Use of Intraoperative Ultrasonography in Sialendoscopy and Sialendoscopy Assisted Surgery - A Retrospective Analysis

Use of Intraoperative Ultrasonography in Sialendoscopy and Sialendoscopy Assisted Surgery - A Retrospective Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of Intraoperative Ultrasonography in Sialendoscopy and Sialendoscopy Assisted Surgery - A Retrospective Analysis Srinidhi Ravi, Milind Navalakhe, Pramod Shiralkar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8803401/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Present management of obstructive salivary gland diseases like sialolithiasis, sialodochocoeles and salivary duct strictures includes sialendoscopy and sialendoscopy assisted minimally invasive procedures. Ultrasonography, Computed tomography scan of the Neck and Magnetic Resonance Sialography are the diagnostic tests available for patients suffering from Obstructive salivary gland diseases. Diagnostic sialendoscopy is comparable to ultrasonography for diagnosis, however due to the higher cost and invasive nature it is not considered the procedure of choice in our country. Ultrasonography is the first imaging modality chosen for patients with obstructive salivary gland disease. Materials and Methods : A retrospective observational study was conducted in a tertiary care centre in the city of Mumbai, India. Retrospective analysis was conducted including data of patients who underwent sialendoscopy and sialendoscopy assisted procedures from January 2014 to September 2025 in a single tertiary care centre. Institutional Ethics committee approval and waiver of consent was taken prior to the start of the study. 170 patients were identified who underwent sialendoscopy and sialendoscopy related procedures. Their primary diagnosis, preoperative imaging, intra operative findings and treatment plan was noted. Patients in whom intraoperative ultrasonography was performed were identified. The pathology, need for intraoperative ultrasonography, the step of surgery when ultrasonography was indicated, ultrasonography findings and surgical outcomes were noted. Results: 18 patients needed intraoperative ultrasonography. Ultrasonography was done intraoperatively in 8 cases of parotid sialolithiasis, 2 cases of parotid duct strictures, 1 case of combined parotid duct stricture with sialolithiasis, 6 cases of submandibular sialolithiasis and 1 case of submandibular duct stenosis. The use and advantage of ultrasonography in each case was analysed. Conclusions : Ultrasonography is a meaningful addition to the intraoperative armamentarium available in the expanding branch of sialendoscopy and sialendoscopy assisted procedures. It reduces operative time, minimises surgical morbidity and facial scarring, improves stone clearance rates, prevents unnecessary repeat procedures, and enhances surgeon confidence in challenging anatomical or pathological scenarios. When available, planned intraoperative ultrasonography should be considered an integral component of advanced sialendoscopy practice, particularly in complex obstructive diseases of the parotid and submandibular ducts. Sialendoscopy sialendoscopy assisted procedures intra-operative ultrasonography obstructive salivary gland diseases Figures Figure 1 Figure 2 Key Message Intraoperative Ultrasonography is a meaningful addition to the armamentarium available in the expanding branch of sialendoscopy and sialendoscopy assisted procedures. It reduces operative time, minimises surgical morbidity and facial scarring, improves stone clearance rates, prevents unnecessary repeat procedures and enhances surgeon confidence in challenging anatomical or pathological scenarios. When available, planned intraoperative ultrasonography should be considered an integral component of advanced sialendoscopy practice, particularly in complex obstructive diseases of the parotid and submandibular ducts. Introduction Present day management of obstructive salivary gland diseases like sialolithiasis, sialodochocoeles and salivary duct strictures includes sialendoscopy and sialendoscopy assisted minimally invasive procedures. Ultrasonography, Computed tomography scan of the Neck and Magnetic resonance Sialography are the diagnostic tests available for patients suffering from Obstructive salivary gland diseases. Ultrasonography is the first imaging modality chosen for patients with obstructive salivary gland disease.[ 1 ] Diagnostic Sialendoscopy is considered the Gold standard investigation of choice in these patients. However, this is expensive and not freely available even in tertiary care centres in India and hence not preferred. Due to its non-invasive character and low cost, ultrasonography can be done repeatedly as necessary without any irradiation and is safe in all patients. For the detection of sialoliths, ultrasonography is shown to be of equal value and comparable to conventional radiographs. [ 2 ] Preoperative imaging characteristics such as stone presence, size, and location provide essential information that can guide surgical planning and clinical outcome expectations for obstructive parotid disease management. [ 3 ] If an obstruction is clinically suspected, the role of imaging consists of confirming the obstruction, identifying its cause, evaluating the position and extent of the obstruction and evaluating for associated complications. [ 4 ] Ultrasonography has a high degree of accuracy, specificity, sensitivity, positive predictive value and negative predictive value.[ 5 ] A study from Erlangen, Germany studied the usefulness of simultaneous ultrasonography and sialendoscopy as a diagnostic tool for patients with sialolithiasis. They concluded that simultaneous use of both sialendoscopy and ultrasonography adds valuable information regarding diagnosis, planning of appropriate treatment, intraoperative management and postoperative follow up.