10.14639/0392-100X-suppl.1-43-2023-12
Over the last 20 years, interventional sialendoscopy has become the therapy of choice for the management of obstructive salivary disorders, favouring a significant reduction in the number of patients undergoing traditional sialadenectomy. The overall success rate of sialendoscopy is around 90% as reported by the largest case series published; recurrence is expected in about 10% of cases, and the patient should be informed about the possibility to undergo further conservative procedures to improve symptoms. Adequate pre-operative assessment, based on ultrasonography, cone beam 3D CT and MR-sialography, is mandatory to reduce the risk of unsuccessful procedures and, therefore, recurrence of obstructive sialadenitis; moreover, in case of recurrence, the surgeon should be experienced enough to manage these cases and be able to perform additional interventions, such as transoral/transfacial sialendoscopy-assisted procedures and imaging-assisted procedures in case of difficult anatomical situations. Botulinum toxin injection and traditional sialadenectomy would be considered as possible salvage treatments in case of failure of all conservative approaches.
text/xml
1827-675X
2614
en
Lorenzo Pignataro
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
recurrent sialadenitis
Recurrent obstructive salivary disease after sialendoscopy. A narrative literature review
Text.Serial.Journal
https://www.actaitalica.it/
43
Annual congress report
2023-04-21
2023-04-21
2023-04-28
2023-04-28
S95-S102
1
Lorenzo Pignataro
2023/04/21
10.14639/0392-100X-suppl.1-43-2023-12
S95
Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
1827-675X
recurrent sialadenitis
S102
Recurrent obstructive salivary disease after sialendoscopy. A narrative literature review
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ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43(SUPPL.1):S95-S102; doi: 10.14639/0392-100X-suppl.1-43-2023-12




Head and Neck section


Recurrent obstructive salivary disease
after sialendoscopy. A narrative literature review
La recidiva della patologia ostruttiva salivare dopo scialoendoscopia.
Una revisione narrativa della letteratura
Pasquale Capaccio1,2, Michele Gaffuri1,3, Pietro Canzi4,5, Lorenzo Pignataro1,3
1
 Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico,
Milan, Italy; 2 Department of Biomedical, Surgical and Dental Sciences, University of Milan, Italy; 3 Department of Clinical Sciences
and Community Health, University of Milan, Milan, Italy; 4 Department of Clinical, Surgical, Diagnostic and Pediatric Sciences,
University of Pavia, Pavia, Italy; 5 Department of Otorhinolaryngology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy


