Sialendoscopy / Salivary Duct Surgery Course

The Department of Otolaryngology- Head and Neck Surgery, University of California, San Francisco School of Medicine presents

November 6, 2014 Hotel Kabuki San Francisco, California

Course Chairs

William R. Ryan, MD, FACS

Jolie L. Chang, MD

University of California, San Francisco

University of California, San Francisco School of Medicine

Acknowledgement of Commercial Support

This CME activity was supported in part by educational grants from the following:

Cook Medical LLC

Hood Laboratories, Inc.

Karl Storz Endoscopy-America, Inc.

IN-KIND SUPPORT:

Cook Medical LLC

Hitachi Aloka Medical

Hood Laboratories, Inc.

Karl Storz Endoscopy-America, Inc.

Stryker Endoscopy

Exhibitors

Baxter Biosurgery / Covidien

Cook Medical

Hitachi Aloka Medical

Karl Storz Endoscopy-America, Inc.

Olympus America, Inc.

Stryker Craniomaxillofacial

University of California, San Francisco School of Medicine Presents

Sialendoscopy / Salivary Duct Surgery Course

EDUCATIONAL OBJECTIVES We specifically anticipate improvements in skills and strategies to:

 Implement sialendoscopy and sialendoscopic-assisted trans-oral salivary duct surgery into one’s practice;  Determine the indications for sialendoscopy and salivary duct surgery versus submandibular or parotid gland resection;  Establish expectations of potential outcomes, advantages and drawbacks of the various salivary duct and salivary gland procedures;  Perform duct surgery procedures including punctal dilation, ductal dilation, sialendoscope insertion and maneuvering, sialendoscopic-guided instrument use (snares, graspers, drills, lasers, dilators), sialolithotomy, sialodochotomy, sialodochoplasty, and transfacial extractions.

ACCREDITATION

The University of California, San Francisco School of Medicine (UCSF) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

UCSF designates this educational activity for a maximum of 8.00 AMA PRA Category 1 Credits™.

The morning lectures are worth 4.25 credits. The afternoon hands-on lab is worth 3.75 credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity meets the requirements under California Assembly Bill 1195, continuing education and cultural and linguistic competency.

The cases used in this course are presented for teaching purposes only. Please observe patient confidentiality. This presentation may be protected under Evidence Code 1156, 1157.

Nurses: For the purpose of recertification, the American Nurses Credentialing Center accepts AMA PRA Category 1 Credit™ issued by organizations accredited by the ACCME.

Physicians Assistants: AAPA accepts category 1 credit from AOACCME, Prescribed credit from AAFP, and AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

GENERAL INFORMATION

Attendance Verification / CME Certificates

Please remember to sign-in on the sign-in sheet when you check in at the UCSF Registration Desk. You only need to sign-in once for the course, when you first check in.

After the meeting, please visit this website to complete the online course evaluation: http://www.ucsfcme.com/evaluation

Upon completing the online evaluation, your CME certificate will be automatically generated and emailed to you.

Evaluation

Your opinion is important to us – we do listen! We have two evaluations for this meeting. The speaker evaluation is the light green hand-out you received when you checked in. Please complete this during the meeting and turn it in to the registration staff before you leave.

The overall conference evaluation is online at: http://www.ucsfcme.com/evaluation

We request you complete this evaluation within 30 days of the conference in order to receive your CME certificate through this format.

Security

We urge caution with regard to your personal belongings. We are unable to replace these in the event of loss. Please do not leave any personal belongings unattended in the meeting room during lunch or breaks or overnight.

Exhibits

Industry exhibits are located outside the general session room during breakfast and coffee break.

Lunch

Lunch will be provided for participants of the afternoon hands-on lab. Everyone else is on their own for lunch. Please visit the conference registration desk or the hotel concierge for a list of nearby eateries.

Final Presentations

PDF versions of the final presentations will be posted online approximately 2-4 weeks post course. Only presentations that have been authorized by the presenter will be included.

Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons

I. Purpose. This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education programs. This document and the attachments are intended to provide physicians with an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories

II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August 11, 2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance. The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services. Failure to provide LEP individuals with access to federally funded programs and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government.

HHS recently issued revised guidance documents for Recipients to ensure that they understand their obligations to provide language assistance services to LEP persons. A copy of HHS’s summary document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ .

As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in designing an LEP program, should conduct an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services.

Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan.

A Recipient’s LEP plan likely will include translating vital documents and providing either on-site interpreters or telephone interpreter services, or using shared interpreting services with other Recipients. Recipients may take other reasonable steps depending on the emergent or non-emergent needs of the LEP individual, such as hiring bilingual staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide interpreter services.

HHS’s guidance provides detailed examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that Recipients may elect to follow when determining whether vital documents must be translated into other languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its written translation obligations.

In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan.

III. California Law – Dymally-Alatorre Bilingual Services Act. The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq.) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows:

“The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends on the right and ability of its citizens and residents to communicate with their government and the right and ability of the government to communicate with them.

The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is other than English, effectively to communicate with their government. The Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would otherwise be entitled.

It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.”

The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm Course Chairs

William R. Ryan, MD, FACS Assistant Professor, Division of Head and Neck Oncologic and Endocrine Surgery, UCSF Salivary Surgery Center, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Jolie L. Chang, MD Assistant Professor, UCSF Salivary Surgery Center, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco

Course Faculty

M. Boyd Gillespie, MD, MSc, FACS Professor; Director, MUSC Salivary Clinic; Vice Chair, Clinical Outreach, Department of Otolaryngology- Head and Neck Surgery, University of South Carolina, Charleston, SC

Andrew H. Murr, MD, FACS Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, Roger Boles, MD Endowed Chair in Otolaryngology Education, UCSF Salivary Surgery Center University of California, San Francisco

Kristina W. Rosbe, MD, FAAP, FACS Professor, Departments of Otolaryngology and Pediatrics; Director, Division of Pediatric Otolaryngology, UCSF Salivary Surgery Center University of California, San Francisco

Rohan R. Walvekar, MD, FACS Associate Professor, Department of Otolaryngology- Head and Neck Surgery; Director, Head and Neck Service, MCLANO & Earl K. Long Hospitals; Director, Clinical Research and Salivary Endoscopy Service, Louisiana State University, New Orleans, LA

Disclosures

The following faculty speakers, moderators and planning committee members have disclosed NO financial interest/arrangement or affiliation with any commercial companies who have provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity:

Jolie L. Chang, MD

Kristina W. Rosbe, MD, FAAP, FACS

The following faculty speakers have disclosed a financial interest/arrangement or affiliation with a commercial company who has provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity. All conflicts of interest have been resolved in accordance with the ACCME Standards for Commercial Support:

M. Boyd Gillespie, MD, MSc, FACS Consultant Inspire Medical Consultant Medtronic Consultant, Research Support Olympus Consultant Surgical Specialties

Andrew H. Murr, MD, FACS Consultant, Stockholder Intersect ENT

William R. Ryan, MD Honorarium WatchLAB Consultant Medtronic

Rohan R. Walvekar, MD, FACS Consultant, Royalties Hood Laboratories Consultant Cook Medical Consultant Medtronic Xomed

This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced.

This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have disclosed no relevant financial relationship.

SAVE THE DATE!

