horn of the thyroid cartilage places it within less than a millimeter of the muscular process of the arytenoid cartilage. Conclusion: These data appear to show that the pars media deserves more attention than it has been given. Its orientation within the thyroid and nonrecurrent laryngeal nerve innervation make it a candidate for arytenoid reanimation. This understanding of the human pars media, further electromyographic examinations to discern function are planned.

Juvenile Recurrent Parotitis: Sialendoscopic Approach

OBJECTIVE To assess the relevance of sialendoscopy as a diagnostic and interventional procedure in juvenile recurrent parotitis (JRP). DESIGN Prospective case series study. SETTING Tertiary care teaching hospital. PATIENTS Sialendoscopy was used to examine 10 children (age range, 1.8-13.0 years) with symptomatic JRP for recurrent swelling of the parotid glands between January 2003 and January 2005. Diagnostic sialendoscopy allowed classification of ductal lesions, and interventional sialendoscopy was used to treat the lesions. Initial data analyzed included the type of endoscope used as well as the size and form of the main duct of the parotid gland. Outcome variables were resolution of symptoms and endoscopic enlargement of the ductal tree. RESULTS Initial ultrasound evaluation of the diseased gland revealed a white Stensen duct without the natural proliferation of blood vessels in all 10 cases. This finding was associated with a true stenosis of the Stensen duct. Two cases of suspected stones according to ultrasonography were subsequently diagnosed as localized stenoses. The sialendoscope was used to dilate the duct with pressurized saline solution in all cases as well as to dilate the 2 cases of stenoses. There were no major complications. The average length of follow-up was 11 months (range, 2-24 months). Seventeen parotid glands were dilated in all 10 patients, with a success rate of 89%. One patient needed repeated sialendoscopies for recurrent symptoms. Two patients presented with a second episode of JRP contralateral to the side initially treated. CONCLUSIONS Diagnostic sialendoscopy is a new procedure that can be used in children for reliable evaluation of salivary ductal disorders, with low morbidity. Sialendoscopic dilation of the main parotid ducts appears to be a safe and effective method for treating JRP.

Pediatric salivary gland obstructive swelling: sialendoscopic approach.

Objective: To assess the efficacy of sialendoscopy as a diagnostic and interventional procedure for salivary ductal pathologies of children.

Histopathology of Submandibular Glands Removed for Sialolithiasis

We reviewed the clinical history of 48 consecutive patients who underwent submandibular gland removal for radiologically proven sialolithiasis. The specimens were examined by a pathologist blinded to the clinical data. A histopathologic classification into 1 of 3 grades was established by evaluating the degrees of atrophy, fibrosis, and inflammation. A correlation between the clinical and pathological variables was sought in order to define clinical variables that would predict abnormal submandibular glands that required extirpation. A significant percentage of the submandibular glands exhibited normal histologic findings. The patients with normal submandibular glands had a clinical evolution similar to that of other patients with severely damaged glands. The only clinical variable that correlated with increased histopathologic alteration was the patients age. In view of the newly available diagnostic and therapeutic techniques for sialolithiasis, a conservative attitude to submandibular gland resection appears justified.

Frey syndrome before Frey: the correct history

Objective: To review the chronology of publications on gustatory sweating before Freys landmark publication.

How Reliable Is Sonography in the Assessment of Sialolithiasis

OBJECTIVE The purpose of this study was to determine the value of sonography for the diagnosis of salivary gland calculi. SUBJECTS AND METHODS In this study, 82 salivary glands in 79 consecutively registered patients with acute or recurrent parotid or submandibular gland swelling were examined with 7.5-12 MHz linear probes. All sonographic examinations were performed by two experienced radiologists without knowledge of the final diagnosis. The reference standard was digital sialography and sialendoscopy with or without surgery for 54 salivary glands and digital sialography alone for 28 glands. RESULTS Sialolithiasis was present in 44 glands and was absent in 38 glands as confirmed by the final diagnosis. The overall sensitivity, specificity, accuracy, and positive and negative predictive values of sonography in the detection of calculi were 77%, 95%, 85%, 94%, and 78%, respectively. False-negative sonographic findings were associated with calculi with a diameter less than 3 mm in nondilated or dilated salivary ducts; most calculi with a diameter of 3 mm or greater were correctly identified. False-positive findings were caused by ductal stenosis with wall fibrosis, which was erroneously interpreted as lithiasis. CONCLUSION Because of its limited sensitivity and limited negative predictive value, sonography does not allow reliable exclusion of small salivary gland calculi. Therefore, further diagnostic investigations are recommended to detect calculi in patients with normal sonographic findings and suspected lithiasis.

Pediatric Sialendoscopy A 5-Year Experience at a Single Institution

OBJECTIVES To evaluate the outcome of our experience in the treatment of salivary gland disorders in children undergoing sialendoscopy and to assess the evolution of the technique. DESIGN Retrospective medical record review. SETTING Tertiary care university hospital. PATIENTS Thirty-eight children with salivary gland disorders undergoing diagnostic and interventional sialendoscopy between January 1, 2003, and November 30, 2008. INTERVENTION Diagnostic and interventional sialendoscopy using general anesthesia. MAIN OUTCOME MEASURES Demographic, clinical, and surgical variables, including age, sex, date of first symptoms, parotid or submandibular location of disease, preoperative ultrasonographic results, sialendoscopy technique, sialendoscopy observations, and complications. RESULTS Pediatric sialendoscopy was performed on the parotid gland in 23 patients (61%) and on the submandibular gland in 15 patients (39%). The most frequent indication for sialendoscopy was recurrent salivary gland swelling. Thirty-two of 38 procedures (84%) were performed endoscopically, whereas a combined intervention was necessary for 3 patients and a submandibular gland excision for another 3 patients. Sialendoscopy allowed the diagnosis of 12 patients with salivary duct lithiasis, 21 with salivary duct stenosis, and 2 with both submandibular lithiasis and stenosis, and findings from 3 sialendoscopies were normal. Preoperative ultrasonographic results were confirmed by sialendoscopy in only 7 patients. Of the 10 patients with lithiasis found using sialendoscopy, only 4 had been detected using preoperative ultrasonography. CONCLUSIONS Sialendoscopy is a pertinent technique for the diagnosis and treatment of salivary gland disorders in children. It also allows the most conservative treatment of sialolithiasis and juvenile recurrent parotitis.