Disclosures The Approach to the Submandibular Duct and Gland Paid - PowerPoint PPT Presentation

11/6/2014 Disclosures The Approach to the Submandibular Duct and Gland � Paid consultant & Research Support on sleep apnea devices M. Boyd Gillespie, M.D., M.Sc. (Inspire Medical; Olympus; Surgical Specialties) Director, MUSC Salivary Clinic � Paid consultant on head and neck surgical devices (Medtronic) UCSF Salivary Endoscopy Course November 6 th , 2014 Thomas Wharton (1614-1673) 17 th century English physician and anatomist � Cambridge educated � Studied SMG and Pancreas � Wharton’s Jelly (Umbilical Cord) � Not to be confused with Aldred Scott Warthin � Izaak Walton The Compleat Angler (1653) 1

11/6/2014 “Smiley” Cheek Retractor North American Experience Ambulatory Operative � Procedure General Anesthesia � Nasal Intubation (SMG) � Oral Intubation (Parotid) � Protect Your Scopes What is the best Endoscope to start with ? Wharton’s Duct (fully dilated) 2.0-2.5 mm Stenson’s Duct (fully dilated ) 1.5-2.0 mm (0.8) - 1.1 - (1.6 mm) cannula: semirigid outer diameter We use this size only in about 80% of all patients 7 2

11/6/2014 Methylene Blue Schaitkin and Marchal Dilators Dilation Wharton’s Duct Not a straight structure Dips Up Then Down 3

11/6/2014 Kolenda System Kolenda System Don’t forget Bartholin’s Duct 4

11/6/2014 Insertion within Wharton´s Duct � Ductal stenosis > 50% (0.8 mm) might be difficult – find duct and open it � Stones > 5mm � Ductal anomalies Be aware – not in Stensen´s duct (danger of stenosis) � Perforations (saline in FOM) Think Combined Approach Courtesy of Johannes Zenk, MD, PhD Ductal Scissors Zeltser, et al. Operative Techniques in Otolaryngology- Head and Neck Surgery 1996; 7: 370-373. 19 5

11/6/2014 Vessel Loop 6

11/6/2014 Courtesy of Johannes Zenk, MD, PhD Courtesy of Johannes Zenk, MD, PhD Gland Excision Submandibular Gland Excision 8 mm fixed, intraglandular left SM stone below Mylohyoid Line Reserved for cases not amendable to minimally invasive approach: � Approximately 5% of cases � SMG- Usually reserved for fixed, intraglandular submandibular stones below mylohyoid line; Can be performed immediately due to low morbidity. 7

11/6/2014 Submandibular Gland Excision Gland Excision Intraglandular stone with stenosis � Incise low in neck (at least 3 fingers) � Avoid sub-platysmal dissection � Deep dissection through soft tissue to posterior digastric � Ligation of facial vein (Hayes Martin maneuver) � Incise glandular fascia adjacent to digastric � Progressively free gland in subfacial plane � Ligate facial artery or branches � Retract mylohyoid � Ligate submandibular ganglion � Palpate duct to ensure removal of all stones. Gland-Preserving Submandibular Surgery Helpful Hints � Use Methylene Blue � Beginners should try Kolinda Introducer Set � Use Tapered Schaitkin Dilators � Gently straighten duct with forceps; tease the dilator up then down � Passing the diagnostic scope will allow the saline to enlarge the duct making it easier to find � Don’t be afraid to make an incision � Extensive work on Wharton’s duct may require sublingual gland excision � Vessel loops are helpful to retract the duct. 8