Clinical Study

Ear, Nose & Throat Journal

1–4
Transoral Sialolitectomy as an Alternative ª The Author(s) 2019
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to Submaxilectomy in the Treatment DOI: 10.1177/0145561319841268
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of Submaxillary Sialolithiasis

Carlos Saga-Gutierrez, MD1, Carlos Miguel Chiesa-Estomba, MD, MSc1,

Ekhiñe Larruscain, MD1, José Ángel González-Garcı́a, MD, PhD1,
Jon Alexander Sistiaga, MD1, and Xabier Altuna, MD, PhD1

Abstract
Introduction: Sialolithiasis is the most common pathology in the submaxillary gland. The introduction of minimally invasive
techniques isolated or associated with sialoendoscopy is replacing glandular resection as a treatment. The conservation of the
gland is justified by the recovery of function and a low recurrence rate. The rate of complications is lower in conservative
techniques than in submandibular gland resection. Patients and Methods: Thirty-three patients with fixed stones in the hilum of
the submaxillary gland were treated by transoral sialolitectomy between July 2015 and July 2018, demographic data of the patients
such as the number of stones, size, time of hospital stay, complications, pre- and postoperative lingual nerve function, and lithiasis
recurrence were collected. Results: The average volume of the stones was 1.02 cm. Complete removal of the stone was possible
in 32 patients. All the patients were operated in the outpatient clinic. Seven (21%) patients reported some degree of alteration of
the lingual nerve function, of which the only one presented a persistence of more than 4 weeks due to an inadvertent injury that
required a microsurgical anastomosis. Conclusions: Transoral sialolitectomy is a reproducible technique with good results and
lower complication rates than submandibular gland resection. Our results in the first 33 cases encourage us to maintain the
combined techniques as standard in the treatment of submaxillary sialolithiasis. Current experience guides the definitive sub-
stitution of submandibular gland resection by conservative techniques in obstructive pathology.

