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M E T H O D O L O G Y A R T I C L E Open Access
Interventional sialendoscopy in
parotidomegaly related to eating disorders
Giuseppe Colella
1
, Giorgio Lo Giudice
2*
, Roberto De Luca
2
, Antonio Troiano
2
, Carmelo Lo Faro
2
,
Vincenzo Santillo
1
and Gianpaolo Tartaro
1
Abstract
Background: To evaluate the viability and efficacy of sialendoscopy for the management of parotidomegaly related
to eating disorders, 6 patients suffering from eating disorders and recurring symptoms of glandular swelling were
followed up at the Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial
Surgery Unit, AOU University of Campania “Luigi Vanvitelli”. After the detection of the impaired gland through
clinical and radiographical analysis, the diagnostic unit was introduced into the duct and was advanced in, reaching
the ductal system. Plaques were washed out, any strictures were dilated both by hydrostatic pressure application
and steroid solution injection directly in the fibrotic area.
Results: Both glands resulted affected in 83% of patients. 11 parotid glands were explored and treated. Strictures
were found in 2 glands (33%), sialectasis in 3 glands (50%), strictures and sialectasis together in 1 glands (17%). In 3
parotid glands (50%) Stenon’s duct was affected, in two (33%) only secondary ducts, in 1 (17%) both. We reached
symptomatic improvement in 5 patients (83%), reporting the spherical volume of the parotid region and pain
reduction.
Conclusions: Our results demonstrate that sialendoscopy is a safe and effective therapeutic method to treat EDs
salivary symptoms. Treating the underlining psychiatric pathology should be the primary goal in patient care to
lower the possible recurrence rate and increase the successful outcome of this technique.
Keywords: Sialendoscopy, Sialoendoscopy, Parotidomegaly, Sialadenosis, Sialoadenosis, Sialadenitis, Sialoadenitis,
Eating disorders, Anorexia, Bulimia
Plain English summary
Patients affected by Eating Disorders such as Anorexia
Nervosa and Bulimia Nervosa often follow compensatory
behaviors to control their weight. Among all behaviors,
if self-induced vomiting is protracted over time, oral
health can be affected on both anatomical and biochem-
ical level. Salivary gland swelling is a pathological alter-
ation that these patients can manifest. The glands can
become visible and sometimes painful, changing the
facial profile. Sialendoscopy is a technique that offers a
minimally invasive approach to non-neoplastic diseases,
allowing the endoscopic visualization of the salivary
glands and their ducts, offering a tool to treat ductal sys-
tem pathologies. The aim of this research was then to
assess the validity of this non-invasive technique to treat
salivary symptoms related to Eating Disorders. The re-
sults showed a reduction of salivary gland volume and
symptom relief in most patients, opening a new path to
treat the consequences of such conditions.
Background
Eating disorders (EDs) are psychological conditions
based on self-misperception of body shape and weight,
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data made available in this article, unless otherwise stated in a credit line to the data.
* Correspondence: Giorgio.logiudice@gmail.com
2
Department of Neurosciences, Reproductive and Odontostomatological
Sciences, Maxillofacial Surgery Unit, University of Naples “Federico II”, 80138
Naples, Italy
Full list of author information is available at the end of the article
Colella et al. Journal of Eating Disorders (2021) 9:25
https://doi.org/10.1186/s40337-021-00378-9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
often leading to severe systemic conditions that require
medical treatment. DSM-V lists different behavioral syn-
dromes in the Feeding and Eating Disorders chapter:
Pica, Rumination Disorder, Avoidant/Restrictive Food
Intake Disorder, Anorexia Nervosa (AN), Bulimia Ner-
vosa (BN), Binge-Eating Disorder and Unspecified Feed-
ing or Eating Disorder [1]. AN clinical characteristics
lead to two subtypes: Anorexia Nervosa Restricting type
(AN-R) and Anorexia Nervosa Binge-eating/Purging
type (AN-BP) whereas BN is distinguished by compensa-
tory actions after binge eating. Patients may follow in-
appropriate compensatory behaviors in order to avoid
guilt perceived after eating or weight gain, such as chew-
ing and spitting, self-induced vomiting, fasting or intake
restriction after food consumption, drug intake such as
laxatives or diuretics, inappropriate use of enemas, and
over-exercising. The self-induced vomiting behaviour ex-
hibited by some patients sabotages the oral health status,
affecting both hard and soft tissues. Clinically, the pa-
tients may show enamel erosion, tooth decay, periodon-
tal diseases, mucositis, and glossitis. The salivary profile
is also affected both biochemically and anatomically
showing altered salivary flow, increased amylase levels,
decreased pH and bicarbonate salivary levels, salivary
gland swelling (mostly affecting the parotid gland), siala-
denosis, and facial swelling coming from parotidomegaly
[2]. Although the mechanisms underlining salivary gland
swelling are still up to debate, this condition must be
treated by the physician: the impact on the patients’
body image is significant, furthermore magnified by the
social pressure to pursuit a symmetric, imperfection-free
face, possibly worsening their dysmorphic disorder. Nah-
lieli and Baruchin introduced rigid salivary gland endos-
copy in 1994 [3]. Since that time, sialendoscopy has
been used for diagnostic and therapeutic purposes [4].