[ 6 ] Ultrasonography is also the first investigation of choice in cases of obstructive salivary gland diseases without sialolithiasis. [ 7 ] The fragility and complex branching of the ductal systems pose significant intraoperative challenges to the sialendoscopist. In such cases, when there is a risk of complication or incomplete resolution of the pathology, the decision made is often to abandon the procedure and reexplore again in a safe setting. Ultrasonography, when available intraoperatively, helps us overcome some operative challenges. Due to the relative novelty of sialendoscopy and sialendoscopy assisted procedures there is a paucity of data available in literature regarding the use of intraoperative ultrasonography in sialendoscopy and sialendoscopy assisted procedures. This retrospective study attempts to bridge this gap in knowledge regarding the usefulness of intraoperative ultrasonography in sialendoscopy and sialendoscopy assisted procedures. Materials & Methods A retrospective observational study was conducted in a tertiary care centre in the city of Mumbai, India. Retrospective analysis was conducted including data of patients who underwent sialendoscopy and sialendoscopy assisted procedures from January 2014 to September 2025. Institutional Ethics committee approval and waiver of consent was taken prior to the start of the study. 170 patients were identified who underwent parotid and submandibular sialendoscopy and sialendoscopy assisted procedures in a single centre. Their primary diagnosis, preoperative imaging, intraoperative findings and treatment plan was noted. Patients in whom intraoperative ultrasonography was performed were identified. The pathology, need for intraoperative ultrasonography, step of surgery when ultrasonography was performed, ultrasonography findings and surgical outcomes were noted. Results 18 cases were identified where intraoperative ultrasonography was done. The gender and diagnosis distribution is as given in Table 1 . Table 2 gives the distribution of surgery done. Table 3 describes the role of ultrasonography in parotid and submandibular ductal diseases including its utility at various stages. Table 4 gives the qualitative analysis of the operative notes by the surgical team. Table 1 Distribution of sialendoscopy cases as per diagnosis. Parotid duct Submandibular duct Total Male Female Male Female Sialolithiasis 5 3 5 1 14 Stricture/ Sialocoele 1 1 0 0 2 Both 0 1 0 1 2 Total 6 5 5 2 18 Table 2 Distribution of cases as per surgery performed Parotid Duct Submandibular Duct Total Sialendoscopy 6 4 10 Combined approach technique 5 3 8 Total 11 7 18 Table 3 Role of ultrasonography in parotid and submandibular ductal diseases including its utility at various stages Sr No Advantage / Use of Intraoperative ultrasonography Parotid Submandibular No. of patients 1 Ultrasonography Shows no remnant stone, no further imaging /scopy needed 5 5 10 2 Incision site marking / Sialolith localisation 5 2 7 3 Intraglandular Stone/ stone fragments [submillimetre] not amenable to sialendoscopy as well as combined approach, left as it is 0 2 2 4 To guide guidewire in proximal duct after dilatation of stenotic segment and entry into dilated duct 2 0 2 5 Floating stone – positioned proximal intraductal and amenable to external approach. Stone not retrieved as patient does not consent for external incision. Ultrasonography done for documentation 1 0 1 6 Decision to go for combined approach taken intraoperatively due to unfavourable position of sialolith fragments after LASER seen on Ultrasonography 1 0 1 7 To assess distance of stone from tip of sialendoscope in proximal sialolith 2 0 2 Table 4 Additional advantages Sr No Advantage / Use of Intraoperative ultrasonography Parotid Submandibular No. of patients 1 Surgical time reduced 11 7 18 2 Blind dissection avoided 2 2 4 3 Patient counselling for need for further imaging and SOS repeat sialendoscopy in future 1 2 3 4 Visualised intraductal calculus flushed out with mucinous debris on dilatation on stricture. Medicolegal Documentation done with ultrasonography as no stone retrieved to show patient 1 1 2 DISCUSSION Ultrasonography has emerged as an essential adjunct to the expanding field of sialendoscopy and sialendoscopy-assisted procedures. While preoperative ultrasonography is well established in the diagnostic work-up of salivary gland disease, its planned and opportunistic intraoperative use remains underutilised. In our series, intraoperative ultrasonography was most frequently employed in cases of parotid sialolithiasis, particularly external combined approach sialendoscopy. Accurate intraoperative localisation of stones allows a targeted, limited skin incision around 1.5 cm in length directly over the stone, minimising tissue dissection. Placement of a 20-gauge needle abutting the stone under ultrasonographic guidance serves as a reliable landmark for sialodochotomy. [IMAGE 1] Image 1. Incision of external combined approach parotid sialendoscopy with 20G needle as guide This approach offers three distinct advantages: first, it simplifies the procedure and reduces operative time by avoiding elevation of a superficial musculoaponeurotic system (SMAS) flap; second, the incision follows the surface anatomy of the Stenson’s duct, thereby minimising the risk of encountering multiple facial nerve branches and third, the patient has a small and neat scar. This technique has proven valuable for both mid-duct and proximal duct stones, especially when the stone lies beyond the reach of the sialendoscope. In proximal intraglandular parotid stones, where endoscopic visualisation is not possible, intraoperative ultrasonography often becomes the only reliable method for stone localisation. In one such case from our series, preoperative imaging demonstrated a calculus located deep within the intraglandular portion of the Stenson’s duct. The sialendoscope could be passed up to 4.5cm and ultrasonography showed the sialolith 2.5cm from the tip of the sialendoscope. [Image 2] Image 2. Distance from tip of sialendoscope to proximal parotid duct sialolith Sonographic localisation enabled precise sialodochotomy through a minimal incision, resulting in successful stone removal and preservation of the parotid gland. This experience highlights how ultrasonography can expand the indications for external combined-approach sialendoscopy, allowing gland-saving surgery even in technically challenging cases. In LASER fragmentation of sialoliths using Holmium or Thulium LASER, the number of fragments and size cannot be determined endoscopically. There is also the possibility of proximal or distal migration of these fragments with the saline irrigation during the sialendoscopy. While most fragments