sialendoscopy-approaches to parotid duct and gland …€¦ · parotid duct and gland for...

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Sialoendoscopic Approaches to the Parotid Duct and Gland

For Sialadentis / Sialolithiasis

William Ryan, MDAssistant Professor

Head and Neck Oncologic/Endocrine/Salivary SurgeryDepartment of Otolaryngology-Head and Neck Surgery

Disclosures

Consultant for Medtronic

Transoral Open Sialodochotomy / Sialodochoplasty

Transoral Sialendoscopy

Transfacial Open Duct Surgery (+/- Sialendoscopy)

Parotidectomy

Intraoperative Ultrasound Guidance

Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis

Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis

Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 5-7mm Stones / Parenchymal stones

Failed Sialendoscopy

ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula

Failed Sialoendoscopy


Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Preparation / Exposure

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Instrumentation

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Identification of Stensen’s Duct Papilla

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Punctal Dilation / Ductal Dilation

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Transoral Open Sialodochoplasty / Sialodochotomy

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Parotid Duct Sialendoscope Insertion

Parotid Duct Impacted Stone

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Parotid Duct SialendoscopyCapabilities and Limitations

FindingsSialoliths

Strictures/StenosisMucous plugsInflammation

Nothing

ManeuveringSemirigid

Obstructions- Mouth / Face / Teeth

VisibilityExtent: To secondary sometimes tertiary tributaries

Sometimes cloudy / bloodyParotid Duct Proximal Stenosis

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Therapeutic Sialendoscopy

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Therapeutic SialendoscopyInstrumentation

Wire-Introducer-Dilator SetForceps

Wire BasketsIrrigation Techniques

StentingTopic Corticosteroids

(Laser Fragmentation / Balloons / Drills)

Wire-Introducer-Dilator Set

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Forceps Removal

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Wire Basket Removal

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Wire Baskets

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Recheck After Sialolith Extraction

Topical Corticosteroid Infusion

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Stent Placement

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Sialendoscopic Assisted Balloon Stenosis Dilation

















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Transfacial Intraoperative Ultrasound Guidance









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Transfacial Open Sialodochotomy / Sialodochoplasty

Sialendoscopy

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Parotidectomy

CONCLUSIONSAlgorithmic Approach

Patient Selection / Establish Expectations

Careful With Entry Into The Duct

Parotid Higher Risk / More Challenging Than Submandibular

Be Prepared For A Staged or Combination Approaches

Ultrasound (Intraopative) Useful

High Efficacy Rate If All Tools Used

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THANK YOU References1 Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L. Modernmanagement of obstructive salivary diseases. Acta Otorhinolaryngol Ital 2007;27:161–172. 2 Koch M, Zenk J, Iro H. Algorithms for treatment of salivary gland obstructions. OtolaryngolClin. North Am 2009;42:1173–1192.

3 Ngu RK, Brown JE, Whaites EJ, Drage NA, Ng SY, Makdissi J. Salivary duct strictures: nature and incidence in benign salivary obstruction. Dentomaxillofac Radiol 2007;36:63–67. 4 Nahlieli O, Bar T, Shacham R, Eliav E, Hecht-Nakar L. Management of chronic recurrent parotitis: current therapy. J Oral Maxillofac Surg 2004;62:1150–1155. 5 Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin North Am 2009;42:1029–1052.

6 Nahlieli O, Nakar LH, Nazarian Y, Turner MD. Sialoendoscopy: a new approach to salivary gland obstructive pathology. J Am Dent Assoc. 2006 Oct;137(10):1394–1400. 7 Koch M, Bozzato A, Iro H, Zenk J. Combined endoscopic and transcutaneous approach for parotid glandsialolithiasis: indications, technique, and results. Otolaryngol Head Neck Surg2010;142:98–103.

8 Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands. Otolaryngol Clin North Am 2009;42:973–1000. 9 Gritzmann N, Rettenbacher T, Hollerweger A, Macheiner P, Hubner E. Sonography of the salivary glands. Eur Radiol 2003;13:964–975. Epub 2002.

1st Complex Case

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Transfacial TranscatheterRecannalization of

Distal Parotid Stenosis With Sialendoscopy

And Ultrasound Guidance

Visit with community otolaryngologist:

Extracted the stone under local anesthesia- Took 1 hour

- Patient passed out during the operation from pain

Since the extraction procedure:Constant pain in his mouth and face

Worsens with chewing

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Physical Exam:

No facial masses Facial nerve 100%

5mm scar in the right buccal mucosaNo expression of saliva from the right Stensen’s duct

Recommended:

Transoral right parotid duct dilation

siaolodochoplastywith sialoendoscopy

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FIRST OPERATION

Aborted the procedure :

Fear injuring the facial nerve

Offered Patient:

Observationvs

Botulinum toxinvs

Right transfacial/transoral sialodochoplastywith stent placement

vsParotidectomy

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SECOND OPERATION

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Video of Transfacial Transcatheter

Anterograde Sialoendoscopy

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Advanced sialendoscope transorally via catheter Retrograde into proximal ductal system

- No further sialoliths or areas of stenosis- Irrigated debris / purulent saliva

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POSTOPERATIVE COURSE

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Discharged POD#1 - serosanguinous drainage

Planned removal of drain 4 days laterPossibility of a salivary fistula

- Did not occur

Planned removal of stent 2 weeks later

3 months after procedure – Asymptomatic/Satisfied

Achieved Our Goals:

- Reconstituted the parotid duct

- Relieved Symptoms

- Avoided parotidectomy

- Increased safety

Risk Reduction

ULTRASOUNDIdentified the parotid duct location

SIALENDOSCOPEAssesses nature of the stricture

Confirms placement of the stent catheterEvaluate the proximal ductules for:

- Additional strictures, mucus plugs, sialoliths, and debris Irrigation to the ductal system

Further treatment of obstruction

DRAWBACKSAdditional training and experience

Costs of the equipment/maintenance/storage

QUESTIONS

Botox before transfacial approach?Parotidectomy no matter what?

Facial nerve monitoring?Drain placement?Duration of drain?Duration of stent?

Extent of incision (modified facelift/ Blair)?

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2nd Complex Case

Transfacial TranscatheterRecannalization of

Distal Parotid Stenosis With Sialendoscopy

And Ultrasound Guidance

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Post-operative Recommendations: - Augmentin 875 mg by mouth twice a day x 7 days (or, if penicillin allergic, Clindamycin 450 mg by mouth three times per day x 7 days).

- Ibuprofen 400mg by mouth every 6 hours x 3 days for pain control and to decrease inflammation. - Increased hydration x 3 days (drink at least 1 more glass of water per meal per day)- Regular submandibular gland massage x 3 days (for 2-3 minutes 3 times per day)- Regular use of sialogogues x 3 days (sugar free candies as much as possible)If Sialodochotomy performed: Soft diet for 2 days, otherwise regular diet. Follow up with me in 1 week and 3 months for ultrasound or earlier if necessary.

Dr. Ryan will call you on the phone in 1 week.

sialendoscopy-approaches to parotid duct and gland …€¦ · parotid duct and gland for...

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