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11/6/2014 Disclosures None Starting Practice Jolie Chang, MD Assistant Professor Department of Otolaryngology, Head and Neck Surgery University of California, San Francisco November 6, 2014 Department of Otolaryngology Department of

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Department of Otolaryngology – Head and Neck Surgery

Starting Practice

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

Outline

  • Equipment
  • Technical Challenges
  • Risks/Complications
  • Caveats
  • Coding
  • Cases

Department of Otolaryngology – Head and Neck Surgery

Equipment is Fragile

  • Sialendoscope

– 0.75mm fiber

– All-in-One

  • Staff Training
  • Repair/Replacement

costs

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Department of Otolaryngology – Head and Neck Surgery

Technique – the Papilla

  • Identify the papilla

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

  • Papilla dilation

– Start with smallest 0000, go back if needed – Conical dilator when at size 0 – Keep papilla in view

Department of Otolaryngology – Head and Neck Surgery

Challenges

  • Dilation of Wharton’s duct papilla

– Rate-limiting step; Up to 20% failure

  • Dilation over guide wire (Chossegros et al. 2006)
  • Limited distal sialodochotomy (Chang JL, Eisele
  • DW. 2012)

– Identify duct in anterior FOM – Preserve papilla

Department of Otolaryngology – Head and Neck Surgery

Distal Sialodochtomy

Department of Otolaryngology – Head and Neck Surgery

Distal Sialodochtomy

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Department of Otolaryngology – Head and Neck Surgery

Distal Limited Sialdochotomy

Department of Otolaryngology – Head and Neck Surgery Department of Otolaryngology – Head and Neck Surgery Department of Otolaryngology – Head and Neck Surgery

Limited distal sialodochotomy

Chang JL, Eisele DW. Laryngoscope 2013.

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Department of Otolaryngology – Head and Neck Surgery

Technique - Sialendoscopy

  • Diagnostic Sialendoscope

– Orient camera – Brightness

  • Introduce sialendoscope: Lab

– Saline irrigation – no air bubbles – Small movements – Backing out the camera helps to find lumen – Advance under visualization

Department of Otolaryngology – Head and Neck Surgery

Postop Care and Complications

  • Postoperative care

– Hydration, massage, abtx

  • Duct stricture (2.5%)
  • Recurrent stones
  • Duct perforation
  • Ranula formation (2.5%)
  • Wire basket/instrument

impaction

  • Temporary lingual nerve

injury (0.4%)

  • FOM swelling, airway
  • Need for gland removal

Witt RL. Laryngoscope 2012.

Department of Otolaryngology – Head and Neck Surgery

Tips - Technical

  • Keep your eyes on the papilla
  • Be careful not to avulse the duct
  • Laser lithotripsy – may require multiple

treatments

  • Dochotomy often required for extraction
  • Beware of duct perforation and excessive

irrigation

  • Avoid sublingual tissue manipulation

Department of Otolaryngology – Head and Neck Surgery

Tips - Imaging

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Department of Otolaryngology – Head and Neck Surgery

Retained Stones

Department of Otolaryngology – Head and Neck Surgery

Sialodochoplasty vs. None: SMG

  • Park et al. Clin Exp Otorhinolaryngol. 2012.
  • Roh et al. Oto-HNS. 2008.

Department of Otolaryngology – Head and Neck Surgery

Future study required

  • Stent placement
  • Steroid irrigation
  • Sialendoscopy for sialadenitis without stones
  • Other forms of lithotripsy

Department of Otolaryngology – Head and Neck Surgery

Coding

  • 42699 Unlisted Salivary Gland Procedure

– Use as secondary code for diagnosis, discovery of stone or stricture – Variable reimbursement – Payment: $0-750 (Medicare $116 – primary; charge $1500)

  • 42606 Ductal dilation and Injection

– Office steroid infusion – Payment: ~$130

  • 76942 Ultrasound needle guided placement

– Payment ~$80

  • 76536 Ultrasound diagnostic head and neck

– Payment ~$60 (Medicare $25)

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Department of Otolaryngology – Head and Neck Surgery

Coding Sialodochoplasty

  • 42500 Primary sialodochoplasty:

– Diagnostic procedure – Payment: ~$700 (Medicare $258)

  • 42505 Complicated sialodochoplasty:

secondary/Complex

– Document complexity: time, why it took longer – Does not bundle with complex intraoral stone codes – Payment: ~$1170 (Medicare $390-434)

Department of Otolaryngology – Head and Neck Surgery

Coding: Sialolithotomy

  • 42335 Sialolithotomy, SMG intraoral, complicated

– Does not bundle with sialodochoplasty codes – Payment: ~$350 (Medicare $122)

  • 42340 Sialolithotomy, Parotid intraoral,

complicated

– Payment: ~$600 (Medicare $160)

Department of Otolaryngology – Head and Neck Surgery

Cases