Sialendoscopy offers a minimally invasive approach to
non-neoplastic diseases, allowing endoscopic intralum-
inal visualization and offering a tool to treat ductal sys-
tem pathologies, reducing or eliminating the need for
sialadenectomy thus avoiding the related surgical risks
[5–8]. This paper aims to evaluate the reliability of sia-
lendoscopy in the management of parotidomegaly re-
lated to eating disorders.
Materials and methods
Six patients were referred to the Multidisciplinary De-
partment of Medical-Surgical and Dental Specialties,
Oral and Maxillofacial Surgery Unit, AOU University of
Campania “Luigi Vanvitelli”and were recruited for this
prospective study from November 2012 to December
2016. The inclusion criteria were: diagnosis of EDs, re-
curring symptoms of glandular swelling either with or
without pain, enlarged volume of the parotid region. Ex-
clusion criteria were: any previous sialendoscopic
treatment and/or botulinum toxin treatment of the par-
otid, previous facial surgery.
Patients were diagnosed with EDs by our center ac-
cording to DSM-V. ED related parotidomegaly and siala-
denosis was diagnosed after clinical and radiological
examination, and exclusion of drinking history, parotid
gland infective diseases, sialolithiasis or tumors.. Mor-
phological analysis was performed through ultrasound
and MRI scans. The spherical volume of the parotid re-
gion was measured according to Metzger at baseline
(T0) and 6 months follow-up (T1) as “V = 4/3 × π× (r1
× r2 × r3)”where r1, r2, and r3 are the semidiameters
for gland height, width, and depth [9]. Signs and symp-
toms improvement were considered as the primary end-
point of this study and it was evaluated assessing salivary
swelling and pain reduction compared to baseline.
After the detection of the impaired gland, local
anesthesia with lidocaine 2% was achieved on the orifice
region. Gradual dilatation of the duct orifice was then
performed, using salivary probes of increased diameter
from 0000 to 0 size and with a 0.5 mm lacrimal probe,
reaching 1.3 mm diameter, matching the outer diameter
of the sialendoscope diagnostic unit (Marchal Sialendo-
scope - Karl Storz). The larger scopes (1.6 mm diameter)
were introduced as needed and a 5 mm papillotomy was
performed in order to prevent false roads creation. The
diagnostic unit was introduced into the duct and was ad-
vanced, until reaching the ductal system while carrying
out continuous lavage with isotonic saline solution. Care
is taken to avoid puncturing or lacerating the duct. The
plaques were washed out; any strictures were dilated
both by hydrostatic pressure application and steroid so-
lution injection directly in the fibrotic area; mucous
plugs and debris were removed with irrigation or for-
ceps. At the end of the procedure, the ductal system was
irrigated with a betamethasone solution (Bentelan 4 mg/
2ml–Alfasigma S.p.a., Milano, Italy) under direct vision
while withdrawing the scope, in order to treat the in-
flammation of the ductal epithelium (sialodochitis) and
to promote the dilatation of ductal strictures.
Sialendoscopy was considered successful when the en-
tire ductal lumen and its branches were clear of any dis-
ease. An antibiotic prophylaxis treatment was performed
with twice a day doses of Amoxicillin 875 mg and Clavu-
lanic acid 125 mg on post-operative phase for one week.
The patients were followed-up at 3 months, 6 months
(T1), and 1 year.
Results
Our cohort included 6 female patients with a mean age
of 22 years. 4 patients came to our attention with a diag-
nosis of AN-BP, 2 with a diagnosis of BN. In patients 1,
3 and 4, eating disorders familiarity was discovered dur-
ing anamnesis. In patients 2 and 4, Generalized Anxiety
Colella et al. Journal of Eating Disorders (2021) 9:25 Page 2 of 6
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Disorder and Major Depression treated with benzodiaze-
pines were associated. Symptoms onset average from our
medical examination was 12.6 months (Table 1,Fig.1).
Before performing this technique, all patients carried
out analgesic and antibiotic drug therapy without any re-
lief. All patients performed ultrasonography and MRI
scans: in 3 patients the preoperative imaging evidenced
hypoechogenic areas, in 2 patients hypoechogenic areas
and punctate calcifications, in 1 patient hypoechogenic
areas and reactive lymph nodes (Table 1, Fig. 2).
