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Salivary Duct Stenosis

last modified on: Thu, 02/01/2018 - 13:13

Salivary Duct Stenosis

Return to Salivary Swelling

see also: LSU Sialendoscopy Course 2016 April 9 and 10 Hoffman Presentations;

UCSF Sialendoscopy Nov 4 2015 Stenoses RAI Sjogrens Evidence and Management

see also: Sialograms and Sialography

see also: 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

  A. Trauma

      1.  Surgical manipulation of oral cavity

      2. (intra-oral dental xrays - (Keliszak et al 2015)

  B. Sialolith

  C. Autoimmune disorders

  D. Viral and bacterial infection

  E. Radiation (I131, External beam)

  F. Unknown

II. Diagnosis

   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

        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 and has estimated radiation exposure 1/4 that of a mammogram:

              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. occassionally 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 counselling

III.  Classification

    A. Parotid - Stensen's duct stenosis (Koch et al 2009) based on sialendoscopy evaluation of tissue quality / luminal narrowing, extet, 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%

    B. Submandibular - Wharton's duct stenosis (Kopec et al  2013) based on site of stenosis - also applied to Stensen's duct

                 Papilla/distal

                 Middle

                 Proximal/hilum

                 Diffuse

       

III. Management

      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

Kopec T, Szyfter W, Wierzbicka M, and Nealis J: Stenoses of the salivary ducts-sialendoscopy based diagnosis and treatment.  British Journal of Oral and Maxillofacial Surgery  Volume 51, Issue 7, October 2013

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