原文題目(出處)： Sialoendoscopically assisted open sialolithectomy for removal of large submandibular hilar calculi. J Oral Maxillofac Surg 2010;68:68-73
原文作者姓名： Sum YX, Liao GQ, Zheng GS Liu HC, Liang YJ, Ou DM 通訊作者學校： Sun Yat-sen University Guanghua School of Stomatology,
Guangzhou, China 報告者姓名(組別)： 洪國雄 Intern E 組
報告日期： 2010.4.12
內文：
Abstract：
• Purpose：clinical efficacy of sialoendoscopically assisted open sialolithectomy for the removal of large submandibular hilar calculi → avoid sialoadenectomy
• Materials and Methods: patients with sialolithiasis scheduled for sialoendoscopic surgery performed with sialoendoscopically assisted open sialolithectomy
• Results: 78 consecutive patients with submandibular sialolithiasis, 18 → sialoendoscopically assisted open sialolithectomy
17 patients, large hilar sialoliths → sialoendoscopically assisted open sialolithectomy
1 patient with multiple sialoliths → open sialoadenectomy
3→Temporary numbness of the tongue for 1 week postoperatively 18 months follow up without any symptoms or signs of recurrence.
• Conclusions: sialoendoscopically assisted open sialolithectomy is an effective and safe surgical technique to remove large submandibular hilar calculi.
Introduction：
•Obstructive salivary gland disease
→one of the most common problems afflicting the salivary glands
→a major cause of salivary gland dysfunction and sialoadenectomy.
•A sialolith located in Wharton’s duct is the most frequent cause of submandibular obstruction and consequent acute or chronic infection.
•Conservative therapeutic approaches
→ gland massage, sialagogues (eg, chewing gum, sour drops) and antibiotics
→can only ease the symptoms.
•Traditionally, sialoadenectomy was always indicated for these patients.
•During the past decade, sialoendoscopy has been introduced as a minimally invasive surgical procedure for the diagnosis and treatment of salivary ductal diseases.
•Advantage of sialoendoscopy
→ surgeons can visualize the duct lumen and the pathologic features,
→ making the diagnosis according to the endoscopic findings.
→ interventional approaches can then be performed to eliminate the obstruction or dilate the duct.
→ preservation of the salivary gland with relief of symptoms in most patients.
•However, the field of sialoendoscopy is still in its infancy. It is a technically demanding procedure and has some limitations.
→ the management of large hilar calculi.
→ A sialolith larger than 1 cm is always impossible to remove intraductally using Sialoendoscopy and is the main cause of surgical failure.
•The aim of the present study was to investigate the clinical efficacy of sialoendoscopically assisted open sialolithectomy for removal of large
submandibular hilar calculi to avoid sialoadenectomy.
(1) ENROLLMENT AND PATIENT CHARACTERISTICS
•From August 2005 to October 2008, 78 consecutive patients with submandibular sialolithiasis underwent sialoendoscopic surgery at Sun Yat-Sen University Guanghua School of Stomatology, Guangzhou, China..
•When we failed to remove large submandibular hilar stones intraductally
→ sialoendoscopically assisted open sialolithectomy.
•The clinical characteristics, pre- and intraoperative data, outcomes, and complications were evaluated prospectively.
(2) SURGICAL TECHNIQUE
•Sialoendoscopic procedures：Semirigid, moderately flexible sialoendoscopes for the surgery under local anesthesia. → intraductal extraction using a wire basket, grasping forceps, and/or balloon catheter.
•Sialoendoscopically assisted open sialolithectomy：for large stones, especially those located in the hilum, were always connected to the ductal wall and could not be released intraductally using sialoendoscopy.
(3) FOLLOW-UP
•Encouraged to massage the affected glands and to stay well hydrated.
•Clinical outcomes were evaluated according to the patients’ symptoms and physical examination and radiographic imaging findings.
•The median follow-up period was 18 months (range, 1 to 38).
