Nils Klintworth

Sialendoscopy in the Diagnosis and Treatment of Sialolithiasis A Study on More Than 1000 Patients

Objective Sialendoscopy and other gland-preserving techniques such as extracorporeal shockwave lithotripsy (ESWL), transoral stone removal, and combinations of these methods have fundamentally changed the therapeutic approach to salivary stones. Since 2003, all patients presenting with sialolithiasis have been diagnosed and treated with the same algorithm and routine salivary gland endoscopy (SGE). Study Design Case series with chart review of patients with sialolithiasis treated between 2003 and 2008 using an algorithm for gland preservation. Setting Tertiary referral academic medical center. Subjects and Methods A total of 1154 patients with suspected sialolithiasis were identified and reviewed. Factors analyzed included stone location, size, surgical method, rate of stone clearance, complications, and rate of short- and long-term symptom resolution. Successful treatment was defined as freedom from symptoms at follow-up. Results Diagnostic sialendoscopy confirmed 221 parotid stones and 812 submandibular stones, of which 206 and 736, respectively, were treated. Transoral stone removal was the most frequently used method to remove submandibular stones (92%), with a smaller percentage able to be removed by SGE alone (5%) with long-term success rates ≥90%. Only 4% (29/736) required submandibular gland removal. Parotid stones were removed by SGE (22%), combined SGE and incisional technique (26%), or ESWL (52%), with long-term success rates of 98%, 89%, and 79%, respectively. Only 8 of 206 (4%) patients eventually required parotidectomy. Conclusion Salivary gland endoscopy is an important diagnostic and therapeutic tool in the management of sialolithiasis but must be combined with additional techniques to ensure a high rate of stone clearance, symptom resolution, and gland preservation.

Postoperative complications after extracapsular dissection of benign parotid lesions with particular reference to facial nerve function

The desirable extent of surgical intervention for benign parotid tumors remains a matter of controversy. Superficial or total parotidectomy as a standard procedure is often said to be the gold standard; however, with it the risk of intraoperative damage to the facial nerve cannot be ignored. For some time now, extracapsular dissection without exposure of the main trunk of the facial nerve has been favored as an alternative for the treatment of discrete parotid tumors. Data on the incidence of facial nerve lesions and other acute postoperative complications of extracapsular dissection have been lacking until now.

Evolution and changing trends in surgery for benign parotid tumors.

The ideal extent of surgical intervention for benign parotid tumors remains a matter of controversy. The aim of the study was to trace the development of surgical therapy in a large cohort, explore its changes in a single institution specializing in salivary gland pathologies over the last 12 years, and determine the extent to which a possible shift in the surgical therapy of parotid benign tumors toward less radical methods was correlated with a change in the incidence of facial palsy and Freys syndrome.

Sonoelastography of parotid gland tumours: initial experience and identification of characteristic patterns.

ObjectivesThe aim of this study was to investigate B-mode and elastographical ultrasound criteria capable of differentiating between benign and malignant parotid tumours and to define characteristic elastographical patterns for pleomorphic adenomas and Warthin’s tumours.MethodsFifty-seven patients with parotid gland tumours were examined using a combination of B-mode and elastographic ultrasounds. The data acquired were analysed retrospectively by two experienced ultrasound operators to identify specific sonographical features of benign and malignant lesions. Additionally, elastographical patterns were defined and analysed for their specificity.ResultsA blurred margin proved to be the only significant criterion in B-mode ultrasound capable of differentiating between malignant and benign tumours. The garland sign was defined as an elastographical pattern found significantly more frequently in malignant tumours, improving sonographical prediction of the benign or malignant nature of a parotid lesion. A logistic regression model was developed that achieved a correct prediction in 87.7% of cases. A “dense core” sign was also specifically defined for pleomorphic adenomas and a “half-half” sign for Warthin’s tumours.ConclusionsElastography is an innovative and powerful diagnostic tool that can improve the sonographical examination of parotid gland tumours by revealing easily recognised and characteristic patterns of tissue distribution.Key Points• Elastography can help differentiate benign from malignant parotid tumours during parotid ultrasound.• The elastographical “garland sign” is more frequent in malignant than benign parotid tumours.• Pleomorphic adenomas show an elastographical “dense core sign”.• Warthin’s tumours show an elastographical “half-half sign”.• Parotid cysts show an elastographical “bull’s-eye sign”.

Diagnostic Imaging in Sialadenitis

This article presents a survey of the imaging procedures in inflammatory changes of the salivary glands. State-of-the-art procedures are described along with a perspective on recent innovations. Various imaging procedures are discussed, including ultrasound, computed tomography, and magnetic resonance imaging. Then, imaging options in different forms of acute and chronic sialadenitis are considered. The choice of method is guided by consideration of the reliability, the side effects, the accessibility, and, ultimately, the costs. The focus is mainly on diagnostic ultrasound and resonance methods because, with their aid, the investigation of almost all the inflammatory diseases of the large salivary glands can be performed with accurate results, without exposing the patient to radiation.

