2. CASE REPORT
A 59-year-old male patient was referred to the Department of
Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Ca’ Granda,
Ospedale Maggiore Policlinico of Milan, Italy due to a painful right
facial swelling caused by a recurrent parotid abscess treated by means
of multiple percutaneous drainages elsewhere. An ultrasonography (US)
assessment of the region using a 7.5 MHz Hitachi H21 scanner (Hitachi
High-Technology Corporation Ltd., Tokyo, Japan) identified a 7-mm
parenchymal stone in the right parotid gland, and a Cone Beam Computed
Tomography scan (CBCT - GE LightSpeed 64 Slice CT scanner, GE Medical
Systems, Waukesha, WI) and a magnetic resonance imaging (MRI - Philips
Gyroscan Intera, Eindhoven, The Netherlands) were used to confirm the
location and size of the stone; imaging results prompted us to adopt a
sialendoscopy-assisted transfacial removal of the stone. The patient was
selected to priority surgery by our internal interdisciplinary medical
board because of long-lasting infectious disease. The patient was
asymptomatic for COVID-19 and 48 hours before surgery underwent two
consecutive nasopharyngeal swabs to detect RNA of SARS-COV-2, both
negative.
The procedure was done under general anaesthesia and an orotracheal tube
was used. After disinfection with a povidone iodine solution, placement
of sterile dressing over and around the head, leaving the mouth and the
right side of the face and neck uncovered, the possible location of the
stone was marked on the facial skin. Patient’s head and chest were
enclosed in a chamber created with a transparent microscope cover
(Galstar LTD, ) (Fig. 1a). Non-penetrating towel clamps were used to
secure the plastic cover to the bed to keep the drape taught over the
surgical field. Two fenestrations were created in the plastic drape to
allow passage of instruments for either a transoral and external
approach, respectively over patient’s mouth and parotid area (Fig.
1b-1c). These materials were readily available at our institution and
are currently used by most otolaryngological surgeons performing ear and
laryngeal surgery. After dilatation with lacrimal dilators (Karl Storz,
Tuttlingen, Germany) of the opening orifice of Stensen’s duct performed
through the opening in the plastic cover over the patient’s mouth, a
sialendoscopic exploration of the duct system of the affected parotid
gland by means of a semirigid sialendoscope (0.8 mm, Nahlieli
sialoendoscope, Karl Storz Co., GmbH, Tuttlingen, Germany) was done.
Once the surgeon could visualise the stone in a lower secondary
parenchymal branch of the duct system, the high-powered light at the tip
of the endoscope allowed to confirm the location of the stone as marked
on the facial skin (Fig. 1d). Continuous aspiration of oral secretions
through the small hole of the plastic transparent drap was done during
the hole procedure to minimize aerosol dispersal. A skin flap was
subsequently raised and the dissection continued involving the parotid
fascia in order to expose the parotid gland in front of the stone and
the proximal tract of Stensen’s duct, through the second opening in the
plastic cover. During the blunt dissection, the buccal branch of the
facial nerve close to the duct surgery was identified. A neurostimulator
(Neuro-Pulse®, Bovie Medical Corporation, ) was used to check the
functioning of the buccal branch and other possible branches of the VII
cranial nerve met during dissection. The light at the tip of the
endoscope allowed the exact position of the stone to be located, and a
secondary parenchymal branch was incised over the stone (Fig. 2a) and
parallel to its direction using a size 11 scalpel; after gentle
dissection using dedicated instruments, the stone was grasped with
forceps, and then removed (Fig. 2b). The duct was then irrigated with
saline and an endoscopic search was done for any residual stones or
debris. A net of hemostatic patch (Tabotam, Ethicon Sarl, ) was
positioned over the incisional area to cover parotid tissue as
previously described5 and preauricular incision was
sutured. A compressive dressing and 48 hours without eating and drinking
was prescribed; peri-operative antibiotic prophylaxis and one week of
postoperative antibiotic therapy with amoxicillin plus clavulanic acid
was given.
A 7-mm nonpalpable salivary stone embedded into the secondary
parenchymal branch of the right Stensen duct was successfully removed
using a sialendoscopy-assisted transfacial approach performed through
STAPID; the presence of the drape did not interphere with the surgical
procedure as well as the senior salivary surgeon (P.C.) did not find any
particular discomfort compared to traditional surgery [5]. The
surgical time was 85 minutes. The stone was completely removed, no
residual debris remained in the duct system and no further surgery was
required. No major or minor complication (i.e., facial nerve palsy,
sialocele, salivary fistula, sialadenitis) occurred during or after the
procedure; postoperative mild gland swelling resolved in a few days with
the application of a pressure dressing. The patient was satisfied with
its facial scar.