Lasers in Surgery and Medicine 44:783786 (2012)

Thulium-YAG Laser Sialendoscopy for Parotid and Submandibular Sialolithiasis

M. Durbec, MD,1 E. Dinkel, MD,1 S. Vigier, MD,1 F. Disant, MD,1 F. Marchal, MD,2 and F. Faure, MD, 1 Hospital Edouard Herriot, 3 Place dArsonval, 69437 Lyon, France 2 Hospital Cantonal, Geneva, Switzerland
1 PhD

Objective: To evaluate the efcacy and safety of thulium-YAG laser in sialendoscopic fragmentation of salivary lithiasis. Design: Retrospective, interventional case series. Material: Sixty-three patients treated by interventional sialendoscopy with thulium-Yag laser fragmentation between 2003 and 2010 at Edouard Herriot Hospital were included in the study. The laser was used for non-oating or large lithiasis (>4 mm). Methods: The sialendoscopic thulium ber laser was used in a pulsed mode with an average power output of 28 W to fragment and facilitate extraction of salivary stones. Several variables were studied: success rate, total number of procedures, total energy per procedure, size and number of salivary stones removed, and complications. Results: Our series of 63 cases includes 40 cases of parotid lithiasis and 23 cases of submandibular lithiasis. In nine cases, two sessions of laser were performed. Stone size was evaluated pre-operatively by ultrasound and varied between 2 and 18 mm. Laser fragmentation was possible in every case. Complete extraction of the lithiasis was possible in 51 cases (73.9%) and partial extraction in eight cases (12.6%). Extraction failed in four cases (6.3%). Mean stone size was 5.4 mm (5.7 mm for parotid glands and 5.0 mm for sub-mandibular glands) and mean energy per procedure was 1,450 J (range: 1,4001,800 J). Ductal perforations were observed in 12.7% of the cases. 65.1% of patients were free of symptoms with a mean follow-up of 18 months. Conclusion: Thulium-YAG laser appears to be an effective and safe technique in the treatment of salivary lithiasis. Lasers Surg. Med. 44:783786, 2012. 2012 Wiley Periodicals, Inc. Key words: sialendoscopy; sialolithiasis; laser; fragmentation INTRODUCTION The development of sialendoscopy in the 1990s revolutionized the diagnostic efcacy for and surgical treatment of salivary glands [14]. Sialendoscopy is minimally invasive and usually enables removal of salivary stones <4 mm by means of a wire basket. However, stones over 4 mm or impacted in the duct require fragmentation with forceps, extra corporeal lithotripsy, or removal of the gland [57]. The thulium laser has been successfully used
2012 Wiley Periodicals, Inc.

in urinary lithiasis and its use in sialolithiasis could facilitate extraction of large or xed stones with minimal tissue damage. In this study, we report the results of 2 mm thuliumYAG laser for the treatment of salivary stones which required fragmentation because they could not be removed with the standard wire basket technique. PATIENTS AND METHODS We present a retrospective study of 542 patients undergoing sialendoscopy at the Department of Otolaryngology of the Lyon University Hospital from January 2003 to February 2010. Institutional review board approval was obtained. Sixty-three patients with non-oating or large lithiasis (>4 mm), in whom sialendoscopy with basket retrieval was unsuccessful, underwent sialendoscopy with thulium-YAG laser fragmentation. All patients were preoperatively evaluated by ultrasound. CT scan, MRI, or sialography was performed when deemed necessary. We collected demographic (age, sex), clinical (surgical indications, imaging details with relevant ndings) and post-operative data (operative time, type of procedure, location of the lithiasis, total energy delivered, perioperative complications, and outcomes). We used the lithiasis, stenosis, and dilatation classication (LSD) to assess the location of the lithiasis (Table 1) [8]. Technique We used the Marchal all in one 1.3 and 1.1 sialendoscope for diagnostic or interventional sialendoscopy [5]. The 1.3 interventional sialendoscope (Karl Storz, Tuttlinghen) has an operating channel of 0.65 mm and an irrigation channel of 0.25 mm. Endoscopy was performed with continuous rinsing saline solution. The laser generator [9] used in the present series was a 15 W modulated