Otolaryngology Update: 2015

November 5 - 7, 2015 Grand Hyatt Hotel San Francisco, California

www.cme.ucsf.edu COURSE PROGRAM

Thursday, November 6, 2014 7:00a Registration and Continental Breakfast 7:20 Welcome and Announcements William R. Ryan 7:30 Introduction to Salivary Duct Surgery / Sialendoscopy Jolie L. Chang 7:50 Equipment Rohan R. Walvekar 8:10 Salivary Gland and Duct Anatomy Andrew H. Murr 8:30 Imaging – Ultrasound, CT, and Other William R. Ryan 8:50 Obstructive Salivary Symptoms and Medical Therapy Kristina W. Rosbe 9:10 Approaches to the Submandibular Duct and Gland M. Boyd Gillespie 9:30 Break 10:00 Approaches to the Parotid Duct and Gland William R. Ryan 10:20 Sialolithiasis and Management M. Boyd Gillespie 10:40 Sialadenitis without Stones: Workup and Management Andrew H. Murr 11:00 Pediatric Salivary Duct Surgery / Sialendoscopy Kristina W. Rosbe 11:20 Getting a Practice Started Jolie L. Chang 11:40 Cases Rohan R. Walvekar 12:00 pm Morning Lecture Session Adjourns

Program continues for Afternoon Hands-On Lab Participants (Limited Enrollment)

12:00 pm Lunch (provided) and Overview 12:45 Shuttle To Surgical Training Center Lab Proctors 1:30 Orientation to Lab Jolie L. Chang 2:00 Skills Lab: Papilla Dilation, Sialendoscopy M. Boyd Gillespie Ultrasound, and Stone Management Chase Heaton 3:00 Break Andrew H. Murr 3:15 Skills Lab: Papilla Dilation, Sialendoscopy Kristina W. Rosbe Ultrasound, and Stone Management William R. Ryan 4:15 Break Trina Sheedy 4:30 Demonstration – Combined Approaches Rohan R. Walvekar 5:00 Skills Lab 5:30 Recap 5:45 pm Hands-on Lab Adjourns / Shuttle To Hotel Kabuki 11/6/2014

Disclosures

• None Introduction to Sialendoscopy and Salivary Duct Surgery

Jolie Chang, MD Assistant Professor Department of Otolaryngology, Head and Neck Surgery University of California, San Francisco Department of Otolaryngology November 6, 2014 Department of – Head and Neck Surgery Otolaryngology – Head and Neck Surgery

Obstructive Salivary Disorders Traditional Management Salivary Stone • Stones Composition 12% • Diagnosis: Imaging (Ryan) Water • Stenoses 12% – Xray, U/S, CT, MRI, Sialography Organic • Systemic disease Inorganic 76% • Conservative treatment – Mumps • Duct dilation – Sjogren’s • Transoral excision – HIV • Duct ligation – Radiation – JRP • Sialadenectomy – Sarcoid

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Minimally Invasive Approach Sialendoscopy Benefits

• Endoscopic visualization of the salivary duct • Diagnostic – Gundlach; Konigsberger et al. HNO. 1990 – Stone location – Nahlieli et al. J Oral Maxillofac Surg. 1994. – Swelling of unknown eitology – Marchal et al. NEMJ. 1999. – Recurrent sialadenitis – FDA approved 2005 • Therapeutic – Stone removal: access to posterior stones – Stenosis dilation – Spares salivary glands – Reduced risk

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

The salivary gland recovers Xerostomia

• Submandibular glands removed for • SMG saliva sialolithiasis have normal histology. – 70% of resting salivary flow (Marchal et al 2001) – Xerostomia: Risk for dental caries • After stone removal, salivary function • After SMG removal improves. (Makdissi et al. 2004) – 22% report xerostomia in long-term follow up • Animal studies: gland tissue recovers (Springbog and Moller. Eur Arch Otorhinolaryngol. 2013.) – Reduced unstimulated salivary flow (Cunning et al. Laryngoscope. 1998.)

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Contraindication Clinical History

• Active infection • History • PMH: prior XRT, RAI, autoimmune disease • Exam: – Salivary expression – Papilla location – Bimanual palpation – Mandibular tori – TMJ, trismus – Imaging

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Sialendoscopy Setup Equipment

• Sialendoscope • General anesthesia – Avoid anticholinergic agents • Diagnostic sheath • Intubation – Oral – Single channel – Nasal: posterior stones in SMG • Therapeutic sheath • Preoperative Medications – Working channel – Antibiotics – Decadron • Positioning

Department of Department of Otolaryngology – Head ENT today. June 2008. Otolaryngology – Head and Neck Surgery and Neck Surgery

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Equipment (Walvekar) Technique – the Papilla

• Identify the papilla – Gland massage – Symmetry – Magnification – Inject papilla – Methylene blue • Papilla dilation – Start with smallest dilator 0000 up to size 3-4 – Avoid making pseudo openings with needle/forceps

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Technique - Sialendoscopy Examination

• Setup • Ducts and branches – Orient camera • Stones – Brightness – Location – Mobility • Introduce sialendoscope – Number – Saline irrigation – no air • Stenoses – Small movements – Location – Backing out helps to find lumen – Extent – Advance under visualization • Other – Be careful of teeth, mandibular tori – Foreign body – Lesions

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Stones – Tools for Management

• Basket/ Dochotomy • Lithotripsy: Laser – Forceps – Endoscopic drill • Combined approach

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Lithotripsy Combined approach

• Impacted large stones • Due to size & location, stone may not be • Fragmentation: amenable to endoscopic management – Forceps; Hand Drill • Sialendoscopy to localize and characterize the – Laser Ho:YAG stone – ECSWL • Submandibular – Endoscopic Intracorporeal SL – Posterior sialodochtomy over palpable stone • Lithotripsy • Parotid – Slow – Transoral sialodochotomy to release distal stones – Can damage duct and scope – Transfacial approach for impacted proximal stones – Multiple sessions required

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Combined Approach

Marchal F. Laryngoscope 2007. Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Stenosis Management Salivary Duct Stenosis • Diagnosis • Koch M et al. Oto HNS 2005 – Sialography – Sialendoscopy in 103 – Sialendoscopy: determine cases with negative location, extent, length imaging (U/S) • Treatment: Dilation – 33% with stones – Dilation: Hydraulic, balloon, – 56% with stenoses – Stents, steroids • Causes of stenosis – Sialodochotomy – Iatrogenic: prior surgery – Combined Approach: – Inflammatory: Excision, Vein graft autoimmune, XRT, RAI – Sialadenectomy

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery Marchal et al. J Stoma 2011 . and Neck Surgery

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Conclusions - Sialendoscopy

• Minimally invasive, gland sparing approach • Diagnostic and therapeutic • Treatment of sialolithiasis and stenosis • Reduced need for sialadenectomy

Department of Otolaryngology – Head and Neck Surgery

7 UCSF Salivary Endoscopy Course 2014 Disclosure I have the following relationship(s) with commercial interests. Basic Set Up and Instruments Hood Laboratories *Walvekar Salivary Stent

Cook Industries Rohan R. Walvekar , MD Department of Otolaryngology & Head Neck Medtronic Xome Surgery Louisiana State University Health Sciences Center A commercial interest is any entity producing, marketing, re-selling, or New Orleans, LA distributing health care goods or services consumed by, or used on, patients.

