Fritsch reported an algorithm for managing a patient with a stone associated with the parotid gland or its duct (Stensen's duct) when extracorporeal lithotripsy is not available. The author is from Indiana University Medical Center in Indianapolis.


Situation: extracorporeal lithotripsy not available


Factors affecting stone removal:

(1) size of the stone

(2) changes in duct wall secondary to acute and chronic inflammation

(3) deposits on the outside of the stone causing adherence to the duct wall



(1) location of the stone

(2) diameter of the stone

Location of the Stone

Diameter of the Stone


distal duct


papillotomy with or without stent; segmental-open procedure may be needed if stone large

mid to proximal duct

< 2 mm

removal by endoscopic forceps or basket


2 to 8 mm

interventional endoscopy with laser lithotripsy, C-arm fluoroscopy, balloon dilation, basket removal. Followed by stent with or without papillotomy


8 to 12 mm

interventional endoscopy with laser lithotripsy, either staged lithotripsy OR endoscopic-open OR endoscopic segmental-open, followed by stent for 4 weeks


> 12 mm

consult specialist


< 5 mm



5 to 12 mm

endoscopic-open OR endoscopic segmental-open


> 12 mm

consult specialist



• Stent placement is needed after removal of a large stone to reduce the chance of duct stenosis during the healing.

• Endoscopic-Open: endoscopic surgery using a preauricular approach to the parotid gland with dissection down to the stone.

• Endoscopic Segmental-Open: an endoscopic-open procedure with wedge resection of diseased parotid gland.

• Endoscopic Segmental-Open: selected if the duct obstruction is severe with ectasias and/or multiple stenoses.


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