MODERN SURGICAL TREATMENT OF TUMORS OF THE LARGE SALIVARY GLANDS

Аннотация

Over the past fifteen years, increasing public demand for minimally invasive surgery and recent technological advances have led to the development of a number of conservative therapeutic treatments for obstructive salivary gland diseases such as stones and duct stenosis. These include extracorporeal shock wave lithotripsy, sialendoscopy, laser intracorporeal lithotripsy, interventional radiology, video-assisted conservative surgical removal of parotid and submandibular stones, and botulinum toxin therapy. Each of these methods can be used as a stand-alone therapeutic method or in combination with one or more of the above options, usually on a day or overnight basis under local or general anesthesia. The multimodal approach is completely successful in approximately 80% of patients and reduces the need for gland removal by 3%, justifying the combination, albeit labor-intensive and relatively expensive, as part of a modern and functional treatment of salivary gland stones. Regarding the treatment of salivary duct anomalies such as strictures andkinks, interventional radiology with fluoroscopically guided balloon ductoplasty appears to be the most appropriate method despite the use of radiation. Operative sialendoscopy alone is the best therapeutic option for all mobile intraluminal causes of obstruction such as microliths, mucus plugs or foreign bodies, or for the local treatment of inflammatory conditions such as recurrent chronic mumps or autoimmune diseases of the salivary glands. Finally, if one of the above methods fails and regardless of the cause of obstruction, botulinumtoxin injection into thesalivary glandparenchyma using color Dopplerultrasound monitoringshould beconsidered before deciding onsurgical removal of thegland. Key words: Salivary glands, salivary stones, salivary duct stenosis, surgical treatment, extracorporeal lithotripsy, sialendoscopy, botulinumtoxintherapy Introducion: Diseases of the salivary glands are relatively common. The most common non-neoplastic disease of the salivary glands is obstructive sialadenitis, which can be caused by stones, fibromucinous plugs, duct stenosis, foreign bodies, anatomical changes or malformations of the duct system leading to mechanical obstruction associated with stasis. Patients with a history of obstructive sialadenitis have recurrent painful periprandial swelling of the affected gland, best known as “meal-time syndrome,” which is often complicated by recurrent bacterial infections, with fever and purulent discharge from the papilla. Sialolithiasis is the main cause of obstructive diseases of the salivary glands, it occurs in 66% of cases and accounts for about 50% of the main diseases of the salivary glands. Postmortem studies have shown a prevalence of salivary gland stones in the general population of 1.2%, although Escudier and McGurk described the incidence of symptomatic salivary gland stones as approximately 59 cases per million per year with a clinical prevalence of 0.45% 9. Sialolithiasis is more common in male patients. The peak incidence is between the ages of 30 and 60 years, and it is rare in children, as only 3% of all cases of sialolithiasis occur in the pediatric population. Sialolithiasis affects the submandibular gland 98,7:ROTCAFTCAPMI .SECNEICSLACIDEM,5202,yaM,5emuloV gro.srehsilbupcimedaca.www in 80-90% of cases, mostly unilaterally10 but without a preferred side; this finding is partly explained by recent postmortem morphometric studies that have shown symmetry between the right and left glands. In our experience, the average size of submandibular stones is about 7.3 mm, although giant sialoliths up to 7 cm have occasionally been described. Most stones are located in the distal third of the duct or at the hilum of the gland; pure intraparenchymal stones are rare. Five to 10% of cases occur in the parotid gland. The difference between parotid and submandibular stones is striking partly related to the ascending duct system of the submandibular gland and the type of secretion (mainly mucous). The sublingual and other small salivary glands are rarely affected (approximately 0-5% of cases). Traditional etiopathogenetic factors associated with stone formation include obstruction, decreased salivary flow rate, dehydration, altered salivary pH associated with oropharyngeal sepsis, and impaired crystalloid solubility3; physiologically, microliths may be detected after precipitation in supersaturated mucus plug solution3 or membrane phospholipids in excess secretory vesicles, which become symptomatic and may act as a nidus in which successive layers of inorganic and organic matter are deposited. In addition to these classical hypotheses, Marshall et al. 4 recently proposed a retrograde theory of lithogenesis, which posits that retrograde migration of food, bacteria, or foreign bodies from the oral cavity into duct system may lead to stone formation, which is facilitated by changes in the sphincter-like mechanism, which are reported in 9