SUMMARY
Over the last 20 years, interventional sialendoscopy has become the therapy of choice
for the management of obstructive salivary disorders, favouring a significant reduction in
the number of patients undergoing traditional sialadenectomy. The overall success rate of
sialendoscopy is around 90% as reported by the largest case series published; recurrence
is expected in about 10% of cases, and the patient should be informed about the possibility
to undergo further conservative procedures to improve symptoms. Adequate pre-operative
assessment, based on ultrasonography, cone beam 3D CT and MR-sialography, is manda-
tory to reduce the risk of unsuccessful procedures and, therefore, recurrence of obstructive
sialadenitis; moreover, in case of recurrence, the surgeon should be experienced enough
to manage these cases and be able to perform additional interventions, such as transoral/
transfacial sialendoscopy-assisted procedures and imaging-assisted procedures in case of
difficult anatomical situations. Botulinum toxin injection and traditional sialadenectomy
would be considered as possible salvage treatments in case of failure of all conservative
approaches.                                                                                          Received: December 15, 2022
                                                                                                     Accepted: January 12, 2023
KEY WORDS: sialendoscopy, salivary stones, salivary stenoses, recurrent sialadenitis
                                                                                                     Correspondence
RIASSUNTO                                                                                            Michele Gaffuri
Negli ultimi 20 anni, la scialoendoscopia interventistica è diventata la terapia di scelta dei       Department of Otolaryngology and Head and Neck
disordini ostruttivi salivari, contribuendo ad una riduzione significativa dei pazienti sotto-       Surgery, Fondazione IRCCS Ca’ Granda Ospedale
posti a scialoadenectomia. Il tasso di successo della scialoendoscopia interventistica è di          Maggiore Policlinico, via Francesco Sforza 35,
circa il 90% del totale dei pazienti trattati, come riportato in letteratura. Il tasso di recidiva   20122 Milan, Italy
                                                                                                     Tel. +39 02 55032823
è invece di circa il 10% dei casi, e il paziente dev’essere informato della possibilità di es-
                                                                                                     E-mail michele.gaffuri@policlinico.mi.it
sere sottoposto ad ulteriori terapie. Un iter clinico e radiologico adeguato, rappresentato
dall’ecografia, dalla TC Cone Beam 3D, dalla scialorisonanza magnetica, è indispensabile
per ridurre il rischio di insuccesso e quindi di recidiva della patologia ostruttiva salivare;         How to cite this article: Capaccio P, Gaf-
inoltre, in quest’ultimo caso, il chirurgo dovrebbe essere sufficientemente esperto per gestire        furi M, Canzi P, et al. Recurrent obstructive
ulteriori procedure endoscopiche e/o chirurgiche, come ad esempio l’approccio transorale/              salivary disease after sialendoscopy. A narra-
transfacciale scialoendoscopico-assistito, o procedure imaging guidate in caso di condizioni           tive literature review. Acta Otorhinolaryngol
                                                                                                       Ital 2023;43(SUPPL.1):S95-S102. https://doi.
anatomiche difficoltose. La tossina botulinica e la scialoadenectomia tradizionale dovreb-
                                                                                                       org/10.14639/0392-100X-suppl.1-43-2023-12
bero essere considerate come possibili opzioni di salvataggio in caso di fallimento di tutte
le terapie conservative.
                                                                                                     © Società Italiana di Otorinolaringoiatria
PAROLE CHIAVE: scialoendoscopia, litiasi salivare, stenosi duttali, scialoadenite ricorrente         e Chirurgia Cervico-Facciale


