Post on 10-Jun-2018
11/6/2014
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Sialoendoscopic Approaches to the Parotid Duct and Gland
For Sialadentis / Sialolithiasis
William Ryan, MDAssistant Professor
Head and Neck Oncologic/Endocrine/Salivary SurgeryDepartment of Otolaryngology-Head and Neck Surgery
Disclosures
Consultant for Medtronic
Transoral Open Sialodochotomy / Sialodochoplasty
Transoral Sialendoscopy
Transfacial Open Duct Surgery (+/- Sialendoscopy)
Parotidectomy
Intraoperative Ultrasound Guidance
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 5-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
11/6/2014
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Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-6mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Transoral Open Sialodochoplasty / Sialodochotomy
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Parotid Duct SialendoscopyCapabilities and Limitations
FindingsSialoliths
Strictures/StenosisMucous plugsInflammation
Nothing
ManeuveringSemirigid
Obstructions- Mouth / Face / Teeth
VisibilityExtent: To secondary sometimes tertiary tributaries
Sometimes cloudy / bloodyParotid Duct Proximal Stenosis
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Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Therapeutic Sialendoscopy
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Therapeutic SialendoscopyInstrumentation
Wire-Introducer-Dilator SetForceps
Wire BasketsIrrigation Techniques
StentingTopic Corticosteroids
(Laser Fragmentation / Balloons / Drills)
Wire-Introducer-Dilator Set
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Sialendoscopic Assisted Balloon Stenosis Dilation
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
11/6/2014
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Transfacial Intraoperative Ultrasound Guidance
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
11/6/2014
21
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Transfacial Open Sialodochotomy / Sialodochoplasty
Sialendoscopy
11/6/2014
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Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
Transoral Open Sialodochotomy / SialodochoplastyDistal Stones / Stenosis
Transoral SialendoscopyMiddle Duct - Hilar Stones / Stenosis
Transfacial Open Duct Surgery (+/- Sialendoscopy)Impacted Stones / > 4-7mm Stones / Parenchymal stones
Failed Sialendoscopy
ParotidectomyParenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula
Failed Sialoendoscopy
Intraoperative Ultrasound Guidance
Confirmation, Localization, Stone Fragmentation, Stenosis Guidance
11/6/2014
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Parotidectomy
CONCLUSIONSAlgorithmic 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 References1 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. OtolaryngolClin. 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 Surg2010;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
11/6/2014
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Transfacial TranscatheterRecannalization 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 mucosaNo expression of saliva from the right Stensen’s duct
Recommended:
Transoral right parotid duct dilation
siaolodochoplastywith sialoendoscopy
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FIRST OPERATION
Aborted the procedure :
Fear injuring the facial nerve
Offered Patient:
Observationvs
Botulinum toxinvs
Right transfacial/transoral sialodochoplastywith stent placement
vsParotidectomy
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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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Discharged POD#1 - serosanguinous drainage
Planned removal of drain 4 days laterPossibility of a salivary fistula
- Did not occur
Planned removal of stent 2 weeks later
3 months after procedure – Asymptomatic/Satisfied
Achieved Our Goals:
- Reconstituted the parotid duct
- Relieved Symptoms
- Avoided parotidectomy
- Increased safety
Risk Reduction
ULTRASOUNDIdentified the parotid duct location
SIALENDOSCOPEAssesses nature of the stricture
Confirms placement of the stent catheterEvaluate the proximal ductules for:
- Additional strictures, mucus plugs, sialoliths, and debris Irrigation to the ductal system
Further treatment of obstruction
DRAWBACKSAdditional training and experience
Costs of the equipment/maintenance/storage
QUESTIONS
Botox before transfacial approach?Parotidectomy no matter what?
Facial nerve monitoring?Drain placement?Duration of drain?Duration of stent?
Extent of incision (modified facelift/ Blair)?
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2nd Complex Case
Transfacial TranscatheterRecannalization of
Distal Parotid Stenosis With Sialendoscopy
And Ultrasound Guidance
11/6/2014
39
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.