Basic Sialendoscopy Set Basic Sialendoscopy Set

Dilator System Marchal Dilator System Instruments for Exposure of the Oral Cavity Probes No.0000 to No.8 Anesthesia – Nasal Intubation is preferred Schaitkin ’s Fluted Dilators \ Epistaxis No.0 – 5 • Pre-op nasal endoscopy to document spurs, Conical Dilator deviated septum or other abnormality Helps to transition between dilators • Afrin and lubricated nasal trumpet while Useful usually once papilla is dilated up to Marchal patient is in preoperative holding area No.1 or 2 dilator Disposable Plastic cheek retractor Bougies (increasing diameter) Dental splints Compatible with 0.4 mm guide wire Jennings's mouth gag COOK Dilator System with Operating Sheath Minnesota and Sweetheart Guide Wire retractors Cook Dilators 1-8

1 Schaitkin Salivary Dilator Set

2 Kolenda Introducer Set (COOK)

Sialendoscopy Sialendoscopy

Sialendoscopes

1.3 mm Marchal* 1.1 mm Erlangen* 1.6 mm Erlangen*

*Karl Storz, Tuttlingen, Germany

Fiberoptic channel Irrigation Port

Interventional Port

Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin N Am 42 (2009) 1029-1052 Sialendoscopy

3 Marchal Sialendoscope Basic Sialendoscopy Set Sialendoscopes 0.8 mm Pediatric diagnostic sialendoscopy Fifth generation endoscopes No interventional channel Original was flexible 1.1 mm “all in one ” Erlangen Sialendoscope 1.3 mm semi rigid scope with 6000 pixels, Can be autoclaved 0.25mm rinsing channel and 0.65mm working Interventional Tools that can be used with the scope channel 0.4 mm guide wire basket 0.4 mm stone basket Laser fiber (Holmium laser) Hand held microburr Does not have a protective sheath Dilate up to No.3 or 4 prior to endoscopy

Basic Sialendoscopy Set Basic Sialendoscopy Set Sialendoscopes 1.6 mm “all in one ” Erlangen Sialendoscope 1.3 mm Marchal “all in one ” scope Can be autoclaved Autoclavable. Interventional Tools that can be used with the scope Interventional Tools that similar to 1.1 Erlangen 0.4/6 mm guide wire basket scope 0.4/6 mm stone basket Does have a protective sheath Cup forceps** Optics are excellent Does not have a protective sheath Dilate up to No.4 / 5 prior to endoscopy Dilate up to No.5 or 6 prior to endoscopy Gentle bend at the tip of the scope Balloon Dilator (Storz) – compatible with all in one scopes

4 Basic Sialendoscopy Set IV Extension Tubing 20 cc syringe Vessel loops Angled Forces with and without teeth Standard Endoscopy Tower and Monitor with recording capabilities** Accessories Disposables Stone baskets Guide wires Cleaning brushes Stents (Hood Laboratories)* Balloon Dilator Not Disposable Three way stopcock/valv e Hand-held micro burr Sialendoscopy Stone forceps

STORZ WIRE BASKETS COOK WIRE BASKETS - - N Gage

5 LSU Sialendoscopy Course Diagnostic Sialendoscopy Data

Diagnostic Sialendoscopy 100% Successful endoscopy Ductal or papillary stenosis in 7/15 (47%) Essentially normal endoscopy in 8/15 (53%) Symptoms improved in 13/15 (87%) cases Rohan R. Walvekar , MD Department of Otolaryngology & Head Neck Surgery Louisiana State University Health Sciences Center New Orleans, LA

Bowen M et al. Diagnostic and Interventional Sialendoscopy: A preliminary experience. 2010 Laryngoscope (accepted for publication)

Success of Diagnostic Endoscopy ~ 95-98% Sialendoscope Cannulation Rate Limiting Step : Dilation of Papilla

SERIAL DILATION USING THE DILATOR SYSTEM Progressive dilation Approaches to the papilla Marchal Dilator System Dilation technique (No.0000 to No.6) Conical dilator Seldinger technique Seldinger technique With bougies Guide wire and bougies With sialendoscope Papillotomy SELDINGER TECHNIQUE USING GUIDE WIRE2 AND Papillotomy BOUGIES (adopted from Chossegros et al ) 25% (7/28) Proximal papillotomy and sialodochoplasty

Successful endoscopy 96% (27/28)

6 Distal Papillotomy and Dilation Followed by Sialodochoplasty and Stent Placement

Papillotomy for diagnostic endoscopy…consequences..

Acknowledgements

Dan W Nuss MD, Faculty and Residents Department of Otolaryngology Head Neck Surgery, LSU HSC, New Orleans, LA Barry Schaitkin, MD (University of Pittsburgh) OR Staff (Our Lady of the Lake Regional Medical Center) Head Neck Center, (Our Lady of the Lake Medical Center)

7 Avoid Complications Technical Problems

Local Anesthesia: Maceration of the papilla: measured traction -Lidocaine 4.5mg/kg (<300mg) -Lidocaine/epineprine 7mg/kg (<500 mg)

MAC (sedation): -Over -Under Avoid creating pseudo-orifices: injection Local Anesthesia: forceps dilators -Beware of ETT position -NO atropine or like medication

Technical Problems Technical Problems

False Passage (papilla): Overinjection of NSS: -do not force the dilator -60cc syringe with IV extender -do not cut the papilla -control your assistant enthusiasm -maintain one port open -in the submandibular area it can Ductal Perforation: lead -do not advance blindly to AIRWAY COMPROMISE -do not force the instrument in -abort if identified

8 Equipment Failure

Be cognizant of the turns: -scope is semi-rigid (it is fragile) -straighten the duct using manual traction and pressure

Be cognizant of the teeth

Have back up gear

The Learning Curve

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Andrew H. Murr, MD Professor and Chairman Roger Boles, MD Endowed Chair in Otolaryngology Education Department of Otolaryngology- Head and Neck Surgery

Salivary Gland and Duct Anatomy UCSF Sialendoscopy/Salivary Duct Surgery Course November 6, 2014 University of California, San Francisco

Salivary Gland and Duct Anatomy Function of Salivary Glands

• Parotid Gland and Stensen’s Duct • Food digestion • Submandibular Gland and Wharton’s Duct – Lubrication • Sublingual Gland and Duct System – Clearance • Minor Salivary Glands • Tooth protection • Taste • Antimicrobial function

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Embryology Duct Ultrastructure Parotid Gland

• Ectoderm origin – Surrounded by mesenchyme • 6-8 weeks of life • Originate at duct orifice – Parotid develops around and between facial nerve • Salivary tissue becomes encapsulated –*Parotid encapsulates last: only in parotid- lymphatic system is contained within parotid tissue prior to encapsulation

Parotid Gland Parotid Gland

• Largest and 1 st to • Tail develop • Accessory parotid • Serous acinar cells – 20% – Purely serous – seromucinous • Parotid fascia • Borders – Lateral Skin – Medial Parapharyngeal space – Superior Zygomatic arch – Posterior EAC – Inferior Styloid/carotid/jugular – Anterior Masseter

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Parotid Gland Parotid Gland Hollinshead

• Arterial supply • Nerve Supply – External carotid – Parasympathetic • Maxillary • IX- preganglionic • Superficial temporal – LSP (ovale) to otic • Transverse facial ganglion • Postganglionic • Venous drainage – Auriculotemporal – Retromandibular – Sympathetic • Maxillary • Superior cervical ganglion • Superficial temporal – Via external carotid – External jugular plexus – Internal jugular

Surgical Nerves Facial Nerve Hollinshead

• Facial nerve • Greater Auricular

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LSD: Stenosis LSD Classification Marchal, F et al., Salivary stones and stenosis, A comprehensive classification. Rev Stomatol Chir Maxillofac 2008; 109: 233-236 Marchal, F et al., Salivary stones and stenosis, A comprehensive classification. Rev Stomatol Chir Maxillofac 2008; 109: 233-236 • Lithiasis Lithiasis • S0 no stenosis • Stenosis • L0 no stones • S1 diaphragmatic • Dilation • L1 floating stone • S2 Unique (main) • L2 fixed stone totally • S3 Diffuse (main) visible • S4 Generalized – A. <8 mm – B. >8 mm • L3 fixed stone partially visibile – A palpable – B non-palpable

LSD: Dilations Marchal, F et al., Salivary stones and stenosis, A comprehensive classification. Rev Stomatol Chir Maxillofac 2008; Stensen’s Duct 109: 233-236 • D0 none • Diameter: 3 mm • D1 unique • Length: 6 cm • D2 multiple • Papilla: .5 mm • Main 1.4 mm • D3 generalized • Primary • Secondary • Tertiary • Terminal

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Endoscopic Duct Anatomy Endoscopic Duct Anatomy

Main Primary Secondary Tertiary

Transillumination Stensen’s Duct

• Key points in the duct – Papilla – Buccinator – Masseter – Accessory – Intra-parotid

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Stensen’s Duct Kiringoda R, Eisele DW, Chang JL. A comparison of parotid imaging characteristics and sialendoscopic findings in obstructive salivary disorders. Laryngoscope. 2014 Jun 16. doi: 10.1002/lary.24787. [Epub ahead of print] PubMed Papilla PMID: 24932900.

