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Neuroradiology Case of the Week

Case 85

Raymond De Guzman MD, John Coniglio MD,
and P-L Westesson, MD, PhD, DDS

Clinical Presentation: A 41-year-old woman had recurrent swelling of the right parotid gland following I-131 treatment of thyroid cancer. She recently had significant swelling of the right parotid gland associated with each meal and each fluid intake. On physical examination, there was slow secretion of the saliva mixed with pus from the Stensen duct on massaging the glands. The traditional techniques to treat this condition have involved superficial or total parotidectomy if the stenosis resulted in recurrent symptomatic sialoadenitis [1]. Other methods used, with varying degrees of success, are duct reimplantation for an osteal lesion, duct ligation, and sialodochoplasty [2-6].

Radiological Findings:  Sialography (1 mL of iohexol; Omnipaque 300 mg I/mL, Nycomed, Princeton, NJ) showed a focal stricture of the proximal portion of the Stensen duct (Fig. 1). The patient was offered duct dilation with interventional radiographic technique, which was performed. After the diagnostic study, 8 mL of 1% lidocaine was infiltrated subcutaneously into the region of stenosis and a sialography dilator was passed through the stenosis into the proximal portion of the duct and into the gland. The duct was sequentially dilated to 5 F with use of the 3-F and 5-F dilators from a micropuncture set (Cook) (Fig. 2). The wire was exchanged for a 0.018-inch, platinum-tip wire (Medi-tech/Boston Scientific, Watertown, MA) and a 2-mm-diameter, 2-cm-long symmetry balloon (Medi-tech/Boston Scientific) was placed in the stenotic area and inflated to a pressure of 16 atm (Figs. 3 & 4). During the procedure, the patient was sedated with 4 mg of midazolam and 250 µg of fentanyl. The patient tolerated the procedure well, with mild to moderate discomfort during the dilatation portion of the procedure. After dilation, the Stensen duct showed a normal diameter through the previously stenotic area (Fig. 5). The patient was discharged after the procedure receiving oral antibiotic therapy (5 days; ampicillin 500 mg QID). She experienced a dull ache for approximately 5 days, which was controlled with over-the-counter analgesics. She had gradually decreasing swelling and pain over the gland that lasted approximately 10 days, but the daily swellings associated with meals and fluid intake did not persist. There were no complications..

Diagnosis: Stenosis of Stenson’s duct; sialoadenitis

Discussion:Balloon dilation of parotid duct strictures has been reported previously [2-5, 7-12]. The results of these earlier case reports are consistent with our findings, namely relief of symptoms after the immediate post procedure swelling had subsided. Balloon dilation appears to be an attractive, nonsurgical, minimally invasive treatment of a difficult clinical problem. The symptom associated with parotid duct strictures is recurrent swelling resulting from food intake; the swelling is usually painful and can require considerable time to resolve. Inflammatory changes frequently develop in the gland secondary to obstruction, as was seen in this patient on the immediate pre-dilation sialogram. The stenosis itself can be secondary to infection, stone formation, surgical procedure, or trauma. Traditionally, this condition has been treated, if recurrent and troublesome, with surgical methods such as duct ligation, gland removal, or duct reimplantation [2-6]. Because these procedures carry greater morbidity, it seems reasonable to attempt balloon dilation prior to invasive surgical procedures.
     We used a 2-mm symmetry balloon, whereas others [2-5] have used a 3-mm balloon. The balloon in our case was twice inflated to a pressure of 16 atm, and pressures were held for approximately 5 seconds. Further studies will be necessary to refine the balloon dilation technique and to establish its long-term results.
     The location of the stenosis is probably significant. The stenosis in this case was located in the proximal portion of the Stensen duct - a stenosis that is located within the gland or closer to the gland is more difficult to treat with balloon dilation because it can be difficult to advance the balloon into, or close to, the gland. We used conscious sedation and subcutaneous local anesthesia with good pain control. Salivary gland dysfunction has been reported after I-131 treatment for thyroid cancer [13].

Summary: We report a case of parotid duct stenosis that was successfully treated with balloon dilation. This technique is less invasive than surgical treatment..

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