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Removing tiny stones in a way that’s easier on patients (2015/03/31)

Doctors don’t know why some people will develop a stone in a tiny salivary duct. It may be no bigger than the tip of a pen, but it can be just big enough to block the duct and lead to a painful swollen gland, trouble eating and other symptoms. The good news is that doctors are learning that removing such a stone doesn’t always have to be a major process.

Yale is a leader in the region—and one of only a few providers in Connecticut—to offer a minimally invasive technique to treat salivary blockages using salivary endoscopy. “The salivary endoscopy procedure can be the difference between open surgery in the head and neck area, which carries more risk—and a minimally invasive experience with a lot less pain,” said Saral M ehra, M.D., a Yale head and neck cancer and reconstructive surgeon.

James Clinton, 62, who lives in Meriden, came to Mehra after four years of frustrating glandular swelling and facial pain, restricted jaw movement, and other symptoms that had stumped his doctors and been diagnosed more than once as a virus. “It was like having a constant toothache,” said Clinton, who resorted to eating soft foods.
The endoscopy procedure involved general anesthesia in the hospital, but Clinton said it was worth it. “Once I was home and the medication wore off, I saw that my face wasn’t puffy, and I had the freedom of opening my mouth properly again,” he said.

Yale specialists perform an average of one to two salivary endoscopies a week, often on “young, healthy patients,” although they are especially common among the elderly and turn up in other age groups, including infants in the first weeks of life.
Patients typically complain about painful glandular swelling that gets worse when the salivary flow is stimulated by hunger or chewing, or the smell or taste of food. A workup with a CT scan or MRI often shows that they have sialolithiasis—one or more benign salivary stones—blocking a duct.
A salivary endoscopy can take anywhere from one to three hours, and typically involves general anesthesia. The surgeon inserts an endoscope that is .8 to 1.6 millimeters in size, with a small camera attached into the salivary duct through the mouth. After the procedure the patient goes home with a little acetaminophen for pain. “For small stones, the patient will be eating and drinking the next day,” said Mehra.
“For small to medium-sized stones, this is the way to go, this is the way of the future,” Mehra said. Larger stones, sometimes as big as a pencil eraser, may require a combined open/endoscopic procedure that could involve incisions in the floor of the mouth, he said.

While the majority of patients have stones, some have salivary blockage for other reasons. Thyroid cancer patients may develop duct obstructions as a side effect of radioactive iodine treatments; others have blockage linked to an autoimmune disease, taking certain medications, and age-related function decline. “It all comes down to duct obstruction, whether it’s a stone, stenosis or a mucous plug. The gland swells up, they start eating and making saliva and the gland gets obstructed,” said Mehra.

While most ear, nose and throat providers know about salivary endoscopy, Mehra believes the procedure will become more common as patients and primary care physicians learn about it.
Meanwhile, Mehra, is tracking his outcomes, and is a participant in an international group that is studying the procedure to learn more about its short- and long-term success. “We know we’re helping with the stones; we want to know more about blockages caused by other problems, such as Sjögren's syndrome and juvenile recurrent parotitis, and why some patients have recurrent swelling,” he said. “We want to learn more about how this procedure can help.”

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