Keywords
lithiasis, gland, submaxillary, sialoendoscopy

Introduction The introduction of sialoendoscopy techniques at the begin-

Lithiasis formation in the Wharton duct represents the most
frequent cause of pathology in the submaxillary gland. Different
authors estimate the global incidence of obstructive sialadenitis
among 1.2 to 5.9 cases per 100 000 inhabitants.1,2 During the last
decades, and even today, the most extended therapeutic option
for this pathology has been the submandibular gland resection
(SGR). The presumption that the functionality of the glandular
parenchyma is irremediably altered after the obstructive process
and the hypothesis related to developing of new stones are the
main arguments for the glandular resection. Submandibular
gland resection is also a well-standardized technique with a low
rate of complications and a low impact on the quality of life of
patients, and reviews from a different group of authors have been
shown that the technique is not risk-free.3
Lithiasis located in the middle or distal portion of the Whar-
ton duct has never been a problem and its resection, under local
anesthesia, with or without partial removal of the sublingual
gland, has been the usual treatment. However, lithiasis located
proximally in the hilum, which appears more frequently than
distal forms,4 implies deeper and more complex approaches.
ning of this century has laid the foundations of a change in the
way of dealing with obstructive salivary pathology. Its appli-
cation in the resection of large stones using combined
approaches has allowed giving value to minimally invasive
techniques described some decades ago.5
This is the reason why in the next paper we review our
experience in the transoral approach in submandibular gland
lithiasis located proximally in the hilum as a valid alternative to
the traditional SGR. Moreover, we describe the technique used,
key points, results, and complications observed.
1
Department of Otorhinolaryngology–Head and Neck Surgery, Hospital
Universitario Donostia, San Sebastian–Donosti, Guipuzkoa–Basque, Spain
Received February 9, 2019; revised March 5, 2019; accepted: March 6, 2019
Corresponding Author:
Carlos Miguel Chiesa-Estomba, Department of Otorhinolaryngology–Head
and Neck Surgery, Hospital Universitario Donostia, Calle Virgen del
Carmen, #28, 5to C. CP. 20012, San Sebastian–Donosti, España.
Email: chiesaestomba86@gmail.com
2 Ear, Nose & Throat Journal XX(X)
Figure 1. Floor of the mouth. Right side. Dissection steps: (a, b, and c): nerve identification. (d and e): lithiasis extraction. (f) Wharton duct
opened. * ¼ lingual nerve; black arrow ¼ Wharton duct; C ¼ calculi.
Patients and Methods
After the approval of the ethics committee of our hospital, all
patients were included prospectively in the obstructive salivary
gland pathology database of the main author between July 2015
and July 2018. During the study period, 45 patients come to our
department with submandibular gland lithiasis located proxi-
mally in the hilum, 12 of them were operated using the tradi-
tional approach through an SGR. Eleven of these 12 patients
were included in a study performed previously by the authors in
the arm of SGR to compare both techniques.6 Moreover, 1
patient was operated using the classic technique due to his
preference and not included in this previous study.
Thirty-three patients were included in the final analysis.
Again, 11 of the 33 patients were included in a previous study
conducted by our group in the arm of transoral approach.6 In all
cases, both the transoral procedure and the possibility of requir-
ing an SGR if it failed were explained. All of them had at least
one proximal calculus at the level of the hilum of the submax-
illary gland, and none had previously been operated on for
salivary gland lithiasis.
In the preoperative visit to the clinic, lingual nerve function
was evaluated in all patients. The variables included in the
study correspond to the average number of lithiasis, the average
size of the lithiasis, average hospital stay, lingual nerve altera-
tion, and complications for the technique.
Transoral sialolitectomy was performed under general
anesthesia with nasotracheal intubation in all patients. In one
case due to cardiac pathology, general anesthesia was contra-
indicated, and mandibular and lingual nerve block associated
with sedation was chosen. To expose the floor of the mouth, a
Ferguson mouthpiece was placed on the contralateral side, and
the assistant positioned at the patient’s head pull the tongue,
showing the glandular hilum. Before incision, we infiltrated the
area with local anesthesia and vasoconstrictor. Then the lithia-
sis was located either by palpation or transillumination using
the optic, placed in front of the lithiasis in the Wharton duct. An
area of mucous and submucosal lax tissue was resected with a
fine-tipped electrosurgical device generating a window of
broad access on the hilum. After this, we will discover the
posterior part of the sublingual gland that we can resect or not
according to the difficulty of the approach. Immediately under
the soft submucosal tissue, through a blunt dissection, we will
discover the path of the lingual nerve that constantly appears as
a thick nerve with a high tolerance to manipulation. Locating
the lingual nerve allows us to advance dissecting toward the
Wharton duct that, following the gland, deepens and turns in an
inferolateral direction over the mylohyoid. The location by
palpation or transillumination at this point is essential since
Wharton differentiation is not as immediate as in the case of
the lingual nerve. Depending on the location of the obstruction,
we must move the nerve medially (in our case more frequent)
or laterally to access the lithiasis. At this time, the assistant’s
collaboration pulling the tongue medially and pushing the
gland simultaneously to make the glandular hilum prominent
on the floor of the mouth makes the dissection easier. Once the
lithiasis is located, we make an incision that shows the yellow-
ish and usually irregular surface of the stone.
We extended the incision as necessary to extract the lithiasis
with a 90 ear hook. Subsequently, through the orifice, we wash
the duct with saline to eliminate possible remains, and we
introduced a sialendoscope to explore all the ductal tree look-
ing for other stones. We did not close the duct usually, both in a
few cases we gave some lax points of approach of the mucosa,
and we did not place a stent (Figure 1).
Saga-Gutierrez et al 3

Table 1. Demographic Data, Complications, and Functional Results.

