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Sialendoscopy- opening New Vistas

Introduction

Every decade, the speciality of Otolaryngology comes up with fascinating, path breaking innovations that have benefited the patient and helped the surgeon alike. Sialendoscopy is one such discovery that has changed our perspective on a common disorder. Sialadenitis is the most frequent presentation of the disease of the salivary glands. Often ignored and improperly managed, the inflammation of the parotid and the submandibular salivary glands do not get the attention it deserves! So far, the treatment of sialadenitis ranged from radiology to assess the calculi, antibiotics to cure infection and external or intra oral incisions to remove the obstruction or worse still, extirpation of the gland itself. Not only did these treatment options result in insufficient cure, but also placed neighboring structures at risk. Sialendoscopy uses minimal surgical invasive techniques which allow optical examination of the salivary ductal system and extraction of stones under endoscopic view. endoscopy and therapeutic procedures are incorporated into one, compact system, simplifying approach.

fig 1. Pathology of sialadenitis

Clinical consequences of Sialolithiasis

Sialolithiasis results in a mechanical obstruction of the salivary duct, causing recurrent glandular swellings during meals, transitory or complicated by bacterial infections accompanied by fever, purulent discharge at the papilla and painful glandular swelling. In the classical attitude, proximal stones close to the papilla are simply extracted, whereas glandular resection is indicated for deeply located stones. In submandibular glands, sialolithiasis surgery still represents 70% to 90% of all actual indications for surgery. A possible reason for this high rate of submandibular resections might be the common belief that a gland suffering from long standing sialolithiasis is no longer functional. In a clinical- histopathological study on 48 patients afflicted with sialolithiasis treated with glandular resection there was no correlation between the number of infectious episodes and the alteration of the gland. Therefore, numerous infectious episodes or a long duration of symptoms cannot be used to predict the degree of glandular alteration, and thus a conservative attitude towards sialolithiasis appears justified. Parotidectomy is rarely performed for inflammatory conditions in parotid glands, because it remains a tedious procedure and carries involves a higher incidence of post-operative paresis.

Fig 2 Stone at the orifice of the submandibular duct

Sialendoscopy

Sialendoscopy was described for the first time in the early 90's. This technique has been introduced in Geneva in 1995 and since then sialendoscopy has improved by research, improved optics and instrumentation so that it is now become standard and routine for the investigation of all patients that present with symptoms of salivary gland diseases and disorders. The endoscope in current use by Dr F Marchal developed in collaboration with Karl Storz Company is a semi-rigid scope that contains two channels; a rinsing and a working channel, with an external diameter of 1.3 mm. Dr Marchal and his collaborators have described their experiences and their experiences have been published in major Oto-laryngological journals. We acquired our sialendoscope set, the first sale in the state of Kerala from Karl Storz in 2010.

Fig 3 . the sialdendoscope set

Indications and contraindications

All salivary swellings of unclear origin are indications for this procedure. There are no contraindications as this non invasive procedure can be performed under local anesthesia even in elderly patients and children. The procedure is not simple, it has be perfected with a long learning curve and complications like hemorrhage, ductal stenosis and iatrogenic perforations with swelling of the floor of the mouth and subsequent airway compromise are not uncommon with inexperienced hands

Operative technique

Sialendoscopy is usually perfomed in the the OPD with the patient sitting or partially recumbent. I personally favour the recumbent position. Anesthesia is first given into the duct by cannulation using 4% lignocaine solution, and then infiltration of the orifice with bupenorphine and adrenaline. progressive dilatation of the orifice is done and the papilla is incised on one side to dilate the opening to pass the endoscopes. Flushing with dilute lignocaine solution is used during the procedure to minimize pain. Diagnostic and intervention sialendoscope provides excellent vision and is recommended for both diagnostic and interventional procedures as it has a working channel and a rinsing channel.

Fig 4. Endoscopic view of the duct and calculi.

Our experience:

We have performed over 150 procedures ,25 salivary endoscopies and removed 4 calculi. one of the calculi was from the parotid gland of a 9 year old boy under local anesthesia. We have had two failures to cannulate, one sub lingual edema that resolved spontaneously and one case of tachycardia following lignocaine instillation. All complications were not permananent. But these are just preliminary figures and I understand that my learning curve is not over yet- but it is a fascinating journey. Let more people be part of it.

References

  • Marchal F, Dulguerov P, Becker M, Barki G, Disant F, Lehmann W. Specificity of parotid sialendoscopy. Laryngoscope. 2001;111:264-271.
  • Marchal F, Dulguerov P, Becker M, Lehmann W. Interventional Sialendoscopy. Minimally Invasive Surgery of the Head, Neck, and Cranial Base. Lippincott Williams Wilkins.
  • Marchal F, Kurt AM, Dulguerov P, Becker M, Lehmann W. Histopathology of submandibular glands removed for sialolithiasis. Ann Otol Rhinol Laryngol 2001;464-469.
  • Som PM, Sugar GMA, Train GB et al. Manifestations of parotid gland enlargement. Radiographic, pathologic and clinical correlations. Radiology 1981;141:415-419.
  • Nahlieli O, Eliav E, Hasson O, Zagury A, Baruchin AM. Pediatric sialolithiasis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000 Dec;90(6):709-712.
 
 
Otology Master Class
From the Organizing desk

Dear friends,

MESIARC CME is here again. We have always strived to bring you the best in Otology, over the past 10 years, Our live surgery workshops, have focused on cutting edge surgery, detailed teaching, scientific deliberations of the highest order and top class video coverage from one of the most advanced otological theatre suites in the world this time, we are focusing on the enigma of budding otologists - cholesteatoma and Otosclerosis. Two very diverse conditions, but requiring surgical expertise of the highest order to deliver good results. The two-day surgical workshops will feature both myself and a luminary in Otology, Dr. Ashesh Bhumker from Thane, Mumbai and we would be demonstrating in detail the finer aspects of surgical techniques that can be adapted by a keen otologist to sustain good results over time.

We have lined up an array of diverse cases- and the techniques that we intend to demonstrate include minimal access stapedotomy, Laser stapes surgery, stapes surgery with stapes head amputation for tendon preservation, bone obliteration technique for cholesteatoma, a variety of grafting techniques, intact canal wall tympanoplasty for limited cholesteatoma and a series of revision surgeries.

Do send in your registrations early as we have to limit attendance to 70 seats. A smaller crowd is ideal for active discussions which is something so characteristic of MESIARC CME programs and we do not want to deviate from that agenda.


Yours truly,

Manoj MP  
Organizing chairman

Otology in Perspective Live Surgery 2015
From the Organizing desk

Mesiarc brings you a unique live surgical workshop- a demonstration of both endoscopic and microscopic otologic skills.

Otologic surgery is special for its intricate anatomy, extreme precision and attention to detail. Traditionally done with the operating microscope, and now in some centers across the world with the endoscope, the repetoire of the art is widening.

Confusion persists. Advocates of endoscopic work claim that the microscope is passe, and traditional surgeons laugh off the ability of the one handed

The truth lies somewhere in between; there are specific conditions that require either of both of the techniques. Dogmatism, they say, is the end of science.

Mesiarc brings you a unique live surgical workshop- a demonstration of both endoscopic and microscopic otologic skills.

MESIARC has always stood for dissipation of knowledge and the live surgical workshops are not pubilicity events, nor are they grandiose. We have just one agenda- to educate.

This workshop with a difference aims to demonstrate both endoscopic and microsopic skills in otologic surgery, while attempting to define which is more suitable for what. Do come and enjoy!


Yours truly,

Manoj MP  
Organizing chairman

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