UCSF Salivary Endoscopy Course 2014 Basic Set Up and Instruments Rohan R. Walvekar, MD Department of Otolaryngology & Head Neck Surgery Louisiana State University Health Sciences Center New Orleans, LA Disclosure I have the following relationship(s) with commercial interests. Hood Laboratories *Walvekar Salivary Stent Cook Industries Medtronic Xome A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Instruments for Exposure of the Oral Cavity Anesthesia Nasal Intubation is preferred Epistaxis Pre-op nasal endoscopy to document spurs, deviated septum or other abnormality Afrin and lubricated nasal trumpet while patient is in preoperative holding area Disposable Plastic cheek retractor Dental splints Jennings's mouth gag Minnesota and Sweetheart retractors Dilator System Marchal Dilator System Probes No.0000 to No.8 Schaitkin s Fluted Dilators \ No.0 5 Conical Dilator Helps to transition between dilators Useful usually once papilla is dilated up to Marchal No.1 or 2 dilator Bougies (increasing diameter) Compatible with 0.4 mm guide wire COOK Dilator System with Operating Sheath Guide Wire 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 Fifth generation endoscopes Original was flexible 1.3 mm semi rigid scope with 6000 pixels, 0.25mm rinsing channel and 0.65mm working channel Sialendoscopes 0.8 mm Pediatric diagnostic sialendoscopy No interventional channel 1.1 mm all in one Erlangen Sialendoscope Can be autoclaved Interventional Tools that can be used with the scope 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 Sialendoscopes 1.3 mm Marchal all in one scope Autoclavable. Interventional Tools that similar to 1.1 Erlangen scope Does have a protective sheath Optics are excellent Dilate up to No.4 / 5 prior to endoscopy Gentle bend at the tip of the scope 1.6 mm all in one Erlangen Sialendoscope Can be autoclaved Interventional Tools that can be used with the scope 0.4/6 mm guide wire basket 0.4/6 mm stone basket Cup forceps** Does not have a protective sheath Dilate up to No.5 or 6 prior to endoscopy Balloon Dilator (Storz) compatible with all in one scopes 4
Sialendoscopy 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/valve Hand-held micro burr Stone forceps STORZ WIRE BASKETS COOK WIRE BASKETS - - N Gage 5
LSU Sialendoscopy Course Diagnostic Sialendoscopy Rohan R. Walvekar, MD Department of Otolaryngology & Head Neck Surgery Louisiana State University Health Sciences Center New Orleans, LA Diagnostic Sialendoscopy Data 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 Bowen M et al. Diagnostic and Interventional Sialendoscopy: A preliminary experience. 2010 Laryngoscope (accepted for publication) Sialendoscope Cannulation SERIAL DILATION USING THE DILATOR SYSTEM Success of Diagnostic Endoscopy ~ 95-98% Rate Limiting Step : Dilation of Papilla Progressive dilation Marchal Dilator System (No.0000 to No.6) Conical dilator Seldinger technique Guide wire and bougies Papillotomy 25% (7/28) SELDINGER TECHNIQUE USING GUIDE WIRE AND BOUGIES (adopted from Chossegros et al 2 ) Approaches to the papilla Dilation technique Seldinger technique With bougies With sialendoscope Papillotomy 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 Local Anesthesia: -Lidocaine 4.5mg/kg (<300mg) -Lidocaine/epineprine 7mg/kg (<500 mg) MAC (sedation): -Over -Under Local Anesthesia: -Beware of ETT position -NO atropine or like medication Technical Problems Maceration of the papilla: measured traction Avoid creating pseudo-orifices: injection forceps dilators Technical Problems Technical Problems Overinjection of NSS: -60cc syringe with IV extender -control your assistant enthusiasm -maintain one port open -in the submandibular area it can lead to AIRWAY COMPROMISE False Passage (papilla): -do not force the dilator -do not cut the papilla Ductal Perforation: -do not advance blindly -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 9