INTRODUCTION
With the introduction of sialendoscopy, a minimally invasive option now exists to treat patients with obstructive sialadenitis and other salivary ductal pathologies (N Engl J Med. 1999;341:1242-1243). Advances in technology have enabled providers of this technique to offer increasingly diverse options for benign salivary disease, including the introduction of calculi basket retrieval, stenosis dilation, and intraductal lithotripsy (Laryngoscope. 2012;122:1306-1311). The application of this diagnostic and therapeutic procedure has been limited by the technical challenges related to cannulation, dilation, and insertion of scope into the salivary duct.
Many dilator options have been devised to ease the introduction of the sialendoscope, yet the learning curve for these techniques has remained arduous. One early strategy included advancing a rigid, center-drilled bougie over a guidewire for papillary dilation (Laryngoscope. 2006;116:842–844). Serial rigid dilation with salivary dilators or lacrimal probes has been the main approach for papillary dilation for many years. More recently, proposed techniques include the use of an epidural tube with the epidural sheath used as the guidewire or utilizing a modified angiocatheter tip attached to the end of the scope to facilitate entrance (Laryngoscope. 2018;128:1392–1394). However, these techniques continue to require additional learned skills and significant anesthesia assistance. The addition of general anesthesia or deep sedation exposes patients to added, perhaps unnecessary, risk and may limit the use of sialendoscopy to therapeutic purposes only (i.e., for patients who have clear pathology discovered on preoperative assessments). With this mentality, sialendoscopy loses its effectiveness as a diagnostic study.
Herein, we demonstrate a novel, simplistic, and rapid approach to cannulation, dilation, and sialendoscope insertion that can be completed in an outpatient setting with the assistance of viscous lidocaine gel (see the supporting video).
METHOD
Figure 1. Application of local anesthesia via lidocaine injection in the parotid duct peri-papillary tissues.
Squires L, et al. Laryngoscope. 2021;131:E2432-E2435
Materials Needed: Surgeon’s choice of salivary endoscope (0.8, 1.1, 1.6 mm Erlangen, or 1.3 mm Marchal) with a camera head, a light source, and a video screen. A salivary access dilating catheter of choice from 4–0 Fr to 7–0 Fr is employed with assistance from a 0.4 mm or 0.01500 guidewire. Intraductal local anesthesia is employed with 2% viscous lidocaine gel, with or without peri-papillary topical cetacaine spray or injectional lidocaine. Saline irrigation (manual or powered) can be used to assist with the endoscopy. Cotton swabs (or intraoral retractors) and nontoothed forceps help facilitate access to the salivary ductal system.
Technique and Setup: Patients are seated in an awake, Fowler’s semi-supine, or an upright position. A self-retaining cheek retractor, dental block, or cotton swabs can be used to facilitate visualization of the papilla. When the patient is awake or under light sedation, there is often no need for retracting instrumentation, especially for submandibular duct papillae, as the patient can assist with visualization of the duct orifices. The first step begins with identification of the papilla followed by application of local anesthesia consisting of topical cetacaine spray, local 1% lidocaine injection with or without epinephrine (Figure 1), or 2% viscous lidocaine gel via cotton swabs. The authors have found this step to be optional even in the office setting. Once papillary anesthesia is obtained, a 0.4 mm or 0.01500 guidewire is then inserted into the papilla followed by the salivary access dilator via Seldinger technique to finish the papillary dilation. Debakey, Gerald, or other nontoothed forceps are useful at this step of the procedure to secure and advance the dilator to the desired level, generally at least 1 cm into duct. While the available salivary access dilating catheters range from 4–0 to 7–0 Fr, usually only one size is needed per case. The authors mainly utilize the 5–0 or 6–0 Fr sizes for the purpose of salivary papilla dilation and access, though the 4–0 Fr can be useful in cases with papillary stenosis and the 7–0 Fr catheter can help prepare the duct for passage of a larger endoscope, such as the Erlangen 1.6 mm.
Many dilator options have been devised to ease the introduction of the sialendoscope, yet the learning curve for these techniques has remained arduous.
Once inserted into the papilla, the guidewire is removed and 1 ml of 2% viscous lidocaine gel is slowly infused into the lumen of the duct. The complete elimination of air bubbles within the syringe is vital to enhance the intraductal view during the sialendoscopy. Backpressure will be noted on the syringe with this infusion. It can be helpful to warn the patients at this point of this additional pressure within their duct as this can lead to some discomfort. Once the lidocaine gel is infused, a 30–60 second delay is employed, with the catheter remaining in place within the papilla to allow for full ductal anesthesia. The catheter is then removed, and at this point, the sialendoscope can be inserted via the widely patent duct with minimal luminal resistance for diagnostic or therapeutic purposes. The stenting and dilating action of the viscous lidocaine within the duct facilitates easy insertion and continued visualization of the entire ductal system. The authors have found that often the lidocaine gel can serve as the only necessary irrigant needed for the entirety of the procedure. In total, procedural access to the individual salivary duct can be completed in an outpatient setting, in under two to three minutes, and is effective with either the parotid or submandibular ducts.
RESULTS
The application of the above technique for dilation and anesthesia of the salivary duct has resulted in quicker introduction of the sialendoscope. This has been observed for all levels of expertise, including early training of resident physicians or novices to sialendoscopy. The time to scope introduction from insertion of the guidewire is often less than five minutes for beginners and trends to under two to three minutes for experienced endoscopists. With such a dramatic decrease in time needed to dilate the papillary system, the patience required of the surgeon and the patient is also lessened immensely. Finally, the feasibility to perform these procedures under local anesthetic or moderate sedation increases. In the first full year the primary author (LS) employed this introduction technique in his university practice, 32 patients were treated with 52 sialendoscopy procedures. All 52 ducts (100%) were obtained utilizing the described technique, and 30/52 (57.7%) endoscopies were able to be completed in the office setting. The majority of cases outside the operating room were completed under moderate sedation (80%). The average number of glands treated in the office per patient was 1.5 glands, while the average number of glands treated per patient in the operating room was 1.83 glands.