Follow-up of parotid pleomorphic adenomas treated by extracapsular dissection

This study was carried out to evaluate tumor recurrence following extracapsular dissection of pleomorphic adenomas of the parotid gland.

Results of Minimally Invasive Gland-Preserving Treatment in Different Types of Parotid Duct Stenosis

OBJECTIVE To assess differences in minimally invasive treatment in various types of Stensen duct stenoses, because sparse data have been published concerning this. DESIGN Retrospective study. SETTING Tertiary reference center, level of evidence: 2b. PATIENTS Ninety-three patients with stenoses. METHODS Treatment of 111 parotid duct stenoses was evaluated with particular attention to which treatment strategies were successful in various types of stenoses (type 1, inflammatory; type 2, web-associated fibrous; and type 3, fibrous). Minimally invasive treatment consisted of sialendoscopy-guided rinsing with cortisone (all cases) and interventional sialendoscopy with instrumental dilation alone or combined with transoral ductal surgery. RESULTS Sialendoscopy-guided rinsing with cortisone was sufficient in 73.0% of cases of type 1 stenosis (21.5% of all cases). Interventional sialendoscopy with instrumental dilation was successful in 47.1% of cases of type 2 stenosis and 70.5% of cases of type 3 stenosis (59.2% of all patients). Interventional sialendoscopy combined with transoral duct surgery was successful in 72.7% of cases of type 3 stenosis (8.6% of all cases). Glands could be preserved in 96.4% of cases. CONCLUSIONS Stenoses that can be differentiated using sialendoscopy seem to require different minimally invasive treatment. Sialendoscopy-guided rinsing with cortisone is an important basic anti-inflammatory treatment, particularly in inflammatory stenoses. Interventional sialendoscopy with instrumental dilation, transoral ductal surgery or a combination of both are the first choice in fibrous stenoses.

Chronic recurrent parotitis

ZusammenfassungDie chronisch rezidivierende Parotitis ist eine nicht obstruktive Erkrankung mit episodischen, meist schmerzhaften Schwellungen. Sie lässt sich in eine juvenile und eine adulte Form trennen, ohne dass die eigentliche Ätiologie der Erkrankung sicher geklärt ist. Diskutiert werden bei der juvenilen Form neben genetischen und angeborenen Faktoren auch die Bedeutung bakterieller Infektionen, die eine geringgradige Entzündung aufrechterhalten. Selten kann die Drüse im Verlauf komplett lymphatisch transformieren. Die juvenile chronisch rezidivierende Parotitis hat in 90% aller Fälle einen selbstlimitierenden Verlauf. Die Diagnose ergibt sich primär aus der Anamnese und den klinischen Symptomen. Als Bildgebung der Wahl gilt die hochauflösende Sonographie. Die Sialendoskopie zeigt typische Befunde bei der juvenilen Form, Gangstrikturen oder Stenosen des distalen Gangsystems bei der adulten Form. Die Therapie der Wahl ist neben der Gabe von Penicillin die Drüsenmassage und Speichelanregung. Bei schwierigen Verläufen ist die Sialendoskopie mit Spülung der Speichelgänge und Instillation von Kortison indiziert. Die totale Parotidektomie ist Ultima ratio und wird selten benötigt.AbstractChronic recurrent parotitis is a non-obstructive disease with episodes of mostly painful swelling of the gland. It is categorized into a juvenile and an adult form, even without clear information on its actual origin. As to the etiology of the juvenile form, genetic factors and duct malformations as well as bacterial infections are discussed. Very rarely a complete lymphatic transformation of the gland might take place. Juvenile chronic recurrent parotitis is self-limiting in about 90% of all cases, as patients grow up. The diagnosis is based on patient history and clinical findings. Sonography is the imaging method of choice. Sialendoscopy shows a typical whitish pattern of the ducts in juvenile disease. Strictures or stenoses are typical for the adult form. The therapy of choice is gland massage and sialagogues, in addition to the administration of antibiotics. In more severe cases sialendoscopy together with rinsing of the ducts and instillation of cortisone are indicated. Total parotidectomy remains the last choice and is rarely necessary.Chronic recurrent parotitis is a non-obstructive disease with episodes of mostly painful swelling of the gland. It is categorized into a juvenile and an adult form, even without clear information on its actual origin. As to the etiology of the juvenile form, genetic factors and duct malformations as well as bacterial infections are discussed. Very rarely a complete lymphatic transformation of the gland might take place. Juvenile chronic recurrent parotitis is self-limiting in about 90% of all cases, as patients grow up. The diagnosis is based on patient history and clinical findings. Sonography is the imaging method of choice. Sialendoscopy shows a typical whitish pattern of the ducts in juvenile disease. Strictures or stenoses are typical for the adult form. The therapy of choice is gland massage and sialagogues, in addition to the administration of antibiotics. In more severe cases sialendoscopy together with rinsing of the ducts and instillation of cortisone are indicated. Total parotidectomy remains the last choice and is rarely necessary.