(4)Results
•78 consecutive patients with sialolithiasis,
-18 were treated with sialoendoscopically assisted open sialolithectomy
immediately after failure of intraductal extraction of large submandibular hilar calculi.
•The success rate of sialoendoscopically assisted open sialolithectomy was 94.4%.
•One patient had a postoperative infection, and 3 developed temporary numbness of the tongue for 1 week postoperatively, and recovered completely without additional intervention. ( Complication rate was 23.5%.)
•During follow-up, all 17 patients were symptom free, and no recurrence was documented.
→The orifice in 11 patients → clear saliva →The orifice in 6 patients→ little or no saliva (5) CASE REPORT
•A 40-year-old woman presented with repeated episodes of left submandibular gland swelling of 8 years’ duration.
•The panoramic radiograph and computed tomography scan showed radiopacity in the hilar area.
•At the 1-year follow-up visit, clear saliva could be observed from the orifice of Wharton’s duct of the left submandibular gland.
•Scintigraphic assessment revealed that the excretion function of the left
submandibular gland had been restored to normal, and the bilateral glands had equivalent function
•The patient was followed up for 30 months with no evidence of recurrence.
(6) Discussion
•Obstructive salivary gland disease continues to be the leading indication for sialoadenectomy.
•Previous studies have revealed that 62% to 80% of submandibular gland excisions result from sialolithiasis.
•Sialoadenectomy can eradicate the obstructive symptoms.
→ Postoperative complications
→ facial nerve injury,
→ obvious functional and cosmetic impairments
•Long-term complications developed in 25.3% of patients after excision of the submandibular gland. (By Berini-Aytes and Gay-Escoda.)
•The common concept that irreversible gland dysfunction would occur in the presence of obstructive diseases with a long course
→ high rate of sialoadenectomy
•A recent study → a significant increase occurs in the functional fraction and the excretion rate of the gland after intraoral open removal of salivary calculi.
•A histopathologic study→ submandibular glands removed for sialolithiasis demonstrated that a significant percentage of the glands exhibited normal histologic findings.
•sialoadenectomy might be overtreatment of ductal disorders, and a conservative attitude toward salivary ductal obstruction appears justified.
•Our recent study using the saliva flow rate test and scintigraphic examination
•Stones larger than 1 cm and located in the hilum are
→always attached to the ductal wall.
→The intraductal approaches, including wire basket and forceps,
→ incapable of releasing such large stones.
→ nearly impossible to pass through the relatively narrow duct channel.
•Therefore, we used the surgical technique of sialoendoscopically assisted open sialolithectomy to remove large submandibular hilar sialoliths in the present study.
•Compared with traditional transoral open sialolithectomy, this endoscopically assisted technique has some advantages.
→duct exploration,
→exact orientation of the sialoliths
→differentiation of the main duct and the lingual nerve
→management of other pathologic features, such as remnant calculi and mucous plugs.
• Identifying and protecting the lingual nerve is one of the most important issues in this procedure.
•The present study had some limitations.
→ the size of our patient population was limited.
→ the glandular functional recovery of each patient after surgery needs to be evaluated.
•For 17 patients who underwent this surgery successfully, all were symptom free during the follow-up period, but little or no saliva was found from the duct orifice in 6 patients.
•Conclusion
→sialoendoscopically assisted open sialolithectomy is an effective and safe surgical technique for the removal of large submandibular hilar calculi.
→The initial clinical outcomes were satisfactory, but the long-term results and the functional recovery of glands are yet to be investigated.
題號 題目
1 下列何者為純漿液性(purely serous)唾液腺？
(A) Submandibular gland (B) Thyroid gland
(C) Parotid gland (D) Sublingual gland
答案(C) 出處：Ten Gate’s Oral Histology 6th edition p.324
題號 題目
2 Where is sialolithiasis most likely develop？
(A) Submandibular gland (B) Thyroid gland
(C) Parotid gland (D) Sublingual gland
答案(A) 出處：Oral and maxillofacial pathology 2nd edition p.393
