Sialoendoscopy balaji

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  • serous
  • Deep part- passes in interval between the mylohyoid ( laterally ) hyoglossus (medially)
  • INTER RELATIONSHIP BETWEEN DUCTAL SYSTEMS
  • STONES WERE VERIFIED TO BE IMPACTED AFTER HILIUM OF THE WHARTONS DUCT UNDER ENDOSCOPIC VIEWAMNEABLE TO BASKET RETRIVAL WERE EXCLUDED
  • Thereafter the entire duct was re-explored for remnant stones or mucous plugs Hilum then sutured after 4Fr angio catheter had been inserted as a stent, Stent left in situ for 1-2 weeks after surgery.
  • Sialoendoscopy balaji

    1. 1. SIALOENDOSCOPY – ASSISTED SIALOLITHECTOMY FOR SUBMANDIBULAR HILAR CALCULI BY A.BALAJI ,. DEPT OF OMFS
    2. 2. INTRODUCTION CLASSIFICATION OF SALIVARY GLANDS FUNCTIONS ANATOMY DISEASES
    3. 3. CLASSIFICATION MAJOR They are paired glands OF SALIVARYGLANDS MINOR parotid sub mandibular sublingual They are numerous widely distributed in the oral cavity. 600 to 1000 in no. mostly located at junction of soft and hard palate
    4. 4. Parotid Gland Secretions Are Serous In nature Sub mandibular gland Mixed But Mostly Serous Sublingual gland Mixed Both Mucous And Serous, Mostly Mucous.
    5. 5. SALIVA  1500 ML per day  PH VALUE:  RESTING GLAND -7  ACTIVE SECRETIONS IS ABOUT 8 FUNCTIONS  Lubrication for speech  Helps in swallowing and mastication  Digestive properties  Antibacterial Immunological properties
    6. 6. COMPOSITIONS  ORGANIC proteins urea uric acid lysozymes IgA Amylase  INORGANIC Sodium potassium chloride bicarbonate calcium phosphate
    7. 7. EMBROYOLOGY  All salivary glands develop from embryonic oral cavity as buds of epithelium that extends into underlying mesenchymal tissues  These epithelial ingrowths or anlages ,are apparent at 8 weeks gestation and then branch to form a primitive ductal system and eventually become canalized to provide structural salivary gland unit for drainage of salivary secretions.  This unit consists of a myoepithelial cell , intercalated duct , striated duct ,excretory duct.
    8. 8.  Around 7 th or 8 th month in utero secretary cells called acini begin to develop around ductal system.  Acinar cells are classified as serous cells –produce thin watery serous secretions. mucous cells-produce thicker mucous secretions.
    9. 9. Anatomy of submandibular salivary gland  Divided into Superficial and deep part  Location-digastric triangle(formed by anterior and posterior belly of digastric muscles and inferior border of the mandible)  Surfacesmedial surface rests anteriorly-mylohyoid muscle middle part-hyoglossus posteriorly-wall of pharynx
    10. 10. ANATOMY OF SUBMANDIBULAR SALIVARY GLAND
    11. 11. surfaces  Inferior surface-is superficial, seen in digastric triangle, directed downwards and laterally.  Lateral surface-is hidden from view of mandible, divided into anterior and posterior part. Anterior part –lies in contact with medial surface of body of mandible below the attachment of mylohyoid muscle. Posterior part-separated from body of mandible by medial pterygoid muscle.
    12. 12. PICTURE SHOWING SUBMANDIBULAR SALIVARY GLAND ,WHARTONS DUCT AND ITS CORELATION WITH ADJOINING STRUCTURES Stylohyoid ligament Inferior alveolar nerve, vessels Nerve to mylohyoid Submandibular salivary gland Sublingual salivary gland Medial pterygoid Mylohyoid genioglossus Lingual nerve Anterior belly of digastric
    13. 13. Deep part - passes in interval between the mylohyoid ( laterally ) hyoglossus (medially) NERVE SUPPLY -Submandibular gland is innervated by the facial nerve through submandibular ganglion via chorda tymphani nerve. BLOOD SUPPLY -Branches of facial and lingual artery LYMPHATICS – drains into submandibular lymph nodes ,through them into deep cervical lymphnodes ,particularly jugulo-omohyoid node.
