Description This “How I Do It” presentation demonstrates my approach to the intraductal treatment of salivary stones using pneumatic lithotripsy. The technique is presented step by step, including endoscopic identification of the stone, positioning and application of the pneumatic probe, fragmentation under direct vision, and removal of the resulting fragments. Procedural videos illustrate the technique and its practical application in routine sialendoscopic stone treatment.

Background Sialendoscopy has enabled the treatment of many salivary stones through a minimally invasive, gland-preserving approach. Stones that cannot be removed intact may require intraductal fragmentation. Pneumatic lithotripsy provides mechanical fragmentation under direct endoscopic control and has been my principal method of intraductal lithotripsy since 2007.

Outcome Objectives Participants will become familiar with the principles and practical steps of intraductal pneumatic lithotripsy, including probe positioning, controlled fragmentation, and endoscopic removal of stone fragments. They will also gain an understanding of how pneumatic lithotripsy can be integrated into routine sialendoscopic management of salivary stones.

Description

This presentation examines whether papillotomy should remain a routine method of gaining access during sialendoscopy. Although dividing the papilla can provide immediate entry and shorten the initial phase of the procedure, this apparent convenience may compromise structures essential for safe and durable treatment. The session explains the papilla’s dual role as a dynamic sphincter and a fixation point for the terminal salivary duct. It demonstrates how incision may concentrate force at the cut edge, allowing ductal tearing, separation, skeletonisation, inversion, or retraction. A papilla-preserving protocol is then presented, beginning with salivary stimulation using lemon juice, precise identification of the emerging ductal droplet, careful cannulation, serial dilation, and temporary stenting before endoscopy. Conventional Marchal dilation, guidewire-assisted techniques, and a modified Marchal dilator are discussed as alternatives. Papillotomy is positioned as a selective option for resistant ostia rather than an automatic opening manoeuvre.

Outcome Objectives

After this presentation, participants will be able to describe the importance of preserving ostial integrity and explain how the papillary collar distributes force while stabilising the terminal duct. They will recognise the potential intraoperative consequences of papillotomy, including ductal tear, loss of support, skeletonisation, inversion, retraction, conversion to floor-of-mouth surgery, and loss of a gland-preserving pathway. Participants will be able to apply an access sequence based on salivary stimulation, ostium identification, atraumatic cannulation, gradual dilation, and stent placement. They will understand that serial dilation is not always a one-directional process: when the next dilator does not pass smoothly, returning to the previous size and re-establishing the tract may be safer than using force or immediately performing papillotomy. Finally, they will identify circumstances in which a limited papillotomy may be justified and the follow-up measures it requires.

Background

Papillotomy was attractive because it solved a difficult entry problem quickly. The surgeon could define the opening directly, avoid dilation steps, and introduce the endoscope. However, the natural ostium is considerably smaller than the ductal lumen and may resist instruments. Cutting the papilla changes more than its diameter. It interrupts a muscular and elastic collar that regulates salivary outflow, limits retrograde exposure to oral contents, and anchors the duct within surrounding tissues. Once this collar is divided, advancing forces may no longer be distributed circumferentially and may instead act along a vulnerable incision edge. Early complications are generally visible, whereas late scarring, fixed narrowing, recurrent obstruction, or ascending contamination may remain under-recognised because many referred patients are not examined endoscopically after returning home. This follow-up gap can make papillotomy appear safer than it is. A preservation-first strategy therefore secures the duct before introducing the endoscope. If papillotomy remains necessary after gentler routes fail, the incision should be limited, the duct stented, and the ostium carefully reviewed endoscopically during follow-up.