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Salivary Endoscopy


Introduction

Salivary endoscopy is a minimally invasive technique for the treatment of a variety of inflammatory salivary gland pathologies. The procedure has been in practice globally since the early 1990s. The small high-resolution telescopes are in their fifth generation of development and now incorporate rinsing and instrumentation capabilities. The technique is useful for removing calculi and treating stenosis, as well as for inflammatory conditions such as Sjögren’s syndrome, recurrent juvenile parotitis, and for the secondary effects of radioactive iodine on the major salivary glands.

Patients most commonly present with meal-time obstructive symptoms of swelling of the gland and discomfort with provocation. The inflammatory processes can have more constant symptoms not associated with meals.

Key Operative Learning Points

  • The dilation of the papilla of the submandibular gland (SMG) and parotid gland is the initial rate-limiting step and requires delicate handling of the tissue.

  • The SMG duct is difficult to access via the papilla but very easy to navigate with the salivary endoscope.

  • Although the papilla of the parotid is relatively easy to dilate, the challenge is where the duct curves around the masseter muscle. Straightening the duct helps to facilitate this part of the endoscopy.

  • The scopes range in size from the diagnostic scope (0.8 mm) to therapeutic scopes (1.1 to 1.6 mm).

Preoperative Period

History

  • History of present illness

    • Duration of symptoms

    • Age at onset

    • Provocation with meals

    • Previous history of calculi

    • Dry eye and/or dry mouth

  • Past medical history

    • History of radioactive iodine

    • Previous surgery of the salivary gland

    • Medical illness

    • Family history

    • Medications:

      • Anticoagulants

Physical Examination

  • Palpation of all major salivary glands

  • Intraoral examination including examination under the operating microscope

    • Notation of size and location of the papilla particularly of SMG

    • Observation of quality and quantity of expressible saliva

    • Palpation for calculi along Wharton’s duct

    • Palpation for calculi at or near the papilla of Stensen’s duct

    • Evaluation of potential surgical challenges to the procedure

      • Teeth

      • Tori

      • Piercings

Imaging

  • Ultrasound (US) is the primary imaging modality outside of the United States and is becoming more popular in the United States. US is able to detect calculi as small as 2 mm and is very good at demonstrating ductal dilation associated with any form of obstruction. It is also a dynamic study and can be done with concurrent salivary stimulation with food. It is also possible to do the study with intraoral palpation to further delineate calculi. The most difficult area to image is the anterior aspect of Wharton's duct.

  • Computerized tomography (CT) without contrast is very good at identifying calculi larger than 1 mm. It is not useful for most cases of stenosis unless the duct is dramatically dilated. Contrast should be used in cases where a neoplasm remains in the differential diagnosis.

  • Sialography

    • Conventional sialography is invasive and very operator and interpreter dependent, but it can be useful in some difficult to understand cases of obstruction.

    • MRI sialography is available in a few centers. No contrast is required because the saliva is used as contrast. It is expensive and has all the limitations of normal MRI. It requires extra back table work and programming to acquire the images.

Indications

  • Obstruction of the salivary glands by history and imaging compatible with calculi or stenosis

  • Inflammatory conditions significant enough to warrant operative intervention due to frequency and severity

  • Symptoms related to administration of I 131

Contraindications

  • Salivary endoscopy during an acute infection is a relative contraindication with the possibility of worsening the infection or perforating the duct.

  • Medical comorbidities should not be a contraindication because most of these procedures can be done using local anesthesia alone or with awake sedation.

Preoperative Preparation

  • Preoperative antibiotics if necessary to control an acute process

Operative Period

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