    14. 14. INNERVATION OF FACIAL NERVE TO SMS GLAND
    15. 15. INTER RELATIONSHIP BETWEEN DUCTAL SYSTEM AND LINGUAL NERVE
    16. 16. LATERAL VIEW
    17. 17. Additional relationships  Gland is covered by 2 layers of fascia formed by splitting of investing layer of deep cervical fascia.  Superficial layer covers the inferior surface of the gland and attaches to the lower border of the mandible.  Deeper layer covers the medial surface and is attached to the mylohyoid line of the mandible.
    18. 18. WHARTONS DUCT•2-4mm in diameter & about 5cm in length. •It opens into the floor of the mouth thru a punctum. •The punctum is a constricted portion of the duct to limit retrograde flow of bacteria-laden oral fluids. •Duct arises in the deep lobe and runs antero medially ,Lingual nerve crosses the duct inferiorly, after immediately arising from deep lobe.
    19. 19. Some terminologies  Sialolith-salivary calculi.  Sialolithiasis-process of formation of salivary calculi.  Sialography or sialogram-repeated radiographic examination of salivary glands after injection of contrast medium into the salivary duct.  Sialochemistry-examination of electrolyte composition of saliva  Sialoendoscopy-specialized procedure that uses a small video camera with a light at the end of the flexible canula, which is introduced into the ductal orifice.  Sialometry-is a measure of salivary flow
    20. 20.  SCINTIGRAPHY-the production of, 2 – dimensional images of distribution of radio activity in the tissues after internal administration of a radiopharmaceutical imaging agent ,the images are obtained by a scintillation camera,(gamma camera).  LITHOTRIPSY-procedure involving the usage of high energy shock waves to fragment and disintegrate or destruct the calculi.
    21. 21. sialolith  They are calcified structure develop with in ductal system of major and minor salivary glands.  Major cause of both-chronic recurring sialadenitis ,acute suppurative sialadenitis.  Stones composed of inorganic calcium and sodium phosphate salts.  They are believed to arise from deposition of these salts around nides of debris with in duct lumen.
    22. 22. Sialoliths continue ……  These debris may include inspissated mucus , bacteria , ductal epithelial cells or foreign bodies (coagulated).  Prevalent in men than women ratio. 2:1.  Peak incidence age = 30-40 years.  Submandibular gland involvement is 80 %.  PH value of these secretion is 6.8-7 %.  Increased concentration of calcium and phosphate ratio.  Mucous Secretions are more viscous.
    23. 23. Pathophysiology  Dehydration  Concentration of saliva  Fasting or Anorexia  Stasis of saliva  Drugs- Anti-histamines, Anti-cholinergics.  Decrease production of saliva  Stone can cause stasis of saliva and subsequent bacterial ascent into the gland.  Infection most commonly from S. aureus or Strep Viridans.
    24. 24. ETIOLOGY OF SIALOLITHS  EXACT CAUSE OF SIALOLITH FORMATION IS NOT KNOWN,  But 3 prerequisites stand out as primary etiology  1) NEUROHUMORAL CONDITION> leading to salivary stagnation .  2) A nidus or matrix for stone formation.  3)some metabolic mechanism may favors precipitation of salivary salts into the matrix in the presence of coexisting inflammation.  4) long tortuous duct and situated lower level than its orifice ,so increased salivary stagnation, so increased calculus formation.
    25. 25. Signs and symptoms  Pain and swelling are exacerbated during     mealtimes Check for flow of whartons duct Check for tenderness of submandibular salivarygland Palpate for stone in floor of the mouth Check mandibular occlusal radiograph
    26. 26. TREATMENT  Conservative       Warm compresses Sour candy Pain relief- analgesics Oral fluids Discontinue anti-histamines Oral antibiotics- Cefalexin 500mg PO QID X 7d.  Surgical     Wire basket retrieval under fluoroscopy. Duct cannulation Gland removal for recurrent cases SIALOLITHECTOMY  Lithotripsy (extra corporeal shockwave lithotripsy)
    27. 27. Sialoendoscope ,lithotriper
    28. 28. PURPOSE  TO ACESS THE CLINICAL EFFECTS OF ENDOSCOPY ASSISTED SIALOLITHECTOMY FOR SUBMANDIBULAR HILAR CALCULI
    29. 29. MATERIALS AND METHODS  STUDY WAS TAKEN IN 70 PATIENTS WITH SYMPTOMATIC STONES IN HILUM OF SUBMANDIBULAR SALIVARY GLANDS.  FROM : DECEMBER 2005 THROUGH MARCH 2011.  OPERATIVE DATA WERE ANALYZED RETROSPECTIVELY AND FOLLOWED PERIODICALLY POSTOPERATIVELY.  GLAND FUNCTION WAS INVESTIGATED BY POST OPERATIVE SYMPTOMS,CLINICAL EXAMINATIONS,SIALOGRAPHY,AND SCINTIGRAPHY.
