Note: last updated before 2015

GENERAL CONSIDERATIONS

1. Indications
   1. Salivary gland swelling of unclear origin
   2. Obstructive sialadenitis
      1. Stones
      2. Strictures
      3. Mucus plugging
      4. Foreign bodies

PREOPERATIVE PREPARATION

1. Evaluation
   1. History and Physical Exam
   2. Imaging of gland (U/S, CT, MRI, sialogram)
2. Consent
   1. Describe procedure, identification and dilation of duct orifice
   2. Risks: perforation of duct, infection or other process leading to swelling with possible impact (airway issue more relevant to floor of mouth swelling with submandibular gland). Potential for scarring of duct, inability to remove stone/deal with stricture; may lead to need for gland removal (parotidectomy or submandibular gland excision) either at the time of sialendoscopy or later. Salivary fistula, lingual nerve neurosensory dysfuction (submandibular sialoendoscopy). Bleeding, infection, reaction to anesthesia.
3. Medications:
   1. Preoperative antibiotics: Unasyn or Clindamycin

NURSING CONSIDERATIONS

1. Room Setup
   1. See Basic Soft Tissue Room Setup
2. Instrumentation and Equipment
   1. Major Instrument Tray 1, Otolaryngology
   2. Major Instrument Tray 2, Otolaryngology
   3. Have available: 0.018 inch introducer (Microwire as used for angiography) which permits placement of a 22 gauge Angiocath over it by way of the Seldinger technique
   4. Sialendoscopy Tray
   5. Sialendoscopy supply basket (including baskets and balloon dilators)
   6. Erlengen telescopes and light cord
   7. 200 Micron laser fiber
   8. Luminis Holmium Laser Settings
   9. Video unit
   10. Howard and Georgetown tables, Mayo stand
   11. Microscope with 250 lens
   12. Bipolar cautery unit available
   13. Monopolar cautery unit available
   14. Nerve stimulator (available for gland excision)
3. Medications (specific to nursing)
   1. Steroid insuflation: mix 2 cc of 250 mg Ampicillin plus 2 cc Solumedrol 40.
   2. Sterile water in 20 cc syringe for infusion through irrigation port of sialendoscope
4. Prep and Drape
   1. Oral prep with throat pack
   2. Drape

ANESTHETIC CONSIDERATIONS

1. Induction
   1. Antibiotics begun with placement of the IV (see Antibiotic protocol).
   2. Orol RAE tube
   3. Black bite block on side opposite to which you will be working.
2. Positioning
   1. Head of bed turned 180 degrees away from anesthesia.

OPERATIVE PROCEDURE

1. Set up
   1. Hang the most recent H&P on the wall in the operating room.
   2. The 0.8 mm diagnostic sialendoscope and the 1.4 mm operative side port sialendoscope should be set up and white balanced. The salivary papilla dilators and 0, 00, 000 lacrimal probes should be arranged. The grasping instruments, baskets and Holmium laser should be set up prior to beginning the case.
2. Probe and dilate the Stenson’s orifice with salivary duct orifice dilator. Let gravity do the work and twirl the dilator in the papilla. Also, retract the cheek/lip laterally to put tension on the duct and straighten it out.
3. Dilate the duct with the 000 lacrimal probe, followed by the 00 probe, followed by the 0 probe, all the while letting gravity do the work rather than pushing the probe.
4. Place the 0.8mm sialendoscope. Pinch the cheek at the oral commissure using a sponge pad for traction and straighten the Stenson’s duct. As you introduce the sialendoscope into the salivary duct orifice use caution and always let gravity do the work. Try to keep the lumen in view at all times and have your assistant irrigate continuously with water via the irrigation port in the sialendoscope using the 20 cc syringe. Keep a close eye on your salivary gland and make sure your irrigation hasn’t caused significant swelling. Inspect the salivary ductal system for strictures, stones or debris. You should be able to cannulate the ducts until you are about 1 cm anterior to the tragus.
5. Sialolith removal techniques
   1. Minigrasping forceps or basket
   2. Mechanical fragmentation
   3. Intracoporeal laser fragmentation
   4. Combination of techniques
6. At the end of the case, or if no strictures or stones are found that would necessitate intervention, remove your sialendoscope and milk the gland in an attempt to express irrigant. Recannulate the duct with the sialendoscope and irrigate with 5 cc of steroid-antibiotic solution. Remove the sialendoscope and hold finger over the papilla. Massage the gland to distribute the steroid-antibiotic solution.

POSTOPERATIVE CARE

1. Discharge to home with Lortab elixr and three doses of anti-biotics.

REFERENCES

Luers J-C, Vent J, and Beutner D: Methylene blue for easy and safe detection of salivary duct papilla in sialendoscopy. Otolaryngology--Head and neck Surgery (2008) 139, 466-7

Marchal F: Sialendoscopy pp 127-149(Chapter 6 in Myers E.N. and Ferris RL eds: Salivary Gland Disorders Springer, Berlin 2007)

Turner MD, Sialoendoscopy and salivary gland sparing surgery.  Oral Maxilloracial Surg Clin N Am 21 (2009) 323-329

Koch M, Iro H, and Zenk J: Sialendoscopy-Based Diagnosis and Classification of Parotid Duct Stenoses. Laryngoscope, 119:1696-1703, (2009)

Koch M, Zenk J, Bozzato A, BummK, Iro H. Sialoscopy in cases of unclear swelling of the major salivary glands. Otolaryngol Head Neck surg (2005);133:863-868

Nahlieli O, Nakr LH, Nazarian Y, Turner M.  Sialoendoscopy: A new approach to salivary gland obstructive pathology.  JADA (2006) 137: 1394-1400.

Papadaki M, McCain JP, Kim K, Katz R, Kaban L, Troulis M.  Interventional sialoendoscopy: early clinical results.  J Oral Maxillofac Surg (2008) 66:954-962

Papadaki M, Kaban L, Kwolek C, Keith D, Troulis M.  Arterial stents for access and protection of the parotid and submandibular ducts during sialoendoscopy.  J Oral Maxillofac Surg (2007) 65:1865-1868

Brown JE.  Minimally invasive techniques for the treatment of benign salivary gland obstruction.  Cardiovasc Intervent Radiol (2002) 25: 345-351.

Fritsch MH: Algorithms for Treatment of Salivary Gland obstructions Witout access to Extracorporeal Lithotripsy. Otolaryngologic Clinics of North America Volume 42, Issue 6, December 2009, pages 1193-1197