Sialendoscopy dr chithra p

Malabar Dental College & Research Centre

1. Sialendoscopy
Seminar presentation no:4
PRESENTED BY
Dr. CHITHRA P
Senior Lecturer
Dept of Oral Medicine & Radiology
Malabar Dental College & Research Centre, Manoor
Chekannoor Road, Mudur PO, 679578,

2. Contents
OIntroduction
ODefinition
OIndications
OContraindications
OPrinciple
OEquipments
OTechnique
OSialoendoscopicview in normal anatomy
OSialendoscopyin pathologic conditions
OAdvantages
OLimitations
OConclusion
OReferences

3. Introduction

4. OSalivary glands are exocrine glands whose secretions flow
into the oral cavity through ducts.
OSialadenitis secondary to obstructive pathologies including
sialoliths, strictures and ductal polyps, remains the most
common disorder of the salivary gland.
OConservative treatment is the first line of therapy which
may fail in 40% of patients leading to recommendation of
surgical excision which in turn has several risks and
complications.

5. OA minimally invasive technique for diagnostic evaluation
as well as therapeutic intervention for obstructive
disorders of the salivary glands.
ODiagnosis and treatment during the same procedure.
SIALENDOSCOPY

6. Definition
OSialo–saliva or salivary glands(derived from Greek word
“sialon” means saliva).
OEndoscopy –“visualisation of the interior of organs and
cavities of the body with an endoscope”.
(Mosby’s Medical Dictionary,9
th
edition,2009)
OSialendoscopy-a method of visualisation of Wharton’s or
Stenson’sduct to visualize sialolithiasis, stenosis, polyps or
sialodochitis.
(Stedman’s Medical Dictionary, 2006)

7. OAminimallyinvasiveprocedurewherebysemirigid
endoscopesareinsertedintothenaturalorificesofthe
submandibularandparotidglandsafterserialdilationto
obtainanendoscopicviewoftheductalsystemwithinthe
salivaryglands.(EncyclopediaofOtolaryngology,2006)
OSialendoscopyusessemi-rigidorflexibleminiaturized
endoscopeswithopticalfibersprovidinghigh-quality
imagestoexploretheparotidandsubmandibularsalivary
ducts.
OSynonym:SalivaryEndoscopy
Definition

8. ODiagnostic evaluation of recurrent or chronic
sialadenitis:
ODuctal stenosis or strictures
OSialolithiasis
OJuvenile recurrent parotitis
Indications

9. Contraindications
OSialendoscopyshouldnotbeattemptedduringtheacute
inflammationofsalivaryglands.Itmayincreasethepain
andswellinginanalreadyinflamedgland.Inflammation
resultsinpoorvisibilityoftheductalsystemwhichmay
resultincomplicationlikeperforationoftheductleading
tostenosisoftheduct,thusincreasingtheoverallfailure
andcomplicationrate.
ORelativecontraindications:Trismus,microstomia,TMJ
pathology,presenceofmandibulartori.
Wilson M et al.Sialendoscopy: Endoscopic Approach to Benign Salivary Gland Diseases.
Advances in Endoscopic Surgery. Nov 2011

10. Principle
OInflammation of salivary glands due to obstructive
pathology in duct like calculus and stricture, the cause
lies in the duct and symptoms are due to stasis of saliva
and secondary infection.
OSialendoscopy addresses the ductal pathology leading to
resolution of gland pathology. So defining feature of this
intervention is that it is duct centric rather than gland
centric.
Singh PP,Vikas G. Sialendoscopy: Introduction, Indications and Technique. Indian J Otolaryngol
Head Neck Surg.2014 66(1):74–78;

11. Equipments
OSialendoscope( A & B)
OSalivary Probes(F)
OConic Dilator(G)
OHollow Rigid Bougie
(E)
OForceps( C&D)
OMicrodrill(I)
OStone extractor(H)
OBalloon catheter(J)
Marchal F. Sialendoscopy: The Endoscopic Approach to Salivary Gland Ductal Pathologies.
Tuttlingen, Germany: Endo Publishing; 2003.

12. Pre procedural planning.
OA complete head and neck examination and an
otolaryngology evaluation are recommended before the
procedure.
OFeatures relevant to successful sialendoscopyshould be
assessed and documented.
OAccessibility to the ductal opening through oral cavity must
be evaluated by paying close attention to the size of the oral
commissure and the tongue, the ability to open mouth, any
pathology of TMJ and the presence of mandibular tori.
OIn addition to this assessment of the nasal septum and upper
airway helps the anesthesiateam to prepare for the for
nasotrachealintubation which is the preferred method for
achieving maximal exposure.
OPreoperative imaging included ultrasound or computed
tomography and, on rare occasions, sialography.

13. Operating Room Set-up
OSialendoscopy can be done as an outpatient procedure in
the clinic with the patient sitting in a chair or partially
recumbent but lying position is preferred which allows for
better surgeon mobility and patient comfort.

14. Anesthetic Technique
OSialendoscopy generally requires local anesthesia of the
papilla and the ductal system. A topical anesthetic paste or
spray (10 or 20%) is applied to either Stensen’s or
Wharton’s papilla at the beginning of the procedure. After
introduction of the sialendoscope, anesthesia of the ductal
system is induced with an irrigation solution of Lidocaine
or Carbostesin 0.5 %.
ODiagnostic sialendoscopy can be performed under local
anesthesia.
OInterventional sialendoscopy, can be done under sedation
or even general anaesthesia. This largely depends on the
level of difficulty of the individual case.

