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Disclosures William Ryan, MD Assistant Professor Consultant for - - PowerPoint PPT Presentation

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11/6/2014 Sialoendoscopic Approaches to the Parotid Duct and Gland For Sialadentis / Sialolithiasis Disclosures William Ryan, MD Assistant Professor Consultant for Medtronic Head and Neck Oncologic/Endocrine/Salivary Surgery Department of

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Sialoendoscopic Approaches to the Parotid Duct and Gland For Sialadentis / Sialolithiasis

William Ryan, MD Assistant Professor Head and Neck Oncologic/Endocrine/Salivary Surgery Department of Otolaryngology-Head and Neck Surgery

Disclosures

Consultant for Medtronic

Transoral Open Sialodochotomy / Sialodochoplasty Transoral Sialendoscopy Transfacial Open Duct Surgery (+/- Sialendoscopy) Parotidectomy Intraoperative Ultrasound Guidance Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 5-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Preparation / Exposure

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Instrumentation

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Identification

  • f Stensen’s Duct Papilla
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Punctal Dilation / Ductal Dilation

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Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-6mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

Transoral Open Sialodochoplasty / Sialodochotomy

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Parotid Duct Sialendoscope Insertion Parotid Duct Impacted Stone

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Parotid Duct Sialendoscopy Capabilities and Limitations

Findings Sialoliths Strictures/Stenosis Mucous plugs Inflammation Nothing Maneuvering Semirigid Obstructions- Mouth / Face / Teeth Visibility Extent: To secondary sometimes tertiary tributaries Sometimes cloudy / bloody

Parotid Duct Proximal Stenosis

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Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

Therapeutic Sialendoscopy

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Therapeutic Sialendoscopy Instrumentation

Wire-Introducer-Dilator Set Forceps Wire Baskets Irrigation Techniques Stenting Topic Corticosteroids (Laser Fragmentation / Balloons / Drills)

Wire-Introducer-Dilator Set

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Forceps Removal

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Wire Basket Removal

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Recheck After Sialolith Extraction Topical Corticosteroid Infusion

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Stent Placement

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Sialendoscopic Assisted Balloon Stenosis Dilation

Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Transfacial Intraoperative Ultrasound Guidance

Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

Transfacial Open Sialodochotomy / Sialodochoplasty Sialendoscopy

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Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Parotidectomy

CONCLUSIONS

Algorithmic Approach Patient Selection / Establish Expectations Careful With Entry Into The Duct Parotid Higher Risk / More Challenging Than Submandibular Be Prepared For A Staged or Combination Approaches Ultrasound (Intraopative) Useful High Efficacy Rate If All Tools Used

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THANK YOU References

1 Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L. Modernmanagement of

  • bstructive salivary diseases. Acta Otorhinolaryngol Ital 2007;27:161–172.

2 Koch M, Zenk J, Iro H. Algorithms for treatment of salivary gland obstructions. Otolaryngol

  • Clin. North Am 2009;42:1173–1192.

3 Ngu RK, Brown JE, Whaites EJ, Drage NA, Ng SY, Makdissi J. Salivary duct strictures: nature and incidence in benign salivary obstruction. Dentomaxillofac Radiol 2007;36:63–67. 4 Nahlieli O, Bar T, Shacham R, Eliav E, Hecht-Nakar L. Management of chronic recurrent parotitis: current therapy. J Oral Maxillofac Surg 2004;62:1150–1155. 5 Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin North Am 2009;42:1029–1052. 6 Nahlieli O, Nakar LH, Nazarian Y, Turner MD. Sialoendoscopy: a new approach to salivary gland obstructive pathology. J Am Dent Assoc. 2006 Oct;137(10):1394–1400. 7 Koch M, Bozzato A, Iro H, Zenk J. Combined endoscopic and transcutaneous approach for parotid glandsialolithiasis: indications, technique, and results. Otolaryngol Head Neck Surg 2010;142:98–103. 8 Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands. Otolaryngol Clin North Am 2009;42:973–1000. 9 Gritzmann N, Rettenbacher T, Hollerweger A, Macheiner P, Hubner E. Sonography of the salivary glands. Eur Radiol 2003;13:964–975. Epub 2002.

1st Complex Case

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Transfacial Transcatheter Recannalization of Distal Parotid Stenosis With Sialendoscopy And Ultrasound Guidance

Visit with community otolaryngologist: Extracted the stone under local anesthesia

  • Took 1 hour
  • Patient passed out during the operation from pain

Since the extraction procedure: Constant pain in his mouth and face Worsens with chewing

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Physical Exam: No facial masses Facial nerve 100% 5mm scar in the right buccal mucosa No expression of saliva from the right Stensen’s duct Recommended: Transoral right parotid duct dilation siaolodochoplasty with sialoendoscopy

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FIRST OPERATION

Aborted the procedure : Fear injuring the facial nerve

Offered Patient: Observation vs Botulinum toxin vs Right transfacial/transoral sialodochoplasty with stent placement vs Parotidectomy

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SECOND OPERATION

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Video of Transfacial Transcatheter Anterograde Sialoendoscopy

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Advanced sialendoscope transorally via catheter Retrograde into proximal ductal system

  • No further sialoliths or areas of stenosis
  • Irrigated debris / purulent saliva
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POSTOPERATIVE COURSE

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Discharged POD#1 - serosanguinous drainage Planned removal of drain 4 days later Possibility of a salivary fistula

  • Did not occur

Planned removal of stent 2 weeks later 3 months after procedure – Asymptomatic/Satisfied

Achieved Our Goals:

  • Reconstituted the parotid duct
  • Relieved Symptoms
  • Avoided parotidectomy
  • Increased safety

Risk Reduction

ULTRASOUND Identified the parotid duct location SIALENDOSCOPE Assesses nature of the stricture Confirms placement of the stent catheter Evaluate the proximal ductules for:

  • Additional strictures, mucus plugs, sialoliths, and debris

Irrigation to the ductal system Further treatment of obstruction DRAWBACKS Additional training and experience Costs of the equipment/maintenance/storage

QUESTIONS

Botox before transfacial approach? Parotidectomy no matter what? Facial nerve monitoring? Drain placement? Duration of drain? Duration of stent? Extent of incision (modified facelift/ Blair)?

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2nd Complex Case Transfacial Transcatheter Recannalization of Distal Parotid Stenosis With Sialendoscopy And Ultrasound Guidance

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Post-operative Recommendations:

  • Augmentin 875 mg by mouth twice a day x 7 days (or, if penicillin

allergic, Clindamycin 450 mg by mouth three times per day x 7 days).

  • Ibuprofen 400mg by mouth every 6 hours x 3 days for pain control and

to decrease inflammation.

  • Increased hydration x 3 days (drink at least 1 more glass of water per

meal per day)

  • Regular submandibular gland massage x 3 days (for 2-3 minutes 3 times

per day)

  • Regular use of sialogogues x 3 days (sugar free candies as much as

possible) If Sialodochotomy performed: Soft diet for 2 days, otherwise regular diet. Follow up with me in 1 week and 3 months for ultrasound or earlier if necessary.

  • Dr. Ryan will call you on the phone in 1 week.