                                                                                                                    OPEN ACCESS

                                                                                                     This is an open access article distributed in accordance with
Introduction                                                                                         the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                     Commercial-NoDerivatives 4.0 International) license. The
Obstructive salivary gland disease is a relatively common event; it has been                         article can be used by giving appropriate credit and mentio-
                                                                                                     ning the license, but only for non-commercial purposes and
estimated, in England, that the incidence of symptomatic sialadenitis and                            only in the original version. For further information: https://
sialolithiasis accounts for 27.5 and 31.5 per million population per annum                           creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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respectively 1; stones are the main obstructive cause, es-     recurrence of obstructive sialadenitis; moreover, in case
pecially in the submandibular gland (80%), followed by         of recurrence, the surgeon should be experienced enough
duct stenoses and anomalies 2, autoimmune inflammatory         to manage these cases and be able to perform additional
disorders such as Sjogren’s disease and immunoglobulin         endoscopic or surgical procedures in a patient, previously
(Ig) G4-related chronic sclerotising sialadenitis 3, radio-    treated, with possible inflammatory or fibrotic sequelae.
iodine induced parotitis 4, foreign bodies 4, and juve-        The aim of this paper is to review the published expe-
nile recurrent parotitis (JRP) 5. Over the last 20 years,      rience on management of recurrent obstructive salivary
interventional sialendoscopy has become the therapy of         disease after sialendoscopy and briefly describe the addi-
choice for management of obstructive salivary disorders,       tional therapeutic options available, including traditional
favouring a significant reduction in the number of patients    sialadenectomy as a possible salvage surgery (Fig. 1).
undergoing traditional sialadenectomy 4. The key role of
sialendoscopy in the gland-preserving management of            Salivary stones
obstructive sialadenitis has been highlighted in the inter-
national literature, but only a few multicentre studies of     First introduced in clinical practice in the 1990s, interven-
large series of patients with a long-term follow-up have       tional sialendoscopy (intSE), together with extracorpor-
been published to date 1,3,4. An Italian multicentre study 4   eal shock-wave lithotripsy (ESWL), intracorporeal laser
studied 1152 patients (553 females; mean age 50 years)         (ILL) or pneumatic lithotripsy (IPL), and transoral duct
who, after clinical and radiological assessment, under-        surgery (TDS), has become part of a novel therapeutic
went a total of 1342 diagnostic and interventional sialen-     work-up for obstructive sialolithiasis, and has contributed
doscopies, 44.6% of which involved the parotid gland;          to reduce the rate of gland resection from 40%-50% to
in this series, 12% (n = 138) of patients underwent mul-       less than 5% 6,7. Prognostic factors influencing therapeu-
tiple treatments to pursue the goal of obtaining recovery      tic success are size, location and mobility of the stone, in
of obstructive symptoms. Salivary stones were the main         combination with the anatomy of the duct system and its
cause of obstruction (55%), followed by ductal stenosis        variations 8. One international report published in 2009
and anomalies (16%), mucous plugs (14.5%) and sialo-           summarised the results after treatment of around 4,700
dochitis (4.7%). While the procedure was successful in         cases in 5 salivary gland centers adopting minimally-
1,309 cases, in 33 cases (2.4%) the procedure could not        invasive treatment procedures: 80.5% of patients were
be concluded mainly because of complete salivary duct          completely cured (stone-free and symptom-free), 16.7%
stenosis (21 cases). Complete therapeutic success was ob-      were partially cured (symptom-free, but not stone-free),
tained in 92.5% of patients after one or more procedures       and 2.9% had to undergo gland resection 8. In this case se-
and was ineffective in < 8% (86 patients). Moreover, in        ries, a total of 1,522 patients were treated by intSE: stones
this case series, the therapeutic success was obtained with    were eradicated in 1,394 (91.6%); some stone fragments
one treatment in 752 patients (65.3%), and in 11.3% of         persisted, and partial success was obtained in 79 (5.2%)
patients after multiple treatments. Finally, in 184 patients   of cases and treatment was unsuccessful in 49 (3.2%). In
(15.9%), the therapeutic success was partial. Zenk et al. 6,   all, 70 patients were subsequently treated with other tech-
in a study involving 1,154 patients treated for parotid and    niques, and 52 refused further intervention or were lost
submandibular stones (5% and 22%, respectively), de-           to follow-up. After further treatment, the overall success
scribed a success rate of > 90% and 98%, although most         rate was 1,460/1,522 (95.9%), and partial success was
patients underwent a combination of endoscopic and tran-       achieved in 57/1,522 (3.7%). In 5/1,522 patients (0.3%),
soral procedures; the authors concluded that sialendosco-      the salivary gland was removed. Management of failure
py is an important diagnostic and therapeutic tool in the      after sialendoscopy and therefore persistence or recur-
management of sialolithiasis, but needs to be combined         rence of obstructive sialolithiasis is mainly related to the
with additional techniques to ensure a high rate of stone      location of the stone: a sialendoscopy-assisted transoral
clearance, symptom recovery, and gland preservation.           surgery is the best option technique for submandibular
These large case series demonstrate that sialendoscopy is      stones 9, while an intracorporeal lithotripsy during inter-
an effective therapeutic option in experienced hands, but      ventional sialendoscopy or a transfacial and/or transoral
recurrence can be expected, and the patient is to be in-       approach to the main duct and parenchyma of the parotid
formed about the possibility to undergo further conserva-      gland is usually proposed to the patient 10-13. This differ-
tive procedures to improve symptoms. Adequate clinical         ence in the way of approaching salivary stones is often
and radiological pre-operative assessment is mandatory to      related to the need of balancing therapeutic efficacy with
reduce the risk of unsuccessful procedures and, therefore,     the desire of the patient to avoid facial nerve damage. The



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 CT: Computed Tomography; TORSS: Transoral Robotic Salivary Surgery; MRI: Magnetic Resonance Imaging; JRP: Juvenile Recurrent Parotitis.