15. Step by step technique
OLocal anesthesiaof the papilla with an anestheticpaste or
spray (10 or 20% lidocaine).
OSuperficial infiltration of the papilla with a local
anestheticsolution and adrenalin.
OIntroduction of salivary probes of increasing diameter.
OIntroduction of the dilator.
OPlacement of dental tampons in the posterior aspect of the
vestibule and gingivo-buccalsulcus. These will later be
replaced with new dry ones during sialendoscopy.
OIntroduction of the sialendoscope.
OIntroduction of a guidewirein the working channel (this
step is optional, depending on the experience of the
surgeon. It facilitates reintroduction of the scope in the
duct).

16. Post operative care
OPostoperative observation in monitored setting with
same day discharge.
OAntibiotic coverage for one week post operative.
OPain control as needed
OThis procedure is not typically painful. The patient may
experience uncomfortable gland swelling secondary to
volume of irrigation, which typically resolves with
massage of the respective gland over 48 to 72 hrs.
OMaintain hydration status and salivary flow with
sialagogues
ONo significant limitation of activities is required

17. Complications
OSelfresolvingpainandswellingoftheglandduetoductal
irrigationandfluidretentionistheonlyfrequent
complaintinthepostoperativeperiod.
OComplicationsincludingperforationoftheductwall(6-
8%),lingualnerveparesthesia(15%),facialnerve
paresthesia(10%)inthecombinedapproach,stenosisof
thepapillaandductalstenosis(2-3%)havebeenreported
(4-7%)andneedtobekeptinmind.
Strychowsky JE et al.Sialendoscopy for the Management of Obstructive Salivary Gland Disease A
Systematic Review and Meta-analysis.Arch Otolaryngol Head Neck Surg.2012;138 (6):542-547

18. Diagnostic
Sialendoscopy

19. Normal anatomy of the salivary duct system
First centimeters of the salivary
duct
Main duct

20. Primary branches. Secondary branches

21. Tertiary branches Terminal branches

22. Pathologic findings

23. Mucous plugs
Thick mucous plug floating in the main duct. Blurred image due to
mucosal plug.

24. Mucous plugs
A mucous plug is attached to the stone which
impairs intraductal vision

25. Sialolithiasis
Floating stones. Multiple stones

26. Stone trapped behind a bifurcation.
Sialolithiasis

27. Ductal stenosis
Endoscopic view of a
concentric stenosis in the
second branch of Stensen’s
duct.
Close-up view of the same
site

28. Ductal stenosis
Stenosis of a third generation Wharton’s duct.

29. Stone Removal by Use of a Wire Basket,
preceded by Laser Fragmentation

30. Advantages
OSialendoscopy can be used both for diagnostic as well as
therapeutic purposes
OSingle sitting procedure.
OFor diagnostic purposes, sialendoscopy is superior to other
imaging modallities for detecting obstructive pathologies.
The radiolucent stones, stenosis, polyps, mucosal plugs
and foreign bodies often missed by imaging methods, can
be visualized by this technique.
OWhen used for therapeutic purposes, sialendoscopy is a
minimally invasive technique enabling endoscopic stone
removal, stricture dilatation and salivary gland lavage.
OGland function remains satisfactory after sialendoscopy for
obstructive diseases.

31. Limitations
The main technical limitations of interventional
sialendoscopyat the present time are:
OThewrithingcourseofthecanalputscertainlimitationson
semi-rigidendoscopy,especiallyincasesofsharplybent
curvatures.
Omanoeuveringwithinthesmallsalivaryductshastobe
absolutelyatraumaticbecauseofpossibleductal
perforation.Significanttraumatotheductalwallcould
resultinlaterstenosis.
Osalivary stones in an extreme posterior location.
Oa fibrosedcanal wall with a reduced diameter, which
impedes advancement of the endoscope.

32. Conclusion
ODiagnostic and interventional sialendoscopy, and sialendo-
scopy-assisted surgical techniques have been a major
advance, not only by providing an accurate means of
diagnosing and locating obstruction, but also permitting
minimally invasive surgical management that can
successfully address obstructive salivary gland disorders
and preclude sialoadenectomyin most cases.
OFuture sialendoscopist’sshould familiarize themselves
with the anatomy and physiology of the salivary glands
and floor of the mouth. They should be competent in
taking care of any potential complication and should be
comfortable with major salivary gland resections if
required. Sialendoscopytraining via hands-on courses and
case observations should be pursued prior to initiating a
sialendoscopypractice.

33. References
OSalivary gland disorders—Myer’s, Robert( Springer)
OMarchal F. Sialendoscopy: The Endoscopic Approach to
Salivary Gland Ductal Pathologies. Tuttlingen, Germany:
Endo Publishing; 2003.
OMeyer A, Delasa B, Hibona R et al.Sialendoscopy: A
new diagnostic and therapeutic tool. European Annals of
Otorhinolaryngology, Head and Neck diseases (2013)
130, 61—65.
OSingh PP,Vikas G. Sialendoscopy: Introduction,
Indications and Technique. Indian J Otolaryngol Head
Neck Surg.2014 66(1):74–78.
OWilson M et al.Sialendoscopy: Endoscopic Approach to
Benign Salivary Gland Diseases. Advances in Endoscopic
Surgery. Nov 2011.

34. OBruchJM,SetluryJ.PediatricSialendoscopy.Adv
Otorhinolaryngol.2012;73:149–152.
OCapaccioP,TorrettaS.Modernmanagementofobstructive
salivarydiseases.ACTAotorhinolaryngologicaitalica
2007;27:161-172.
ONahlieli O, Nakar LH, Nazarian Y, et al. Sialoendoscopy: a
new approach to salivary gland obstructive pathology. J Am
Dent Assoc 2006;137(10):1394—400.
Ohttp://emedicine.medscape.com/article/1520153-overview
Owww.sialendoscopy.com.

35. Thank
you……………….