A 45-year-old patient presents with recurrent submandibular sialadenitis. A CT scan reveals a single 10 mm stone impacted in the gland hilum. According to the modern therapeutic paradigm, what is the most appropriate gland-preserving management?

E) Salivary endoscopy has caused a paradigm shift in the management of salivary stones. For large or impacted stones that cannot be removed by endoscopy alone, a "combined approach" integrating endoscopic techniques (for precise localization) with a small transoral or external surgical incision for removal is a safe, effective, gland-preserving alternative with high success rates. | A) Antibiotics and sialagogues are conservative measures for acute inflammation but do not address the mechanical obstruction from a large stone, leading to recurrence. | B) Complete gland excision was the traditional approach for large stones but is now considered second-line after gland-preserving techniques fail, to avoid surgical morbidity and loss of gland function. | C) ESWL is less effective for large, impacted submandibular stones compared to parotid stones and often requires multiple sessions. | D) Retrieving an impacted 10 mm stone with a basket via sialendoscopy alone is unlikely to succeed due to the limited diameter of the basket and duct. | C) Patients with large or complex salivary stones should be referred to centers with expertise in interventional sialendoscopy and combined approaches. | D) The answer would change if investigations revealed severe fibrosis and atrophy of the gland with complete loss of function, in which case primary gland excision might be the best option. | E) Consultant Pearl: The modern paradigm for sialolithiasis is: "remove the stone, save the gland," often accomplished via a combined approach. | F) References: CUMMINGS OTOLARYNGOLOGY–HEAD AND NECK 7th Ed 2021.pdf — p. 1158