SIALOENDOSCOPY – ASSISTED

SIALOLITHECTOMY FOR SUBMANDIBULAR HILAR

CALCULI

BY A.BALAJI ,.DEPT OF OMFS

INTRODUCTION

CLASSIFICATION OF SALIVARY GLANDS

FUNCTIONS ANATOMY DISEASES

CLASSIFICATION OF SALIVARYGLANDS

MINOR

They are numerous widely distributed in the oral cavity.

600 to 1000 in no. mostly located at junction of soft and hard palate

MAJOR

They are paired glands

parotid

sub mandibula

r

sublingual

SecretionsAre

SerousIn

nature

MixedBut

MostlySerous

MixedBoth

MucousAnd

Serous,Mostly

Mucous.

ParotidGland

Sub mandibular

gland

Sublingual

gland

SALIVA

1500 ML per day PH VALUE: RESTING GLAND -

7 ACTIVE

SECRETIONS IS ABOUT 8

FUNCTIONS Lubrication for

speech Helps in

swallowing and mastication Digestive properties

Antibacterial Immunological properties

COMPOSITIONS

ORGANIC proteins urea uric acid

lysozymes IgA

Amylase

INORGANIC Sodium potassium chloride bicarbonate calcium phosphate

EMBROYOLOGY

All salivary glands develop from embryonic oral cavity as buds of epithelium that extends into underlying mesenchymal tissues

These epithelial ingrowths or anlages ,are apparent at 8 weeks gestation and then branch to form a primitive ductal system and eventually become canalized to provide structural salivary gland unit for drainage of salivary secretions.

This unit consists of a myoepithelial cell , intercalated duct , striated duct ,excretory duct.

Around 7 th or 8 th month in utero secretary cells called acini begin to develop around ductal system.

Acinar cells are classified as serous cells –produce thin watery

serous secretions. mucous cells-produce thicker

mucous secretions.

Anatomy of submandibular salivary gland Divided into Superficial and deep part Location-digastric triangle(formed by

anterior and posterior belly of digastric muscles and inferior border of the mandible)

Surfaces- medial surface rests anteriorly-mylohyoid muscle middle part-hyoglossus posteriorly-wall of pharynx

ANATOMY OF SUBMANDIBULAR SALIVARY GLAND

surfaces

Inferior surface-is superficial, seen in digastric triangle, directed downwards and laterally.

Lateral surface-is hidden from view of mandible, divided into anterior and posterior part.

Anterior part –lies in contact with medial surface of body of mandible below the attachment of mylohyoid muscle.

Posterior part-separated from body of mandible by medial pterygoid muscle.

PICTURE SHOWING SUBMANDIBULAR SALIVARY GLAND ,WHARTONS DUCT AND ITS CORELATION WITH

ADJOINING STRUCTURES

Stylohyoid ligamentInferior alveolar nerve,

vesselsNerve to mylohyoid

Submandibular salivary gland

Sublingual salivary glandMedial pterygoid

MylohyoidgenioglossusLingual nerve

Anterior belly of digastric

Deep part - passes in interval between the mylohyoid ( laterally ) hyoglossus (medially)

NERVE SUPPLY -Submandibular gland is innervated by the facial nerve through submandibular ganglion via chorda tymphani nerve.

BLOOD SUPPLY -Branches of facial and lingual arteryLYMPHATICS – drains into submandibular lymph nodes ,through them into deep cervical lymphnodes ,particularly jugulo-omohyoid node.

INNERVATION OF FACIAL NERVE TO SMS GLAND

INTER RELATIONSHIP BETWEEN DUCTAL SYSTEM AND LINGUAL NERVE

LATERAL VIEW

Additional relationships

Gland is covered by 2 layers of fascia formed by splitting of investing layer of deep cervical fascia.

Superficial layer covers the inferior surface of the gland and attaches to the lower border of the mandible.

Deeper layer covers the medial surface and is attached to the mylohyoid line of the mandible.

WHARTONS DUCT-•2-4mm in diameter & about 5cm in

length.•It opens into the floor of the mouth thru a punctum. •The punctum is a constricted portion of the duct to limit retrograde flow of bacteria-laden oral fluids.•Duct arises in the deep lobe and runs antero medially ,Lingual nerve crosses the duct inferiorly, after immediately arising from deep lobe.

Some terminologies Sialolith-salivary calculi. Sialolithiasis-process of formation of salivary calculi.

Sialography or sialogram-repeated radiographic examination of salivary glands after injection of contrast medium into the salivary duct.

Sialochemistry-examination of electrolyte composition of saliva

Sialoendoscopy-specialized procedure that uses a small video camera with a light at the end of the flexible canula, which is introduced into the ductal orifice.

Sialometry-is a measure of salivary flow

SCINTIGRAPHY-the production of, 2 – dimensional images of distribution of radio activity in the tissues after internal administration of a radiopharmaceutical imaging agent ,the images are obtained by a scintillation camera,(gamma camera).

LITHOTRIPSY-procedure involving the usage of high energy shock waves to fragment and disintegrate or destruct the calculi.

sialolith

They are calcified structure develop with in ductal system of major and minor salivary glands.

Major cause of both-chronic recurring sialadenitis ,acute suppurative sialadenitis.

Stones composed of inorganic calcium and sodium phosphate salts.

They are believed to arise from deposition of these salts around nides of debris with in duct lumen.

Sialoliths continue ……

These debris may include inspissated mucus , bacteria , ductal epithelial cells or foreign bodies (coagulated).

Prevalent in men than women ratio. 2:1. Peak incidence age = 30-40 years. Submandibular gland involvement is 80 %. PH value of these secretion is 6.8-7 %. Increased concentration of calcium and

phosphate ratio. Mucous Secretions are more viscous.