seen endoscopically are extracted with the help of an appropriate basket, there are times where the surgeon has a suspicion of remnant fragments. The size of the retrieved fragments is also compared to the preoperative imaging to ensure complete clearance. Submillimetre stones often extrude spontaneously from the dilated salivary duct post-procedure and do not need additional care. However, any larger fragments missed or remaining in the duct or smaller branches can cause recurrent or persistent symptoms. In such cases, patients need repeat imaging and repeat sialendoscopy. An ultrasonography done intraoperatively enables identification of remnant stones, their dimensions and precise location. At times, when small fragments migrate deep into the gland, they are no longer accessible endoscopically. Ultrasonographic documentation of such migration helps the surgeon avoid unnecessary prolongation of surgery in the search of such a stone. Fragmentation of large misshapen staghorn calculi leads to multiple fragments and a larger fragment left behind accidently will result in the patient having no resolution of symptoms and a wasted procedure. Ultrasonography helps in both situations, one to stop further exploration if stone size is not significant [< 1mm] and to explore and at times convert to combined approach in case of larger fragments not accessible to our sialendoscope. In patients with parotid duct stenosis, there are certain challenges with intraoperative navigation of the sialendoscope. After successful dilatation of the stenosis, the scope enters a wide duct and orientation of the path to the proximal duct is difficult. In such cases, a guidewire is inserted under ultrasonographic guidance. The sialendoscope can be railroaded over the guidewire into the proximal duct. The duct lumen thus can be evaluated till the branching or masseteric bend. The ultrasonography also clearly shows the widened duct post dilatation documenting the successful outcome. This reduces surgical time as well as improves surgical precision. Any incomplete dilatation of the duct is flagged and remedial measures are taken. In large submandibular sialolithiasis, the location of the sialolith determines the difficulty of combined approach surgery. Sialoliths distally located are amenable to endoscopic visualisation and are easily palpable in the floor of mouth. In case of proximally located large stones, the surgeon relies on palpatory feedback. The stone feels hard and a firm stent is sutured in situ in the distal duct for easy localisation. Proximally the duct lies deeper away from the floor of the mouth. In a chronically fibrosed gland the palpatory feedback can be misleading at times. Ultrasound helps in such cases to mark the site of the sialolith in relation to the floor of the mouth with the aid of a 22G needle placed under guidance. In one of the cases in our study, the submandibular gland was hard on palpation, and the ultrasound showed a calculus encased in a lesion in the submandibular gland. To avoid unnecessary exploration of a large part of the deep lobe of the gland through the floor of mouth ultrasonography was done. This aided the incision marking, and precise dissection was possible. Additionally, an intraoral biopsy of the hard submandibular gland tissue was taken as well. This was reported as chronic sialadenitis in histopathology. There are instances where the salivary duct papilla is stenosed and a small calculus is reported just proximal to the papilla. On successful dilatation, thick mucinous secretions and stagnant saliva gush out. Small calculi or small chalk like particles may be flushed out with these secretions and with saline irrigations. The surgeon focussing on the monitor in front may miss this and continue to search for the calculus in the duct in vain. Ultrasonography confirms both adequate dilatation and absence of residual stones in the duct, providing reassurance of procedural success and avoiding unnecessary exploration. CONCLUSION In our experience, intraoperative ultrasonography significantly enhances surgical precision, expands the applicability of minimally invasive techniques, and contributes to gland preservation with minimal morbidity. Overall, intraoperative ultrasonography contributes in several meaningful ways: it reduces operative time, minimises facial scarring in external combined approach procedures, improves stone clearance rates, prevents unnecessary repeat procedures, and enhances surgeon confidence in challenging anatomical or pathological scenarios. When available, planned intraoperative ultrasonography should be considered an integral component of advanced sialendoscopy practice, particularly in complex obstructive diseases of the parotid and submandibular ducts. In a study in Slovenia in 372 patients, Computed Tomography navigation was used intraoperatively in 6 patients. They were used for non-palpable and sialendoscopically invisible or partially visible stones. [ 8 ] CT navigation needs expensive equipment available in few centres in our country. This is also associated with radiation exposure for the patients. Intraoperative ultrasonography on the other hand is more accessible in our setup and cheaper as well. There is no radiation risk and repeated use is safe. A study done in California on 56 patients on surgeon performed ultrasonography showed a 94% positive predictive value and 91% negative predictive value for intraoperative identification of sialoliths. They concluded that surgeon performed sialendoscopy was useful to determine short term response post sialendoscopy assisted ductal surgeries. [ 9 ] In our institute, we rely on the radiologist for inputs, radiological training of the sialendoscopist will help reduce some of the challenges of manpower and thereby cost of intraoperative sialendoscopy. Despite the added cost, ultrasonography has distinct advantages depending on the case, including reduced intraoperative time, lesser morbidity, reduced facial scarring, improved sialolith clearance rate, lesser need for repeat imaging or repeat sialendoscopy post operatively. This helps in patient guidance and counselling and gives the surgeon and patient clarity on the outcomes of the procedure. We recommend a future study on the cost benefit analysis of use of intraoperative