Die chronisch rezidivierende Parotitis

ZusammenfassungDie chronisch rezidivierende Parotitis ist eine nicht obstruktive Erkrankung mit episodischen, meist schmerzhaften Schwellungen. Sie lässt sich in eine juvenile und eine adulte Form trennen, ohne dass die eigentliche Ätiologie der Erkrankung sicher geklärt ist. Diskutiert werden bei der juvenilen Form neben genetischen und angeborenen Faktoren auch die Bedeutung bakterieller Infektionen, die eine geringgradige Entzündung aufrechterhalten. Selten kann die Drüse im Verlauf komplett lymphatisch transformieren. Die juvenile chronisch rezidivierende Parotitis hat in 90% aller Fälle einen selbstlimitierenden Verlauf. Die Diagnose ergibt sich primär aus der Anamnese und den klinischen Symptomen. Als Bildgebung der Wahl gilt die hochauflösende Sonographie. Die Sialendoskopie zeigt typische Befunde bei der juvenilen Form, Gangstrikturen oder Stenosen des distalen Gangsystems bei der adulten Form. Die Therapie der Wahl ist neben der Gabe von Penicillin die Drüsenmassage und Speichelanregung. Bei schwierigen Verläufen ist die Sialendoskopie mit Spülung der Speichelgänge und Instillation von Kortison indiziert. Die totale Parotidektomie ist Ultima ratio und wird selten benötigt.AbstractChronic recurrent parotitis is a non-obstructive disease with episodes of mostly painful swelling of the gland. It is categorized into a juvenile and an adult form, even without clear information on its actual origin. As to the etiology of the juvenile form, genetic factors and duct malformations as well as bacterial infections are discussed. Very rarely a complete lymphatic transformation of the gland might take place. Juvenile chronic recurrent parotitis is self-limiting in about 90% of all cases, as patients grow up. The diagnosis is based on patient history and clinical findings. Sonography is the imaging method of choice. Sialendoscopy shows a typical whitish pattern of the ducts in juvenile disease. Strictures or stenoses are typical for the adult form. The therapy of choice is gland massage and sialagogues, in addition to the administration of antibiotics. In more severe cases sialendoscopy together with rinsing of the ducts and instillation of cortisone are indicated. Total parotidectomy remains the last choice and is rarely necessary.Chronic recurrent parotitis is a non-obstructive disease with episodes of mostly painful swelling of the gland. It is categorized into a juvenile and an adult form, even without clear information on its actual origin. As to the etiology of the juvenile form, genetic factors and duct malformations as well as bacterial infections are discussed. Very rarely a complete lymphatic transformation of the gland might take place. Juvenile chronic recurrent parotitis is self-limiting in about 90% of all cases, as patients grow up. The diagnosis is based on patient history and clinical findings. Sonography is the imaging method of choice. Sialendoscopy shows a typical whitish pattern of the ducts in juvenile disease. Strictures or stenoses are typical for the adult form. The therapy of choice is gland massage and sialagogues, in addition to the administration of antibiotics. In more severe cases sialendoscopy together with rinsing of the ducts and instillation of cortisone are indicated. Total parotidectomy remains the last choice and is rarely necessary.

Der Stellenwert der extrakorporalen Stoßwellenlithotripsie bei der Therapie der Sialolithiasis

INTRODUCTION Extracorporeal shock wave lithotripsy (ESWL) is now judged alongside other therapeutic alternatives like salivary gland endoscopy (SGE). The present analysis investigates the significance of ESWL within the scope of a defined treatment algorithm. METHODS A retrospective analysis of data obtained between 2003 and 2009. The results were analysed according to the therapeutic modality used. Successful treatment was defined as an absence of symptoms or stones at follow-up examination. RESULTS During the period studied, 206 patients with parotid stones and 736 with submandibular stones underwent treatment. Among the latter group, 5 % were treated exclusively by SGE, 92 % underwent transoral stone removal and 3 % received ESWL. The long-term success rates were 93 %, 90 % and 94 %, respectively. Patients with parotid stones were treated in 78 % of cases by ESWL and 22 % underwent SGE exclusively. The overall long-term success rates here were 85 % and 98 %, respectively. CONCLUSION ESWL remains an important therapeutic tool in the management of sialolithiasis. The method is particularly important as a gland-preserving tool in the therapy of parotid stones and selected cases of submandibular stones, even though it is not available in the US due to the lack of official equipment approval.