Conict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest and none were reported. This material has never been published and is not currently under evaluation by any other peer-reviewed journal. *Corresponding to: M. Durbec, MD, Pavillon U, Hospital Edouard Herriot, 3 Place dArsonval, 69437 Lyon, France. E-mail: mickael.durbec@chu-lyon.fr Accepted 7 October 2012 Published online 6 December 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/lsm.22094

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TABLE 1. LSD Classication [8] Score L0 L1 L2 L3 Endoscopic definition Duct free of stones Floating stones a: fixed stone, totally visible, <8 mm b: fixed stone, totally visible, >8 mm a: fixed stone, partially visible, palpable b: fixed stone, partially visible, non-palpable

2 mm thulium laser with a ber of 273 mm in diameter (LISA society). The type of anesthesia depended on general health, age, patients choice, location, size, and number of salivary stones. The sialendoscope was used to identify the salivary stone and then the laser beroptic tip was brought in contact with the stone. The laser tip was applied in the middle of the stone to avoid ductal perforation or potential nerve injury. The tip of the endoscope is positioned 1 cm away from the extremity of the laser ber to avoid overheating of the optic lens of the endoscope during the procedure. The laser was used in pulse mode with a rst output pulse power of 2 W, duration of 50 milliseconds and repetition rate of 8 Hz. We progressively increased the pulse duration up to a maximum of 8 W to obtain sufcient fragmentation (Figs. 1 and 2). Since the maximal diameter of the main duct is 2 mm for the parotid and 3 mm for the sub-mandibular gland, the objective was to cut a salivary stone into fragments of <2 mm diameter. The fragments were retrieved with wire baskets after the laser. A second session of laser assisted sialendoscopy was performed when the initial procedure lasted too long or when the operator felt that there was a risk of duct perforation. At the end of the procedure, endoscopy was repeated to identify residual lithiasis. Size of the fragments was measured and

Fig. 2. Fragments of lithiasis after laser fragmentation.

recorded in order to compare with the size estimated by ultrasound. Mean follow up was 18 months. Every patient received a 6 days post-operative course of oral amoxicillin and clavulanic acid and non-steroid anti-inammatory medication.

RESULTS We report 63 cases, including 32 men and 31 women. The average age of patients is 50 years (minimum: 5, maximum: 74). 40 cases were parotid lithiasis and 23 cases sub-mandibular lithiasis. Sialendoscopy was performed under general anaesthesia in 61.3% or neuroleptanalgesia in 39.7%. One salivary stone was noted per treated gland in all cases. Mean time of intervention was 69 minutes. In total there were 72 procedures on 63 patients including nine re-treatments (six cases for parotid stones and three cases for submandibular stones). Lithiasis Localization, Size, and Radiation Energy Mean lithiasis size was 5.4 mm (5.7 mm for parotid gland and 5.0 mm for sub-mandibular gland) and a mean delivered energy of 1,450 J (range: 1,4001,800 J) in sequences of 12 seconds. Results of Fragmentations Total extraction after fragmentation was possible in 51 cases; 32 for parotid gland (80% success rate) and 19 for submandibular gland (82.6%; Photos 1 and 2). For eight patients, we found lithiasis associated with ductal stenosis and all were treated successfully. We had eight cases of partial extraction and four procedure failures. In 28 cases, a precise localization of the lithiasis was noted. We report a total extraction success rate in the main duct of the gland of 87.5% (n 8), in the second branch of 83.3% (n 6) and in the third branch of 50% (n 14; Table 2).

Fig. 1. Laser ber and lithiasis fragmentation.

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TABLE 2. Results of the Study Parotid gland (n 40) Size (mm) Total extraction Partial extraction Failure Total Two procedures Neuroleptanalgesia General anesthesia Total 5,675 mm (4; 18 mm) 32 5 3 40 6 16 24 40 Submandibular gland (n 23) 4.95 mm (2; 14 mm) 19 3 1 23 3 9 14 23 Total Mean 5.41 mm 51 8 4 63 9 25 (39.7%) 38 (61.3%) 63