Figure 1. Therapeutic algorithm for recurrent obstructive salivary disease after sialendoscopy.

recent clinical experience with sialendoscopy-assisted la-
ser and pneumatic intracorporeal lithotripsy (ISWL), has
contributed to pursuing the minimal invasive therapeutic
pathway 11.
A separate consideration is management of pure unpalpa-
ble parenchymal stones. In the past, ESWL was consid-
ered to be the best option, especially for parotid stones,
but nowadays this technique has almost been abandoned
and is available in very few centres in Europe (10). In-
terventional sialendoscopy with ESWL or ISWL can be
useless if the stone is not reachable due to acute duct an-
gles of the secondary branches of duct system and this is
the case in 5%-15% of stones. A sialendoscopy-assisted
transfacial approach with computed tomography (CT)
navigation (Fig. 2) has been recently proposed for inac-
cessible and unpalpable parenchymal parotid stones 14,15.
With regards to pure parenchymal submandibular stones,
sialendoscopy-assisted transoral robotic salivary sur-
gery (TORSS) has been recently described for unpalpa-
ble stones 16. Finally, botulinum toxin therapy finalised
to functional silencing of the affected gland may be pro-
posed to patients with recurrent obstructive disease after
sialendoscopy before planning traditional invasive sialad-                              Figure 2. Sialendoscopy-assisted transfacial approach with CT navigation
enectomy.                                                                               guidance for an unpalpable parotid stone.



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P. Capaccio et al.




Duct stenosis
Two main classification of duct strictures have been pub-
lished to date. Koch et al. 17 divided these in three types:
• type I: marked inflammation, slight fibrotic remodelling
   of the wall, obstructive plaques;
• type II: fibrotic stenosis, short segment slight to moder-
   ate (< 50%) narrowing, “web-like” or megaduct;
• type III: marked fibrotic stenosis, high grade obstruction
   (> 50%), segmental or diffuse fibrotic reaction.
ESGS classification identified 5 different conditions:
S0: no stenosis; S1: intraductal diaphragmatic stenosis;
S2: unique main duct stenosis; S3: multiple or diffuse main
duct stenosis; S4: generalised ductal stenosis 2.
The development of minimally-invasive treatment options
for salivary duct stenosis, including sialendoscopy-assisted
procedures, has led to a significant reduction in the failure
rate after conservative treatment and therefore in the rate
of gland resection 4, which now accounts for less than 10%
of cases. According to Koch et al. 17, sialendoscopy-guided
therapy fails in 10.7% and 5.2% of patients, respectively,
for the parotid and submandibular glands. Failures may be
secondary to inadequate pre-operative diagnostic work-up,
which is essential to obtain a precise characterisation of
stenoses and choose the ideal treatment. From a diagnostic
point of view, traditional sialography has been progressive-
ly replaced by dynamic ultrasonography (US) and magnet-
ic resonance (MR) sialography; in particular, dynamic MR
sialography (stimulation with citric acid) does not require      Figure 3. Transoral (sialodochoplasty) sialendoscopy-assisted approach for
                                                                 parotid duct stenosis.
contrast media 4 since saliva is used as a natural contrast
due to specific sequences and this permits to outline and
depict the normal and pathologic anatomical course of the
salivary duct system. MR-sialography may be not sufficient
to identify duct anomalies, and in particular type I inflam-
matory stenoses that can be better visualised by diagnos-
tic sialendoscopy 17. According to Koch et al. 17,18, parotid
sialendoscopy is useful for type I inflammatory limited
circumferential stenosis, while for type II (severe stenosis
with megaduct) and III stenoses (severe diffused stenosis),
the best approach is use of combined procedures: in such
cases, a transoral 19 (Fig. 3) or transfacial sialendoscopy-
assisted approach 13,14 can be useful to restore salivary duct
patency and resolve the stenosis. Moreover, in case of a dif-
ficult anatomical situation secondary to recurrent infection
and/or previous surgery with complete scarring of the duct
and anatomical distortion, increasing the risk of failure or
intra-operative facial nerve injury, an imaging-assisted ap-
proach 14,15 with CT and/or MRI guidance (Fig. 4) can be
useful to achieve therapeutic success. Intraparenchymal
injection of botulinum toxin 20 under US-guidance to si-
lence the gland and/or parotidectomy can be considered as        Figure 4. CT/MRI-assisted transoral approach for a parotid duct stenosis.



