Transfacial Ultrasound-guided Gland-preserving Resection ...Poster Design & Printing by...
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Poster Design & Printing by Genigraphics ® - 800.790.4001 M. Boyd Gillespie, M.D., M.Sc. Department of Otolaryngology – Head and Neck Surgery Medical University of South Carolina 135 Rutledge Avenue MSC 550 Charleston, SC 29425-5500 Ph (843) 792-6012 Fax (843) 792-0546 Email [email protected] Objective. Review surgical techniques and outcomes of ultrasound-guided, transfacial, gland-preserving removal of difficult parotid stones. Study Design. Retrospective case series. Methods. Patients who underwent ultrasound- guided, combined transfacial-endoscopic operation for symptomatic parotid sialolithiasis from June 2010 through June 2012 at two tertiary care university hospitals were evaluated. Outcome measurements included stone size, stone location, complications, symptom relief and gland preservation rate. Results. A total of fourteen patients underwent ultrasound-guided, transfacial operation for symptomatic parotid sialolithiasis. Ten out of fourteen patients (71%) had completely successful therapy defined by no symptoms post-operatively with a preserved, functional gland. Three of the four patients without complete symptom resolution did endorse symptom improvement, while the fourth patient eventually underwent parotidectomy. Needle localization was used to aid in transfacial stone retrieval in 57% of cases. Conclusion. Ultrasound-guided, combined transfacial-endoscopic removal of certain parotid stones is a safe and suitable alternative to parotidectomy for patients in whom endoscopy or shock wave therapy for stone retrieval is ineffective, unavailable or contraindicated. Needle localization is a useful adjunct in stone retrieval. Transfacial Ultrasound-guided Gland-preserving Resection of Parotid Sialoliths William W. Carroll, M.D. 1 ; Rohan R. Walvekar, M.D. 2 ; M. Boyd Gillespie, M.D., M.Sc 1 1 Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 2 Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana. • Complete success: 71% (10/14) were symptom & stone free with a preserved gland at a median follow-up of 12 months • Partial treatment success: 21% (3/14) had mild obstruction despite being stone free at a median follow-up of 10 months but were improved from preoperative baseline. There was no difference between symptom- free and symptomatic patients with regard to stone size (7.5 mm versus 7.7 mm) or rate of multiple stones (20% v. 33%). • Treatment failure: One patient (7%) had a large stone at the hilum removed, but a second, deep stone could not be removed due to proximity to the main trunk of the facial nerve. This patient subsequently underwent parotidectomy after 4 months of follow-up. • Study Design. Retrospective case series of fourteen adult patients who failed medical therapy. Included in this study were those patients who underwent conversion from endoscopy alone to combined transfacial endoscopic surgery with intra-operative ultrasound. •Surgical technique. • General anesthesia and nasotracheal intubation • Ostium visualized and dilated with a series of Marchal probes (Karl Storz, Endoscopy, Culver City, CA) followed by wider dilation with a tapered dilator. A 0.8 mm diameter Erlangen endoscope (Karl Storz) was used to locate stone, flush out debris, and dilate. Then 1.1 mm and 1.6 mm scopes with working channels were used for endoscopic removal. Conversion to transfacial approach was utilized for stones not amenable to endoscopic retrieval alone. • The location of the underlying stone was marked on the skin (Fig 1a & b) • Buccal branch was monitored above the oral commissure (Fig 2a). • An iodine drape with a hole cut at the mouth allowed for endoscopic oral access (Fig 2b). Ultrasound-guided, transfacial/endoscopic combined resection of certain parotid stones is a safe and suitable alternative to parotidectomy for patients in whom endoscopy or shock wave therapy for stone retrieval is ineffective, unavailable or contraindicated. Needle localization is a safe and useful adjunct in stone retrieval. Additional long-term follow up and