Surgical techniques
The surgical procedures were performed under general anesthesia with
nasotracheal intubation. A mouth prop was inserted in the contralateral
side of the lesion, and a cheek retractor was placed to provide a full
view of the buccal space. Salivary dilators were used to locate and
dilate the orifice of the Stensen duct. Then, a 1.3-mm (diameter)
sialendoscope (Tuttlingen, German, Karl Stroz, Germany) was inserted
into the duct. The duct was irrigated with normal saline to flush
debris, dilate the duct, and identify any areas of ductal obstruction.
When the stenosis was identified, mechanical bougination was attempted
using the sialendoscope itself and any other available microinstruments,
such as baskets or balloons. The sialendoscope could be advanced into
the portion of the megaduct when the stenotic lesion was successfully
dilated. However, the transoral sialodochoplasty was combined with
sialendoscopy when sialendoscopic findings suggested high-grade
strictures at high risk of recurrence or complication, and the stenotic
portion was distally located so that the dilated duct could be pulled to
connect with the oral mucosa. A circumferential incision was made around
the orifice after checking the type and stenosis grade using a
sialendoscope. Dissection was performed with Metzenbaum scissors to
identify the duct and to skeletonize the distal part of the Stensen duct
from the buccinators muscle and surrounding soft tissues. After finding
the stenotic lesion and accompanying megaduct, dissection was performed
carefully to avoid perforating the dilated ductal wall and to release
the duct from the buccal space (Fig. 1A). The megaduct was then pulled
into the oral cavity. The duct was incised with a #15 blade onto the
megaduct wall, forward in the longitudinal direction (Fig. 1B). The duct
distal to the stenotic area was excised, and the wall of the megaduct
was then sutured to the surrounding buccal mucosa with 4.0 Vicryl
sutures (Fig. 1C and 1D). Sialendoscopy confirmed the integrity of the
duct, and a salivary stent was inserted and sutured with adjacent buccal
mucosa. A salivary duct stent was placed through a neo-orifice and was
maintained for 2 weeks post-operation. After stent removal, all patients
were instructed to massage the parotid glands after stimulation with
sialagogues.