New Delhi, Feb 28: In a rare medical case, a 50-year-old man here underwent surgery for removal of multiple stones from his thin 3 mm salivary duct. The sialendoscopy permanently removed these stones in a scarless and incisionless fashion, said doctors on Tuesday.

Sialendoscopy is an innovative technique that uses extremely narrow endoscopes to diagnose and treat many conditions of the salivary glands.

Problems for Satyender Khatri, a Delhi resident, started some three-four years ago when he complained of recurrent swelling and pain below the left jaw area on food intake.

Despite being diagnosed to have stones in the left submandibular duct region, which kept on recurring, and having undergone an oral incision and stone removal many times in the past, Khatri did not get any relief.

On accelerating pain, Khatri underwent CT scan and found a large 7mm stone midway in the submandibular duct and multiple small stones present in the junction of the gland and the duct with the largest being 4mm in size.

"Many such patients suffer the agony of recurrent pain on eating. In most of the cases, the cause is as simple as a stone or narrowing in the salivary gland duct, which causes obstruction to outflow leading to infection," said Varun Rai, Associate Consultant at Sir Ganga Ram Hospital.

Rai said that when they examined Khatri, they found that his left submandibular gland had swollen to twice its size and the ultrasound showed the presence of the stone in the duct situated in the floor of mouth and just a widened duct behind the stone.

"The normal size of the duct is just 3 to 5 mm in diameter and a 7 mm size stone had stretched the ductal wall, causing extreme blockage leading to his problems," he added.

Having known the problem of recurrence, the team of doctors performed CT scan of the gland, which revealed multiple stones behind the stone leading from the duct to almost inside the gland.

According to medical sciences, such patients are managed initially with antibiotics and then treated with excision of the gland, which would leave an unsightly scar and, for the unlucky ones even a lower lip paralysis.

However, in Khatri's case the doctors wanted to do something different and safer, and therefore the decided to perform the sialendoscopic approach.

According to the medical procedure, during the sialendoscopic approach under full anaesthesia the normal opening of the duct is identified under magnification and then dilated using a special set of dilators.

"After the opening is sufficiently wide, a Sialendoscope, which is a miniature endoscope, is introduced and the entire ductal system is visualised and the obstruction can be directly addressed without any incision for small stones," said Rai.

Explaining the complex case of Khatri, Rai said that the larger stone was first brought to the opening of the duct and then removed.

"Then the smaller stones present in the back of the duct were addressed and the 4mm stone was removed using microforceps. Endoscopy check then revealed five other smaller stones along with a lot of debris present in the part of the duct, which was almost inside the gland. These stones were also removed using a completely endoscopic approach and the duct was flushed of all debris," said Rai.

Rai said that an estimated six million Indians have stones in their salivary gland duct.

Delhi man undergoes rare surgery for multiple stones in salivary duct