Introduction to Sialendoscopy and Salivary Duct Surgery Jolie - - PowerPoint PPT Presentation

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Department of Otolaryngology – Head and Neck Surgery

Introduction to Sialendoscopy and Salivary Duct Surgery

Jolie Chang, MD Assistant Professor Department of Otolaryngology, Head and Neck Surgery University of California, San Francisco November 6, 2014

Department of Otolaryngology – Head and Neck Surgery

Disclosures

• None

Department of Otolaryngology – Head and Neck Surgery

Obstructive Salivary Disorders

• Stones
• Stenoses
• Systemic disease

– Mumps – Sjogren’s – HIV – Radiation – JRP – Sarcoid

12% 12% 76%

Salivary Stone Composition

Water Organic Inorganic

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Traditional Management

• Diagnosis: Imaging (Ryan)

– Xray, U/S, CT, MRI, Sialography

• Conservative treatment
• Duct dilation
• Transoral excision
• Duct ligation
• Sialadenectomy

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Minimally Invasive Approach

• Endoscopic visualization of the salivary duct

– Gundlach; Konigsberger et al. HNO. 1990 – Nahlieli et al. J Oral Maxillofac Surg. 1994. – Marchal et al. NEMJ. 1999. – FDA approved 2005

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Sialendoscopy Benefits

• Diagnostic

– Stone location – Swelling of unknown eitology – Recurrent sialadenitis

• Therapeutic

– Stone removal: access to posterior stones – Stenosis dilation – Spares salivary glands – Reduced risk

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The salivary gland recovers

• Submandibular glands removed for

sialolithiasis have normal histology. (Marchal et al 2001)

• After stone removal, salivary function
• improves. (Makdissi et al. 2004)
• Animal studies: gland tissue recovers

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Xerostomia

• SMG saliva

– 70% of resting salivary flow – Xerostomia: Risk for dental caries

• After SMG removal

– 22% report xerostomia in long-term follow up (Springbog and Moller. Eur Arch Otorhinolaryngol. 2013.) – Reduced unstimulated salivary flow (Cunning et al. Laryngoscope. 1998.)

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Contraindication

• Active infection

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Clinical History

• History
• PMH: prior XRT, RAI, autoimmune disease
• Exam:

– Salivary expression – Papilla location – Bimanual palpation – Mandibular tori – TMJ, trismus – Imaging

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Sialendoscopy Setup

• General anesthesia

– Avoid anticholinergic agents

• Intubation

– Oral – Nasal: posterior stones in SMG

• Preoperative Medications

– Antibiotics – Decadron

• Positioning

ENT today. June 2008.

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Equipment

• Sialendoscope
• Diagnostic sheath

– Single channel

• Therapeutic sheath

– Working channel

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Equipment (Walvekar)

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Technique – the Papilla

• Identify the papilla

– Gland massage – Symmetry – Magnification – Inject papilla – Methylene blue

• Papilla dilation

– Start with smallest dilator 0000 up to size 3-4 – Avoid making pseudo

• penings with

needle/forceps

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Technique - Sialendoscopy

• Setup

– Orient camera – Brightness

• Introduce sialendoscope

– Saline irrigation – no air – Small movements – Backing out helps to find lumen – Advance under visualization – Be careful of teeth, mandibular tori

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Examination

• Ducts and branches
• Stones

– Location – Mobility – Number

• Stenoses

– Location – Extent

• Other

– Foreign body – Lesions

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Stones – Tools for Management

• Basket/ Dochotomy
• Lithotripsy: Laser

– Forceps – Endoscopic drill

• Combined approach

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Lithotripsy

• Impacted large stones
• Fragmentation:

– Forceps; Hand Drill – Laser Ho:YAG – ECSWL – Endoscopic Intracorporeal SL

• Lithotripsy

– Slow – Can damage duct and scope – Multiple sessions required

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Combined approach

• Due to size & location, stone may not be

amenable to endoscopic management

• Sialendoscopy to localize and characterize the

stone

• Submandibular

– Posterior sialodochtomy over palpable stone

• Parotid

– Transoral sialodochotomy to release distal stones – Transfacial approach for impacted proximal stones

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Combined Approach

Marchal F. Laryngoscope 2007.

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Salivary Duct Stenosis

• Koch M et al. Oto HNS 2005

– Sialendoscopy in 103 cases with negative imaging (U/S) – 33% with stones – 56% with stenoses

• Causes of stenosis

– Iatrogenic: prior surgery – Inflammatory: autoimmune, XRT, RAI

Marchal et al. J Stoma 2011.

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Stenosis Management

• Diagnosis

– Sialography – Sialendoscopy: determine location, extent, length

• Treatment: Dilation

– Dilation: Hydraulic, balloon, – Stents, steroids – Sialodochotomy – Combined Approach: Excision, Vein graft – Sialadenectomy

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Conclusions - Sialendoscopy

• Minimally invasive, gland sparing approach
• Diagnostic and therapeutic
• Treatment of sialolithiasis and stenosis
• Reduced need for sialadenectomy