prospective trials with larger cohorts are needed to better determine the role of this surgical technique in the management of chronic sialadenitis. • Chronic sialadenitis of the major salivary glands is a common disorder encountered by head and neck surgeons. It is estimated that annually, 30 to 60 people per million require treatment for symptomatic sialadenitis caused by obstructive stones (1). • Forty percent of cases fail to respond to conservative treatment and these patients traditionally underwent parotidectomy (2). However, pathologic analyses demonstrate a normal and functioning gland excluding the obstruction in most cases (3,4). Parotidectomy for chronic sialadenitis is associated with prolonged (>3 months) facial paresis in up to 25% to 60% of patients, with permanent facial paralysis estimated at twice that observed with treatment of benign tumors (5). • Minimally invasive, gland-preserving technologies have emerged over the last two decades, eliminated the need for gland resection in the majority of patients. • An estimated 10% of parotid stones, however, remain resistant to treatment (6). Stones that are > 6 mm in size, adherent to the duct wall or intraglandular in location are often impervious to SGE alone. • Here we report several cases using a combined transfacial- endoscopic approach with the addition of intraoperative ultrasound, with or without needle localization. The aim of this study is to review surgical techniques and initial outcomes. INTRODUCTION METHODS AND MATERIALS 1. Escudier MP, McGurk M. Symptomatic sialadenitis and sialolithiasis in the English population, an estimate of the cost of hospital treatment. Br Dent J. 1999;186:463-466. 2. O’Brien CJ, Murrant NJ. Surgical management of chronic parotitis. Head Neck 1993;15:445–449. 3. Su YX, Xu JH, Liao GQ, et al. Salivary gland functional recovery after sialendoscopy. Laryngoscope. 2009;119: 646–652 4. Marchal F, Kurt AM, Dulguerov P, et al. Histopathology of submandibular glands removed for sialolithiasis. Ann Otol Rhinol Laryngol. 2001;110:464– 469. 5. Moody AB, Avery CM, Walsh S, et al. Surgical management of chronic parotid disease. Br J Oral Maxillofac Surg. 2000;38:620–622. 6. Koch M, Bozzato A, Iro H, et al. Combined endoscopic and transcutaneous approach for parotid gland sialolithiasis: Indications, technique and results. Otolaryngol Head Neck Surg. 2010; 142:98-103. 7. Nahlieli O, London D, Zagury A, et al. Combined approach to impacted parotid stones. J Oral Maxillofac Surg. 2002;60:1418–1423. 8. McGurk M, MacBean AD, Fan KF, et al. Endoscopically assisted operative retrieval of parotid stones. Br J Oral Maxillofac Surg. 2006; 44:157– 160. 9. McGurk M, MacBean A, Fan K, et al. Conservative management of salivary stones and benign parotid tumours: a description of the surgical techniques. Ann R Austalas Coll Dent Surg. 2004; 17:41-44. 10. Marchal F. A combined endoscopic and external approach for extraction of large stones with preservation of parotid and submandibular glands. Laryngoscope. 2007;117:373– 377. 11. Walvekar R, Bomeli S, Carrau R, et al. Combined approach technique for the management of large salivary stones. Laryngoscope. 2009; 119:1125-1129. CONCLUSIONS REFERENCES Figure 1. Ultrasound was used to identify the stone (a), allowing marking of the overlying skin (b). Figure 2. The facial nerve monitor was placed to monitor the buccal branch of the nerve (a), followed by placement of an iodoform drape (b). ABSTRACT CORRESPONDENCE Figure 3. A sterilely covered ultrasound probe (a) allowed needle localization of the stone (b). Figure 4. The stone was exposed and removed (a) followed by exploration of the open duct for addition fragments with the endoscope (b). 