# Efficacy and Tolerability of Transoral Sialolithotomy in Non‐Palpable Submandibular Lithiasis

## TL;DR

Transoral sialolithotomy is effective and safe for removing non-palpable submandibular stones, with an 87% success rate and minimal complications.

## Contribution

Demonstrates that non-palpability should not exclude patients from transoral sialolithotomy, even without sialendoscopy.

## Key findings

- Non-palpable stones had an 87% success rate with TSL and a complication rate under 1%.
- Non-palpable stones were significantly smaller (mean 5.3 mm) compared to palpable stones (mean 9 mm).
- Palpability was strongly associated with surgical success (OR = 11.03).

## Abstract

Transoral sialolithotomy (TSL) is the oldest technique used to remove submandibular stones. While it was initially limited to palpable and anterior stones, its indications have broadened. Although non‐palpability has traditionally been considered a contraindication, our experience suggests TSL remains feasible in such cases. This study aimed to evaluate the efficacy and safety of TSL for non‐palpable submandibular lithiasis. Secondary objectives were to identify distinguishing characteristics of non‐palpable stones and factors associated with surgical success.

We conducted a retrospective, monocentric study at Conception University Hospital, Marseille, including all patients treated with TSL between April 2014 and January 2024. Demographic and clinical data were collected: stone laterality, size, location, palpability, multiplicity, operative time, and complications. Univariate and multivariate logistic regression analyses were used to assess factors influencing success.

A total of 457 patients were included (380 with palpable stones, 77 with non‐palpable). TSL achieved an 87% success rate for non‐palpable stones, with a complication rate under 1%. Non‐palpable stones were significantly smaller (mean 5.3 mm vs. 9 mm). Palpability was strongly associated with success (OR = 11.03 [2.95–55.00], p < 0.001).

TSL is an effective and safe option for non‐palpable submandibular stones. The absence of palpability alone should not exclude patients from this technique, even in the absence of sialendoscopy. However, patients should be informed of the increased risk of failure. Based on our surgical experience, systematic 3‐D imaging, general anesthesia for deep gland exposure, and pressurized saline flushing improve the success of TSL in non‐palpable stones.

4.

Transoral sialolithotomy has long been considered inappropriate for non‐palpable submandibular stones. In this retrospective cohort of 457 patients, we compared outcomes between palpable and non‐palpable stones, showing that the technique allows successful removal in 87% of non‐palpable cases, with no associated complications. This suggests it can be considered even in centers without access to endoscopic or fragmentation techniques.