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alternative options in case of recurrence of parotid duct ste-         controlled trial showed that sialendoscopy resulted in an
nosis, since ligature of the parotid duct is effective in only         increased salivary flow during follow-up over 60 weeks and
50% of patients 17.                                                    reduced xerostomia 35. Furthermore, irrigating the duct sys-
Submandibular duct stenosis can be adequately managed                  tem with saline and/or steroid solution can also alleviate
after failure of sialendoscopy by a sialendoscopy-assisted             complaints in patients with inflammatory disease (Fig. 5).
transoral approach with positioning of a salivary stent to             A recent systematic literature review provided support for
guarantee the long-term patency of salivary duct lumen 8;              the use of sialendoscopy in the treatment of SJS sialad-
adequate pre-operative imaging work-up with US and MR-                 enitis with an expected, at least temporary, improvement
sialography is mandatory to define the exact location and              of symptoms in 90% to 99% of cases 36. Furthermore, we
type of stenosis. Submandibular sialadenectomy is advo-                have recently shown that interventional sialendoscopy with
cated only in the case of hilar or intraparenchymal stenosis.          steroid duct irrigation significantly reduces the number of
                                                                       painful episodes of sialadenitis and improves the subjec-
Autoimmune obstructive sialadenitis                                    tive sensation of oral dryness and other disease symptoms
                                                                       in patients with SJS; in terms of recurrence, the beneficial
Autoimmune diseases of major salivary glands essentially               effects of interventional sialendoscopy is reduced if only
include Sjögren’s syndrome and a complex of disorders                  interventional sialendoscopy is performed without a cycle
classified as IgG4 related diseases. Sjögren’s syndrome                of outpatient steroid duct irrigations, and increases when
(SJS) is a systemic autoimmune disease that affects 0.2%-              it is combined with a cycle of outpatient steroid ductal ir-
0.4% of the general population. It is characterised by an              rigations, with an objective clinical improvement of 75 and
immuno-mediated destruction of exocrine glands (mainly                 87%, respectively 37. With regard to IgG4-related disease,
salivary and lacrimal glands) and often by B lymphocyte                both Mikuliz’s disease and Kuttner’s disease have recently
activation and proliferation with production of auto-anti-             been considered as variations of IgG4-related sialadenitis
bodies, such as rheumatoid factor (RF), anti-SS-A/Ro and               that most frequently involves the submandibular gland.
anti-SS-B/La 21,22. The precise aetiology of SJS is unknown,           Biopsy of the affected gland is necessary to formulate a
but is probably triggered by both genetic and environmen-              diagnosis of IgG4-related sialadenitis, although lip biopsy
tal factors. Patients with SS are usually enrolled according           has been proposed as an alternative technique; serum IgG4
to the 2002 American-European Consensus Group (AECG)                   concentration > 135 mg/dl has been defined as a thresh-
criteria 23; almost recently a joint venture between SJS rec-          old value for diagnosis. Traditional management of this
ognised experts from the American College of Rheuma-                   salivary disorder was based on sialadenectomy. Long-term
tology (ACR) and European League Against Rheumatism                    systemic steroid therapy is nowadays considered first-line
(EULAR) have produced a new set of criteria for SJS that               treatment and prednisone represents the most widely used
has been recently published 24. An international steering              drug. Our initial evidence in treating patients with IgG4-
committee of the European League Against Rheumatism                    related sialadenitis by interventional sialendoscopy and ir-
(EULAR) SJS Task Force has also developed two disease                  rigations with steroids is that this therapy has a transitory
activity indices: the EULAR Sjögren’s Syndrome Patient
Reported Index (ESSPRI), which measures the symptoms
of patients with primary SJS in 3 domains (dryness, pain, fa-
tigue) using 0-10 numerical scales 25-27 and the EULAR SJS
Disease Activity Index (ESSDAI) 26-28 that provides a stand-
ardised instrument for homogeneous evaluation of system-
ic activity in clinical trials and daily practice 23,29. This latter
scoring system is composed by a number of domains for
different organs and systems. The glandular domain allows
grading the swelling of submandibular and parotid glands
by a semiquantitative method. The management of SJS pa-
tients is still debated because there is no effective treatment
for the disease as a whole 29 and low-dose systemic steroid
therapy is often ineffective for the management of recur-
rent sialadenitis 30. Interventional sialendoscopy has been
described as an alternative means of controlling the num-
ber of episodes of sialadenitis 31-34. A recent randomised             Figure 5. Outpatient intraductal steroid irrigation.