1a 1b 2a 2b 3a 3b 4a 4b RESULTS • Surgical technique. • A modified Blair incision was made & flaps raised over parotid gland fascia, preserving the sensory branches of the great auricular nerve. • The stone was visualized with ultrasound and in some cases, a 23- gauge needle was inserted (Fig 3a & b). The parotid fascia was incised overlying the stone. • Blunt dissection with a fine hemostat along the needle tract. If a facial nerve branch was visualized, it was traced out and preserved. • The duct was opened with an 11-blade & the stone(s) removed with Rosen needles & cerumen curettes (Fig 4a). • The endoscope & ultrasound were then used to investigate for retained fragments (Fig 4b). • The duct was repaired with 5-0 PDS suture and the parotid fascia reapproximated with 4.0 vicryl. • A stent was placed endoscopically if the main Stensen’s duct was stenosed or strictured. A compressive dressing was applied for 72 hours. • Mean age: 52 years old (range, 31-66 years). • Sex: Male (64%; 9/14), Female (36%; 5/14) • Four patients (29%) had multiple stones. • Intra-operative ultrasound use: (100%; 14/14) • Needle localization: (57%; 8/14). • Facial nerve visualization: (36%; 5/14). • Mean size of removed stones: 7.7 mm (range, 2-12 mm). • Reasons for conversion to transfacial-endoscopic-approach: • (1) intraglandular stones in ducts too small to be visualized with the endoscope (40%; 8/20 stones) • (2) significant stenosis/scar that limited approach (30%; 6/20 stones) • (3) stone too large/hard/adherent to duct wall to fragment (30%; 6/20 stones) • Complications: • Facial weakness (0%) • Mild periauricular anesthesia in two patients (14%) • One sialocele – resolved with 10 days of robinol & 2 needle aspirations • One salivary fistula – resolved with pressure dressing DISCUSSION • The present study is comparable in success rates to previous studies using combined endoscopic transfacial methods (6-11). The majority of patients (93%) were rendered stone free with symptomatic improvement, of which 71% were completely asymptomatic. • Unique to our series is the method of combining intraoperative ultrasound with needle localization, which afforded easier and quicker access to certain stones and was safe (no facial nerve injuries). •A combined transfacial and endoscopic procedure is indicated for: • (1) large stones (>6mm) • (2) stones adherent to the duct wall • (3) parenchymal stones (without access to lithotripsy) • (4) failed attempts at stone removal with other procedures • (5) patient specific contraindications (such as a stenotic ostium)
Transcript of Transfacial Ultrasound-guided Gland-preserving Resection ...Poster Design & Printing by...
Poster Design & Printing by Genigraphics® - 800.790.4001
M. Boyd Gillespie, M.D., M.Sc.Department of Otolaryngology – Head and
Neck SurgeryMedical University of South Carolina
135 Rutledge Avenue MSC 550Charleston, SC 29425-5500
Ph (843) 792-6012Fax (843) 792-0546
Email [email protected]
Objective. Review surgical techniques and outcomes of ultrasound-guided, transfacial, gland-preserving removal of difficult parotid stones.
Study Design. Retrospective case series.
Methods. Patients who underwent ultrasound-guided, combined transfacial-endoscopic operation for symptomatic parotid sialolithiasis from June 2010 through June 2012 at two tertiary care university hospitals were evaluated. Outcome measurements included stone size, stone location, complications, symptom relief and gland preservation rate.
Results. A total of fourteen patients underwent ultrasound-guided, transfacial operation for symptomatic parotid sialolithiasis. Ten out of fourteen patients (71%) had completely successful therapy defined by no symptoms post-operatively with a preserved, functional gland. Three of the four patients without complete symptom resolution did endorse symptom improvement, while the fourth patient eventually underwent parotidectomy. Needle localization was used to aid in transfacial stone retrieval in 57% of cases.
Conclusion. Ultrasound-guided, combined transfacial-endoscopic removal of certain parotid stones is a safe and suitable alternative to parotidectomy for patients in whom endoscopy or shock wave therapy for stone retrieval is ineffective, unavailable or contraindicated. Needle localization is a useful adjunct in stone retrieval.
Transfacial Ultrasound-guided Gland-preserving Resection of Parotid SialolithsWilliam W. Carroll, M.D.1; Rohan R. Walvekar, M.D.2; M. Boyd Gillespie, M.D., M.Sc1
1Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 2Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana.
