What is the management approach for a patient with a parotid duct stone?

Management of Parotid Duct Stone

For parotid duct stones, sialendoscopy-assisted minimally invasive surgical extraction is the primary treatment approach, achieving success rates of 69-100% while preserving gland function in over 90% of cases. 1, 2

Initial Diagnostic Approach

• Ultrasound is the first-line imaging modality to confirm stone presence and location within the parotid duct system 2
• Conventional sialography or MR-sialography can provide additional anatomical detail when ultrasound findings are equivocal 2
• Sialendoscopy establishes definitive diagnosis and characterizes the stone to guide treatment planning 2

Treatment Algorithm Based on Stone Location

Stones Near Duct Opening (Distal)

• Intraoral transoral removal is the simplest approach for stones close to the papilla 3
• Direct visualization and extraction through the oral cavity without need for external incisions 3

Stones in Mid-Duct

• Sialendoscopy-assisted transcutaneous approach is preferred 3, 4
• Direct transcutaneous incision over the stone location (used in 27/70 patients in one series) 4
• Combination of sialoendoscopic and ultrasound examination to precisely locate the stone 4
• Can be performed under local anesthesia in selected cases (22/70 patients) 4

Stones Near Parotid Gland (Proximal)

• Pre-auricular approach with endoscopic assistance (used in 40/70 patients) 4
• Extraoral approach allows precise stone identification and removal while avoiding lengthy parotidectomy 3
• Avoids facial nerve injury risk associated with formal parotidectomy 3

Procedural Details

• Average stone size successfully removed: 7.2 mm 4
• Success rate for stone retrieval: 85 stones from 69 patients (>98%) 4
• Duct management options post-extraction:
  • Duct repair in 6/8 cases 5
  • Duct ligation in 2/8 cases 5
• Mean follow-up demonstrates durability: 10-25.5 months without major complications 5, 4

Management of Complications and Failures

• If duct stricture is encountered: Sialendoscopic-controlled opening and dilation is the dominant method for parotid duct stenoses 2
• For inflammatory vs. fibrotic stenosis: Characterization via sialendoscopy guides specific treatment 2
• In 10-15% of cases requiring combined treatment: Sequential application of endoscopic and surgical techniques achieves success 2
• Long-term complications are rare (3/69 patients): persistent stone fragments, fibrous stricture causing obstruction, or visible scarring 4

Critical Advantages Over Traditional Parotidectomy

• No facial nerve weakness reported in minimally invasive series 4
• No salivary fistula formation 4
• Gland preservation and function maintained in over 90% of cases 2
• Shorter operative time and recovery compared to formal gland excision 3

When to Consider Parotidectomy

• Reserve gland excision only for: stones inaccessible by minimally invasive techniques, recurrent stones after failed conservative management, or concurrent gland pathology requiring removal 3
• This represents less than 10% of cases when modern endoscopic techniques are available 2