Complications Peri-operative complications: Ductal perforations were seen in eight cases (12.7%) and oral oor oedema in two cases (3.2%). There was no case of bleeding or facial nerve damage. Post-operative complications: 5/63 cases (7.9%) came back with post-operative infection and swelling in the days following the surgery, which resolved with antibiotic treatment with no recurrence of infection at 1-month follow-up. Success rate within follow-up period: 65.1% of parotid stone patients were free of symptoms (n 40) compared to 91.3% of the sub-mandibular stone patients (n 23) with a mean follow up of 18 months. When both glands are considered, 78% of cases were free of symptoms. The rest of the patients presented with recurrent sialolithiasis, but none of them with ranula, infections, or ductal stenosis. DISCUSSION This is the rst series of thulium-YAG laser assisted sialendoscopy for fragmentation and extraction of salivary stones. Our results show that this technique is effective in totally removing large or xed salivary stones in 73.9% of cases and partially in 12.6%. Sialendoscopy has revolutionized the management of salivary lithiasis with good results for extraction of stones under 4 mm for submandibular glands and under 3 mm for parotids with the use of grasping baskets [1012]. Success is reported to be better when the ratio between the stone size and the diameter of the channel is low. The most efcient sialendoscopes are the sialendoscope 1.3-mm all- in-one device (reference 11575; Karl Storz GmbH, Tuttlingen, Germany) and the semi-rigid optic endoscopic device (reference 11576; Karl Storz Co., Tuttlingen). Salivary stones larger than 4 mm or xed far in the small duct divisions of the glands are difcult to extract

(classication LSD of salivary lithiasis described in the Table 1) [8]. For these cases, intraductal laser fragmentation in sialendoscopy has been reported (Table 3), but the indications, results and complications have not previously been specically described. The rst attempts of laser fragmentation of salivary lithiasis in vitro were described by Gundlach et al. [13]. These were cases of extracorporeal lithotripsy (ECL) by excimer laser. Another laboratory study demonstrated stone fragmentation with a 110-W thulium ber optic laser at 1.94 mm [9]. The rst series of laser assisted sialolithiasis removal was described by Marchal et al. [1,2] (holmium laser) and NahlieliRaif et al. [11,14] (erbium laser) and showed that the use of laser improved the success rate of extraction of complicated lithiasis from 35% to 70%. Failure of laser fragmentation is usually because the stone cannot be seen as in cases of stenotic or tortuous ducts. Facial nerve injuries, Freys syndrome, papilloma stenosis, or duct perforations [413,15,16] were not described. In our study, we used a ber optic thulium-YAG laser, whose effectiveness has already been proven in urolithiasis [9]. The success rate of thalium-YAG laser procedures on this study on 63 patients, with no recurrent symptoms, was 65.1% for parotid and 91.3% for submandibular stones. The procedure was performed in both adults and children [17,18]. These results are similar to the holmium and erbium laser techniques previously described. Cases of failure were usually because small fragments were lost in the depth of the gland during laser pulses. The laser power can be regulated appropriately for hardness and size of the salivary stone. Thulium laser can
TABLE 3. Laser Fragmentation Sialolithiasis in the Literature Author Gundlach et al. [13] Arzoz et al. [7] Marchal et al. [12] Nahieli [14] Papadaki et al. [20] lithotripsy laser Faure (2010) Cases 12 39 5 18 37 63 Success 11 27 5 15 14 51 Rates (%) 91.60 69 100 83.30 37.90 81

