Parotid duct dilation and steroid insufflation in clinic

 see detail of catheter insertion in video: Salivary Cannulation and Infusion Techniques and Sialogram Technique

 return to:Salivary Swelling,  Sialograms and Sialography ; Sialogram Technique,  Sjogren's Syndrome, Sialogram Left Parotid Sjogrens Syndrome

1. GENERAL CONSIDERATIONS
   1. Clinic based intraductal infusion of corticosteroids is one option for the treatment of painful salivary swelling associated with Sjögren’s syndrome or other inflammatory processes of the parotid gland.
   2. Also, clinical based dilation of distal strictures of the salivary duct is possible under local anesthesia.
   3. Both represent simple procedures, performed in the microscope room in clinic, lasting less than 10 minutes, and provides excellent relief for the patient.
2. CONSENT FOR PROCEDURE
   1. Identify the indications/technique/alternatives and risks:
      1. Bleeding, infection, reaction to the steroid
      2. Need for further treatment/procedures
      3. Damage to adjacent structures
         1. Possible scarring or perforation of duct
         2. Possible persistence/exacerbation of pain/swelling
3. NURSING CONSIDERATIONS
   1. See pictures above for set up. Requires 0.015 inch guidewire, 22 gauge angiocath, possible dilators, KY jelly, viscous lidocaine (2%)
   2. Set up in microscope room
   3. Kenalog 10 is used for infusions
4. ANESTHESIA CONSIDERATIONS
   1. A 4x4 piece of gauze is soaked in Topical 2% viscous lidocaine and applied to the duct region for several minutes
5. OPERATIVE PROCEDURE
   1. Visualize duct with microscope
   2. Pre-load 22 gauge angiocath onto 0.018 inch guidewire
   3. Pick up 0.015 inch guidewire with DeBakey forceps and dip tip of guidewire in KY jelly (may also use 0.015 inch Cook guide wire with 24 gauge angiocath on it)
   4. Place guidewire into duct and slide angiocatheter over guide wire into duct. As an alternative, it may be necessary to dilate with the hollow Marchal dilators before placing the angiocatheter
   5. Remove guidewire and attach syringe with steroids
   6. Infuse 2.0-3.0 cc of Kenalog 10.
      1. It is useful to leave the catheter in place with syringe attached for 2 minutes to prevent the steroids from flowing out of the duct, and to allow the triamcinolone to work into gland

Note that we currently use the 0.015 guidewire in the picture rather than 0.018 teflon coated guidewire used previously

1. REFERENCES
   1. Izumi M, Eguchi K, Nakamura H, Takagi Y, Kawabe Y, Nakamura T.  Corticosteroid irrigation of parotid gland for treatment of xerostomia in patients with Sjögren’s syndrome.  Ann Rheum Dis 1998 ;57:464-469
   2. Diggelmann HR, Hoffman HT: Intraductal infusion of steroids in patients with Sjogren syndrome to treat painful salivary swelling: Report of 2 cases. Ear Nose Throat J. 2015 Jun;94(6):238-9