Masseter Kiringoda R, Eisele DW, Chang JL. A comparison of parotid imaging Submandibular Gland characteristics and sialendoscopic findings in obstructive salivary disorders. Laryngoscope. 2014 Jun 16. doi: 10.1002/lary.24787. [Epub ahead of print] PubMed PMID: 24932900.

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SMG Submandibular Gland

• Submandibular triangle • Arterial Supply – Level 1 – Facial artery – Borders: • Mandible • Venous drainage • Digastric – Facial vein • Mylohyoid • Hayes-Martin Maneuver – Superficial lobe » Above mylohyoid • Nerve supply – Deep lobe – Parasympathetic • Seromucinous • VII (nervous intermedius) to Chorda Tympani • Lingual nerve via submandibular ganglion – Sympathetic- superior cervical ganglion

Wharton’s Duct Eisele and Chang, Laryngoscope, 2012

• ~ 4 mm • 5 cm in length • Papilla

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Papilla [fom] Medial/Below/Above [neck] Combs et al, Int. J of OMFS 2009

Wharton’s Duct Wharton’s Duct Hollinshead

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Imaging Sublingual Gland

• Unencapsulated • B/t mylohyoid and geniohyoid/genioglossus • Within sublingual space • Mucous secreting • Ducts of Rivinus – 8-10 ducts opening into FOM • Bartholin Duct which joins Wharton’s Duct

Sublingual Duct(s) Ranula

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OHNS Faculty and Residents

Thank you!

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Sialadenitis / Sialolithiasis Imaging Ultrasound, CT, and Others Disclosures William Ryan, MD Assistant Professor Consultant for Medtronic Head and Neck Oncologic/Endocrine/Salivary Surgery Department of Otolaryngology-Head and Neck Surgery

Establishing Diagnosis – Etiology - Sialolith - Stenosis PURPOSES OF IMAGING - Inflammation / Fibrosis - Tumor, Cyst - Single Gland / Generalized

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Establishing Diagnosis – Etiology Establishing Diagnosis – Etiology - Sialolith - Sialolith - Stenosis - Stenosis

- Size (Number) of Sialolith(s) - Size (Number) of Sialolith(s) >4-7mm – OPEN (combination) >4-7mm – OPEN (combination)

- Location of Sialolith(s) / Stenosis(es) - Location of Sialolith(s) / Stenosis(es) Parotid, Submandibular Parotid, Submandibular Distal, Proximal, Parenchymal Distal, Proximal, Parenchymal

Location of Sialolith (Stenosis) Determine Indication for: -> Treatment Observation / Conservative Measures Distal: Referral (oral medicine, rheumatology, neurology, etc) Transoral or Sialendoscopy Sialendoscopy Proximal: Transoral Open Sialendoscopy or Transoral Transcervical / Transfacial Combined Approach Transcervical/Transfacial Open Combination

Sialadenectomy Parenchymal: Transcervical / Transfacial Combined Approach or Sialedenectomy

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Modalities Modalities

Ultrasound Ultrasound (Ultrasound Guided Sialendoscopy / Sialithotomy) (Ultrasound Guided Sialendoscopy / Sialithotomy)

CT neck CT neck

Others: Others: Head / Dental X-ray Head / Dental X-ray MRI MRI Sialogram Sialogram MR Sialogram MR Sialogram

Ultrasound and CT Ultrasound Advantages Common place / available 7.5-13 MHz linear probe Interpretable High Resolution has improved sensitivity Cheaper Establishing Diagnosis - Etiology Efficient Location (Number) Non-invasive Determining Treatment No radiation

Surgeon-performed / In-clinic Dynamic (real time / intraoperative) Dynamic dilation (with sialagogues) Better lymph node definition Easy repeat follow up (extension of physical exam)

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Ultrasound Disadvantages Ultrasound Disadvantages

Sensitivity: 77-81% Sensitivity: 77-81% Specificity: 94-95% Specificity: 94-95% PPV: 94% PPV: 94% NPV: 78% NPV: 78% Accuracy 85-86% Accuracy 85-86%

Can’t totally rule out sialolithiasis Can’t totally rule out sialolithiasis No deep parotid lobe evaluation No deep parotid lobe evaluation Operator dependent Operator dependent

CT Neck Advantages CT Neck Disadvantages

Need 1 mm slices False positives NON-CONTRAST BETTER Less ductal definition

Less Operator Dependent Radiation More Sensitive (more with contrast) Expensive Precise location of sialoliths Another visit Better floor of mouth definition Better tumor / infiltrative process delineation

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Submandibular Ultrasound

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Parotid Ultrasound

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Intraoperative Ultrasound Guided Sialendoscopy/Sialolithotomy

- Updated Imaging At Time of the Procedure

- Intraoperative Sialolith / Stenosis Location

- Intraoperative Sialolith Removal Confirmation

- Sialendoscope / Forceps Guidance (Retrieval / Fragmentation)

- Needle Catheter Insertion

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Dynamic Assessment

Finger Floor of Mouth Manipulation Finger Floor of Mouth Manipulation

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Intraoperative Sialolith Confirmation Forceps Guidance (of Removal) (Retrieval / Fragmentation)

Sialendoscope Guidance

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Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234 Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234

Carroll W W et al. Otolaryngology -- Head and Neck Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234 Surgery 2012;148:229-234

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Carroll W W et al. Otolaryngology -- Head and Neck Carroll W W et al. Otolaryngology -- Head and Neck Surgery 2012;148:229-234 Surgery 2012;148:229-234

Carroll W W et al. Otolaryngolo gy -- Head and Neck Surgery 2012;148:229 Carroll W W et al. Otolaryngology -- Head and Neck -234 Surgery 2012;148:229-234

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Submandibular CT

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Parotid CT

Tonsilith

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• Screen Shot 2014-10-29 at 10.01.34 AM

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Others MRI

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MRI

Sometimes an incidental finding

Better Soft Tissue Definition Better Parotid (Deep) Evaulation Tumor Type Prediction

No Radiation

Expensive Time-Consuming Claustraphobia Contraindications: Pacemakers, etc

Less PPV / NPV

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Sjogren’s Sjogren’s

Carcinoma

X-rays

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Sialography

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Sialography Old Gold Standard Better / Comprehensive - Sialolith size/ location - Duct morphologic structure Sjogren’s - Diagnostic Sometimes therapeutic

Drawbacks: Invasive Irradiation CAN PUSH STONE UP FURTHER Perforation / Infection / Pain Anaphylactic shock

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MR Sialography T2 pulse sequence Non-invasive No contrast MR Sialography No irradiation No pain

Time-consuming (45 mins) Expensive Claustrophobia Dental artifacts Misses very small stones (CT better)

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112 patients with chronic parotitis

CT, MR, U/S, Sialography scans Positive and negative for sialoloths

63% PPV for endoscopic visualization 100% NPV for sialoliths

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CONCLUSIONS

Ultrasound – Adequate - Inexpensive / In clinic CONCLUSIONS CT Scan – Highly sensitive / thorough - Expensive / Radiation

MRI / Sialography / MR Sialography - Interpretable - Possibly More Accurate - Expensive – May Not Change Management

CONCLUSIONS THANK YOU

Location of Sialolith (Stenosis) Dictates Treatment / Expectations

- Distal: Transoral or Sialendoscopy

- Proximal: Sialendoscopy or Transoral or Transcervical / Transfacial Combined Approach

- Parenchymal: Transcervical / Transfacial Combined Approach or Sialedenectomy

26 Obstructive Salivary Symptoms and Medical Therapy for Pediatric Salivary Gland Disease I have no financial disclosures Kristina W. Rosbe, MD, FAAP, FACS Professor of Otolaryngology and Pediatrics Director, Division of Pediatric Otolaryngology Department of Otolaryngology-HNS University of California, San Francisco

