Recent progress in the treatment of intractable sialolithiasis / 北京大学学报(医学版)

Sialolithiasis occurs in approximately 0.45% to 1.20% of the general population. The typical clinical symptom manifests as a painful swelling of the affected glands after a meal or upon salivary stimulation, which extremely affects the life quality of the patients. With the development of sialendoscopy and lithotripsy, most sialoliths can be successfully removed with preservation of the gland. However, sialoliths in the deep hilar-parenchymal submandibular ducts and impacted parotid stones located in the proximal ducts continue to pose great challenges. Our research center for salivary gland diseases (in Peking University School and Hospital of Stomatology) has used sialendoscopy for 17 years and treated >2 000 patients with salivary gland calculi. The success rate was approximately 92% for submandibular gland calculi and 95% for parotid calculi. A variety of minimally invasive surgical techniques have been applied and developed, which add substantial improvements in the treatment of refractory sialolithiasis. Further, the radiographic positioning criteria and treatment strategy are proposed for these intractable stones. Most of the hilar-parenchymal submandibular stones are successfully removed by a transoral approach, including transoral duct slitting and intraductal basket grasping, while a small portion of superficial stones can be removed by a mini-incision in submandibular area. Impacted stones located in the distal third of parotid gland ducts are removed via "peri-ostium incision", which is applied to avoid a cicatricial stenosis from a direct ostium incision. Impacted parotid stones located in the middle and proximal third of the Stensen's duct are removed via a direct mini-incision or a peri-auricular flap. A direct transcutaneous mini-incision is commonly performed under local anesthesia with an imperceptible scar, and is indicated for most of impacted stones located in the middle third, hilum and intraglandular ducts. By contrast, a peri-auricular flap is performed under general anesthesia with relatively larger operational injury of the gland parenchyma, and should be best reserved for deeper intraglandular stones. Laser lithotripsy has been applied in the treatment of sialolithiasis in the past decade, and holmium ∶YAG laser is reported to have the best therapeutic effects. During the past 3 years, our research group has performed laser lithotripsy for a few cases with intractable salivary stones. From our experiences, withdrawal of the endoscopic tip 0.5-1.0 cm away from the extremity of the laser fiber, consistent saline irrigation, and careful monitoring of gland swelling are of vital importance for avoidance of injuries of the ductal wall and the vulnerable endoscope lens during lithotripsy. Larger calculi require multiple treatment procedures. The risk of ductal stenosis can be alleviated by endoscopic dilation. In summary, appropriate use of various endoscopy-assisted lithotomy helps preserve the gland function in most of the patients with refractory sialolithiasis. Further studies are needed in the following aspects: Transcervical removal of intraglandular submandibular stones, intraductal laser lithotripsy of impacted parotid stones and deep submandibular stones, evaluation of long-term postoperative function of the affected gland, et al.

Three-dimentional radiographic features of 67 maxillary radicular cysts / 北京大学学报(医学版)

