Malabar Dental College & Research Centre

1. Sialendoscopy
Seminar presentation no:4
PRESENTED BY
Dr. CHITHRA P
Senior Lecturer
Dept of Oral Medicine & Radiology
Malabar Dental College & Research Centre, Manoor
Chekannoor Road, Mudur PO, 679578,

2. Contents
O Introduction
O Definition
O Indications
O Contraindications
O Principle
O Equipments
O Technique
O Sialoendoscopic view in normal anatomy
O Sialendoscopy in pathologic conditions
O Advantages
O Limitations
O Conclusion
O References

3. Introduction

4. O Salivary glands are exocrine glands whose secretions flow
into the oral cavity through ducts.
O Sialadenitis secondary to obstructive pathologies including
sialoliths, strictures and ductal polyps, remains the most
common disorder of the salivary gland.
O Conservative treatment is the first line of therapy which
may fail in 40% of patients leading to recommendation of
surgical excision which in turn has several risks and
complications.

5. O A minimally invasive technique for diagnostic evaluation
as well as therapeutic intervention for obstructive
disorders of the salivary glands.
O Diagnosis and treatment during the same procedure.
SIALENDOSCOPY

6. Definition
O Sialo – saliva or salivary glands(derived from Greek word
“sialon” means saliva).
O Endoscopy – “visualisation of the interior of organs and
cavities of the body with an endoscope”.
(Mosby’s Medical Dictionary,9th edition,2009)
O Sialendoscopy- a method of visualisation of Wharton’s or
Stenson’s duct to visualize sialolithiasis, stenosis, polyps or
sialodochitis.
(Stedman’s Medical Dictionary, 2006)

7. O A minimally invasive procedure whereby semirigid
endoscopes are inserted into the natural orifices of the
submandibular and parotid glands after serial dilation to
obtain an endoscopic view of the ductal system within the
salivary glands. (Encyclopedia of Otolaryngology,2006)
O Sialendoscopy uses semi-rigid or flexible miniaturized
endoscopes with optical fibers providing high-quality
images to explore the parotid and submandibular salivary
ducts.
O Synonym : Salivary Endoscopy
Definition

8. O Diagnostic evaluation of recurrent or chronic
sialadenitis:
O Ductal stenosis or strictures
O Sialolithiasis
O Juvenile recurrent parotitis
Indications

9. Contraindications
O Sialendoscopy should not be attempted during the acute
inflammation of salivary glands. It may increase the pain
and swelling in an already inflamed gland. Inflammation
results in poor visibility of the ductal system which may
result in complication like perforation of the duct leading
to stenosis of the duct, thus increasing the overall failure
and complication rate.
O Relative contraindications: Trismus, microstomia, TMJ
pathology, presence of mandibular tori.
Wilson M et al.Sialendoscopy: Endoscopic Approach to Benign Salivary Gland Diseases.
Advances in Endoscopic Surgery. Nov 2011

10. Principle
O Inflammation of salivary glands due to obstructive
pathology in duct like calculus and stricture, the cause
lies in the duct and symptoms are due to stasis of saliva
and secondary infection.
O Sialendoscopy addresses the ductal pathology leading to
resolution of gland pathology. So defining feature of this
intervention is that it is duct centric rather than gland
centric.
Singh PP,Vikas G. Sialendoscopy: Introduction, Indications and Technique. Indian J Otolaryngol
Head Neck Surg.2014 66(1):74–78;

11. Equipments
O Sialendoscope( A & B)
O Salivary Probes(F)
O Conic Dilator(G)
O Hollow Rigid Bougie
(E)
O Forceps( C&D)
O Microdrill (I)
O Stone extractor(H)
O Balloon catheter(J)
Marchal F. Sialendoscopy: The Endoscopic Approach to Salivary Gland Ductal Pathologies.
Tuttlingen, Germany: Endo Publishing; 2003.

12. Pre procedural planning.
O A complete head and neck examination and an
otolaryngology evaluation are recommended before the
procedure.
O Features relevant to successful sialendoscopy should be
assessed and documented.
O Accessibility to the ductal opening through oral cavity must
be evaluated by paying close attention to the size of the oral
commissure and the tongue, the ability to open mouth, any
pathology of TMJ and the presence of mandibular tori.
O In addition to this assessment of the nasal septum and upper
airway helps the anesthesia team to prepare for the for
nasotracheal intubation which is the preferred method for
achieving maximal exposure.
O Preoperative imaging included ultrasound or computed
tomography and, on rare occasions, sialography.

13. Operating Room Set-up
O Sialendoscopy can be done as an outpatient procedure in
the clinic with the patient sitting in a chair or partially
recumbent but lying position is preferred which allows for
better surgeon mobility and patient comfort.

14. Anesthetic Technique
O Sialendoscopy generally requires local anesthesia of the
papilla and the ductal system. A topical anesthetic paste or
spray (10 or 20%) is applied to either Stensen’s or
Wharton’s papilla at the beginning of the procedure. After
introduction of the sialendoscope, anesthesia of the ductal
system is induced with an irrigation solution of Lidocaine
or Carbostesin 0.5 %.
O Diagnostic sialendoscopy can be performed under local
anesthesia.
O Interventional sialendoscopy, can be done under sedation
or even general anaesthesia. This largely depends on the
level of difficulty of the individual case.

