Sialendoscopy-Approaches to Parotid Duct and Gland-Lecture-10

11/6/2014

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.