Sialoendoscopy

Considerations

• • Anatomy

  • Indications

    • Sialolithiasis

    • Diagnostic evaluation of recurrent unexplained sialadenosis

  • Radioiodine-induced sialadenitis

  • Refractory symptoms from any salivary gland pathology that does not respond to conservative management

  • Children with recurrent parotitis

    • Recurrent sialadenitis from autoimmune processes such as Sjögren syndrome, including biopsy 

• Sialolithiasis, approach algorithm 

  • • Smaller stones (< 4 mm in the submandibular gland, < 3 mm in the parotid gland) are amenable to endoscopic removal

    • Intermediate-size stones (5-7 mm) may have to be fragmented further with either a holmium laser or lithotripsy before endoscopic extraction

    • Large stones (> 8 mm) usually necessitate the use of a combined technique for stone removal

• Contraindications 

• 2009: Algorithms for treatment of salivary gland obstructions

• 2010: New era of Endoscopic Approach for Sialolithiasis: Sialendoscopy

• 2013: Sialoendoscopy and combined approach for the management of salivary gland stones

• 2015: Sialoendoscopy: state of the art, challenges and further perspectives. Round Table, 101(st) SIO National Congress, Catania 2014

• 2015: Management of obstructive salivary disorders by sialendoscopy: a systematic review

• 2016: Parotitis and Sialendoscopy of the Parotid Gland

Preparation

• • Peri-operative medications

    • Antibiotic

    • Dexamethasone 

  • Intubation 

    • Orotracheal tube is often adequate 

    • Nasotracheal tube is only needed when the submandibular stone is located posterior, at or behind the hilum 

      • Note: Dr. Rasgon prefers nasotracheal intubation for all submandibular cases 

  • Rotate bed

    • Dr. Rasgon - 180 degrees

    • Dr. Durr - ~100 degrees 

  • Equipment 

    • Lip protector 

    • Microscope, positioned at head of bed - preferred by Dr. Rasgon

    • Sialoendoscopy tray - contains intraoral instrumentation, including mouth prop (bite guard)

    • Minor plastics tray 

    • Conical dilators - preferred by Dr. Rasgon

    • Marchal bougie dilators - similar to lacrimal probes 

    • Sialoendoscope - 1.1 mm diameter 

    • Camera - set tower to "Flexi-scope" and light cable 

      • 20% light setting 

    • Baskets

      • Submandibular stones: Use 2.2 Fr / 1 cm balloon rather than a large one to make sure it fits 

    • If sialodocholithotomy performed 

      • Local anesthesia - 1% Lidocaine with 1:100,000 Epinephrine, only needed prior to incision

      • Needle point Bovie 

        • vs 11 blade

        • vs Ball point scissor 

      • Bishop-Hartman forceps 

      • 6-0 Polysorb, CV-11 (vascular) needle 

Procedure

Sample operative report

Post-op

• • Standard salivary gland conservative measures to encourage saliva flow 

    • Excellent oral hydration and hygiene

      • Rinse the mouth after meals for the first week

    • Hourly gland massage

    • Sialogogues - lemon wedges, sour hard sugar free candy, Lemon Heads 

• Discharge medications

  • • Analgesic 

• • Ibuprofen

    • Antibiotic - optional  

      • Note: Dr. Rasgon prefers a 7-10 day course for patients with stones

  • Follow-up 

    • RTC 1 week and PRN afterward  

  • CPT codes

    • 76536 - Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with image documentation

    • 42660 - Dilation and catheterization of salivary duct, with or without injection

    • 42699 - Unlisted procedure, salivary glands or ducts

    • 42330 - Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral

    • 42335 - Sialolithotomy; submandibular (submaxillary), complicated, intraoral

    • 42340 - Sialolithotomy; parotid, extraoral or complicated intraoral

    • 42500 - Plastic repair of salivary duct, sialodochoplasty; primary or simple

    • 42505 - Plastic repair of salivary duct, sialodochoplasty; secondary or complicated

Pearls & Pitfalls

High-Yield

Links

• eMedicine - Sialendoscopy