 |
Fig 1 :
Semi-rigid Outer diameter 1.3 mm, with working
and rinsing channel. From the article ? all in one
?, Marchal Sialendoscope. |
Diagnostic Sialendoscopy
In patients considered with sialolithiasis, involving the submandibular
or parotid glands, the diagnosis of the condition may include
the use of ultrasound, sialography or an MR-sialogram.
Ultrasound when used is a non-invasive and cheap
diagnostic technique, which has limits on its diagnostic
abilities, stones that are greater in size 3 mm.
The technique is very user dependant and thus has
additional limitations. Sialography, which has been
considered the “gold-standard” for diagnosis of Sialolithiasis,
is being used less frequently, because its interpretation and
correlation with pathology does not have a good correlation to
patient’s symptoms. The MR-sialography allows for reconstruction
of the salivary ductal system without the use of the need for
Contrast or dye injection. This technique has also got disadvantages
and may not be performed on all suitable patients.
Sialendoscopy was described for the first
time in the early 90’s. This technique has been introduced in Geneva in 1995
and since then sialendoscopy has improved by research, improved
optics and instrumentation so that it is now become standard
and routine for the investigation of all patients that present
with symptoms of salivary gland diseases and disorders. The endoscope
in current use by Dr F Marchal developed in collaboration with
Karl Storz Company is a semi-rigid scope that contains two channels;
a rinsing and a working channel, with an external diameter of
1.3 mm. Dr Marchal and his collaborators have described their
experiences and their experiences have been published in major
Oto-laryngological journals (1 – 3).
The Technique
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2 |
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3 |
Figure 2 :
Normal ductal system, illustrating first and second
generation branches.
Figure 3 :
A localised stenosis in a secondary duct of Stensen's
ramification. |
4 |
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5 |
Figure 4 / 5 :
The shape and size of the stones found are variable
- some round and some rregular. |
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 |
| Balloon catheter and basket |
6 |
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7 |
Figure 6-7:
Stone retrieval with metallic basket using endoscopic
control. |
8 |
|
Figure 8 :
Laser fragmentation of the stones:
allowing for some fragments to be removed with baskets,
and others to be washed-out by rinsing. |
|
Sialendoscopy is performed
routinely and ambulatory, with patients seated or lying down
supine. After the application of local anaesthetic to the duct
papillae, it is dilated so that it can accommodate the endoscope
without causing trauma to the duct or cause pain to the patient.
The endoscopy is performed by the use of a rinsing anaesthetic
solution. This technique allows for anaesthesia of the ductal
system, the ability of fluid to clear of the stones or concretments
identified within the ducts, and also for rinsing the scope.
The ductal system can be explored from the primary ducts to
the secondary and even tertiary ducts, and allows for the identification
of stones and ductal stenosis. Other pathologies may be identified
using this technique and include polyps, and stenoses which
cannot be detected by the previously described diagnostic tests.
According to F. Marchal and P. Dulguerov (3), sialendoscopy
has been possible in 98% of cases performed on 450 cases studied.
The procedure lasts between 12 – 40 minutes, and the
difficulties are usually associated with small ductal systems
or small angle ramifications. They report no significant complication
such as perforation or excessive bleeding which required additional
therapeutic interventions.
Interventional Sialendoscopy
At least 70% of submandibular gland excisions
are indicated and performed for chronic inflammations associated
with sialadenitis. This operation is not without significant
patient risks, haemorrhage, or paralysis of neighbouring nerves – lingual,
hypoglossal and the marginal branch of the facial nerve. During
the 90’s the use of external Lithotripsy was developed,
in an attempt to identify a more simple treatment for salivary
stones. Unfortunately, this method does not allow for the removal
of all stones that are encountered or present. With the use
of sialendoscopy it is now possible to make the diagnosis of
stone retained within the salivary ductal system but also to
remove these stones when identified, using the same procedure.
Concerments up to 3 mm in the parotid and 4 mm in the submandibular
gland can be extracted using endoscopic control with the use
of a metallic wire basket procedure. The stones bigger in diameter
(approx 10% in the last series) are destroyed or fragmented by
the use of a laser, and then extracted (Fig 6). All of
these procedures or operations are performed using the same techniques
at the same patients visit. In the series of F. Marchal and colleagues,
the need for a general anaesthetic was necessary in 24% of cases.
In more than 50% of cases there was identified more than one
stone, within the salivary ductal system which was
causing patients symptoms.
Of 45 stones identified within the parotid ductal system, two
patients had to be treated by conventional parotidectomy, and
only five of 110 patients with stones in the submandibular glands
required their gland to be removed as treatment. All of the other
patients had their stones removed by the techniques of sialendoscopy,
but more than 50% required more than one procedure to achieve
all stones to be extracted.
Comment
The use of endoscopes in otology, laryngology
and rhinology and the performance of microsurgical procedures
are common place in ENT practice for decades, now with the
introduce of endoscopy for salivary glands has allowed for
clinicians to consider the possibly to increasing their ability
to improve quality care for their patients who resent with
salivary gland symptoms and disorders.
There is no doubt that diagnostic and interventional sialendoscopy
of salivary glands will soon be included in the repertoire
of all clinicians and be considered as a standard of practice
within a short period of time.
Markus WOLFENSBERGER
President of the Swiss Society of ORL, Head and Neck Surgery
Head, Dept of Head and Neck Surgery, University Hospital
Basel, Switzerland
References
1. Marchal F, Dulguerov P, Becker M,
Barki G, Disant F, Lehmann W. Specificity of parotid sialendoscopy.
Laryngoscope 2001; 111 : 264-71.
2. Marchal F, Dulguerov P, Becker M, Barki G, Disant F,
Lehmann W. Submandibular diagnostic and interventional sialendoscopy
: new procedure for ductal disorders. Ann Otol Rhinol Laryngol
2002; 111 : 27-35.
3. Marchal F, Dulguerov P. Sialolithiasis management
: the state of the art. Arch Otolaryngol Head Neck Surg
2003; 129 : 951-6. |
Geneva
- Switzerland