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 1 11/6/2014 Preparation / Exposure 2 11/6/2014 Instrumentation 3 11/6/2014 Identification of Stensen’s Duct Papilla 4 11/6/2014 Punctal Dilation / Ductal Dilation 5 11/6/2014 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 6 11/6/2014 7 11/6/2014 Parotid Duct Sialendoscope Insertion Parotid Duct Impacted Stone 8 11/6/2014 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 9 11/6/2014 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 10 11/6/2014 Therapeutic Sialendoscopy Instrumentation Wire-Introducer-Dilator Set Wire-Introducer-Dilator Set Forceps Wire Baskets Irrigation Techniques Stenting Topic Corticosteroids (Laser Fragmentation / Balloons / Drills) 11 11/6/2014 12 11/6/2014 Forceps Removal 13 11/6/2014 Wire Basket Removal 14 11/6/2014 Wire Baskets 15 11/6/2014 16 11/6/2014 Recheck After Sialolith Extraction Topical Corticosteroid Infusion 17 11/6/2014 Stent Placement 18 11/6/2014 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 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 19 11/6/2014 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 20 11/6/2014 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 21 11/6/2014 22 11/6/2014 23 11/6/2014 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 24 11/6/2014 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 25 11/6/2014 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 26 11/6/2014 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 27 11/6/2014 Physical Exam: No facial masses Facial nerve 100% 5mm scar in the right buccal mucosa