ultrasonography. Declarations Funding Declaration: This is not a funded study. We did not receive any funding to conduct this study. Human ethics and consent to participate declarations: This study was conducted after approval from Institutional Ethics Committee for Biomedical and Health Research. Waiver of consent was obtained for this Retrospective study was obtained from the from Institutional Ethics Committee for Biomedical and Health Research prior to the start of the study. References Koch M, Sievert M, Iro H, Mantsopoulos K, Schapher M (2021) Ultrasound in Inflammatory and Obstructive Salivary Gland Diseases: Own Experiences and a Review of the Literature. J Clin Med 10(16):3547. https://doi.org/10.3390/jcm10163547 Yuasa K, Nakhyama E, Ban S, Kawazu T, Chikui T, Shimizu M, Kanda S (1997) Submandibular gland duct endoscopy. Diagnostic value for salivary duct disorders in comparison to conventional radiography, sialography, and ultrasonography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 84:578–581 Kiringoda R, Eisele DW, Chang JL (2014) A comparison of parotid imaging characteristics and sialendoscopic findings in obstructive salivary disorders. Laryngoscope 124:2696–2701. https://doi.org/10.1002/lary.24787 Sobrino-Guijarro B, Cascarini L, Lingam RK (2013) Advances in imaging of obstructed salivary glands can improve diagnostic outcomes. Oral Maxillofac Surg 17:11–19. https://doi.org/10.1007/s10006-012-0327-8 Goncalves M, Mantsopoulos K, Schapher M, Iro H, Koch M (2018) Ultrasound Supplemented by Sialendoscopy: Diagnostic Value in Sialolithiasis. Otolaryngology–Head Neck Surg 159(3):449–455. 10.1177/0194599818775946 Koch M et al (2022) Simultaneous Application of Ultrasound and Sialendoscopy and its Value in the Management of Sialolithiasis. Ultraschall in der Medizin-European. J Ultrasound 43(03):289–297 Goncalves M, Mantsopoulos K, Schapher M, Iro H, Koch M (2021) Ultrasound in the diagnosis of parotid duct obstruction not caused by sialolithiasis: diagnostic value in reference to direct visualization with sialendoscopy. Dentomaxillofac Radiol 50(3):20200261. 10.1259/dmfr.20200261 Epub 2020 Oct 8. PMID: 33002385; PMCID: PMC7923063 Anicin A, Urbancic J (2021) Sialendoscopy and CT navigation assistance in the surgery of sialolithiasis. Radiol Oncol 55(3):284–291. 10.2478/raon-2021-0015 PMID: 33768767; PMCID: PMC8366728 Larson AR, Aubin-Pouliot A, Delagnes E, Zheng M, Chang JL, Ryan WR (2017) Surgeon-Performed Ultrasound for Chronic Obstructive Sialadenitis Helps Predict Sialendoscopic Findings and Outcomes. Otolaryngol Head Neck Surg 157(6):973–980 Epub 2017 Sep 5. PMID: 28871894 Additional Declarations Competing interest reported. Dr Srinidhi Ravi and Dr Pramod Shiralkar declare that they have no competing financial or non-financial interests. Dr Milind Navalakhe declares that he is co-editor in The Egyptian Journal of Otolaryngology. He has no other competing financial or non-financial interests. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 31 Mar, 2026 Reviews received at journal 21 Mar, 2026 Reviews received at journal 20 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviewers agreed at journal 15 Mar, 2026 Reviewers invited by journal 15 Mar, 2026 Editor assigned by journal 09 Feb, 2026 Submission checks completed at journal 09 Feb, 2026 First submitted to journal 06 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8803401","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":607087322,"identity":"9c4d19ac-fd77-4419-9210-2c3cbf9dfc24","order_by":0,"name":"Srinidhi Ravi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIiWNgGAWjYFACxgaGBLYDPGB2QgWQYGZuIEXLGZAWRkJaQIDtAFR7G9QQfEB+9uG2Bw/K7sgwSB9+JvFwXm00fztQy4+KbTi1GJxLbDdIOPeMh4EvzUwicdvx3BmHGRsYe87cxq2Fh7FNIrHtMA8DD4OxQeK2Y7kNQC3MjG24tcj3wLWwfzZInHMsdz4hLQxn4Fp4DB8kNtTkbiCkxQCkJeHcYR42Hp7CBwnHDuRuBGo5iM8v8j3szyR/lB225+dh33DwR01d7rzzhw8++FGBx2EwwAahDoPJA4TVI0AdKYpHwSgYBaNghAAAApZYPqvcUHkAAAAASUVORK5CYII=","orcid":"","institution":"K J Somaiya Medical College","correspondingAuthor":true,"prefix":"","firstName":"Srinidhi","middleName":"","lastName":"Ravi","suffix":""},{"id":607087326,"identity":"9b9d69e1-1c4d-4b90-b98f-8aff5f766ecc","order_by":1,"name":"Milind Navalakhe","email":"","orcid":"","institution":"King Edward Memorial Hospital and Seth G.S. 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Dr Srinidhi Ravi and Dr Pramod Shiralkar declare that they have no competing financial or non-financial interests. \nDr Milind Navalakhe declares that he is co-editor in The Egyptian Journal of Otolaryngology. He has no other competing financial or non-financial interests.","formattedTitle":"\u003cp\u003eUse of Intraoperative Ultrasonography in Sialendoscopy and Sialendoscopy Assisted Surgery - A Retrospective Analysis\u003c/p\u003e","fulltext":[{"header":"Key Message ","content":"\u003cul\u003e\n \u003cli\u003eIntraoperative Ultrasonography is a meaningful addition to the armamentarium available in the expanding branch of sialendoscopy and sialendoscopy assisted procedures.\u003c/li\u003e\n \u003cli\u003eIt reduces operative time, minimises surgical morbidity and facial scarring, improves stone clearance rates, prevents unnecessary repeat procedures and enhances surgeon confidence in challenging anatomical or pathological scenarios.\u003c/li\u003e\n \u003cli\u003eWhen available, planned intraoperative ultrasonography should be considered an integral component of advanced sialendoscopy practice, particularly in complex obstructive diseases of the parotid and submandibular ducts.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003ePresent day management of obstructive salivary gland diseases like sialolithiasis, sialodochocoeles and salivary duct strictures includes sialendoscopy and sialendoscopy assisted minimally invasive procedures. Ultrasonography, Computed tomography scan of the Neck and Magnetic resonance Sialography are the diagnostic tests available for patients suffering from Obstructive salivary gland diseases. Ultrasonography is the first imaging modality chosen for patients with obstructive salivary gland disease.