Pathophysiology

Dehydration Concentration of saliva

Fasting or Anorexia Stasis of saliva

Drugs- Anti-histamines, Anti-cholinergics. Decrease production of saliva

Stone can cause stasis of saliva and subsequent bacterial ascent into the gland. Infection most commonly from S. aureus or

Strep Viridans.

ETIOLOGY OF SIALOLITHS EXACT CAUSE OF SIALOLITH FORMATION IS

NOT KNOWN, But 3 prerequisites stand out as primary

etiology 1) NEUROHUMORAL CONDITION> leading to

salivary stagnation . 2) A nidus or matrix for stone formation. 3)some metabolic mechanism may favors

precipitation of salivary salts into the matrix in the presence of coexisting inflammation.

4) long tortuous duct and situated lower level than its orifice ,so increased salivary stagnation, so increased calculus formation.

Signs and symptoms

Pain and swelling are exacerbated during mealtimes

Check for flow of whartons duct Check for tenderness of

submandibular salivarygland Palpate for stone in floor of the

mouth Check mandibular occlusal

radiograph

TREATMENT

Conservative Warm compresses Sour candy Pain relief- analgesics Oral fluids Discontinue anti-histamines Oral antibiotics- Cefalexin 500mg PO QID X 7d.

Surgical Wire basket retrieval under fluoroscopy. Duct cannulation Gland removal for recurrent cases SIALOLITHECTOMY

Lithotripsy (extra corporeal shockwave lithotripsy)

Sialoendoscope ,lithotriper

PURPOSE

TO ACESS THE CLINICAL EFFECTS OF ENDOSCOPY ASSISTED SIALOLITHECTOMY FOR SUBMANDIBULAR HILAR CALCULI

MATERIALS AND METHODS

STUDY WAS TAKEN IN 70 PATIENTS WITH SYMPTOMATIC STONES IN HILUM OF SUBMANDIBULAR SALIVARY GLANDS.

FROM : DECEMBER 2005 THROUGH MARCH 2011.

OPERATIVE DATA WERE ANALYZED RETROSPECTIVELY AND FOLLOWED PERIODICALLY POSTOPERATIVELY.

GLAND FUNCTION WAS INVESTIGATED BY POST OPERATIVE SYMPTOMS,CLINICAL EXAMINATIONS,SIALOGRAPHY,AND SCINTIGRAPHY.

DIAGNOSIS

BY, ONE OR A COMBINATION OF RADIOGRAPHIC INDICATORS

CROSS SECTIONAL MANDIBULAR OCCLUSAL FILMS

LATERAL PROJECTIONS OF GLAND CONE BEAM COMPUTED

TOMOGRAPHY

CASE SELECTION

INCLUSION CRITERION WAS THAT ,THE STONES WERE SITUATED AT OR PROXIMES TO THIRD MANDIBULAR MOLAR REGIONS

STONES WERE VERIFIED TO BE IMPACTED AFTER HILIUM OF THE WHARTONS DUCT UNDER ENDOSCOPIC VIEW

AMNEABLE TO BASKET RETRIVAL WERE EXCLUDED

SIALOENDOSCOPY

LADUSCOPE T FLEX PD-HS-0250 ENDOSCOPE

HIGLY FLEXIBLE ,SEMIRIGID ENDOSCOPE WITH NITINOL SHEATH

80 MM LONG 1.1mm OUTER DIAMETER 0.4 mm WORKING LENGTH CHANNEL SEPARATE CHANNEL FOR IRRIGATION

PROCEDURE

Main duct of the gland is explored and induction of endoscope done by persistent irrigation.

Small and mobile stones at distal or middle part of the duct were removed by basket entrapment.

Impacted hilar stones were then removed by as endoscopy assisted sialolithectomy technique.

After the stone was verified ,a 2-3 cm incision was made in the floor mucosa according to the light transmitted through endoscope.

As the assistant raised the floor of the mouth with digital pressure in submandibular triangle.

The duct was isolated from the surrounding tissues with particular care to avoid damage to lingual nerve.

Then the hilum was incised at the precise location of the stone and the stone was removed.

Thereafter the entire duct was re-explored for remnant stones or mucous plugs

Hilum then sutured after 4Fr angio catheter had been inserted as a stent, Stent left in situ for 1-2 weeks after surgery.

TREATMENT

Amoxicillin or cefaclor was administrated for 7 days.

Hydration was achieved by the patient drinking more than 2 liters of water a day , and patient advised to avoid sialogogues and spicy foods.

After stent and sutures were removed ,frequent self massaging and sialogogues were recommended.

FOLLOW UP

post operative Clinical assessment was done, to diagnose, any recurrence and

changes in size of the gland . Consistency of the affected gland. Appearance of the ostium ,and the

amount and the nature(clear or milky) of salivary flow on massage.

Siolography

Sialography of submandibular salivarygland was performed with water soluble contrast agent , diatrizoate meglumine, using a closed intravenous catheter (22 gauge),.

After catheter was introduced ,1.5 to 2ml of contrast solution was injected carefully.

Lateral views and 5-min emptying film were taken , and appearance of main ducts, branch ducts and parenchyma were analyzed.

A-Lateral view x-ray showing large stone

B-Stone was removed through an incision at the genu of whartons

duct

C-Extracted stone fragments

D-Six month follow up sialogram shows

proximal duct dilation (filling film)

E-No persistent contrast opacified on functional

film

Different case reports

CONCLUSION

SIALOENDOSCOPY ASSISTED INTRA ORAL REMOVAL IS SAFE AND EFFECTIVE GLAND-PRESERVATION TECHNIQUE FOR PATIENTS WITH LARGE CALCULI AT HILUM OF THE WHARTONS DUCT .

A short movie…by use of endoscopy assisted lithotripsy with a lithotripter