ONLINE EXCLUSIVES

Wireless mobile ultrasonography-

assisted parotid duct stone removal
Na Rae Oh, MD; Joo Hyun Woo, MD, PhD; Dong Young Kim, MD, PhD;
Min Kwan Baek, MD, PhD

Abstract
Ultrasonography is highly sensitive for the diagnosis of
sialoliths. Recently, wireless mobile ultrasonography was
developed. We describe the case of a 49-year-old man
who presented with painful postprandial left cheek swell-
ing. Computed tomography detected a solitary 5-mm
parotid duct stone with infection at the anterior portion
of the left masseter muscle. Transoral stone removal was
planned, although difficulty was expected in view of the
surrounding infection. Surgery was performed under the
guidance of mobile ultrasonography, and the stone was
removed safely.
Introduction
Obstructive disease accompanied by sialolithiasis is
common in the salivary gland. Parotid gland sialoli-
thiasis accounts for 19% of all cases of salivary gland
stones.1 Surgical removal is the treatment of choice for
parotid duct stones, and several options have been in-
troduced. Selection of a surgical method depends on
the size and location of the stone, as well as the sur-
geon’s preference.2
Conventionally, calculi in the distal section of the
parotid duct near the punctum are removed via an
intraoral approach.3 When a parotid duct stone is lo-
cated on the lateral portion of the masseter muscle or
on the intraglandular portion, an external approach is
commonly selected.
Dissection of the parotid gland may cause facial nerve
injury,4,5 although a microendoscope-guided external
approach has minimized the elevation of the skin flap
and preserved the parotid gland.6 Sialendoscopy is a
popular method of managing sialolithiasis. However,
handling of the endoscope and basket requires delicate
skills, and its use is limited to stones with a diameter
of 8 mm or larger.3,7
A few authors have reported their experience using
ultrasonography to assist in the removal of parotid
duct stones.8,9 They found this approach to be safe and
without the complications that are associated with
parotid gland dissections, including facial nerve injury.
In this article, we describe our experience with using
wireless mobile ultrasonography during the removal of
a parotid duct stone via the transoral approach.
Case report
A 49-year-old man presented with a 1-week history of
a painful postprandial swelling of the left cheek. His
history included a parotid mass excision 8 years earli-

From the Department of Otorhinolaryngology–Head and Neck Surgery,

Gachon University College of Medicine, Gil Medical Center,
Incheon, Republic of Korea.
Corresponding author: Joo Hyun Woo, MD, PhD, Department of
Otorhinolaryngology–Head and Neck Surgery, Graduate School
of Medicine, Gachon University, Gil Medical Center, 1189, Guwol-
dong, Namdong-gu, Incheon, Republic of Korea. Email: woojh@ Figure 1. Purulent discharge is expressed from the left parotid
gilhospital.com duct orifice during cheek compression.

