click for more detail: Etiology / Diagnosis / Classification / Management

See also: Salivary Disorders University of Iowa Publications 2012 - 2021 Salivary Swelling; LSU Sialendoscopy Course 2016 April 9 and 10 Hoffman Presentations; UCSF Sialendoscopy Nov 4 2015 Stenoses RAI Sjogrens Evidence and Management; Sialograms and Sialography; Parotid Duct Stricture Dilation with Salivary Balloon and Ultrasound Guidance; Ultrasound aided parotid ductoplasty - sialodochoplasty; Case example dilation technique for salivary duct stenosis with fluoroscopy

 

I. Etiology of Salivary Duct Stenosis (Parotid Duct Stricture - Submandibular Duct Stricture)

(click to see more detail: Etiology of Salivary Duct Stenosis)

A. Trauma

1.  Surgical manipulation of oral cavity

2. Intra-oral dental xrays (Kieliszak 2015); Dental prosthesis

B. Sialolith

C. Autoimmune disorders

D. Viral and bacterial infection

E. Radiation (I131, External beam)

F. Other  

G. Unknown

II. Diagnosis of Salivary Duct Stenosis (Parotid Duct Stricture - Submandibular Duct Stricture)

         (click to see more detail: Diagnosis of Salivary Duct Stenosis (Parotid Duct Stricture - Submandibular Duct Stricture)

A. Evaluation based on presenting signs and symptoms

1. Ultasound considered first (and sometimes last) radiographic evaluation

2. In our practice (Hoffman) we begin with ultrasound and consider CT or MRI and commonly perform a sialogram

a. The duct cannulation and dilation are all done with microscopic control by the surgeon in the radiology suite

b. Radiocontrast dye (water soluble Isovue 370) is instilled by radiology with assistance by the surgeon

B. Role for sialography (see: Sialograms and Sialography)

1. According to many it is "a difficult invasive procedure with radiation exposure and therefore is not indicated"

2. According to practice at the University of Iowa it is not considered difficult nor invasive: 

a. valuable in delineating ductal anatomy in a way not possible by other means

b. useful in identifying accessibily to the duct under local anesthesia before subjecting a patient to a general anesthesia

c. may be therapuetic by the process of dilating the distal duct (relieving distal stricture) and flushing the gland with radiocontrast

d. useful in identifying normal ductal anatomy to redirect evaluation of pain away from salivary origin (ddx now directed to TMJ, dental, 'atypical facial pain')

e. identify abnormalities that can be addressed w/o sialendoscopy (normal duct anatomy with acinar abnormalities treated in clinic with steroid infusion)

f. prepare surgical approach (open vs endoscopic) – assist in patient counseling

III. Classification of Salivary Duct Stenosis (Parotid Duct Stricture - Submandibular Duct Stricture)

(click to see more detail: Classification of Salivary Duct Stenosis (Parotid Duct Stricture - Submandibular Duct Stricture) University of Iowa Sialogram Classification and Grading Scale)

A. University of Iowa Sialogram Classification and Grading Scale (click to see more detail: Iowa Sialogram Classification)

Addresses Anatomy of Ductal Stenosis - adaptable for Parotid and Submandibular Sialograms

1º (main duct): segment of duct from the oral cavity to the first major bifurcation

2º (secondary): segement of duct proximal to first major bifurcation and distal to second bifurcation

3º (tertiary): any duct proximal to the second bifurcation (including those that could be considered 4º = quaternary)

B. Parotid - Stensen's duct stenosis (Koch et al 2009) based on sialendoscopy evaluation of tissue quality / luminal narrowing, extent, number, location and considerations for etiology

Type I: Inflammation dominated with variable narrowing of the lumen; slight fibrotic remodeling; obstructive plaques

Type II: Fibrotic stenosis, often short segment and web-associated, predominant incomplete (luminal narrowing <50%); circular or web-like encroachments of the duct wall, megaduct

Type III: Fibrotic stenosis, massive fibrotic reaction of the duct wall - predominantly high-grad luminal narrowing >50%

C. Submandibular - Wharton's duct stenosis (Kopec et al  2013) based on site of stenosis measured by distance from punca at time of sialendoscopy - also applied to Stensen's duct

Papilla/distal

Middle

Proximal/hilum

Diffuse

IV. Management of Salivary Duct Stenosis (Parotid Duct Stricture - Submandibular Duct Stricture)

(click to see more detail: Management of Salivary Duct Stenosis (Parotid Duct Stricture - Submandibular Duct Stricture)

A. Duct dilation

Mechanical (ballon, sialendoscope, bougie)

Hydrostatic (instillation of saline / kenalog / radiocontrast)

B. Observation with intermittent medical therapy (steroids/antibiotics/botox)

C. Parotidectomy

D. Duct reconstruction (vein graft)

E. Tympanic neurectomy

F. Other (see: Ultrasound aided parotid ductoplasty - sialodochoplasty)

References

Koch M: Long-term results and subjective outcome after gland-preserving treatment in parotid duct stenosis. Laryngoscope 2014 vol 124 pp 1813-8

Marchal (editor) Sialendoscopy - The Hands-On Book 2015 printed in France Imprimerie Gutenberg, Meythet, France copyright 2015 by European Sialendoscopy Training Center (ESTC)

Kieliszak CR, Shokri T, Joshi AS: Acquired Wharton's duct stenosis after dental radiographs treated with sialendoscopy  BMJ Case Rep 2015

Ngu RK, Brown JE, Whaites EJ,et al. Salivary duct strictures: nature and incidence in benign salivary obstruction. Dentomaxillofac Radiol 2007;36:63–7.

Kopec T, Szyfter W, Wierzbicka M,et al. Stenoses of the salivary ducts-sialendoscopy based diagnosis and treatment. Br J Oral Maxillofac Surg 2013;51:e174–177.

Koch M, Iro H, and Zenk J: Sialendoscopy-based diagnosis and classification of parotid duct stenosis. Laryngoscope 2009 Sep;119(9):1696-703

Koch M, Iro H, Kunzel J, Psychogios G, Bozzato A, and Zenk J: Diagnosis and gland-preservjng minimally invasive therapy for Wharton's duct stenoses. Laryngoscope 122 (2012) pp 552-558

Thorpe RK, Foggia MJ, Marcus KS, Policeni B, Maley JE, Hoffman HT. Sialographic Analysis of Radioiodine-Associated Chronic Sialadenitis. Laryngoscope. 2020 Nov 17. doi: 10.1002/lary.29279. Epub ahead of print. PMID: 33200832.

Foggia MJ, Peterson J, Maley J, Policeni B, Hoffman HT. Sialographic analysis of parotid ductal abnormalities associated with Sjogren's syndrome. Oral Dis. 2020 Jul;26(5):912-919. doi: 10.1111/odi.13298. Epub 2020 Mar 3. PMID: 32031309.

Truong K, Hoffman HT, Policeni B, Maley J. Radiocontrast Dye Extravasation During Sialography. Ann Otol Rhinol Laryngol. 2018 Mar;127(3):192-199. doi: 10.1177/0003489417752711. Epub 2018 Jan 7. PMID: 29308655.