Office-Based Procedures

History

• 1.

  History of present illness

  • a.

    Duration of the mass in the neck may impact the decision to pursue further evaluation

    • 1)

      A persistent or slowly progressive mass in the neck lasting for more than 3 weeks should be screened for malignancy.

  • b.

    Does the patient have any associated symptoms or high-risk behavior?

    • 1)

      Does the patient display fevers, chills, malaise, weight loss, otalgia, odynophagia, dysphagia, hoarseness, or hemoptysis? Does the patient have a history of smoking/alcohol use or hazardous exposure?

  • c.

    How long has the patient experienced problems with the saliva gland?

    • 1)

      Acuity of symptoms relates to gland health—ongoing periodic swelling (reversible damage) versus persistent enlargement (end-stage fibrosis).

  • d.

    How many glands are affected?

    • 1)

      Multiple gland involvement is likely inflammatory/autoimmune (radioactive iodine induced sialadenitis or Sjogren’s syndrome). Solitary gland symptoms are more suggestive of focal obstruction (sialolithiasis or stricture).

  • e.

    What symptoms is the patient experiencing?

    • 1)

      Obstructive symptoms—Swelling of the gland, pain, salty discharge, prandial association

    • 2)

      Inflammatory symptoms—Dry eyes, dry mouth, multigland involvement, history of radioactive iodine, chronic swelling

  • f.

    Is there a prandial relationship to these symptoms?

    • 1)

      Sialadenitis is exacerbated by the salivary stimulus of a meal. Pain with mastication and swelling that persists for more than a few hours, or occurs upon arousal from sleep, is more indicative of temporomandibular joint disorders.

• 2.

  Past medical history

  • a.

    Prior treatment: Antibiotic therapy, sialogouges, steroid therapy

  • b.

    Medical illness: Renal calculi; Sjogren’s syndrome, diabetes mellitus, severe dehydration

  • c.

    Surgery: Parathyroidectomy, renal lithotripsy

  • d.

    Family history: Autoimmune diseases

  • e.

    Medications

    • 1)

      Antihypertensive medications

    • 2)

      Antiplatelet medications

Physical Examination

• 1.

  Neck

  Examination of the neck may reveal a fixed or a mobile mass.

• 2.

  Oral cavity

  Examination of the oral cavity may reveal turbid discharge from the salivary ducts, palpable submucosal masses consistent with calculi, or oral cavity lesions. If calculi are palpated, the location and the size of the calculi should be noted.

• 3.

  Salivary glands

  Examination may reveal a swollen or firm salivary gland, draining sinus, and nodularity to the skin (seen with Sjogren’s syndrome).

• 4.

  Pharynx/larynx

  Examination may reveal a primary malignant lesion within the oropharynx, hypopharynx, or larynx responsible for the mass in the neck.

Imaging

Ultrasonography ( Fig. 87.1 ) of the salivary glands may reveal salivary gland masses, calculi, abnormal architecture of the gland, cyst formation (seen in Sjogren’s syndrome, HIV, atypical infections), ductal dilation (seen with salivary stricture or sialolithiasis), honeycomb appearing parenchyma (seen with lymphoma and Sjogren’s syndrome). In the neck, ultrasound can visualize vital neck anatomy (thyroid, lymph nodes, and vessels), characterize palpable mass in the neck, or visualize nonpalpable malignant adenopathy. Using characteristic imaging criteria, thyroid and neck masses can be radiographically triaged for biopsy (see Chapter 78 and Chapter 64 ).

• 1.

  Computed tomography (CT)

  CT scan may reveal salivary calculi, markedly dilated ducts, saliva gland masses, and a mass in the neck and thyroid. When performed with contrast, the CT scan may reveal primary aerodigestive tract lesions and malignant adenopathy (>1 cm, round, necrosis), reveal pharyngeal space lesions (deep lobe parotid tumors), and help classify vascular lesions.

• 2.

  CT angiography

  Useful when the clinician suspects a vascular tumor (carotid body) or anticipates trauma to the carotid artery

• 3.

