Sheelu Srinivas

Consultant ENT Surgeon, Kauvery Hospital, Electronic City, Bangalore

*Correspondence: drsheelusrinivas@gmail.com

Sialendoscopy: Shifting paradigms in treatment of salivary gland disease

Background

Sialendoscopy offers a duct centric approach to management of salivary gland diseases.

Majority of salivary gland diseases like sialadenitis are due to ductal pathologies like stone, stricture, or stenosis. Sialendoscopy gives an opportunity to treat pathologies like recurrent sialadenitis – post radiation or autoimmune aetiologies, without removal of gland.

Patients were offered gland removal in the past that carried morbidity of open surgery. It is not indicated anymore in majority of pathologies of salivary glands. Now we can approach ductal disease and inflammatory diseases of salivary glands through specially designed scopes.

The technique involves the use of a small, very thin, semi-rigid scope. The scope is then placed into one of the major salivary gland ducts, located either under the tongue (submandibular gland) or in the cheek, next to the upper teeth (parotid gland).

Special instruments can then be inserted into the ducts, to either dilate areas of narrowing(stenosis) or to break up and remove stones(sialoliths).

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Fig. 1. Sialendoscope and instruments.

We would like to present following case we have performed at our unit.

Case 1:

A 45-years-aged old male presented with history of recurrent right submandibular swelling during the last 2 years. He was repeatedly treated with antibiotics.

Ultrasound revealed Right submandibular sialadenitis. MRI of gland revealed 7 mm stone at the proximal end of Whartons duct.

Due to the deep location of stone, patient was counselled about Sialendoscopy removal and combined approach in case the stone is not retrievable with scope alone.

However, the stone could be removed with the use of basket, and a stent was kept for 1 week.

Patient, post operative, has free flow of saliva and no pain or swelling post meals.

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Fig. 2. Stone in the proximal Whartons duct.

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Fig. 3. Storz basket in situ

Case 2:

A 50-year-old female presented with recurrent right submandibular Sialadenitis.

Ultrasound and MRI revealed chronic sialadenitis with narrowing of the salivary ductal system. No stones were seen, and the obstruction was due to stricture.

We planned Sialendoscopy and dilatation of the ducts along with antibiotic irrigation. Sialendoscopy was possible with small scope as the ducts were narrow and pale. Hydrostatic dilatation also helps for removal the mucus plugs in the ductal system.

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Fig. 4. Sialendoscopy showing tertiary ducts with pale mucosa.

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Fig. 5. Salivary stent in situ.

Discussion

Average follow up in the above patients was 4 months. COSS/VAS scores are maintained, and long-term outcomes were also measured.

We followed up the patients on clinical examination and on the basis of relief of symptoms.

We had a case of proximal 1.4 cm stone for which floor of mouth was dissected and submandibular duct was approached near the gland. This case has a 1 year follow up with no recurrence of symptoms. Gland has been preserved. Patients did not agree for follow up Sialendoscopy as they were symptom free.

The clinical application of Sialendoscopy is a breakthrough in the management of salivary gland disorders as it has a dual role in diagnosis and management of the salivary gland pathologies. It is safe and effective method and is an organ preservation technique. The procedure requires specialised instruments and sequential learning. From patient perspective it is a boon for patients with sialoliths, strictures and inflammatory pathologies like Sjogren’s and post chemo-radiotherapy sialadenitis.

References

[1] Annick Aubin-Pouliot, et al. The Chronic Obstructive Sialadenitis Symptoms (COSS) Questionnaire to assess sialendoscopy-assisted surgery. Laryngoscope 2016;126(1):93-9.

[2] Elise A. Delagnes, et al. Sialadenitis without sialolithiasis: Prospective outcomes after sialendoscopy-assisted salivary duct surgery. Laryngoscope 2017;127(5):1073-1079.

sheelu

Dr. Sheelu Srinivas

Consultant ENT Surgeon

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