Disclosures. Sialoendoscopic Approaches to the Parotid Duct and Gland For Sialadentis / Sialolithiasis. Consultant for Medtronic

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

2 Preparation / Exposure 2

3 Instrumentation 3

4 Identification of Stensen s Duct Papilla 4

5 Punctal Dilation / Ductal Dilation 5

6 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 Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-6mm Stones / Parenchymal stones Failed Sialendoscopy Transoral Open Sialodochoplasty / Sialodochotomy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance 6

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8 Parotid Duct Sialendoscope Insertion Parotid Duct Impacted Stone 8

9 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 Sometimes cloudy / bloody Parotid Duct Proximal Stenosis 9

10 Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Intraoperative Ultrasound 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) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Therapeutic Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance 10

11 Therapeutic Sialendoscopy Instrumentation Wire-Introducer-Dilator Set Forceps Wire Baskets Irrigation Techniques Stenting Topic Corticosteroids Wire-Introducer-Dilator Set (Laser Fragmentation / Balloons / Drills) 11

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13 Forceps Removal 13

14 Wire Basket Removal 14

15 Wire Baskets 15

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17 Recheck After Sialolith Extraction Topical Corticosteroid Infusion 17

18 Stent Placement 18

19 Sialendoscopic Assisted Balloon Stenosis Dilation Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance 19

20 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

21 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 Transfacial Open Sialodochotomy / Sialodochoplasty Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance 21

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24 Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Open Sialodochotomy / Sialodochoplasty Distal Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transoral Sialendoscopy Middle Duct - Hilar Stones / Stenosis Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Transfacial Open Duct Surgery (+/- Sialendoscopy) Impacted Stones / > 4-7mm Stones / Parenchymal stones Failed Sialendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Parotidectomy Parenchymal Stones / Multiple Stones / Generalized fibrosis / Fistula Failed Sialoendoscopy Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance Intraoperative Ultrasound Guidance Confirmation, Localization, Stone Fragmentation, Stenosis Guidance 24

25 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

26 THANK YOU References 1 Capaccio P, Torretta S, Ottavian F, Sambataro G, Pignataro L. Modernmanagement of obstructive salivary diseases. Acta Otorhinolaryngol Ital 2007;27: Koch M, Zenk J, Iro H. Algorithms for treatment of salivary gland obstructions. Otolaryngol Clin. North Am 2009;42: 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: Nahlieli O, Bar T, Shacham R, Eliav E, Hecht-Nakar L. Management of chronic recurrent parotitis: current therapy. J Oral Maxillofac Surg 2004;62: Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin North Am 2009;42: Nahlieli O, Nakar LH, Nazarian Y, Turner MD. Sialoendoscopy: a new approach to salivary gland obstructive pathology. J Am Dent Assoc Oct;137(10): 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: Katz P, Hartl DM, Guerre A. Clinical ultrasound of the salivary glands. Otolaryngol Clin North Am 2009;42: Gritzmann N, Rettenbacher T, Hollerweger A, Macheiner P, Hubner E. Sonography of the salivary glands. Eur Radiol 2003;13: Epub st Complex Case 26

27 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

28 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 28

29 FIRST OPERATION Offered Patient: Aborted the procedure : Fear injuring the facial nerve Observation vs Botulinum toxin vs Right transfacial/transoral sialodochoplasty with stent placement vs Parotidectomy 29

30 SECOND OPERATION 30

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32 Video of Transfacial Transcatheter Anterograde Sialoendoscopy 32

33 Advanced sialendoscope transorally via catheter Retrograde into proximal ductal system - No further sialoliths or areas of stenosis - Irrigated debris / purulent saliva 33

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35 POSTOPERATIVE COURSE 35

36 Discharged POD#1 - serosanguinous drainage Planned removal of drain 4 days later Possibility 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 QUESTIONS ULTRASOUND Identified the parotid duct location SIALENDOSCOPE Assesses nature of the stricture Confirms placement of the stent catheter Evaluate the proximal ductules for: - Additional strictures, mucus plugs, sialoliths, and debris Irrigation to the ductal system Further treatment of obstruction DRAWBACKS Additional training and experience Costs of the equipment/maintenance/storage 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)? 36

37 2 nd Complex Case Transfacial Transcatheter Recannalization of Distal Parotid Stenosis With Sialendoscopy And Ultrasound Guidance 37

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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. 39