  Magnetic resonance imaging

  Useful when the clinician suspects soft tissue masses (superficial or deep lobe parotid lesions), vascular lesions (glomus tumors, paragangliomas), or neural tumors (schwannomas, neurofibromas)

• 4.

  Angiography

  May be required for evaluation of carotid body tumors and preoperative embolization. If carotid artery injury or sacrifice is anticipated, angiography may be used to direct therapy (embolization/stenting) or assess for circle of Willis communication (balloon occlusion).

Indications

• 1.

  Mass in the neck, thyroid, or saliva glands refractory to conservative therapy

  Ultrasound and FNA allow for imaging characterization and pathologic assessment of the lesion. The ultrasound enhances accuracy of the biopsy and may help distinguish malignant from benign lesions. FNA directs future management/treatment. Even when lymphoma is suspected, FNA provides an initial diagnostic assessment of the concerning adenopathy, which will prevent the clinician from inadvertently performing an excisional or incisional biopsy of metastatic adenopathy and contaminating the neck. With enough passes, lymphoma may be identified by FNA alone and confirmed with flow cytometry, obviating the need for a surgical procedure and expediting patient care. With the exception of Hodgkin’s lymphoma, which may show a polymorphous lymphoid population on cytology, lymphoma will often reveal a monoclonal population on cytology, confirming the clinical diagnosis of lymphoma. In some cases, patients may still require incisional or excisional biopsy to further categorize the type of lymphoma, but following this algorithm, at least other malignancies have been excluded prior to violating the neck.

• 2.

  Recurrent acute and chronic sialadenitis

  Sialendoscopy with or without sialolithotomy effectively relieves salivary gland obstruction related to high viscosity salivary debris, sialolithiasis, or salivary stricture. Patients with chronic progressive salivary dysfunction from autoimmune disease (Sjogren’s syndrome) and radioactive iodine therapy for thyroid cancer also respond symptomatically to sialendoscopy. Ultrasonography is also useful in localizing nonpalpable salivary calculi, directing incisions in the floor of the mouth for salivary calculi, and managing complex salivary strictures (visualization of balloon dilator position, transfacial access to dilated proximal parotid duct for Seldinger technique anterograde dilation). Typically calculi less than 3 mm are amenable to endoscopic retrieval. Larger calculi greater than or equal to 4 mm often require the addition of a cutdown and ductotomy or fragmentation of the calculi.

• 3.

  Transcutaneous injections and vocal fold motion

  In addition to the imaging and biopsy guidance afforded by ultrasonography, the ultrasound can also be effective for targeting Botox injections into the salivary glands for sialorrhea or into the muscles of mastication for refractory temporomandibular joint pain with associated muscle hypertrophy (temporalis and masseter). Ultrasound may also be used to map difficult laryngeal anatomy and direct injections into the subglottis (steroid for subglottic stenosis) and vocal folds for augmentation, and direct Botox for spasmotic dysphonia. In many patients, vocal fold and/or arytenoid motion may be seen through the cricothyroid or thyrohyoid membranes.

Contraindications

• 1.

  Patients with strong vasovagal reactions

  Patients who report vigorous vasovagal reactions are not suitable for in-office minor procedures. FNA may be possible, but patients require preprocedural counseling, and the clinician should be prepared to handle an episode.

• 2.

  Antiplatelet therapy or bleeding disorders

  Patients with bleeding disorders are best managed in an operating room setting. Those on antiplatelet therapy should discontinue therapy prior to elective procedures. FNA may still be performed safely in these patients, as the bore of the needle is narrow in caliber. Patients should be prepared for likely bruising at the biopsy site.

Preoperative Preparation

• 1.

  External surfaces should be cleansed with alcohol prior to the procedure.

• 2.

  Discontinue antiplatelet drugs if possible prior to invasive salivary procedures.

• 3.

  In the case of FNA, slides should be prepared and labeled and containers ready.

• 4.

  When performing intraoral procedures, a suction should be made available.

Anesthesia

• 1.