                                                                                                                                             S99
P. Capaccio et al.




beneficial effect but is ineffective overall, thus favouring     methasone) 39. Recent published case series report com-
recurrence of sialadenitis if not associated with long-term      plete therapeutic success after one sialendoscopy in about
systemic steroid therapy.                                        75% of cases, and a higher success rate after multiple pro-
                                                                 cedures 5,41,42: in a series of 32 consecutive patients, Capac-
Radioiodine-induced sialadenitis                                 cio et al. 41 reported complete therapeutic success in 25 pa-
                                                                 tients, while in three cases a second endoscopic procedure
Interventional sialendoscopy has been recognised as an           was useful for relief of symptoms; one of the four remain-
efficient therapeutic option for radioiodine-induced si-         ing patients was treated with medical therapy (steroid and
aladenitis if standard medical treatments (hydration, siala-     non-steroid anti-inflammatory drugs, sialogogues); Ezer et
gogues, anti-inflammatory drugs) fail 38. The parotid gland      al. 42 reported that over 75% of patients treated with inter-
is most frequently affected due to a better ability to intake    ventional sialendoscopy had no JRP recurrences after mul-
iodine in comparison with the submandibular gland 39.            tiple procedures (usually three sialendoscopies). The main
The subsequent salivary gland obstruction, secondary to          reason for recurrence of the disease could be intrinsic in the
parenchymal injuries due to an increased permeability of         nature of this condition: some studies have suggested that
the gland vascular endothelium with leakage of proteins          the pathophysiology of JRP is immune-mediated, as shown
and electrolytes, is responsible of the fibrotic and stenotic    by colour Doppler US findings of reactive lymphatic tissue
feature of the main Stensen’s duct and its branches; inter-      in the affected glands 41, and by the histopathologic evi-
ventional sialendoscopy, mainly based on ductal hydraulic        dence of lymphocyte infiltrates near the salivary ducts 41,42
dilation with saline solution plus steroids, and in case of      in children undergoing parotidectomy. Indeed, most of our
stenosis on ductal balloon dilation, is effective in 89.3%       patients with JRP show high grade of adeno-tonsillar hy-
of cases, as reported by a recent review of the literature in-   pertrophy or had previously undergone tonsillectomy and/
cluding 122 patients and 264 sialendoscopic procedures 40.       or adenoidectomy 5 thus confirming the exuberant lym-
In this series, complete therapeutic success was achieved        phatic reactivity of these patients for whom irrigation with
in 33.1% of patients, and partial success in 56.2% of pa-        saline solution and steroids may be not sufficient to com-
tients, with 5.9% of patients requiring multiple procedures.     pletely extinguish the immunological burning state; moreo-
The rate of unsuccessful treatment, and thus the rate of si-     ver, it has been previously reported that controlling general
aladenitis recurrence, was 10.7% (13 patients); one patient      concomitant comorbidities such as atopy, associated with
(0.8%) underwent parotidectomy for severe obstructive            JRP in severe cases, may help in controlling symptoms and
disease. The rate of recurrences is similar to that of stones    the pathology 42. In reality, the management of recurrences,
and stenosis, with about 10% of patients having persisting       especially when multiple sialendoscopies have been per-
symptoms and recurrent inflammation. In such cases, a cy-        formed with any or partial success, is still based on medical
cle of outpatient duct irrigation with steroids can further      therapy, as previously described.
contribute to silence the inflammatory reaction of the duct
system 40; moreover, the use of oral steroids may help in        Conclusions
controlling the severity of symptoms. To date, none of the
patients treated with interventional sialendoscopy plus out-     In the last 30 years, the development and the diffusion of
patient steroid duct irrigations had to undergo transcervical    minimally-invasive and conservative procedures such as
sialadenectomy in our long-term clinical experience 4.           extracorporeal and intracorporeal lithotripsy, interventional
                                                                 sialendoscopy, sialendoscopy-assisted transoral and trans-
                                                                 facial surgical approaches for management of obstructive
Juvenile Recurrent Parotitis (JRP)                               salivary disease has dramatically reduced the indication
Sialendoscopy is a valid and safe diagnostic and therapeu-       for traditional invasive parotidectomy or submandibular si-
tic tool for management of JRP; the procedure is usually         aladenectomy; in favour of those who supported the choice
performed under general anaesthesia, but local anaesthesia       of gland removal, there was previous evidence of asso-
and deep sedation have been recently described 5. Typical        ciation of chronic inflammatory condition of the affected
endoscopic features of JRP are whitish appearance of the         gland in 65% of patients with sialolithiasis and a recurrence
duct wall, mucous plugs, duct kinking and fibrotic stric-        rate of about 50% in patients undergoing a cycle of extra-
tures; interventional sialendoscopy is essentially performed     corporeal shock-wave lithotripsy 43. On the other hand, the
by hydraulic dilation of the duct system up to the tertiary      long-term experience acquired in dedicated international
ductal branches thanks to continuous irrigation with saline      centres demonstrated, in particular for salivary stones, that
solution and final irrigation with steroids (usually dexa-       multimodal therapy i.e., the combination of multiple thera-