Number %

Sex
Male 15 45.45
Female 18 54.55
Age 49 (14; min: 18/max: 86)
Average number of lithiasis 1.56 (0.71; min: 1/max: 3)
Lithiasis average size 1.02 (0.47; min: 0.7/max:
2.3)
Mean hospital stay <1 day
Mean surgical time 49 min (12; min: 35/max:
63)
Complications
Floor of the mouth edema 1 3
Postoperative pain 2 6
Granuloma formation 1 3 Figure 2. Schematic representation of the hilum gland.
Lingual nerve damage 1 3
Lithiasis not founded 1 3
Postoperative lingual nerve alteration radiology, locating pathology in the ductal tree, and allows us to
Lingual preoperative 33 100 treat directly through the optic work channels or combined trans-
normofunction oral or transfacial approaches.7,8 At the same time, the introduc-
Lingual postoperative 26 78.8 tion of sialoendoscopy has meant a change in the surgeon’s vision
normofunction
on the treatment pathway and the interest in the application of
Lingual postoperative alteration 7 21.2
Follow-up 14 (9; min: 6/max: 36) minimally invasive techniques has been enhanced; recovering
Recurrence 1 3 approaches described many years ago.
In 1953, Seldin et al5 published his experience using transoral
approaches to extract lithiasis in the submaxillary gland. Despite
The statistical analysis was carried out using the JASP pro- the good results shown in their work, in the last 60 years, gland-
gram, version 0.8.5.1 computer software (University of ular resection has been the norm and, in most countries, mini-
Amsterdam). The quantitative variables within the study are mally invasive approaches whose efficacy has been proven
expressed as mean (standard deviation), the results are recently by more authors have not been taken into account.1,9,10
expressed as a total plus percentage. When we start the application of minimally invasive
approaches, we compared our results with those obtained by
SGR and detected similar rates in clinical resolution and com-
Results plications with a significant reduction in hospitalization time.6
Thirty-three patients met the inclusion criteria. Sixteen (45.45%) On this occasion, we found that these good results have been
were men and 18 (54.55%) were women, the average age was 49 maintained by increasing the number of cases operated.
years (14 years; min: 18/max: 86). The average number of stones The anatomical complexity in the hilum of the submaxillary
in the sample was 1.56 (0.71; min: 1/max: 3), the average size of gland is low; the lingual nerve is situated superiorly and medially
the stones was 1.02 cm (0.47 cm; min: 0.7/max: 2.3). All patients to the gland in its posterior zone. In its anterior course runs
were discharged in the afternoon after surgery. In 7 (21.2%) lateral to the Wharton and crossing it medially at the height of
patients, some degree of lingual nerve alteration was evidenced the second molar (Figure 2). In many cases, we are faced with
in the postoperative follow-up; in 1 of the cases, the loss of sensi- large stones that are easily palpable so the stone itself will mark
tivity was total due to an inadvertent section of the nerve during the path of dissection, but the previous location of the lingual
the dissection, requiring repair by microsurgical suture. In 1 case, nerve is required to avoid the risk of injury. We can find small
it was not possible to locate the lithiasis during surgery, opting for branches of the facial artery that we can control with bipolar
an expectant attitude in the absence of symptoms. The rest of the coagulation, and the lingual artery and vein will usually be sepa-
data and complications are described in detail in Table 1. rated from the dissection area by the fibers of the hyoglossus
muscle. The hypoglossal nerve will be less accessible when it
appears in this approach in a deep position concerning the lin-
Discussion gual nerve. However, maintaining a stable space between the
The development of specific material and the accumulated expe- displaced tongue and the jaw during the dissection can be diffi-
rience make glandular resection techniques reserved, as a first cult—being the assistant collaboration crucial in this procedure.
therapeutic option, exclusively for the tumor pathology. Lithiasis, The nerve manipulation, necessary in some cases, can be
stenosis, and chronic inflammatory conditions can benefit from associated with an abnormal lingual sensitivity or hypoesthe-
minimally invasive procedures associated with sialoendoscopy. sia. Postsurgical pain, even in deep dissections, can be easily
This technique has demonstrated a diagnostic utility superior to controlled with commonly used analgesics.
4 Ear, Nose & Throat Journal XX(X)
Transoral approach complications are less frequent and less
severe than in SGR. Authors such as Combes review their
complication rates and face those published in glandular resec-
tion, showing lower rates in transoral techniques.9 Regarding
intraoperative complications, these are related to the limited
access rather than the anatomical complexities of the dissec-
tion. In our series, the most significant complication occurred
as a result of poor control of the separation system that directly
injured the lingual nerve. The development of specific retractor
that allow us stable and atraumatic access to the hilum will be
able to reduce the complication rate, which is already low.
Some authors have already proposed devices that favor
approach.11
Our results and the data from other groups demonstrate the
advantages of the transoral approach, providing an apparent
advantage over glandular resection. For the patient, the post-
operative period is more tolerable, and they can come back to
regular activity in a shorter period, being the postoperative pain
easy to control. We also conserve the submandibular gland
whose functional and anatomical recovery after the period of
obstruction has been demonstrated by multiple works.12-14 Some
surgeons use recurrence rates as an argument to rule out these
techniques. However, the recurrence rates detected in different
studies rule out the systematic reappearance of the pathol-
ogy.1,5,10 Finally, we avoid the aesthetic alteration of the scars
and the volume defect derived from the external approach.
Obviating the clear advantages for the patient, the transoral
sialolitectomy also implies significant cost reductions compar-
ing an outpatient surgery with a procedure with almost 2 to 3
days of hospital admission; this reduction is undeniable if we
refer to a simple transoral approach without sialoendoscopy in
the case of palpable and unique lithiasis. Moreover, this can be
considered an effective option in those centers where the mate-
rial necessary for a combined technique is not available.15
Although several publications show a large series of patients
treated by this technique under local anaesthesia,1 we consider
that general anesthesia can facilitate the procedure, especially
in the first cases. Being the approach under local anesthesia, an
excellent option for those patients with anesthetic contraindi-
cation as long as the anatomy is favorable.
In our current experience, there are no recurrence or tissue
injury data that justify the sacrifice of the glandular parenchyma
as a way to resolve the obstructive pathology in lithiasis siala-
denitis. The transoral approach has been sufficiently proven and
defined during the last decades to be universally accepted as the
first option in the treatment of submaxillary sialolithiasis. Our
experience in the first 33 cases treated with this technique has
allowed us to restrict SGR, as the first choice, exclusively for
cases of submaxillary tumor pathology. The accumulated knowl-
edge about transoral approaches with and without sialoendo-
scopy indicates reductions in the time of admission,
complications, and costs concerning the classic SGR.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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