Objectives Pediatric Salivary Gland Disease

• Review most common pediatric salivary – Immune gland disorders • Hypogammaglobulinemia, IgG3 def, IgA def, Sjogren’s • Review other potential work-up – Genetic factors – Infectious • Understand role of imaging in pediatric • paramyxovirus, EBV, CMV, parvovirus, strep pneumo, hflu salivary gland disorders – Congenital ductal abnormalities • Review non-surgical management – Salivary gland neoplasms rare – Other • Sarcoid, lymphoma Pediatric Salivary Gland Disease Juvenile Recurrent Parotitis (JRP)

– Sialadenitis – Recurrent parotid inflammation +/- fevers • Mumps (paromyxovirus) – First episode generally between 3 and 6 years of age • JRP (juvenile recurrent parotitis) – Interval between episodes mean 15 days-2 months – Stones – Mutation in serine protease inhibitor (SPINK1) • Parotid – Elevated matrix metalloproteinases (MMP) 2 and 9 • Submandibular

Pediatric Salivary Gland Disorders: Juvenile Recurrent Parotitis (JRP) Other Workup – Histopathology • Autoimmune blood profile •Early – Duct ectasia • Rheumatology Consultation – Lymphocytes – Plasma cells •Late – Periductal inflammation – Lymph follicles – Lymphatic transformation of gland parenchyma Pediatric Salivary Gland Disorders: Pediatric Salivary Gland Disorders: Role of Imaging Imaging Study of Choice

• Rule out neoplasm • Minimize morbidity • Examine all glands • Sensitivity • Identify stones • Specificity

Pediatric Salivary Gland Disorders: Pediatric Salivary Gland Disorders: Imaging Study of Choice JRP

• Ultrasound • Diffuse microcalcifications • MRI • CT Juvenile Recurrent Parotitis (JRP) Juvenile Recurrent Parotitis (JRP)

– Historical treatment – Medical treatment • Wait until “burns-out” • Sialogogues • Gland excision • Hydration • Analgesics • Avoid antibiotics unless fevers and/or severe pain

Juvenile Recurrent Parotitis (JRP) Juvenile Recurrent Parotitis (JRP)

– Medical treatment – Surgical treatment • Schneider et al • Sialendoscopy – Sialendoscopy (15) versus antibiotic tx (21) – Pale, atrophic ductal mucosa – Outcomes= inflammatory episodes, pain intensity pre and post – Intraductal debris intervention • Irrigation – SS differences between pre and post-tx – Saline alone – No ss differences between groups – Saline plus steroids – Other? > MMP inhibitors > Target-specific anti-inflammatory mediators Laryngoscope 2014 ;124:451-455. Conclusions

• Rule out stone or neoplasm in unilateral disease • Conservative treatment of JRP successful the majority of the time • Sialendoscopy appropriate for the minority of patients with severe effects on QOL 11/6/2014

Disclosures The Approach to the Submandibular Duct and Gland Paid consultant & Research Support on sleep apnea devices M. Boyd Gillespie, M.D., M.Sc. (Inspire Medical; Olympus; Surgical Specialties) Director, MUSC Salivary Clinic Paid consultant on head and neck surgical devices (Medtronic) UCSF Salivary Endoscopy Course November 6th , 2014

Thomas Wharton (1614-1673) 17 th century English physician and anatomist Cambridge educated Studied SMG and Pancreas Wharton’s Jelly (Umbilical Cord) Not to be confused with Aldred Scott Warthin Izaak Walton The Compleat Angler (1653)

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“Smiley” Cheek Retractor North American Experience Ambulatory Operative Procedure General Anesthesia Nasal Intubation (SMG) Oral Intubation (Parotid)

Protect Your Scopes What is the best Endoscope to start with ? Wharton’s Duct (fully dilated) 2.0-2.5 mm Stenson’s Duct (fully dilated ) 1.5-2.0 mm cannula: semirigid outer diameter (0.8) -1.1 - (1.6 mm)

We use this size only in about 80% of all patients

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Methylene Blue Schaitkin and Marchal Dilators

Dilation

Wharton’s Duct Not a straight structure Dips Up Then Down

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Kolenda System Kolenda System

Don’t forget Bartholin’s Duct

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Insertion within Wharton´s Duct Ductal stenosis > 50% (0.8 mm) might be difficult – find duct and open it Stones > 5mm Be aware – not in Stensen´s duct (danger of stenosis) Ductal anomalies Perforations (saline in FOM) Think Combined Approach

Courtesy of Johannes Zenk, MD, PhD Zeltser, et al. Operative Techniques in Otolaryngology- Head and Neck Surgery 1996; 7: 370-373. Ductal Scissors

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Vessel Loop

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Courtesy of Johannes Zenk, MD, PhD Courtesy of Johannes Zenk, MD, PhD

Submandibular Gland Excision Gland Excision 8 mm fixed, intraglandular left SM stone below Mylohyoid Line Reserved for cases not amendable to minimally invasive approach: Approximately 5% of cases SMG- Usually reserved for fixed, intraglandular submandibular stones below mylohyoid line; Can be performed immediately due to low morbidity.

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Gland Excision Submandibular Gland Excision Intraglandular stone with stenosis Incise low in neck (at least 3 fingers) Avoid sub-platysmal dissection Deep dissection through soft tissue to posterior digastric Ligation of facial vein (Hayes Martin maneuver) Incise glandular fascia adjacent to digastric Progressively free gland in subfacial plane Ligate facial artery or branches Retract mylohyoid Ligate submandibular ganglion Palpate duct to ensure removal of all stones.

Gland-Preserving Submandibular Surgery Helpful Hints

Use Methylene Blue Beginners should try Kolinda Introducer Set Use Tapered Schaitkin Dilators Gently straighten duct with forceps; tease the dilator up then down Passing the diagnostic scope will allow the saline to enlarge the duct making it easier to find Don’t be afraid to make an incision Extensive work on Wharton’s duct may require sublingual gland excision Vessel loops are helpful to retract the duct.

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Sialoendoscopic Approaches to the Parotid Duct and Gland For Sialadentis / Sialolithiasis Disclosures William Ryan, MD Assistant Professor Head and Neck Oncologic/Endocrine/Salivary Surgery Consultant for Medtronic Department of Otolaryngology-Head and Neck Surgery

Transoral Open Sialodochotomy / Sialodochoplasty Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis

Transoral Sialendoscopy Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis

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

Parotidectomy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy

Intraoperative Ultrasound Guidance Intraoperative Ultrasound Guidance 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 Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis

Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis

Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy

Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy

Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis

Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transoral Open

Transfacial Open Duct Surgery (+/- Sialendoscopy) Sialodochoplasty / Sialodochotomy Impacted Stones / > 4-6mm Stones / Parenchymal stones Failed Sialendoscopy

Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy

Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Parotid Duct Sialendoscope Insertion

Parotid Duct Impacted Stone

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Parotid Duct Sialendoscopy Capabilities and Limitations

Findings Sialoliths Strictures/Stenosis Mucous plugs Inflammation Nothing

Maneuvering Semirigid Obstructions- Mouth / Face / Teeth

Visibility Extent: To secondary sometimes tertiary tributaries Parotid Duct Proximal Stenosis Sometimes cloudy / bloody

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Transoral Open Sialodochotomy / Sialodochoplasty Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Distal Stones / Stenosis

Transoral Sialendoscopy Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Middle Duct - Hilar Stones / Stenosis

Transfacial Open Duct Surgery (+/- Sialendoscopy) Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Failed Sialendoscopy

Parotidectomy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Failed Sialoendoscopy

Intraoperative Ultrasound Guidance Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis

Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis

Transfacial Open Duct Surgery (+/- Sialendoscopy) Therapeutic Sialendoscopy Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy

Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy

Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Therapeutic Sialendoscopy Instrumentation Wire-Introducer-Dilator Set Wire-Introducer-Dilator Set Forceps Wire Baskets Irrigation Techniques Stenting Topic Corticosteroids

(Laser Fragmentation / Balloons / Drills)

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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

Transoral Open Sialodochotomy / Sialodochoplasty Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Distal Stones / Stenosis

Transoral Sialendoscopy Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Middle Duct - Hilar Stones / Stenosis

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Transfacial Intraoperative Ultrasound Guidance

Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis

Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis

Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy

Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy

Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis

Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Transfacial Open Duct Surgery (+/- Sialendoscopy) Sialodochotomy / Sialodochoplasty Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Sialendoscopy

Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy

Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance

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Transoral Open Sialodochotomy / Sialodochoplasty Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Distal Stones / Stenosis

Transoral Sialendoscopy Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Middle Duct - Hilar Stones / Stenosis

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Parotidectomy

CONCLUSIONS

Algorithmic 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 References

1 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. Otolaryngol Clin. 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 Surg 2010;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 Transcatheter Recannalization 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 mucosa No expression of saliva from the right Stensen’s duct

Recommended:

Transoral right parotid duct dilation siaolodochoplasty with sialoendoscopy

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FIRST OPERATION

Offered Patient:

Observation Aborted the procedure : vs Fear injuring the facial nerve Botulinum toxin vs Right transfacial/transoral sialodochoplasty with stent placement vs Parotidectomy

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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 Achieved Our Goals: Planned removal of drain 4 days later Possibility of a salivary fistula - Reconstituted the parotid duct - Did not occur - Relieved Symptoms

Planned removal of stent 2 weeks later - Avoided parotidectomy - Increased safety 3 months after procedure – Asymptomatic/Satisfied

Risk Reduction QUESTIONS

ULTRASOUND Identified the parotid duct location Botox before transfacial approach? Parotidectomy no matter what? SIALENDOSCOPE Assesses nature of the stricture Facial nerve monitoring? Confirms placement of the stent catheter Drain placement? Evaluate the proximal ductules for: - Additional strictures, mucus plugs, sialoliths, and debris Duration of drain? Irrigation to the ductal system Duration of stent? Further treatment of obstruction Extent of incision (modified facelift/ Blair)?

DRAWBACKS Additional training and experience Costs of the equipment/maintenance/storage

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Transfacial Transcatheter Recannalization of 2nd Complex Case 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.

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Disclosures Gland Preserving Approach to Salivary Stones Paid consultant & Research Support on sleep apnea devices M. Boyd Gillespie, M.D., M.Sc. (Inspire Medical; Olympus; Surgical Specialties) Director, MUSC Salivary Clinic Paid consultant on head and neck surgical devices (Medtronic) UCSF Salivary Endoscopy Course November 6 th , 2014

Sialendoscopy circa 2007

Get Stones….Not Stoned

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Introduction: Salivary Stones The Limitations of Surgery Major source of obstructive salivary swelling Est. incidence 1 in 10,000-20,000 per year Risk factor- smoking; dry mouth (medications) Mucous core surrounded by inorganic shell (calcium hydroxylapatite); Mean growth 1mm/year Readily diagnosed by US or CT (contrast not needed) Stones < 2mm may be missed by either technique

High-rate of FN paresis (40-50%) and paralysis (5%) after gland resection for inflammatory disorders. Glands with chronic sialadenitis are often histologically normal Marchal F, et al. Ann Otol Rhinol Laryngol. 2001; 110: 464-469. Glands with chronic sialadenitis can resume normal function if the obstruction is relieved. Su YX, et al. Laryngoscope 2009; 119: 464-452.

Ambulatory Operative Treatment strategy Procedure I. Small Stones/Mobile Stones (1-5mm) General Anesthesia Interventional Endoscopy Nasal Intubation (SMG) Oral Intubation (Parotid) OR time 2 hours II. Medium sized stones (5-10mm) Endoscopy + combined measures

III. Large Stones (>10mm) Combined approaches

IV. Gland removal Multiple stones (>3) or failures

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Small Stones Interventional Sialendoscopy Case 1 for treatment Small ( ≤ 5 mm) Mobile Salivary Stones 0.38-0.6 mm 0.78 mm 0.38-0.78 mm (Parotid or SMG)

23 year old male presents with intermittent left parotid gland swelling. CT scan suggests a small 3mm stone at the hilum of the parotid. 0.7 mm Patient continues to have symptoms after several weeks of hydration, massage, and sialogogues.

3 mm stone at hilum of left parotid 1st line- Endoscopic Basket Retrieval

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Case 2 5 mm stone at hilum of left parotid Small ( ≤ 5 mm) Fixed Salivary Stones (Parotid or SMG)

46 year old woman presents with intermittent left parotid gland swelling. CT scan suggests a 5 mm stone at of the hilum of the left parotid. Patient continues to have symptoms after several weeks of hydration, massage, and sialogogues.

st 1 Line- Intermediate Stones Endoscopic Approach with Stone Shattering Case 3 Intermediate (5-10 mm) or Fixed Salivary Stones 55 year old woman presents with intermittent right SMG swelling. CT scan suggests a 8 mm stone at proximal right Wharton’s duct. Patient has had several cases of acute sialadenitis in last 3 months requiring 2 course of antibiotics.

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1st Line- Endoscopic Shattering versus 8 mm stone in proximal Wharton’s duct Combined Approach (Endoscopic-Open) Technique Step 1- Insert scope to confirm stone is not amendable to endoscopic shattering (hard, fixed, too large); Irrigation of infection and debris; Dilation of duct (assist with visualization during open approach). Step 2- Incision of tissue overlying duct/ gland. Step 3- Stone localization with endoscope. Step 4- Direct opening of duct with stone extraction. Step 5- Passage of scope to irrigate gland and remove remaining fragments. Step 6- Repair duct (Sialodochoplasty-SMG)

Step 1- Determine if Amendable to Endoscopic Shaterring (Forceps; Hand Drill; Laser) Endoscopic Removal Intracorporeal Laser Lithotripsy (Holmium; 200 micron; 2.5-3.5 watts)

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Step 2- Plan Incision Step 4- Opening of duct with direct stone extraction

Case 4 Step 4- Opening of duct with direct stone extraction Intermediate (5-10 mm), or Fixed Parotid Salivary Stones 52 year old man presents with intermittent left parotid gland swelling. US of gland: Lymph node v. stone? 6 mm irregular stone found on diagnostic sialendoscopy

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Intermediate Stone (5-10mm): 1st Line: Endoscopic Shaterring Endoscopic Mobilization and Shattering (Basket, Handrill, Laser, Forceps) (Basket; Forceps; Hand Drill; Laser) Papillotomy

Video Courtesy of Johannes Zenk, MD, PhD 26

Case 5 Papillotomy Intermediate to Large (> 5 mm), Deep (beyond scope), or Fixed Parotid Salivary Stones

36 year old man presents with intermittent right parotid gland swelling. CT scan suggests a 8 mm stone at hilum of gland.

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st 8mm stone at hilum of right parotid 1 Line- Parotid Transfacial Approach (Endoscopic-Open) Technique Step 1- Apply NIMS; Insert scope to confirm stone is not amendable to endoscopic shattering (hard, fixed, too large); Irrigation of infection and debris; Dilation of duct (assist with visualization during open approach). Step 2- Raise preauricular flap Step 3- Stone localization with endoscope/ US (needle). Step 4- Divide parotid fascia and gland Step 5- Direct opening of duct with stone extraction. Step 6- Passage of scope to irrigate gland and remove remaining fragments. Step 7- Repair duct (5.0 PDS) and close fascia; pressure dressing.

NIMS on buccal branch Endoscopic Localization

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Localization of Stone: Endoscopy Localization of Stone: Ultrasound

23 Gauge Needle with Methylene Blue

Opening of duct with direct stone extraction Pass scope again to remove remaining fragments

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Repair Duct Transfacial Stone Removal 5.0 PDS for duct and 4.0 vicryl for fascia. Apply jaw bra pressure dressing for 72 hours.