• Complete success: 71% (10/14) were symptom & stone free with a preserved gland at a median follow-up of 12 months
• Partial treatment success: 21% (3/14) had mild obstruction despite being stone free at a median follow-up of 10 months but were improved from preoperative baseline. There was no difference between symptom-free and symptomatic patients with regard to stone size (7.5 mm versus 7.7 mm) or rate of multiple stones (20% v. 33%).
• Treatment failure: One patient (7%) had a large stone at the hilum removed, but a second, deep stone could not be removed due to proximity to the main trunk of the facial nerve. This patient subsequently underwent parotidectomy after 4 months of follow-up.
• Study Design. Retrospective case series of fourteen adult patients who failed medical therapy. Included in this study were those patients who underwent conversion from endoscopy alone to combined transfacial endoscopic surgery with intra-operative ultrasound.
•Surgical technique.
• General anesthesia and nasotracheal intubation
• Ostium visualized and dilated with a series of Marchal probes (Karl Storz, Endoscopy, Culver City, CA) followed by wider dilation with a tapered dilator. A 0.8 mm diameter Erlangen endoscope (Karl Storz) was used to locate stone, flush out debris, and dilate. Then 1.1 mm and 1.6 mm scopes with working channels were used for endoscopic removal. Conversion to transfacial approach was utilized for stones not amenable to endoscopic retrieval alone.
• The location of the underlying stone was marked on the skin (Fig 1a & b)
• Buccal branch was monitored above the oral commissure (Fig 2a).
• An iodine drape with a hole cut at the mouth allowed for endoscopic oral access (Fig 2b).
Ultrasound-guided, transfacial/endoscopic combined resection of certain parotid stones is a safe and suitable alternative to parotidectomy for patients in whom endoscopy or shock wave therapy for stone retrieval is ineffective, unavailable or contraindicated. Needle localization is a safe and useful adjunct in stone retrieval. Additional long-term follow up and prospective trials with larger cohorts are needed to better determine the role of this surgical technique in the management of chronic sialadenitis.
• Chronic sialadenitis of the major salivary glands is a common disorder encountered by head and neck surgeons. It is estimated that annually, 30 to 60 people per million require treatment for symptomatic sialadenitis caused by obstructive stones (1).
• Forty percent of cases fail to respond to conservative treatment and these patients traditionally underwent parotidectomy (2). However, pathologic analyses demonstrate a normal and functioning gland excluding the obstruction in most cases (3,4). Parotidectomy for chronic sialadenitis is associated with prolonged (>3 months) facial paresis in up to 25% to 60% of patients, with permanent facial paralysis estimated at twice that observed with treatment of benign tumors (5).
• Minimally invasive, gland-preserving technologies have emerged over the last two decades, eliminated the need for gland resection in the majority of patients.
• An estimated 10% of parotid stones, however, remain resistant to treatment (6). Stones that are > 6 mm in size, adherent to the duct wall or intraglandular in location are often impervious to SGE alone.
• Here we report several cases using a combined transfacial-endoscopic approach with the addition of intraoperative ultrasound, with or without needle localization. The aim of this study is to review surgical techniques and initial outcomes.
INTRODUCTION
METHODS AND MATERIALS
1. Escudier MP, McGurk M. Symptomatic sialadenitis and sialolithiasis in the English population, an estimate of the cost of hospital treatment. Br Dent J. 1999;186:463-466.
2. O’Brien CJ, Murrant NJ. Surgical management of chronic parotitis. Head Neck 1993;15:445–449.
3. Su YX, Xu JH, Liao GQ, et al. Salivary gland functional recovery after sialendoscopy. Laryngoscope. 2009;119: 646–652
4. Marchal F, Kurt AM, Dulguerov P, et al. Histopathology of submandibular glands removed for sialolithiasis. Ann Otol Rhinol Laryngol. 2001;110:464– 469.
5. Moody AB, Avery CM, Walsh S, et al. Surgical management of chronic parotid disease. Br J Oral Maxillofac Surg. 2000;38:620–622.
6. Koch M, Bozzato A, Iro H, et al. Combined endoscopic and transcutaneous approach for parotid gland sialolithiasis: Indications, technique and results. Otolaryngol Head Neck Surg. 2010; 142:98-103.