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Diagnostic Sialendoscopy is considered the Gold standard investigation of choice in these patients. However, this is expensive and not freely available even in tertiary care centres in India and hence not preferred. Due to its non-invasive character and low cost, ultrasonography can be done repeatedly as necessary without any irradiation and is safe in all patients. For the detection of sialoliths, ultrasonography is shown to be of equal value and comparable to conventional radiographs. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Preoperative imaging characteristics such as stone presence, size, and location provide essential information that can guide surgical planning and clinical outcome expectations for obstructive parotid disease management. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] If an obstruction is clinically suspected, the role of imaging consists of confirming the obstruction, identifying its cause, evaluating the position and extent of the obstruction and evaluating for associated complications. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Ultrasonography has a high degree of accuracy, specificity, sensitivity, positive predictive value and negative predictive value.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] A study from Erlangen, Germany studied the usefulness of simultaneous ultrasonography and sialendoscopy as a diagnostic tool for patients with sialolithiasis. They concluded that simultaneous use of both sialendoscopy and ultrasonography adds valuable information regarding diagnosis, planning of appropriate treatment, intraoperative management and postoperative follow up.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Ultrasonography is also the first investigation of choice in cases of obstructive salivary gland diseases without sialolithiasis. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] The fragility and complex branching of the ductal systems pose significant intraoperative challenges to the sialendoscopist. In such cases, when there is a risk of complication or incomplete resolution of the pathology, the decision made is often to abandon the procedure and reexplore again in a safe setting. Ultrasonography, when available intraoperatively, helps us overcome some operative challenges. Due to the relative novelty of sialendoscopy and sialendoscopy assisted procedures there is a paucity of data available in literature regarding the use of intraoperative ultrasonography in sialendoscopy and sialendoscopy assisted procedures. This retrospective study attempts to bridge this gap in knowledge regarding the usefulness of intraoperative ultrasonography in sialendoscopy and sialendoscopy assisted procedures.\u003c/p\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cp\u003eA retrospective observational study was conducted in a tertiary care centre in the city of Mumbai, India. Retrospective analysis was conducted including data of patients who underwent sialendoscopy and sialendoscopy assisted procedures from January 2014 to September 2025. Institutional Ethics committee approval and waiver of consent was taken prior to the start of the study. 170 patients were identified who underwent parotid and submandibular sialendoscopy and sialendoscopy assisted procedures in a single centre. Their primary diagnosis, preoperative imaging, intraoperative findings and treatment plan was noted. Patients in whom intraoperative ultrasonography was performed were identified. The pathology, need for intraoperative ultrasonography, step of surgery when ultrasonography was performed, ultrasonography findings and surgical outcomes were noted.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e18 cases were identified where intraoperative ultrasonography was done. The gender and diagnosis distribution is as given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e gives the distribution of surgery done. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e describes the role of ultrasonography in parotid and submandibular ductal diseases including its utility at various stages. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e gives the qualitative analysis of the operative notes by the surgical team.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of sialendoscopy cases as per diagnosis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eParotid duct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eSubmandibular duct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSialolithiasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStricture/ Sialocoele\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of cases as per surgery performed\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParotid Duct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubmandibular Duct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSialendoscopy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined approach technique\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRole of ultrasonography in parotid and submandibular ductal diseases including its utility at various stages\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSr No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvantage / Use of Intraoperative ultrasonography\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParotid\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubmandibular\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo. of patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUltrasonography Shows no remnant stone, no further imaging /scopy needed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncision site marking / Sialolith localisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntraglandular Stone/ stone fragments [submillimetre] not amenable to sialendoscopy as well as combined approach, left as it is\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo guide guidewire in proximal duct after dilatation of stenotic segment and entry into dilated duct\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFloating stone \u0026ndash; positioned proximal intraductal and amenable to external approach. Stone not retrieved as patient does not consent for external incision. Ultrasonography done for documentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecision to go for combined approach taken intraoperatively due to unfavourable position of sialolith fragments after LASER seen on Ultrasonography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTo assess distance of stone from tip of sialendoscope in proximal sialolith\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdditional advantages\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSr No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvantage / Use of Intraoperative ultrasonography\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParotid\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubmandibular\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo. of patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgical time reduced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlind dissection avoided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient counselling for need for further imaging and SOS repeat sialendoscopy in future\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVisualised intraductal calculus flushed out with mucinous debris on dilatation on stricture. Medicolegal Documentation done with ultrasonography as no stone retrieved to show patient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eUltrasonography has emerged as an essential adjunct to the expanding field of sialendoscopy and sialendoscopy-assisted procedures. While preoperative ultrasonography is well established in the diagnostic work-up of salivary gland disease, its planned and opportunistic intraoperative use remains underutilised.\u003c/p\u003e \u003cp\u003eIn our series, intraoperative ultrasonography was most frequently employed in cases of parotid sialolithiasis, particularly external combined approach sialendoscopy. Accurate intraoperative localisation of stones allows a targeted, limited skin incision around 1.5 cm in length directly over the stone, minimising tissue dissection. Placement of a 20-gauge needle abutting the stone under ultrasonographic guidance serves as a reliable landmark for sialodochotomy. [IMAGE 1]\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eImage 1. Incision of external combined approach parotid sialendoscopy with 20G needle as guide\u003c/p\u003e \u003cp\u003eThis approach offers three distinct advantages: first, it simplifies the procedure and reduces operative time by avoiding elevation of a superficial musculoaponeurotic system (SMAS) flap; second, the incision follows the surface anatomy of the Stenson\u0026rsquo;s duct, thereby minimising the risk of encountering multiple facial nerve branches and third, the patient has a small and neat scar. This technique has proven valuable for both mid-duct and proximal duct stones, especially when the stone lies beyond the reach of the sialendoscope.\u003c/p\u003e \u003cp\u003eIn proximal intraglandular parotid stones, where endoscopic visualisation is not possible, intraoperative ultrasonography often becomes the only reliable method for stone localisation. In one such case from our series, preoperative imaging demonstrated a calculus located deep within the intraglandular portion of the Stenson\u0026rsquo;s duct. The sialendoscope could be passed up to 4.5cm and ultrasonography showed the sialolith 2.5cm from the tip of the sialendoscope. [Image 2]\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eImage 2. Distance from tip of sialendoscope to proximal parotid duct sialolith\u003c/p\u003e \u003cp\u003eSonographic localisation enabled precise sialodochotomy through a minimal incision, resulting in successful stone removal and preservation of the parotid gland. This experience highlights how ultrasonography can expand the indications for external combined-approach sialendoscopy, allowing gland-saving surgery even in technically challenging cases.\u003c/p\u003e \u003cp\u003eIn LASER fragmentation of sialoliths using Holmium or Thulium LASER, the number of fragments and size cannot be determined endoscopically. There is also the possibility of proximal or distal migration of these fragments with the saline irrigation during the sialendoscopy. While most fragments seen endoscopically are extracted with the help of an appropriate basket, there are times where the surgeon has a suspicion of remnant fragments. The size of the retrieved fragments is also compared to the preoperative imaging to ensure complete clearance. Submillimetre stones often extrude spontaneously from the dilated salivary duct post-procedure and do not need additional care. However, any larger fragments missed or remaining in the duct or smaller branches can cause recurrent or persistent symptoms. In such cases, patients need repeat imaging and repeat sialendoscopy. An ultrasonography done intraoperatively enables identification of remnant stones, their dimensions and precise location. At times, when small fragments migrate deep into the gland, they are no longer accessible endoscopically. Ultrasonographic documentation of such migration helps the surgeon avoid unnecessary prolongation of surgery in the search of such a stone. Fragmentation of large misshapen staghorn calculi leads to multiple fragments and a larger fragment left behind accidently will result in the patient having no resolution of symptoms and a wasted procedure. Ultrasonography helps in both situations, one to stop further exploration if stone size is not significant [\u0026lt;\u0026thinsp;1mm] and to explore and at times convert to combined approach in case of larger fragments not accessible to our sialendoscope.\u003c/p\u003e \u003cp\u003eIn patients with parotid duct stenosis, there are certain challenges with intraoperative navigation of the sialendoscope. After successful dilatation of the stenosis, the scope enters a wide duct and orientation of the path to the proximal duct is difficult. In such cases, a guidewire is inserted under ultrasonographic guidance. The sialendoscope can be railroaded over the guidewire into the proximal duct. The duct lumen thus can be evaluated till the branching or masseteric bend. The ultrasonography also clearly shows the widened duct post dilatation documenting the successful outcome. This reduces surgical time as well as improves surgical precision. Any incomplete dilatation of the duct is flagged and remedial measures are taken.