  Local: Although these procedures can be performed in the operating room, the administration of local anesthesia is sufficient for FNA and most salivary procedures in the vast majority of patients. From a practical standpoint, these procedures are performed in the office, and therefore avoidance of sedation expedites patient throughput, decreases the need for additional patient monitoring, and allows patients to transport themselves to and from clinic. Injectable 1% lidocaine with 1:100,000 epinephrine into the skin site overlying the FNA improves patient comfort with the FNA, particularly when multiple passes are planned. For sialendoscopy, an intraductal irrigation with a 2% lidocaine solution is sufficient anesthesia for diagnostic endoscopies and sialolith wire basket retrievals. The clinician should be careful to limit the volume and pressure of the irrigation, as high-pressure irrigation will result in cell/duct damage, diffusion of local anesthetic into the soft tissues, and patient discomfort. It is recommended to limit the volume of lidocaine irrigation to less than 5 cc. If further irrigation is required, due to length of the procedure, the clinician should then transition to sterile saline.

• 2.

  Awake sedation: This may improve patient tolerance with FNA in select cases, but requires the physician obtain sedation privileges and that the clinic setting is appropriately outfitted for sedation. One of the challenges with sedation can be the depth of sedation: too little and the patient will move, deleteriously affecting efficacy of the procedure; too much and the respiratory drive and airway protection may be suppressed. Therefore, sedation is not recommended for sialendoscopy but may be a feasible route for select cases of FNA, such as the otherwise healthy adult or child whose anxiety over needles prevents a purely local anesthetic approach.

• 3.

  General: Reserved for pediatric patients and those with developmental delays who are unable to cooperate and remain still for an FNA, for patients with large parotid calculi requiring transfacial cutdown procedures, and those unable/unwilling to undergo salivary procedures under local anesthesia.

Positioning

• 1.

  Chair: The patient is positioned ideally in an adjustable procedure chair. For FNA procedures, the clinician may elect to stand and have the patient sitting upright, or sit and position the patient supine. In cases where the patient becomes vasovagal, the clinician should have the ability to place the patient in a supine or slightly Trendelenburg position. For salivary procedures, the patient is ideally positioned in the upright sitting position to allow for optimal patient control of secretions and ergonomic positioning for the physician, particularly while performing endoscopy and viewing the monitor.

• 2.

  Prone

• 3.

  Lateral recumbent

Perioperative Antibiotic Prophylaxis

• 1.

  None: Not required unless the patient has a prosthetic implant (heart valve) and sialolithotomy is planned

• 2.

  Second-generation cephalosporin

• 3.

  Clindamycin

Monitoring

• 1.

  None

Instruments and Equipment to Have Available

• 1.

  FNA

  • a.

    Ultrasound

  • b.

    Fine-bore needles (23 to 25 gauge), 1 to 1.5 inch length

  • c.

    10-mL Luer-lock syringes

  • d.

    Glass slides

  • e.

    95% alcohol or a spray fixative

  • f.

    Alcohol swabs

  • g.

    1% lidocaine with 1:100, 000 epinephrine, or alternative local anesthesia

  • h.

    IV extension tubing (optional). The tubing is ideal for ultrasound-guided suction aspiration technique, as the operator holds the needle at the hub and therefore has markedly improved dexterity. ( Fig. 87.2 )

    

  • i.

    Balanced salt solution (optional) for rinsing the needle

• 2.

  Sialendoscopy.

  • a.

    Salivary dilators/probes

    • 1)

      Conical dilators, Marchal dilators, tapered dilators, Bougie dilators

  • b.

    Sialendoscopes: Diagnostic (0.8 mm) and interventional scopes (0.4 mm working channel; 0.6 mm working channel)

  • c.

    Sterile normal saline

  • d.

    2% lidocaine solution

  • e.

    IV extension tubing

  • f.

    Light cord; HD video camera attachment and video tower

  • g.

    Yankauer suction and tubing

  • h.

    Injectable local anesthesia (noted previously)

• 3.

  Sialolithotomy

  • a.

    Items listed under sialendoscopy

  • b.

    0.4 mm and 0.6 mm wire baskets

  • c.

    Endoscopic graspers

  • d.

    11 or 15 blade scalpel

  • e.

    Fine-toothed forceps

  • f.

    Salivary stents