7. Nahlieli O, London D, Zagury A, et al. Combined approach to impacted parotid stones. J Oral Maxillofac Surg. 2002;60:1418–1423.
8. McGurk M, MacBean AD, Fan KF, et al. Endoscopically assisted operative retrieval of parotid stones. Br J Oral Maxillofac Surg. 2006; 44:157– 160.
9. McGurk M, MacBean A, Fan K, et al. Conservative management of salivary stones and benign parotid tumours: a description of the surgical techniques. Ann R Austalas Coll Dent Surg. 2004; 17:41-44.
10. Marchal F. A combined endoscopic and external approach for extraction of large stones with preservation of parotid and submandibular glands. Laryngoscope. 2007;117:373–377.
11. Walvekar R, Bomeli S, Carrau R, et al. Combined approach technique for the management of large salivary stones. Laryngoscope. 2009; 119:1125-1129.
CONCLUSIONS
REFERENCES
Figure 1. Ultrasound was used to identify the stone (a), allowing marking of the overlying skin (b).
Figure 2. The facial nerve monitor was placed to monitor the buccal branch of the nerve (a), followed by placement of an iodoform drape (b).
ABSTRACT
CORRESPONDENCE
Figure 3. A sterilely covered ultrasound probe (a) allowed needle localization of the stone (b).
Figure 4. The stone was exposed and removed (a) followed by exploration of the open duct for addition fragments with the endoscope (b).
1a 1b
2a 2b
3a 3b
4a 4b
RESULTS• Surgical technique.
• A modified Blair incision was made & flaps raised over parotid gland fascia, preserving the sensory branches of the great auricular nerve.
• The stone was visualized with ultrasound and in some cases, a 23-gauge needle was inserted (Fig 3a & b). The parotid fascia was incised overlying the stone.
• Blunt dissection with a fine hemostat along the needle tract. If a facial nerve branch was visualized, it was traced out and preserved.
• The duct was opened with an 11-blade & the stone(s) removed with Rosen needles & cerumen curettes (Fig 4a).
• The endoscope & ultrasound were then used to investigate for retained fragments (Fig 4b).
• The duct was repaired with 5-0 PDS suture and the parotid fascia reapproximated with 4.0 vicryl.
• A stent was placed endoscopically if the main Stensen’s duct was stenosed or strictured. A compressive dressing was applied for 72 hours.
• Mean age: 52 years old (range, 31-66 years). • Sex: Male (64%; 9/14), Female (36%; 5/14)• Four patients (29%) had multiple stones.
• Intra-operative ultrasound use: (100%; 14/14) • Needle localization: (57%; 8/14). • Facial nerve visualization: (36%; 5/14). • Mean size of removed stones: 7.7 mm (range, 2-12 mm).
• Reasons for conversion to transfacial-endoscopic-approach: • (1) intraglandular stones in ducts too small to be visualized with the endoscope (40%; 8/20 stones)• (2) significant stenosis/scar that limited approach (30%; 6/20 stones)• (3) stone too large/hard/adherent to duct wall to fragment (30%; 6/20 stones)
• Complications: • Facial weakness (0%)• Mild periauricular anesthesia in two patients (14%)• One sialocele – resolved with 10 days of robinol & 2 needle aspirations• One salivary fistula – resolved with pressure dressing
DISCUSSION• The present study is comparable in success rates to previous studies using combined endoscopic transfacial methods (6-11). The majority of patients (93%) were rendered stone free with symptomatic improvement, of which 71% were completely asymptomatic.
• Unique to our series is the method of combining intraoperative ultrasound with needle localization, which afforded easier and quicker access to certain stones and was safe (no facial nerve injuries).
•A combined transfacial and endoscopic procedure is indicated for:• (1) large stones (>6mm)• (2) stones adherent to the duct wall• (3) parenchymal stones (without access to lithotripsy)• (4) failed attempts at stone removal with other procedures• (5) patient specific contraindications (such as a stenotic ostium)