\u003c/p\u003e \u003cp\u003eIn large submandibular sialolithiasis, the location of the sialolith determines the difficulty of combined approach surgery. Sialoliths distally located are amenable to endoscopic visualisation and are easily palpable in the floor of mouth. In case of proximally located large stones, the surgeon relies on palpatory feedback. The stone feels hard and a firm stent is sutured in situ in the distal duct for easy localisation. Proximally the duct lies deeper away from the floor of the mouth. In a chronically fibrosed gland the palpatory feedback can be misleading at times. Ultrasound helps in such cases to mark the site of the sialolith in relation to the floor of the mouth with the aid of a 22G needle placed under guidance. In one of the cases in our study, the submandibular gland was hard on palpation, and the ultrasound showed a calculus encased in a lesion in the submandibular gland. To avoid unnecessary exploration of a large part of the deep lobe of the gland through the floor of mouth ultrasonography was done. This aided the incision marking, and precise dissection was possible. Additionally, an intraoral biopsy of the hard submandibular gland tissue was taken as well. This was reported as chronic sialadenitis in histopathology.\u003c/p\u003e \u003cp\u003eThere are instances where the salivary duct papilla is stenosed and a small calculus is reported just proximal to the papilla. On successful dilatation, thick mucinous secretions and stagnant saliva gush out. Small calculi or small chalk like particles may be flushed out with these secretions and with saline irrigations. The surgeon focussing on the monitor in front may miss this and continue to search for the calculus in the duct in vain. Ultrasonography confirms both adequate dilatation and absence of residual stones in the duct, providing reassurance of procedural success and avoiding unnecessary exploration.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn our experience, intraoperative ultrasonography significantly enhances surgical precision, expands the applicability of minimally invasive techniques, and contributes to gland preservation with minimal morbidity. Overall, intraoperative ultrasonography contributes in several meaningful ways: it reduces operative time, minimises facial scarring in external combined approach procedures, improves stone clearance rates, prevents unnecessary repeat procedures, and enhances surgeon confidence in challenging anatomical or pathological scenarios. When available, planned intraoperative ultrasonography should be considered an integral component of advanced sialendoscopy practice, particularly in complex obstructive diseases of the parotid and submandibular ducts. In a study in Slovenia in 372 patients, Computed Tomography navigation was used intraoperatively in 6 patients. They were used for non-palpable and sialendoscopically invisible or partially visible stones. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] CT navigation needs expensive equipment available in few centres in our country. This is also associated with radiation exposure for the patients. Intraoperative ultrasonography on the other hand is more accessible in our setup and cheaper as well. There is no radiation risk and repeated use is safe. A study done in California on 56 patients on surgeon performed ultrasonography showed a 94% positive predictive value and 91% negative predictive value for intraoperative identification of sialoliths. They concluded that surgeon performed sialendoscopy was useful to determine short term response post sialendoscopy assisted ductal surgeries. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] In our institute, we rely on the radiologist for inputs, radiological training of the sialendoscopist will help reduce some of the challenges of manpower and thereby cost of intraoperative sialendoscopy. Despite the added cost, ultrasonography has distinct advantages depending on the case, including reduced intraoperative time, lesser morbidity, reduced facial scarring, improved sialolith clearance rate, lesser need for repeat imaging or repeat sialendoscopy post operatively. This helps in patient guidance and counselling and gives the surgeon and patient clarity on the outcomes of the procedure. We recommend a future study on the cost benefit analysis of use of intraoperative ultrasonography.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eFunding Declaration: This is not a funded study. We did not receive any funding to conduct this study.\u003c/p\u003e\n\u003cp\u003eHuman ethics and consent to participate declarations: This study was conducted after approval from Institutional Ethics Committee for Biomedical and Health Research. Waiver of consent was obtained for this Retrospective study was obtained from the from Institutional Ethics Committee for Biomedical and Health Research prior to the start of the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKoch M, Sievert M, Iro H, Mantsopoulos K, Schapher M (2021) Ultrasound in Inflammatory and Obstructive Salivary Gland Diseases: Own Experiences and a Review of the Literature. J Clin Med 10(16):3547. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/jcm10163547\u003c/span\u003e\u003cspan address=\"10.3390/jcm10163547\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYuasa K, Nakhyama E, Ban S, Kawazu T, Chikui T, Shimizu M, Kanda S (1997) Submandibular gland duct endoscopy. Diagnostic value for salivary duct disorders in comparison to conventional radiography, sialography, and ultrasonography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 84:578\u0026ndash;581\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKiringoda R, Eisele DW, Chang JL (2014) A comparison of parotid imaging characteristics and sialendoscopic findings in obstructive salivary disorders. Laryngoscope 124:2696\u0026ndash;2701. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/lary.24787\u003c/span\u003e\u003cspan address=\"10.1002/lary.24787\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSobrino-Guijarro B, Cascarini L, Lingam RK (2013) Advances in imaging of obstructed salivary glands can improve diagnostic outcomes. Oral Maxillofac Surg 17:11\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10006-012-0327-8\u003c/span\u003e\u003cspan address=\"10.1007/s10006-012-0327-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoncalves M, Mantsopoulos K, Schapher M, Iro H, Koch M (2018) Ultrasound Supplemented by Sialendoscopy: Diagnostic Value in Sialolithiasis. Otolaryngology\u0026ndash;Head Neck Surg 159(3):449\u0026ndash;455. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0194599818775946\u003c/span\u003e\u003cspan address=\"10.1177/0194599818775946\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoch M et al (2022) Simultaneous Application of Ultrasound and Sialendoscopy and its Value in the Management of Sialolithiasis. Ultraschall in der Medizin-European. J Ultrasound 43(03):289\u0026ndash;297\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoncalves M, Mantsopoulos K, Schapher M, Iro H, Koch M (2021) Ultrasound in the diagnosis of parotid duct obstruction not caused by sialolithiasis: diagnostic value in reference to direct visualization with sialendoscopy. Dentomaxillofac Radiol 50(3):20200261. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1259/dmfr.20200261\u003c/span\u003e\u003cspan address=\"10.1259/dmfr.20200261\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2020 Oct 8. PMID: 33002385; PMCID: PMC7923063\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnicin A, Urbancic J (2021) Sialendoscopy and CT navigation assistance in the surgery of sialolithiasis. Radiol Oncol 55(3):284\u0026ndash;291. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2478/raon-2021-0015\u003c/span\u003e\u003cspan address=\"10.2478/raon-2021-0015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 33768767; PMCID: PMC8366728\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLarson AR, Aubin-Pouliot A, Delagnes E, Zheng M, Chang JL, Ryan WR (2017) Surgeon-Performed Ultrasound for Chronic Obstructive Sialadenitis Helps Predict Sialendoscopic Findings and Outcomes. Otolaryngol Head Neck Surg 157(6):973\u0026ndash;980 Epub 2017 Sep 5. PMID: 28871894\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Sialendoscopy, sialendoscopy assisted procedures, intra-operative ultrasonography, obstructive salivary gland diseases","lastPublishedDoi":"10.21203/rs.3.rs-8803401/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8803401/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003ePresent management of obstructive salivary gland diseases like sialolithiasis, sialodochocoeles and salivary duct strictures includes sialendoscopy and sialendoscopy assisted minimally invasive procedures. Ultrasonography, Computed tomography scan of the Neck and Magnetic Resonance Sialography are the diagnostic tests available for patients suffering from Obstructive salivary gland diseases. Diagnostic sialendoscopy is comparable to ultrasonography for diagnosis, however due to the higher cost and invasive nature it is not considered the procedure of choice in our country. Ultrasonography is the first imaging modality chosen for patients with obstructive salivary gland disease.\u003c/p\u003e\u003ch2\u003eMaterials and Methods :\u003c/h2\u003e \u003cp\u003eA retrospective observational study was conducted in a tertiary care centre in the city of Mumbai, India. Retrospective analysis was conducted including data of patients who underwent sialendoscopy and sialendoscopy assisted procedures from January 2014 to September 2025 in a single tertiary care centre. Institutional Ethics committee approval and waiver of consent was taken prior to the start of the study. 170 patients were identified who underwent sialendoscopy and sialendoscopy related procedures. Their primary diagnosis, preoperative imaging, intra operative findings and treatment plan was noted. Patients in whom intraoperative ultrasonography was performed were identified. The pathology, need for intraoperative ultrasonography, the step of surgery when ultrasonography was indicated, ultrasonography findings and surgical outcomes were noted.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003e18 patients needed intraoperative ultrasonography. Ultrasonography was done intraoperatively in 8 cases of parotid sialolithiasis, 2 cases of parotid duct strictures, 1 case of combined parotid duct stricture with sialolithiasis, 6 cases of submandibular sialolithiasis and 1 case of submandibular duct stenosis. The use and advantage of ultrasonography in each case was analysed.\u003c/p\u003e\u003ch2\u003eConclusions :\u003c/h2\u003e \u003cp\u003eUltrasonography is a meaningful addition to the intraoperative armamentarium available in the expanding branch of sialendoscopy and sialendoscopy assisted procedures. It reduces operative time, minimises surgical morbidity and facial scarring, improves stone clearance rates, prevents unnecessary repeat procedures, and enhances surgeon confidence in challenging anatomical or pathological scenarios. When available, planned intraoperative ultrasonography should be considered an integral component of advanced sialendoscopy practice, particularly in complex obstructive diseases of the parotid and submandibular ducts.\u003c/p\u003e","manuscriptTitle":"Use of Intraoperative Ultrasonography in Sialendoscopy and Sialendoscopy Assisted Surgery - A Retrospective Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:56:06","doi":"10.21203/rs.3.rs-8803401/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-31T14:45:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T12:28:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T13:40:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"246731544519063517835219691808278591157","date":"2026-03-16T16:50:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"144714240604176340097927322579534429963","date":"2026-03-16T11:18:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57264790703017534378256132931266574893","date":"2026-03-15T20:24:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-15T20:01:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-09T10:11:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-09T10:08:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Otolaryngology","date":"2026-02-06T06:26:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7be09dae-14c0-4d6d-892f-98e466f69361","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-15T15:08:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:56:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8803401","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8803401","identity":"rs-8803401","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}