Case 5 Intermediate to Large (> 5 mm) or Fixed Stones within 2 cm of Parotid Ostium

Mean follow-up of 1 year 10/14 (71%) stone-free and symptom-free 3/14 (21%) stone-free and improved with intermittent symptoms 1/14 (7%) required follow-up parotidectomy Complications in 4/14 (29%)- 2 with periauricular anesthesia, 1 salivary fistula, 1 sialocele. Facial nerve seen in 5/14 (36%) of cases

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5mm stone fixed 1cm beyond left 1st Line- Parotid Transbuccal Approach (Endoscopic-Open) parotid ostium Technique Step 1- Insert scope to confirm stone is not amendable to endoscopic shattering (hard, fixed, too large); Irrigation of infection and debris; Dilation of duct (assist with visualization during open approach). Step 2- Semilunar incision anterior to ostium; divide buccinator fibers. Step 3- Localize stone with endoscopic transillumination. Step 4- Open duct and remove stone. Step 5- Repair duct (5.0 PDS) and close mucosa. Step 6- Consider ductal stent (Hood; Sialotechology)

Transbuccal Incision Repair Duct

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Consider Stent Direct Transfacial Approach Massive Parotid Stone with Abscesses

Gland Excision Massive Parotid Stone with Abscesses Questions or Concerns:

[email protected]

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Andrew H. Murr, MD Professor and Chairman Roger Boles, MD Endowed Chair in Otolaryngology Education Department of Otolaryngology- Head and Neck Surgery

Sialadenitis without Stones: RAI, Autoimmune, and Management UCSF Sialendoscopy/Salivary Duct Surgery Course November 6, 2014 University of California, San Francisco

Sialadenitis without Stones Case

• Bacterial sialadenitis • 43 year old female • Radioactive Iodine (RAI) effects • Bilateral Parotid swelling • Autoimmune Disease • In tact VIIth nerve 1/6 • Other • No discrete mass

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Differential Diagnosis of Gland Enlargement: Bacterial Is there pus in the duct? Sialadenitis Yes No • Erythema Bacterial Sialadenitis Other categories • Tenderness • Pus in duct • Dehydrated • Diabetic • Elderly • Often unilateral • “Surgical Parotitis”

Salivary Duct Stenosis RAI Koch et al., Arch OHNS, Sept., 2012

Types Causes • RadioActive Iodine Sialadenitis • Inflammatory • Allergic • Web associated • Infectious • Fibrous • Granulomatous • RAI associated • Autoimmune

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Radioiodine (I131) Papillary Thyroid Carcinoma

• Key treatment modality for management of benign and malignant thyroid disease • Utility is due to propensity of thyroid follicular cell uptake •I131 beta emissions cause cellular necrosis

Increasing incidence of differentiated thyroid cancer in the United States, 1988-2005 131 Chen A. et al; Cancer, 2009 I Radiation Sialadenitis

• Salivary glands also concentrate iodine through selective sodium/iodine symporter • Symporter most prevalent in ductal epithelial cells •I131 creates a dose-related injury to salivary glands • Serous glands and acini are more susceptible than mucinous acini: Parotid = serous • Parotid gland more affected than submandibular or sublingual salivary glands

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I131 Radiation Sialadenitis Morbidity and Quality of Life

•I131 injury causes: • Dingle et al: OHNS, May, 2013 - acute and chronic inflammation n = 145 well-differentiated thyroid cancer - duct lumen narrowing and stricture patients formation - altered saliva, mucous plugs • Dose dependent increase in sialadenitis • Salivary stagnation ; obstructive symptoms ( >150mCi I131 2.47 times more likely) • Pain, gland swelling; exacerbated by meals • Xerostomia , taste alteration • Reduced oral and overall QOL if received • Clinical incidence and severity variable >150mCi I131

131 Incidence – I Sialadenitis Prevention –Lack of consensus Van Nostrand; Oral Dis, 2011 Van Nostrand, Oral Diseases, 2011 • Variable • Hydration • Sialagogues • Discontinuation of anticholinergic meds • Gland massage • Anti-inflammatory meds • Cholinergic meds

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Pale mucosa with ductal stenosis, Therapy ductal debris and mucous plugs

• Medical – Hydration – Gland massage – Heat – Anti-inflammatory medication – Cholinergic medication • Interventional – Sialendoscopy – Sialadenectomy

Technique Post-irrigation Gland Swelling

•Introduction of diagnostic sialendoscope •Ductal lumen inspected thoroughly •Duct flushed with copious saline irrigation •Confirmation of gland engorgement

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I131 Radiation Sialadenitis - I131 Radiation Sialadenitis - Sialendoscopy Sialendoscopy • Nahlieli, Nazarian; Oral Diseases, 2006 • De Luca et al; Br J OMFS, 52(7), 2014 n=15 (100 mg hydrocortisone) n=30 (“hydrocortisone solution” irrigation) 100% symptom-free 77% improved symptoms • Kim et al; Laryngoscope, 117, 2007, 133-136 f/u 2wks – 84 months n=6 50% symptom-free • Bomeli et al; Laryngoscope, 2009 n=12 (40 mg triamcinolone in 5cc NSS) 75% improved symptoms

Pre-treatment Patient Characteristics Prendes et al. Arch OHNS, 2012 Prendes, B. L. et al. Arch Otolaryngol Head Neck Surg 2012

11 patients - all patients had previously attempted and failed conservative management - 7/11 (64%) of patients had been treated with a least one course of antibiotics for an episode of presumed bacterial sialadenitis - median time after I 131 16 months

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Treatment Results Proposed Mechanisms of Benefit

• Instrument dilation of papilla and duct • Saline hydraulic dilation of ductal system • Flushing of debris from duct • Additional benefit of steroid irrigation and dosing of steroid irrigant is unclear

Summary Autoimmune

• Sialendoscopy for I 131 induced sialadenitis • Sjogrens provides therapeutic benefit for most patients with symptoms recalcitrant to conservative medical therapy • Effective in providing a sustained period of patient-reported improvement in symptoms • Further experience with this treatment modality, its timing, and long-term outcomes data are needed

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Sjogren’s Syndrome Sjogren’s Syndrome

Primary Secondary: • Inflammation of salivary • Associated with connective tissue disease- glands • RA • Lacrimal gland involved • Keratoconjunctivitis • SLE sicca • Scleroderma • Dermatomyositis

Sjogren’s Work-up Sjogren’s Imaging

Primary Secondary • SSA and SSB • ESR • SS rho and SS la • ANA • “Sjogrens Antibodies” • RF • CBC • EBV • Quantitative immunoglobulins

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Primary Sjogren’s: 20 Years Salivary Gland Biopsy Gomes, JOMFS, Jan-Mar, 2012 • Minor salivary gland – ~50% sensitivity • Parotid tail biopsy – ~100% sensitivity

Sjogrens Treatment Other-viral: Mumps

• Symptomatic treatment Systemic treatment • Xerostomia • Corticosteroids/antibiotics – Dental caries • Surveillance for non- • Flouride Hodgkin lymphoma • Dental hygiene – Artificial saliva – Sialogogues – Pilocarpine • Salagen – Role for Sialendoscopy with irrigation

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Other- viral: HIV Other • Pneumoparotitis • Alcoholism • Bulemia • Sarcoid

OHNS Faculty and Residents Conclusion

Sialendoscopy with or without steroid irrigation can be a diagnostic and therapeutic treatment in cases of: • RAI sialadenitis • Sjogren’s • HIV Differential includes: • Viral and other pathologies

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Thank you!

