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.