Teaching Case

Recurrent left parotid gland swelling.

The patient suffered from recurrent painful left parotid gland swelling during meal times for several months. This usually settled gradually after 4 – 5 hours.
Sialogram showed a stricture in the parotid duct which was subsequently dilated.
Prior to dilatation, a sialogram was performed to confirm the extent of the stricture. The duct orifice was then dilated with a lacrimal duct dilator (4 French) and a 0.018 inch hydrophilic steerable SV5 guidewire was introduced followed by a Savvy angioplasty balloon (4 – 3.4 Fr diameter, 2cm long). The parotid duct was initially dilated up to 2.5mm then further dilated to 3mm. The balloon was inflated for 10 – 15 minutes up to 15 atmospheres. A post procedure sialogram confirmed satisfactory dilatation of the parotid duct stricture

Recurrent salivary gland swelling can be due to salivary duct obstruction of which majority are due to calculi but up to 25% can be caused by a stricture. Parotid duct strictures tend to be more common than submandibular duct strictures probably due to the fact that parotid duct diameter is less than that of the submandibular duct. Until recently, the only treatment for symptomatic strictures was adenectomy which carries significant risks such as facial nerve injury and cosmetic deformity.
Balloon dilatation of ductal strictures is a less invasive technique which may eliminate the need for surgery. More parotid than submandibular strictures are presented for treatment by interventionalists as there is increased morbidity associated with adenectomy of parotid gland as compared to that of submandibular gland.
Many salivary duct strictures appear densely fibrotic and show necking of the fully dilated balloon even at 15 atmospheres inflation pressure. This is commonly observed in long standing strictures of the elderly population where there is significant proximal dilatation to the stricture. Complete dilatation is normally achieved in younger patients with a short history of obstruction. It is thus important to select the suitable patients who include those with strictures in the main duct and patency beyond the stricture.
Complete elimination of the stricture in the immediate post treatment sialogram has been reported up to 87%. Although up to half the cases done in a study series had recurrence of stricture, symptomatic improvement is achieved and maintained in majority of cases even though it is not always reflected radiographically. In certain cases of recurrent salivary duct strictures where patients are not in favour for surgical management, the use of a cutting balloon technique may be considered.