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Pediatric Salivary Duct Surgery/Sialendoscopy I have no financial disclosures Kristina W. Rosbe, MD, FAAP, FACS Professor of Otolaryngology and Pediatrics Director, Division of Pediatric Otolaryngology Department of Otolaryngology-HNS University of California, San Francisco

Objectives Juvenile Recurrent Parotitis (JRP) • Recurrent parotid inflammation • Understand appropriate indications for – Weeks-months between pediatric sialendoscopy episodes • Review technical pearls of pediatric – Unknown cause; can resolve in puberty sialendoscopy • Treatment • Understand expected outcomes of – Conservative pediatric sialendoscopy – Parotidectomy – Duct Sclerosis – Sialendoscopy

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Pediatric Salivary Gland Disorders: Technique Role of Imaging

Technique Technique

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Technique Tips I’ve learned

• Palpate gland to locate papilla • Nasotracheally intubate • 180 degrees • Be kind to the papillae • 0.5mg/kg Decadron IV • Angle is everything • 40mg/ml Kenalog in 30 cc saline • Slide larger dilator along current one • Need more than two hands • Continuous irrigation • Know when to stop

Postop Care Complications

• Duct stricture • Hydration • Duct perforation/false passage • Massage • Infection • +/-Antibiotics • Ranula formation • Analgesics • Wire basket/instrument impaction • Temporary lingual nerve injury

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Review of Current Pediatric Literature Review of Current Pediatric Literature • Israel • Lyon, France – 70 patients with JRP (2 episodes/12 – 38 patients months) – JRP: 21 – Modular salivascope PolyDiagnost with – Sialolithiasis: 14 60ml saline and 100mg hydrocortisone – Normal: 3 – Ave follow-up: 12 months – Ave follow-up: 24 months – 5 repeat endoscopy;9 repeat episode 14/70 (20%) – 4 recurrence (19%) – Ave time to recurrence: 6 mo J Oral Maxillofac Surg 2009;67:162-167.

Arch OHNS 2010;136(1):33-36

Review of Current Pediatric Literature Review of Current Pediatric Literature • Lyon, France • U of Iowa and U of Pitt – Technique – 18 patients/33 procedures • Solution: 50% xylocaine (2%) and 50% Saline (0.9%) with 120mg – JRP: 12 (2 or more episodes) prednisolone – Sialolithiasis: 4 • Post-op: 7 days Augmentin and 3 – Outcomes: 8/12 (67%) asymptomatic days Decadron 1mg/kg/d after 1 proc – Complications – Complications: 3/18 (17%) • Stensen duct perforation • airway obstruction Arch OHNS 2012;138(10):912-915

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Review of Current Pediatric Literature Review of Current Pediatric Literature • U of Iowa and U of Pitt • U of Iowa and U of Pitt – Outcomes – Complications •Ave f/u=11.7 months • Transient swelling • Pain at 1 week •JRP – 8 pts=1 procs • Possible ductal breech with stent placement – 2 pts=2 procs – 1 pt=parotidectomy – 1 pt lost to f/u

Review of Current Pediatric Literature UCSF Experience • U of Iowa and U of Pitt Table I: All Patients -- Age and Episodes at Presentation – Outcomes N Mean SD Age (All Patients) 50 7.48 4.18 •Sialolithiasis Stone Patients 10 12.4 3.6 JRP Patients 40 6.26 3.36 – Aborted in submandib stone – ended up with

gland removal Episodes at Presentation (All – Laser tip embedded in stone – broke off – gland Patients) 50 6.51 5.25 removed Stone Patients 10 3.89 1.76 JRP Patients 40 7.1 5.6

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UCSF Experience Conclusions

Table V:Patients w Sialendoscopy v. Nonintervention N Mean SD p • Diagnostic and therapeutic

Age at Presentation

Non-Intervention 17 5.73 2.81 0.5863 Intervention (Sialendoscopy) 9 7.22 4.47 • Treatment of sialadenitis and Episodes at Presentation

Non-Intervention 17 4.76 2.39 0.0016 sialolithiasis Intervention (Sialendoscopy) 9 10.66 5.83

Episodes Post-Visit

Non-Intervention 17 1.35 3.37 0.0737 • Minimally invasive, gland sparing Intervention (Sialendoscopy) 9 2.78 3.63 Follow-up Visit Months approach Non-Intervention 17 51.12 29.35 0.1001 Intervention (Sialendoscopy) 9 29.56 22.70 Total Cost • Patient selection important Non-Intervention 17 698.12 1739.74 <.0001 Intervention (Sialendoscopy) 9 31338.33 1874.33

Future Directions • Can this procedure be done in the office in children • What type of flushing agent most effective –Saline –Steroids –Antibiotics –Other immune modulators

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Disclosures

• None Starting Practice

Outline Equipment is Fragile

• Sialendoscope • Equipment – 0.75mm fiber • Technical Challenges – All-in-One • Risks/Complications • Staff Training • Caveats • Repair/Replacement costs • Coding • Cases

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Technique – the Papilla Challenges

• Dilation of Wharton’s duct papilla • Identify the papilla – Rate-limiting step; Up to 20% failure – Gland massage • Dilation over guide wire (Chossegros et al. 2006) – Symmetry – Methylene blue • Limited distal sialodochotomy (Chang JL, Eisele DW. 2012) – Magnification – Identify duct in anterior FOM – Inject papilla – Preserve papilla • Papilla dilation – Start with smallest 0000, go back if needed – Conical dilator when at size 0 – Keep papilla in view

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Distal Sialodochtomy Distal Sialodochtomy

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Distal Limited Sialdochotomy

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Limited distal sialodochotomy

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery Chang JL, Eisele DW. Laryngoscope 2013.

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Technique - Sialendoscopy Postop Care and Complications

• Postoperative care • Diagnostic Sialendoscope – Hydration, massage, abtx – Orient camera • Duct stricture (2.5%) – Brightness • Recurrent stones • Introduce sialendoscope: Lab • Duct perforation – Saline irrigation – no air bubbles • Ranula formation (2.5%) – Small movements • Wire basket/instrument – Backing out the camera helps to find lumen impaction – Advance under visualization • Temporary lingual nerve injury (0.4%) • FOM swelling, airway Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery • Need for gland removal Witt RL. Laryngoscope 2012.

Tips - Technical Tips - Imaging

• Keep your eyes on the papilla • Be careful not to avulse the duct • Laser lithotripsy – may require multiple treatments • Dochotomy often required for extraction • Beware of duct perforation and excessive irrigation • Avoid sublingual tissue manipulation

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Retained Stones Sialodochoplasty vs. None: SMG

• Park et al. Clin Exp Otorhinolaryngol. 2012. • Roh et al. Oto-HNS. 2008.

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Future study required Coding

• 42699 Unlisted Salivary Gland Procedure • Stent placement – Use as secondary code for diagnosis, discovery of • Steroid irrigation stone or stricture • Sialendoscopy for sialadenitis without stones – Variable reimbursement • Other forms of lithotripsy – Payment: $0-750 (Medicare $116 – primary; charge $1500) • 42606 Ductal dilation and Injection – Office steroid infusion – Payment: ~$130 • 76942 Ultrasound needle guided placement – Payment ~$80 • 76536 Ultrasound diagnostic head and neck Department of Department of – Payment ~$60 (Medicare $25) Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

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Coding Sialodochoplasty Coding: Sialolithotomy

• 42500 Primary sialodochoplasty: • 42335 Sialolithotomy, SMG intraoral, complicated – Diagnostic procedure – Does not bundle with sialodochoplasty codes – Payment: ~$700 (Medicare $258) – Payment: ~$350 (Medicare $122) • 42505 Complicated sialodochoplasty: • 42340 Sialolithotomy, Parotid intraoral, secondary/Complex complicated – Document complexity: time, why it took longer – Payment: ~$600 (Medicare $160) – Does not bundle with complex intraoral stone codes – Payment: ~$1170 (Medicare $390-434)

Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery

Cases

Department of Otolaryngology – Head and Neck Surgery