E36 www.entjournal.com ENT-Ear, Nose & Throat Journal April/May 2018

 Wireless mobile ultrasonography-assisted parotid duct stone removal
Figure 2. Contrast-enhanced CT demonstrates the left parotid
duct stone (arrow) and surrounding cellulitis.
er. One year before presentation, he developed an in-
termittent oral pus-like discharge.
On examination, a diffuse, hard, fixed, mass-like
lesion was palpated in the left parotid area. A vertical
incision line that had been made during the patient’s
previous parotid surgery was inspected. When the swol-
len left cheek was compressed, a purulent discharge was
expressed from the left parotid duct orifice (figure 1).
Contrast-enhanced computed tomography (CT)
demonstrated a 5-mm left parotid duct stone at the
anterior portion of the left masseter muscle, as well as
a dilated duct with a peripherally enhanced wall (figure
2). The distance from the orifice to the stone was 2 cm.
We planned removal of the stone via a mobile ul-
trasonography-assisted transoral approach. The mo-
bile ultrasound scanner
(SONON 300C; Healce- A
rion; Seoul, Republic of
Korea) was connected to
a personal smart phone
via Bluetooth (figure 3,
A). A probe was inserted
into the parotid duct, and
an anterior hemi-ellip-
tical incision was made
on the duct orifice. The
dissection was performed Figure 3. A: Wireless mobile ultrasonography is viewed on a personal smart phone via Bluetooth to
along the duct, although identify the parotid duct stone. B: Dissection with mosquito forceps (arrow) is performed to access the
stone (arrowhead) under mobile ultrasonographic guidance (as = acoustic shadow).
Volume 97, Number 4-5
a precise demarcation of the duct was impossible to
determine because of surrounding fibrosis. The dissec-
tion was then completed under the guidance of mobile
ultrasonography (figure 3, B). We identified the stone
(figure 4) and safely removed it.
The patient was discharged 2 days after the operation
without any morbidity.
Discussion
Diagnosis. The primary symptom of sialolithiasis is
painful postprandial swelling of the salivary gland.1
Bimanual palpation is essential in the physical exam-
ination to find a stone. However, palpation of small pa-
rotid duct stones can be challenging because the duct
is embedded in buccal soft tissue.10
Because parotid duct stones are usually radiolucent
and they are not distinguishable from arteriosclerosis
of the lingual artery, phlebolithiasis, and calcified
lymph nodes around the duct, a simple x-ray is not
effective for the differential diagnosis.11 On the other
hand, noncontrast CTs can precisely identify a stone,
and they are widely used for this purpose.12
Ultrasonography is highly sensitive for the diagnosis
of salivary stones; for stones larger than 2 mm, the de-
tection rate is 90%.13 Furthermore, ultrasonography is
easily performed for diagnosis as well as surgery, and
it carries no risk of radiation exposure.
Treatment. Although surgical treatment is empha-
sized for parotid duct stones, patients with small stones
might benefit from medical treatment with a sialagogue
or lemon juice, which stimulate salivary secretion.1
However, sialagogues may be ineffective in patients with
a medium to large stone, and they can cause colic pain.
B
www.entjournal.com E37
 Oh, Woo, Kim, Baek

The diagnostic accuracy of mobile ultrasonography

for sialolithiasis has not been reported. Of course, it is
suspected that the sensitivity of mobile ultrasonography
would be less than that of classic ultrasonography. The
mobile ultrasonography device used in our case was
originally developed for use in abdominal examinations,
and it had a convex probe. For this reason, the resolution
was low, although the focus could be controlled in 2 cm
of depth. However, it was sufficiently capable to detect
the 5-mm stone.

References
Figure 4. The stone (arrow) is identified in the soft tissue.
Several surgical methods have been used to manage
parotid duct stones. A transoral, external, or sialen-
doscopic approach can be selected, depending on the
location and size of the stone and the preference of the
surgeon. In our case, we used a transoral approach
because the stone was located on the anterior border
of the masseter muscle.
Insertion of a lacrimal probe into the duct is helpful to
safely demarcate it during a transoral procedure. How-
ever, the extent of surgery could become more invasive
(1) if the stone cannot be found because it is small or
(2) as a result of a tortuous parotid duct or movement
of the stone. This risk might be mitigated by the use of
intraoperative ultrasonography.
In our case, preoperative CT detected an infectious
condition around the parotid duct, and therefore we
expected a difficult dissection. For this reason, we
planned the wireless mobile ultrasonography-guided
stone removal. It was difficult to precisely demarcate
the duct during the operation, despite the insertion of
the lacrimal probe into the duct. It was impossible to
follow the duct or to identify the stone at the anterior
border of the masseter muscle because of the fibrosis.
Therefore, we proceeded to complete the dissection
under ultrasonographic guidance.
A mobile ultrasound scanner is smaller than the classic
ultrasound device, and it does not require a carrier or
additional space for maintenance. It is also much less
expensive, and it can be freely used without limitations
of time and space.
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E38 www.entjournal.com ENT-Ear, Nose & Throat Journal April/May 2018