Both glands resulted affected in 5 out of 6 patients
(83%). 11 parotid glands were explored and treated; in 5
patients the procedure was completed with no complica-
tions. However, in 1 case the procedure was discontin-
ued at the initial stage due to pain intolerance and
anxiety. The procedure was then performed again after
1 week (Table 2).
Strictures were found in 2 glands (33%), sialectasis in 3
glands (50%), strictures and sialectasis together in 1
gland (17%). In 3 parotid glands (50%) Stenon’s duct was
affected, in 2 glands (33%) only secondary ducts, in 1
(17%) both (Fig. 3).
No diagnosis of sialolithiasis was made in our patients.
No major complications such as nerve damage,
hemorrhage, airway impairment, ductal perforation or
kinks were observed. Symptomatic improvement was
reached in 5 patients at T1 (83%). The patients showed
spherical volume reduction of the parotid region and
pain reduction at T1 (Table 2, Fig. 4).
One patient (patient 6) with bilateral parotidomegaly
did not reach symptom relief nor spherical volume re-
duction after performing 4 sialendoscopies in succession
at a time interval of 6 months. In this case, we observed
an endoscopic pattern of sialectasis bilaterally. One pa-
tient (patient 5) did not show immediate improvement
and they underwent a further sialendoscopy within a 3–
5 months interval from their first treatment, obtaining
success.
Discussion
Studies found in literature describe non-inflammatory
swelling of the salivary glands as a symptom underlining
eating disorders [10,11]. The enlarged area of the ana-
tomical region of the parotid gland and, occasionally, of
the submandibular gland, are described in patients with
AN and BN, while other glands may not show any
macroscopic alterations [12,13]. Parotid swelling inci-
dence has been estimated from 10 to 50% and may be ei-
ther uni- or bilateral [14–17]. Some studies presume the
etiology of this condition to be a combination of an ab-
normally low body mass index (BMI), nutritional defi-
ciency, functional hypertrophy, and neurovegetative/
hormonal dysregulation. Binge eating and purging be-
haviour by vomiting seems to be directly connected to
Table 1 Patients’demographics. (AN-BP - Anorexia Nervosa Binge eating/Purging type; BN - Bulimia Nervosa)
Patient Sex Age Symptoms Onset
(months)
Eating
Disorder
Eds
Familiarity
Comorbidities Ultrasound Findings
1 F 18 12 BN yes None Hypoechogenic areas and punctate
calcifications
2 F 23 6 AN-BP no Generalized Anxiety Disorder and
Major Depression
Hypoechogenic areas
3 F 25 6 BN yes None Hypoechogenic areas and reactive
lymph nodes
4 F 27 18 AN-BP yes Generalized Anxiety Disorder and
Major Depression
Hypoechogenic areas and punctate
calcifications
5 F 17 4 AN-BP no Autoimmune Thyroiditis Hypoechogenic areas
6 F 20 3 AN-BP no DM1,
Fibromialgia
Hypoechogenic areas
Fig. 1 T0 external view examination
Colella et al. Journal of Eating Disorders (2021) 9:25 Page 3 of 6
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Fig. 2 MRI assessment shows reduction of the parotid gland volume bilaterally. Coronal T2w at T0 (a) and T1 (b); axial T2w at T0 (c) and T1 (d);
coronal STIR at T0 (e) and T1 (f); axial STIR at T0 (g) and T1 (H). BAR: 1 cm
Table 2 Sialendoscopic features and outcomes. (StD - Stenon’s duct; SeD - Secondary ducts)
Patient Gland Findings Intervention Complications Parotid region spherical volume
(T0)
Parotid
region spherical volume
(T1)
1L
Parotid
R
Parotid
Sialectasis StD Dilatation and
removal
None 5 cm L
4,8 cm R
4.5 cm L
3.2 cm R
2R
Parotid
Stricture StD Stricture
SeD
Dilatation and
removal
None 4.5 cm 2 cm
3L
Parotid
R
Parotid
Stricture SeD Dilatation and
removal
None 2.9 cm L
4cm R
1.2 cm L
3cm R
4L
Parotid
R
Parotid
Stricture SeD
Sialectasis SeD
Dilatation and
removal
None 3.7 cm L
4.4 cm R
2.1 cm L
3.2 cm R
5L
Parotid
R
Parotid
Sialectasis StD Dilatation and
removal
None 6.2 cm L
6.5 cm R
2.5 cm L
1.8 cm R
6L
Parotid
R
Parotid
Sialectasis StD Dilatation and
removal
Failed 4
endoscopies
6.3 cm L
4.5 cm R
6.2 cm L
4.5 cm R
Colella et al. Journal of Eating Disorders (2021) 9:25 Page 4 of 6
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the onset of the swelling, usually beginning 2–6 days after
the trigger episode. This sign tends to fade in early stages if
the behaviour is not protracted in time and is generally pain-
less [18]. Histological examinations show changes within the
parenchyma of the parotids, including hypertrophy of the
cells and increased storage of adipose tissue [10,14–16].
