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Click for more details: Etiology/Diagnosis/Classification/Management

Overview

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Etiology of Salivary Duct Stenosis

Parotid Duct Stricture - Submandibular Duct Stricture

  • Trauma
    • Surgical manipulation of oral cavity
    • Intra-oral dental x-rays (Kieliszak 2015)
    • Dental prosthesis
  • Sialolith
  • Autoimmune disorders
  • Viral and bacterial infection
  • Radiation (I-131, External beam)
  • Other
  • Unknown

Diagnosis of Salivary Duct Stenosis

 Parotid Duct Stricture - Submandibular Duct Stricture

  • Evaluation based on presenting signs and symptoms
    • Ultrasound considered first (and sometimes last) radiographic evaluation
    • In our practice (Hoffman) we begin with ultrasound and consider CT or MRI and commonly perform a sialogram
      • The duct cannulation and dilation are all done with microscopic control by the surgeon in the radiology suite
      • Radiocontrast dye (water soluble Isovue 370) is instilled by radiology with assistance by the surgeon
  • Role for sialography (see: Sialograms and Sialography)
    • According to many it is "a difficult invasive procedure with radiation exposure and therefore is not indicated"
    • According to practice at the University of Iowa, it is not considered difficult nor invasive:
      • Valuable in delineating ductal anatomy in a way not possible by other means
        • Useful in identifying accessibly to the duct under local anesthesia before subjecting a patient to a general anesthesia
        • Prepare surgical approach (open vs endoscopic) – assist in patient counseling
      • May be therapuetic by the process of dilating the distal duct (relieving distal stricture) and flushing the gland with radiocontrast
      • Useful in identifying normal ductal anatomy to redirect evaluation of pain away from salivary origin (differential diagnosis now directed to TMJ, dental, and "atypical facial pain")
      • Identify abnormalities that can be addressed w/o sialendoscopy (normal duct anatomy with acinar abnormalities treated in clinic with steroid infusion)

Classification of Salivary Duct Stenosis

Parotid Duct Stricture - Submandibular Duct Stricture

  • University of Iowa Sialogram Classification and Grading Scale (click to see more detail: Iowa Sialogram Classification)
  • Addresses Anatomy of Ductal Stenosis - adaptable for Parotid and Submandibular Sialograms
    • 1º (main duct): segment of duct from the oral cavity to the first major bifurcation
    • 2º (secondary): segement of duct proximal to first major bifurcation and distal to second bifurcation
    • 3º (tertiary): any duct proximal to the second bifurcation (including those that could be considered 4º = quaternary)
  • Parotid - Stensen's duct stenosis (Koch et al 2009) based on sialendoscopy evaluation of tissue quality / luminal narrowing, extent, number, location and considerations for etiology
    • Type I: Inflammation dominated with variable narrowing of the lumen; slight fibrotic remodeling; obstructive plaques
    • Type II: Fibrotic stenosis, often short segment and web-associated, predominant incomplete (luminal narrowing <50%); circular or web-like encroachments of the duct wall, megaduct
    • Type III: Fibrotic stenosis, massive fibrotic reaction of the duct wall - predominantly high-grad luminal narrowing >50%
  • Submandibular - Wharton's duct stenosis (Kopec et al  2013) based on site of stenosis measured by distance from punca at time of sialendoscopy - also applied to Stensen's duct
    • Papilla/distal
    • Middle
    • Proximal/hilum
    • Diffuse

Management of Salivary Duct Stenosis

Parotid Duct Stricture - Submandibular Duct Stricture

  • Duct dilation
    • Mechanical (ballon, sialendoscope, bougie)
    • Hydrostatic (instillation of saline / kenalog / radiocontrast)
  • Observation with intermittent medical therapy (steroids/antibiotics/botox)
  • Parotidectomy
  • Duct reconstruction (vein graft)
  • Tympanic neurectomy
  • Other (see: Ultrasound aided parotid ductoplasty - sialodochoplasty)

References

Koch M: Long-term results and subjective outcome after gland-preserving treatment in parotid duct stenosis. Laryngoscope 2014 vol 124 pp 1813-8

Marchal (editor) Sialendoscopy - The Hands-On Book 2015 printed in France Imprimerie Gutenberg, Meythet, France copyright 2015 by European Sialendoscopy Training Center (ESTC)

Kieliszak CR, Shokri T, Joshi AS: Acquired Wharton's duct stenosis after dental radiographs treated with sialendoscopy  BMJ Case Rep 2015

Ngu RK, Brown JE, Whaites EJ,et al. Salivary duct strictures: nature and incidence in benign salivary obstruction. Dentomaxillofac Radiol 2007;36:63–7.

Kopec T, Szyfter W, Wierzbicka M,et al. Stenoses of the salivary ducts-sialendoscopy based diagnosis and treatment. Br J Oral Maxillofac Surg 2013;51:e174–177.

Koch M, Iro H, and Zenk J: Sialendoscopy-based diagnosis and classification of parotid duct stenosis. Laryngoscope 2009 Sep;119(9):1696-703

Koch M, Iro H, Kunzel J, Psychogios G, Bozzato A, and Zenk J: Diagnosis and gland-preservjng minimally invasive therapy for Wharton's duct stenoses. Laryngoscope 122 (2012) pp 552-558

Thorpe RK, Foggia MJ, Marcus KS, Policeni B, Maley JE, Hoffman HT. Sialographic Analysis of Radioiodine-Associated Chronic Sialadenitis. Laryngoscope. 2020 Nov 17. doi: 10.1002/lary.29279. Epub ahead of print. PMID: 33200832.

Foggia MJ, Peterson J, Maley J, Policeni B, Hoffman HT. Sialographic analysis of parotid ductal abnormalities associated with Sjogren's syndrome. Oral Dis. 2020 Jul;26(5):912-919. doi: 10.1111/odi.13298. Epub 2020 Mar 3. PMID: 32031309.

Truong K, Hoffman HT, Policeni B, Maley J. Radiocontrast Dye Extravasation During Sialography. Ann Otol Rhinol Laryngol. 2018 Mar;127(3):192-199. doi: 10.1177/0003489417752711. Epub 2018 Jan 7. PMID: 29308655.

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