Transoral carbon dioxide laser sialolithectomy with topical anaesthesia. A simple, effective, and minimally invasive method

Abstract

Sialolithiasis frequently causes a variable degree of inflammation of the submandibular gland and stone removal can be a critical issue when incursion is deep, causing neck infection or abscess formation. The authors present their 6-year experience of performing sialolithectomy with CO 2 laser. Nineteen patients with stones in Wharton’s duct were treated with CO 2 laser. Topical anaesthesia was applied by maintaining the patient in an upright position after spraying 10% lidocaine onto the oral cavity. The laser was set up in continuous mode at 4–6 W with a focusing spot. Locating the stone was accomplished by manual palpation or lacrimal probe insertion with or without the aid of radiological images. The success rate was 95%; only one procedure was unsuccessful, necessitating stone removal under general anaesthesia. Mean stone size was 0.37 cm. Only one patient developed ranula after laser surgery. The results suggest that transoral CO 2 laser sialolithectomy is simple and safe, with a low incidence of complications, and can be readily managed on an out-patient basis. This technique can be chosen for first-line treatment of sialolithiasis in cases where the stone is above the hilum of Wharton’s duct.

Sialolithiasis is the most frequent cause of diseases affecting the salivary glands. In post-mortem studies, the incidence of sialolithiasis was 1%, although it is estimated to account for 1 per 15,000 hospital admissions . Sialolithiasis results in mechanical obstruction of the salivary duct, causing infection and abscess formation that can become a potential source of deep neck infection. Removal of the stone is clinically important. Various types of lasers are used to treat sialolithiasis, including pulsed-dye laser treatment to fragment salivary stones and treatment with carbon dioxide (CO 2 ) laser or diode laser .

CO 2 laser is the most commonly used laser for surgery of the upper aerodigestive tract. A unique characteristic of CO 2 laser is the scattering of the beam when it encounters hard tissue, which was first reported by B arak et al. in 1993 . A flash or burst of light emanates from hard tissue when contacted by the laser beam, and this phenomenon has been used to locate sialoliths in Wharton’s duct . The authors report their experience with a series of CO 2 laser sialolithectomies over 6 years, including preparation of anaesthesia before laser sialolithectomy, and highlight the low rate of postoperative complications.

Material and methods

Nineteen patients received CO 2 laser surgery for removal of a sialolith in Wharton’s duct ( Fig. 1 A ) in the authors’ department from 2002 to 2008. Each patient’s chart records were reviewed, including their demographic data, methods used to diagnose the disease, size of the sialolith, complications of the sialolith, postoperative complications (e.g. persistent oral pain, weakness of mouth angle or saliva drooling, or tongue movement paralysis), and duration of follow-up.

Fig. 1
(A) A sialolith was noted within the distal part of the left Wharton’s duct (arrow). (B) CO 2 laser was used to incise the mucosa over the sialolith. A whitish stone could be clearly identified (arrow), and no significant blood oozing was noted. (C) Using a curved mosquito hemostat to dilate the incision wound, the stone (arrow) could easily be grasped and removed from the duct. (D) 9 weeks after laser operation, the incision wound was completely healed (arrow). No extravasation of saliva was noted. The left side submandibular gland swelling resolved at the same time.

Before surgery, 2–3 puffs of 10% lidocaine (Xylocaine 10% pump spray, AstraZeneca AB, Södertälje, Sweden) were sprayed onto the floor of the mouth. The patient was seated in an upright position with head leaning slightly forward. After 10–15 min, the patient was asked to spit out as much of the anaesthetic as he/she could. The patient then lay in a supine position on the operating table, draped in traditional fashion. The laser used was an UltraPulse ® Encore™ (Lumenis Inc., Israel). A power setting of 4–6 W in continuous mode was selected. A CO 2 laser with a focusing spot was used to perform a line incision following the path of the duct above the anticipated location of the sialolith ( Fig. 1 B). When a light flash was encountered, the laser was stopped. A curved mosquito hemostat was used to dilate the incision wound slightly and grasp the stone ( Fig. 1 C). The floor of the mouth was loosely closed with 4/O Chromic Catgut when the stone was located in the posterior half of Wharton’s duct; when the stone was in the anterior half of the duct, no suture was placed and the incision was left for secondary intention.

Results

Nineteen patients with submandibular gland duct stones, including 12 males and seven females whose ages ranged from 8 to 54 years (mean 29.9 ± 13.3 years), were treated with CO 2 laser between 2002 and 2008 ( Table 1 ). Before surgery, three patients had oral pain, six patients had tenderness of the floor of the mouth, neck swelling with pain and 10 patients suffered from postprandial neck swelling with pain. Computed tomography (CT) examination was arranged for the six patients with neck swelling because clinical palpation could not provide a definite diagnosis; two of them were admitted to a hospital ward due to severe infection. All patients received transoral laser sialolithectomy under topical anaesthesia within 48 h of diagnosis, and all stones were removed successfully, except one case in which the stone had to be removed under general anaesthesia. The success rate was 95%. The mean size of the stones was 0.37 cm (range 0.1–2.0 cm). None of the 19 cases experienced unhealed fistula formation after surgery ( Fig. 1 D). Only two patients had a short mild tingling sensation during the operation. None of the patients had postoperative complication except one patient with ranula, which might be due to inadvertent injury of the adjacent sublingual gland. All patients were followed for up to 3.5 years (range 1.0–3.5 years).

Table 1
The demographic data, clinical data regarding preoperative diagnostic tool, the size of sialolith, complicated formation of abscess and follow-up time of patients with sialolith treated with carbon dioxide laser.
No. Sex Age Clinical manifestations Preoperative diagnostic image tool Size of the sialolith (cm) Combination of abscess formation within Wharton’s duct Admission to ward or not Postoperative complication Follow-up time (year)
1 M 47 Postprandial neck swelling with pain Occlusal X-ray 1.1 No No 0.5
2 F 18 Oral pain Palpation 0.2 No No 0.7
3 M 50 Oral pain Palpation 0.1 No No 1
4 M 47 Neck swelling with pain CT 0.3 Yes No 1.5
5 M 15 Neck swelling with pain CT 0.4 Yes No 1.5
6 F 29 Neck swelling with pain CT 0.5 Yes Yes 1.5
7 M 54 Postprandial neck swelling with pain Palpation 2.0 No No Ranula formation 2
8 M 34 Postprandial neck swelling with pain Palpation 0.4 No No 2
9 M 40 Neck swelling with pain CT 0.2 Yes No 2
10 M 35 Postprandial neck swelling with pain Palpation 0.5 No No 2
11 M 33 Postprandial neck swelling with pain Palpation 0.3 No No 2.5
12 F 19 Postprandial neck swelling with pain Palpation 0.4 No No 2.5
13 M 29 Neck swelling with pain CT 0.5 Yes Yes 3
14 F 8 Neck swelling with pain CT 0.2 Yes No 3
15 F 18 Postprandial neck swelling with pain Palpation 0.5 No No 3.5
16 F 15 Postprandial neck swelling with pain US (neg), palpation 0.3 No No 3.5
17 F 19 Oral pain Palpation 0.1 No No 3.5
18 M 30 Postprandial neck swelling with pain Palpation 0.3 No No 3.5
19 M 29 Postprandial neck swelling with pain palpation 0.3 No No 3.5
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Feb 7, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Transoral carbon dioxide laser sialolithectomy with topical anaesthesia. A simple, effective, and minimally invasive method
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