Hyposalivation is another typical feature reported in patients
affected by both AN subtypes and BN, thus possibly concur-
ring to the persistence of the glands inflammatory state. The
genesis of this phenomenon could come from vomiting, star-
vation and antidepressant medications that have antisialago-
guesideeffects.Theappetitesuppressantmayalsoplaya
role in this pathological sign [2,19]. Since this plethora of
signs tend to subside after ED treatment and resolution, due
to the inflammatory trigger removal, a step-by-step treat-
ment approach should be followed: intensive pharmaco-
logical, sialendoscopic and then surgical approaches should
be kept for refractory cases in long-history ED patients. Re-
ports of effective sialogogue drug use such as pilocarpine,
can be found in literature and could be used as primary
treatment in such patients [20,21].
While performing sialoendoscopy, phlogistic findings
were detected. Strictures were founded in 2 glands (33%),
sialectasis in 3 glands (50%), strictures and sialectasis to-
gether in 1 gland (17%). Each of these features, typical of
chronic sialoadenitis, is widely described in literature and
successfully treated with sialendoscopy [21,22].
Sialendoscopy is a technique able to offer a minimally in-
vasive and gland-preserving approach to non-neoplastic sal-
ivary glands diseases. In our work, we obtained encouraging
results that justify the possibility of treating EDs salivary
symptoms with a conservative procedure reaching symptom-
atic improvement in most of the patients treated. The mor-
phological analysis showed spherical volume reduction of the
parotid region, less incidence of salivary swelling and pain re-
duction (Table 2). Only 1 patient with bilateral parotidome-
galy reached neither symptoms relief nor spherical volume
reduction after performing 4 sialendoscopies in succession at
a time interval of 6 months. Botulinum toxin injection of the
salivary glands is used to treat sialorrhea, salivary fistulae, first
bite syndrome, Frey syndrome and sialoadenitis [23]. Cos-
metic off-label use has been reported in literature due to its
parenchymal atrophy effects in order to reduce gland volume
thus performing facial recontouring [24]. This treatment, re-
ported to be possible in both percutaneous and intraductal
infusion, could be used to treat those parotidomegaly cases
refractory to the sialendoscopic therapy [25]. The surgical
treatment (superficial or total parotidectomy) should be care-
fully pondered by the surgeon and used as a last resort, con-
sidering that a slight significant percentage of symptomatic
pain is usually referred, the young mean age of the patients
in question, and the related risks of such surgical procedures.
Conclusions
Sialendoscopy is a versatile procedure, worthwhile to
treat EDs salivary symptoms refractory to common
therapy. Despite the small cohort of patients consid-
ered, our results are promising and should push the
researchers to widen its application fields. Treating
the underlining psychiatric pathology should be the
primary goal in patient care, in order to lower the
possible recurrence rate and increase the successful
outcomes of this technique.
Fig. 3 Sialendoscopic photogram of right parotid primary
duct stricture
Fig. 4 T1 external view examination
Colella et al. Journal of Eating Disorders (2021) 9:25 Page 5 of 6
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Abbreviations
AN: Anorexia Nervosa; AN-BP: Anorexia Nervosa Binge eating/Purging type;
AN-R: Anorexia Nervosa Restricting type; BN: Bulimia Nervosa; DSM-
V: Diagnostic and statistical manual of mental disorders - 5th edition;
ED: Eating disorder; MRI: Magnetic Resonance Imaging
Acknowledgements
Not applicable.
Authors’contributions
Data curation, A.T; formal analysis, C.L.F.; investigation, V.S.; project
administration, G.C.; supervision, G.T.; writing—original draft, R.D.L.;
writing—review and editing, G.L.G. All authors read and approved the final
manuscript.
Funding
This research received no external funding.
Availability of data and materials
Data are available upon reasonable request from the corresponding author.
Ethics approval and consent to participate
The study was approved by the internal ethical committee of the University
(AOU-SUN 165/2011).
Consent for publication
The patients involved in this study granted consent for publication.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral
and Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”,
80138 Naples, Italy.
2
Department of Neurosciences, Reproductive and
Odontostomatological Sciences, Maxillofacial Surgery Unit, University of
Naples “Federico II”, 80138 Naples, Italy.
Received: 14 September 2020 Accepted: 4 February 2021
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