15. Step by step technique
O Local anesthesia of the papilla with an anesthetic paste or
spray (10 or 20% lidocaine).
O Superficial infiltration of the papilla with a local
anesthetic solution and adrenalin.
O Introduction of salivary probes of increasing diameter.
O Introduction of the dilator.
O Placement of dental tampons in the posterior aspect of the
vestibule and gingivo-buccal sulcus. These will later be
replaced with new dry ones during sialendoscopy.
O Introduction of the sialendoscope.
O Introduction of a guidewire in the working channel (this
step is optional, depending on the experience of the
surgeon. It facilitates reintroduction of the scope in the
duct).

16. Post operative care
O Postoperative observation in monitored setting with
same day discharge.
O Antibiotic coverage for one week post operative.
O Pain control as needed
O This procedure is not typically painful. The patient may
experience uncomfortable gland swelling secondary to
volume of irrigation, which typically resolves with
massage of the respective gland over 48 to 72 hrs.
O Maintain hydration status and salivary flow with
sialagogues
O No significant limitation of activities is required

17. Complications
O Self resolving pain and swelling of the gland due to ductal
irrigation and fluid retention is the only frequent
complaint in the post operative period.
O Complications including perforation of the duct wall (6-
8%), lingual nerve paresthesia(15%), facial nerve
paresthesia (10%) in the combined approach ,stenosis of
the papilla and ductal stenosis(2-3%) have been reported
(4-7%) and need to be kept in mind.
Strychowsky JE et al.Sialendoscopy for the Management of Obstructive Salivary Gland Disease A
Systematic Review and Meta-analysis. Arch Otolaryngol Head Neck Surg.2012;138 (6):542-547

18. Diagnostic
Sialendoscopy

19. Normal anatomy of the salivary duct system
First centimeters of the salivary
duct Main duct

20. Primary branches. Secondary branches

21. Tertiary branches Terminal branches

22. Pathologic findings

23. Mucous plugs
Thick mucous plug floating in the main duct. Blurred image due to
mucosal plug.

24. Mucous plugs
A mucous plug is attached to the stone which
impairs intraductal vision

25. Sialolithiasis
Floating stones. Multiple stones

26. Stone trapped behind a bifurcation.
Sialolithiasis

27. Ductal stenosis
Endoscopic view of a
concentric stenosis in the
second branch of Stensen’s
duct.
Close-up view of the same
site

28. Ductal stenosis
Stenosis of a third generation Wharton’s duct.

29. Stone Removal by Use of a Wire Basket,
preceded by Laser Fragmentation

30. Advantages
O Sialendoscopy can be used both for diagnostic as well as
therapeutic purposes
O Single sitting procedure.
O For diagnostic purposes, sialendoscopy is superior to other
imaging modallities for detecting obstructive pathologies.
The radiolucent stones, stenosis, polyps, mucosal plugs
and foreign bodies often missed by imaging methods, can
be visualized by this technique.
O When used for therapeutic purposes, sialendoscopy is a
minimally invasive technique enabling endoscopic stone
removal, stricture dilatation and salivary gland lavage.
O Gland function remains satisfactory after sialendoscopy for
obstructive diseases.

31. Limitations
The main technical limitations of interventional
sialendoscopy at the present time are:
O The writhing course of the canal puts certain limitations on
semi-rigid endoscopy, especially in cases of sharply bent
curvatures.
O manoeuvering within the small salivary ducts has to be
absolutely atraumatic because of possible ductal
perforation. Significant trauma to the ductal wall could
result in later stenosis.
O salivary stones in an extreme posterior location.
O a fibrosed canal wall with a reduced diameter, which
impedes advancement of the endoscope.

32. Conclusion
O Diagnostic and interventional sialendoscopy, and sialendo-
scopy-assisted surgical techniques have been a major
advance, not only by providing an accurate means of
diagnosing and locating obstruction, but also permitting
minimally invasive surgical management that can
successfully address obstructive salivary gland disorders
and preclude sialoadenectomy in most cases.
O Future sialendoscopist’s should familiarize themselves
with the anatomy and physiology of the salivary glands
and floor of the mouth. They should be competent in
taking care of any potential complication and should be
comfortable with major salivary gland resections if
required. Sialendoscopy training via hands-on courses and
case observations should be pursued prior to initiating a
sialendoscopy practice.

33. References
O Salivary gland disorders—Myer’s, Robert( Springer)
O Marchal F. Sialendoscopy: The Endoscopic Approach to
Salivary Gland Ductal Pathologies. Tuttlingen, Germany:
Endo Publishing; 2003.
O Meyer A, Delasa B, Hibona R et al. Sialendoscopy: A
new diagnostic and therapeutic tool. European Annals of
Otorhinolaryngology, Head and Neck diseases (2013)
130, 61—65.
O Singh PP,Vikas G. Sialendoscopy: Introduction,
Indications and Technique. Indian J Otolaryngol Head
Neck Surg.2014 66(1):74–78.
O Wilson M et al.Sialendoscopy: Endoscopic Approach to
Benign Salivary Gland Diseases. Advances in Endoscopic
Surgery. Nov 2011.

34. O Bruch JM, Setlury J.Pediatric Sialendoscopy. Adv
Otorhinolaryngol. 2012; 73:149–152.
O Capaccio P, Torretta S. Modern management of obstructive
salivary diseases. ACTA otorhinolaryngologica italica
2007;27:161-172.
O Nahlieli O, Nakar LH, Nazarian Y, et al. Sialoendoscopy: a
new approach to salivary gland obstructive pathology. J Am
Dent Assoc 2006;137(10):1394—400.
O http://emedicine.medscape.com/article/1520153-overview
O www.sialendoscopy.com.

35. Thank
you……………….