How to: In-Office Transoral Hilar Sialolithotomy is a Cost-Effective and Patient-Centered Procedure

by Alexandra E. Tunkel, BA, Tatiana Ferraro, BS, Timothy B. Shaver, MD, Weston L. Niermeyer, MD, Esther Lee, DO, and Arjun S. Joshi, MD •

INTRODUCTION

Submandibular salivary stones located in more proximal portions of the submandibular duct or within the gland have historically been managed by removing the entire submandibular gland; however, as gland-sparing techniques have risen in favor, treatment is often sialendoscopy or transoral sialolithotomy under general anesthesia. For larger stones, transoral sialolithotomy is preferred over sialendoscopy (Otolaryngol Clin North Am. 2021;54:553-565). Management of sialolithiasis via transoral sialolithotomy has been shown to result in improved parenchymal changes, recanalization of Wharton’s duct, and improvements in quality of life (Otolaryngol Clin North Am. 2021;54:553-565; Ear Nose Throat J. 2019;98:287-290; Eur Arch Otorhinolaryngol. 2023;280:5031-5037).

There have been increasing efforts across otolaryngology to perform in-office procedures with local anesthesia. Benefits include reducing the time and economic costs imposed on patients, as well as avoiding the inherent risks of general anesthesia (Otolaryngol Head Neck Surg. 2019;160:255-260; Am J Otolaryngol. 2022;43:103424). For distal or mid-ductal stones, transoral sialolithotomy under local anesthesia is routinely performed; however, hilar or intraglandular stones have traditionally required general anesthesia for removal (Otolaryngol Clin North Am. 2021;54:553-565; Ear Nose Throat J. 2019;98:287-290; Eur Arch Otorhinolaryngol. 2023;280:5031-5037). This case series aims to showcase the efficacy and efficiency of in-office transoral submandibular sialolithotomy for hilar and intraglandular stones. This novel practice, unique to the senior author (A.J.), has the potential to minimize costs and risks associated with traditional sialolithotomies under general anesthesia.

METHODS

Design and Subjects

A retrospective chart review was conducted for patients who underwent in-office transoral sialolithotomy for hilar or intraglandular sialoliths by the senior author (A.J.) from January 2020 to July 2022. A total of 40 patients met these criteria. Each chart was reviewed to determine patient demographics, sialolith size and laterality, procedure success, and associated complications. This investigation was deemed exempt from the George Washington University institutional review board review (NCR224117).

Initial Evaluation and Patient Selection

In-office transoral sialolithotomy is offered to practically all patients with a localizable, accessible stone identified on ultrasound performed during initial evaluation. Cases in which patients are not offered this procedure are largely based on the size and location of the sialolith. In patients with small, 1–2-mm intraglandular stones or, conversely, extremely large stones greater than 4 cm that replace the gland, this technique is not indicated. In the senior author’s experience, all stones greater than 4 cm, irrespective of the location, are unlikely to be amenable to transoral removal due to adhesion to the salivary gland. Ultrasound localization can help identify if a transoral approach is feasible, especially when determining the depth of the stone within the submandibular gland, as deeper stones are less likely to be successfully removed transorally. Additionally, eliciting a dental history or a prior experience with transoral procedures under local anesthesia can be helpful in predicting a patient’s tolerance of an in-office transoral sialolithotomy.

Surgical Technique