OBJECTIVE@#To analyze the three-dimensional radiographic characteristics of maxillary radi-cular cysts using cone-beam computed tomography (CBCT) and spiral CT.@*METHODS@#Clinical records, histopathological reports, and CBCT or non-enhanced spiral CT images of 67 consecutive patients with maxillary radicular cysts were retrospectively acquired, and radiographic features, including size, shape, expansion, internal structure and relationship with the surrounding tissues, were analyzed. The lesions were divided into three types according to the involved tooth number, as follows: type Ⅰ (single tooth), the epicenter of the cyst was located at the apex of a nonvital tooth, without involvement of the neighbo-ring tooth; type Ⅱ (adjacent tooth involvement), the cyst was located at the apex of a nonvital tooth with involvement of the mesial and/or distal tooth root; and type Ⅲ (multi-teeth), the cyst involved the apexes of ≥4 teeth. Besides, these cysts were classified as another three types on sagittal views, as follows: centripetal, the root apex was oriented centripetally to the center of the cyst; palatal, the cyst was located mainly at the palatal side of the apex; and labial/buccal, the cyst was located mainly at the labial/buccal side of the apex.@*RESULTS@#Totally, 67 patients with maxillary radicular cysts were acquired, including 38 males and 29 females, and their ages ranged from 13 to 77 years. Among them, 46 lesions (68.7%) were located in the anterior maxilla and 65 (97.0%) were round or oval. Labial/buccal cortex expansion was present in 43 cases (64.2%) and palatal cortex expansion in 37 cases (55.2%). The nasal floor was invaded in 27 cases (40.3%), the maxillary sinus was invaginated in 26 cases (38.8%), and root resorption was present in 9 cases (13.4%). The average diameter of lesions was (20.89±8.11) mm mesio-distally and (16.70±5.88) mm bucco-palatally. In spite of the 4 residual cysts, the remaining 63 lesions included 14 type Ⅰ, 26 type Ⅱ and 23 type Ⅲ cysts according to the involved tooth number. Besides, the 63 lesions included 46 centripetal, 15 palatal and 2 buccal cysts on sagittal views.@*CONCLUSION@#The maxillary radicular cysts were frequently well-circumscribed round or oval radiolucency, with significantly different sizes. According to the involved tooth number, it can be divided into single tooth, adjacent tooth involvement and multi-teeth types. On sagittal views, the root-cyst relationship was centripetal in most cases, while a minority of cysts expanded palatally or buccally.

Inflammation grading and sialoendoscopic treatment of 131I radioiodine-induced sialadenitis / 北京大学学报(医学版)

OBJECTIVE@#To investigate the inflammation grading of 131I radioiodine-induced sialadenitis based upon sialoendoscopic and sialographic appearances, and to evaluate the results of sialoendoscopic intervention.@*METHODS@#The patients diagnosed with 131I radioiodine-induced sialadenitis and underwent sialoendoscopic exploration and intervention procedures in Peking University Hospital of Stomatology from Nov. 2012 to Oct. 2018 were included in this study. The appearances of sialogaphy and sialoendoscopy were analyzed and classified. The treatment options included irrigation with saline and dexamethasone and mechanical dilatation by sialoendoscope. The patients were followed up after treatment.@*RESULTS@#Forty-two patients with 131I radioiodine-induced sialadenitis were included. There were 5 males and 37 females, with a male-to-female ratio of 1 ∶7.4. Symptoms included recurrent swelling and pain in the parotid glands, and dry mouth. Sialography showed stenosis in the main duct,and in some cases nonvisua-lization of the branches. Sialoendoscopy showed narrowing of the main duct, and the branch duct atresia was seen. The appearances of sialogaphy and sialoendoscopy were analyzed and classified into 3 groups: (1) Mild inflammation: stenosis and ectasia occurred in the main duct, whereas the 0.9 mm sialoendoscope could pass through easily. (2) Moderate inflammation: one point of severe stricture could be seen in the main duct where 0.9 mm sialoendoscope could not be passed through. (3) Severe inflammation: two points or more of severe strictures or diffused strictures occurred in the main duct. Thirty-three patients with 65 affected glands were examined by both sialography and sialoendoscopy. Eight glands were classified as mild inflammation, 23 glands moderate inflammation, and 34 glands severe inflammation. The duration of follow-up ranged from 3-72 months. The clinical results were evaluated as good in 22 glands, fair in 22 glands, and poor in 19 glands, with an overall effective rate of 69.8% (44/63).@*CONCLUSION@#The clinical, sialographic and sialoendoscopic appearances of 131I radioiodine-induced sialadenitis showed their characteristics. We proposed an inflammation grading standard for the 131I radioiodine-induced sialadenitis based on the appearances of sialography and sialoendoscopy. Sialoendoscopy can significantly alleviate the clinical symptoms, which is an effective therapy, and better for early lesions.