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                                                                                                               Recurrence after sialendoscopy




peutic procedures such as extracorporeal or intracorporeal       manuscript, approval of the manuscript’s submission.
lithotripsy and interventional sialendoscopy, is more effec-
tive in terms of recurrence than each therapeutic modality       Ethical consideration
used individually. Clear indications are now available in        Ethics approval was not required for this study because it
the literature based on different classification criteria, but   was based on published studies.
with the common evidence that by exactly following those
indications the risk of recurrence after sialendoscopy is ex-    References
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type I inflammatory stenoses, while sialendoscopy-assisted       7
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and therefore of multiple salivary procedures. Interven-         8
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doscopic procedure is necessary in some patients to obtain       9
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JRP. The role of interventional sialendoscopy in patients        10
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with IgG4-related sialadenitis is still debated, since very           tracorporeal shock wave lithotripsy in sialolithiasis therapy. HNO
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                                                                 11
                                                                      Koch M, Schapher M, Sievert M, et al. Intraductal fragmentation in
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Conflict of interest statement                                        sults. Otolaryngol Head Neck Surg 2022;167:457-464. https://doi.
The authors declare no conflict of interest.                          org/10.1177/01945998211051296
                                                                 12
                                                                      Roland LT, Skillington SA, Ogden MA. Sialendoscopy-assisted
Funding                                                               transfacial removal of parotid sialoliths: a systematic review and
                                                                      meta-analysis. Laryngoscope 2017;127:2510-2516. https://doi.
This research did not receive any specific grant from fund-           org/10.1002/lary.26610
ing agencies in the public, commercial, or not-for-profit        13
                                                                      Overton A, Combes J, McGurk M. Outcome after endoscopi-
sectors.                                                              cally assisted surgical retrieval of symptomatic parotid stones. Int J
                                                                      Oral Maxillofac Surg 2012;41:248-251. https://doi.org/10.1016/j.
Author contributions                                                  ijom.2011.10.010
PC, MG: study conception, acquisition and analysis of da-
                                                                 14
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the manuscript. All authors: review of the final draft of the         lary.27621




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