    30. 30. DIAGNOSIS  BY, ONE OR A COMBINATION OF RADIOGRAPHIC INDICATORS  CROSS SECTIONAL MANDIBULAR OCCLUSAL FILMS  LATERAL PROJECTIONS OF GLAND  CONE BEAM COMPUTED TOMOGRAPHY
    31. 31. CASE SELECTION INCLUSION CRITERION WAS THAT ,THE STONES WERE SITUATED AT OR PROXIMES TO THIRD MANDIBULAR MOLAR REGIONS STONES WERE VERIFIED TO BE IMPACTED AFTER HILIUM OF THE WHARTONS DUCT UNDER ENDOSCOPIC VIEW AMNEABLE TO BASKET RETRIVAL WERE EXCLUDED
    32. 32. SIALOENDOSCOPY  LADUSCOPE T FLEX PD-HS-0250      ENDOSCOPE HIGLY FLEXIBLE ,SEMIRIGID ENDOSCOPE WITH NITINOL SHEATH 80 MM LONG 1.1mm OUTER DIAMETER 0.4 mm WORKING LENGTH CHANNEL SEPARATE CHANNEL FOR IRRIGATION
    33. 33. PROCEDURE  Main duct of the gland is explored and induction of endoscope done by persistent irrigation.  Small and mobile stones at distal or middle part of the duct were removed by basket entrapment.  Impacted hilar stones were then removed by as endoscopy assisted sialolithectomy technique.  After the stone was verified ,a 2-3 cm incision was made in the floor mucosa according to the light transmitted through endoscope.
    34. 34. As the assistant raised the floor of the mouth with digital pressure in submandibular triangle. The duct was isolated from the surrounding tissues with particular care to avoid damage to lingual nerve. Then the hilum was incised at the precise location of the stone and the stone was removed. Thereafter the entire duct was re-explored for remnant stones or mucous plugs Hilum then sutured after 4Fr angio catheter had been inserted as a stent, Stent left in situ for 1-2 weeks after surgery.
    35. 35. TREATMENT  Amoxicillin or cefaclor was administrated for 7 days.  Hydration was achieved by the patient drinking more than 2 liters of water a day , and patient advised to avoid sialogogues and spicy foods.  After stent and sutures were removed ,frequent self massaging and sialogogues were recommended.
    36. 36. FOLLOW UP  post operative Clinical assessment was done, to diagnose, any recurrence and  changes in size of the gland .  Consistency of the affected gland.  Appearance of the ostium ,and the amount and the nature(clear or milky) of salivary flow on massage.
    37. 37. Siolography  Sialography of submandibular salivarygland was performed with water soluble contrast agent , diatrizoate meglumine, using a closed intravenous catheter (22 gauge),.  After catheter was introduced ,1.5 to 2ml of contrast solution was injected carefully.  Lateral views and 5-min emptying film were taken , and appearance of main ducts, branch ducts and parenchyma were analyzed.
    38. 38. A-Lateral view x-ray showing large stone B-Stone was removed through an incision at the genu of whartons duct C-Extracted stone fragments D-Six month follow up sialogram shows proximal duct dilation (filling film) E-No persistent contrast opacified on functional film
    39. 39. Different case reports
    40. 40. CONCLUSION  SIALOENDOSCOPY ASSISTED INTRA ORAL REMOVAL IS SAFE AND EFFECTIVE GLANDPRESERVATION TECHNIQUE FOR PATIENTS WITH LARGE CALCULI AT HILUM OF THE WHARTONS DUCT .
    41. 41. A short movie…by use of endoscopy assisted lithotripsy with a lithotripter
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