Patients should understand that the goals of treatment with sialendoscopy-guided surgery are to reduce the frequency and severity of salivary gland swelling and pain. —Jolie Chang, MD
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October 2021
Many patients with salivary gland disease have persistent, bothersome symptoms despite months or years of symptomatic management, Dr. Ogden said. The opportunity to improve or fix the underlying salivary gland problem is appealing, especially when compared to submandibular or parotid gland removal.
Dr. Mohyuddin typically orders a CT scan preoperatively to objectively assess for glandular architecture, potential neoplastic changes, and possible stone location. Patients will usually have had a history of recurrent and/or intermittent gland inflammation, which worsens during and after meals, or they may have required antibiotics.
Dr. Chang evaluates patients with imaging, typically ultrasound, to determine if there are salivary duct stones, salivary duct dilation, or salivary parenchymal inflammation. “Patients should understand that the goals of treatment with sialendoscopy-guided surgery are to reduce the frequency and severity of salivary gland swelling and pain,” Dr. Chang said.
Dr. Mohyuddin noted the importance of discussing the risks and benefits of salivary endoscopy with patients. “Certain disease processes may limit this technology’s use, so it’s important to set realistic patient expectations,” she said. If stones are stuck at the hilum of the duct or within the glandular parenchyma, especially for submandibular gland stones, then she usually favors gland removal over endoscopic intervention. Occasionally, a combined endoscopic/open transfacial approach may be needed for stones within the parotid parenchyma.
As otolaryngologists, gaining familiarity with the equipment is the major step needed to perform these procedures. —William R. Ryan, MD
Learning the Ropes
Sialendoscopy is a technically challenging procedure that requires substantial operator experience. “As otolaryngologists, gaining familiarity with the equipment is the major step needed to perform these procedures,” Dr. Ryan said.
Dr. Hsu said the technical challenges of the small endoscope size and difficult channels of access into the ducts call for practiced hands. Many training programs now teach these techniques, but in practice, the basics of cannulating the ducts atraumatically can be learned through training courses and in the office with lacrimal duct probes. There are also international training courses available with experts who helped invent and design the equipment. Successfully navigating the ducts using sialendoscopes, however, simply requires repetition and a delicate touch.
While most otolaryngology surgeons and head and neck surgeons are well trained in removing the salivary glands, the anatomy of the floor mouth and salivary ducts, and their relation to important nerves such as the lingual nerve and facial nerve in the floor mouth and buccinator space, respectively, are not well known, Dr. Walvekar said.
Consequently, Dr. Walvekar recommends that a novice sialendoscopy surgeon seek appropriate education by attending a certified sialendoscopy hands-on training course. Endoscopy manufacturers often have salivary endoscopy courses listed on their websites. In addition, the American Academy of Otolaryngology–Head and Neck Surgery often has dedicated instructional courses and off-site courses that are sponsored by industry, such as the Collaborative for Advanced Sialendscopy Education (C.A.S.E.), to support sialendoscopy training and education.
Dr. Mohyuddin uses loop magnification to help her better visualize the ductal orifice. For her, cannulating the duct is typically the most time-consuming part of the procedure. Serial dilation of the duct can be quite difficult to perform due to resistance with probe advancement and risk for ductal perforation. Subsequent deployment of wire baskets for stone extraction can be challenging due to stone size and location. Stones that are proximally located and beyond 7 mm in size are difficult to mobilize. She has sometimes had to perform a cut-down approach to deliver a stone from the duct. If this is done, she will place a hollow stent to allow for mucosal healing and minimize risk for stenosis.