A Combined Endoscopic and External Approach for Extraction of Large Stones With Preservation of Parotid and Submandibular Glands

INTRODUCTION Large salivary gland stones have always been a therapeutic challenge. When they cannot be accessed easily by simple marsupialization,1 the removal of the gland becomes mandatory. The advent of external lithotripsy2 gave hope for a conservative treatment, but the success rates ranged from 40% in the submandibular to 75% in the parotid glands with specifically poor results in case of large stones. Interventional sialendoscopy, first described in the 1990s, became popular when technologic improvements made interventions reproducible for hundreds of patients in the years after 2000.3–8 Nevertheless, success rates of interventional sialendoscopy with intraductal laser fragmentation and basket extraction of stones remained attainable in only 80%. The remaining 20% of failures were not only the result of large-sized stones (6 mm and up), but also stenotic ducts, mostly in the parotid gland.7 Generally, when the stone was considered too large to be fragmented, and/or when the stenosis was too tight to be dilated, the only solution was to remove the gland with its associated significant morbidity. To avoid excision of these salivary glands, we report two new techniques combining sialendoscopy and external surgery.