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DURBEC ET AL. 6. Lari N, Chossegros C, Thiery G, Guyot L, Blanc JL, Marchal F. Sialendoscopy of the salivary gland. Rev Stomatol Chir Maxillofac 2008;109:167171. 7. Arzoz E, Santiago A, Fernando E, Palomero R. Endoscopic intracorporeal lithotripsy for lithiasis. J Oral Maxillofac Surg 1996;54:847850. 8. Marchal F, Chossegros C, Faure F, Delas B, Pabst G, Fischer U, Studer R, Hagemann M, Bizeau A, Schaitkin B, Carrau R, Eisele D, Greger D, Van der Poorten V, Guntinas-Lichius O, Cenjor C, Campisi D, Buchwald C, Homoe P, Mortensen B, Trikeriotis D, Yu C, Wang S, Kolenda J, Irvine R, Tarabichi M, Barki G. Salivary stones and stenosis. A comprehensive classication. Rev Stomatol Chir Maxillofac 2008;30:14. 9. Nathaniel M. Fried thulium ber laser lithotripsy: An in vitro analysis of stone fragmentation using a modulated 110Watt thulium ber laser at 1.94 mm. Lasers Surg Med 2005; 37:5358. 10. Nahlieli O, Baruchin AM. Sialoendoscopy: Three years experience as a diagnostic and treatment modality. J Oral Maxillofac Surg 1997;55(9):912918; discussion 920. 11. Nahlieli O, Baruchin AM. Endoscopic technique for the diagnosis and treatment of obstructive salivary gland diseases. J Oral Maxillofac Surg 1999;57(12):13941401; discussion 4012. 12. Marchal F, Dulguerov P, Becker M, Barki G, Disant F, Lehmann W. Specicity of parotid sialendoscopy. Laryngoscope 2001;111(2):264271. 13. Gundlach PSH, Hopf J, Mu ller G, Hirst L, Scholz C. Die endoskopisch Kontrollierte Laserlithotripsie von Speichelsteinen: In-vitro-Untersuchungen und erster klinischer Einsatz. HNO 1990;38:247249. 14. Raif J, Vardi M, Nahlieli O, Gannot I. An Er:YAG laser endoscopic ber delivery system for lithotripsy of salivary stones. Lasers Surg Med 2006;38:580587. 15. Walvekar R, Razfar A, Carrau R, Schaitkin B. Sialendoscopy and associated complications: A preliminary experience. Laryngoscope 2008;118:776779. 16. Walvekar RR, Razfar A, Carrau RL, Schaitkin B. Sialendoscopy and associated complications: A preliminary experience. Laryngoscope 2008;118:776779. 17. Faure F, Quenin S, Dulguerov P, Froehlich P, Disant F, Marchal F. Pediatric salivary gland obstructive swelling: Sialendoscopic approach. Laryngoscope 2007;117:1364 1367. 18. Faure F, Froehlich P, Marchal F. Paediatric sialendoscopy. Curr Opin Otolaryngol Head Neck Surg 2008;16: 6063. 19. Capaccio P, Ottaviani F, Manzo R, Schindler A, Cesana B. Extracorporeal lithotripsy for salivary calculi: A long-term clinical experience. Laryngoscope 2004;114:10691073. 20. Papadaki ME, McCain JP, Kim K, Katz RL, Kaban LB, Troulis MJ. Interventional sialendoscopy: Early clinical results. J Oral Maxillofac Surg 2008;66(5):954962. 21. Marchal F. A combined endoscopic and external approach for extraction of large stones with preservation of parotid and submandibular glands. Laryngoscope 2007;117(2):373 377. 22. Salles F, Chossegros C, Guyot L, Brignol L, Cheynet F, re ` se endobuccale des lithiases submandibuBlanc JL. Exe rieures: 36 cas. Rev Stomatol Chir Maxillofac laires poste 2008;30:14. 23. Benazzou S, Salles F, Cheynet F, Brignol L, Guyot L, re ` se des lithiases poste rieures de la glande Chossegros C. Exe submandibulaire par abord endobuccal. Rev Stomatol Chir Maxillofac 2008;30:14.

also remove lithiasis located in second and third ductal divisions, where combined approaches are not efcient and where the only treatment is usually parotidectomy or submandibulectomy. Compared with extra-corporeal lithotripsy [716,19,20], success rate with laser (absence of recurrence of symptoms) is twice as good for the submandibular stones and almost equivalent for the parotid stones. Compared with a combined approach, laser appeared to be safest, with least risk to the facial nerve [2123]. The main risk with laser sialendoscopy is duct perforation and thermal injury to the surrounding nerves, vessels, and soft tissue. Thermal injury can be minimized effects with good irrigation which also allows evacuation of stone fragments. However, irrigation can cause oral oor oedema, which generally disappears within a few days after the procedure. Strong irrigation and repeated endoscopic passage with inammatory mucosis increases the risk of duct perforation. In vivo wetlab training can increase surgeon skills for visualization and localization of the ducts and lithiasis and reduce the rate of complications. CONCLUSION This study demonstrates that intraductal fragmentation of salivary stones with thulium-Yag laser [18] and with wire basket retrieval is an efcient and safe procedure. Thulium laser produces sufcient power to fragment salivary stones with low risk of damaging surrounding tissues. Prospective studies comparing laserassisted intraductal fragmentation with ECL and combined approach are warranted. ACKNOWLEDGMENTS The work was not sponsored by any commercial organization but founded through general resources of the department. REFERENCES
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