Sialendoscopy salivary ductal system. (ATINEZA 2015 BRITISH ASSOC

Sialendoscopy is an emerging minimally
invasive technique that is employed as a diagnostic and therapeutic aid in various
non-neoplastic salivary gland disorders such as sialolithiasis, sailadenitis
and other obstructive pathologies. Sialendoscopy offer superior diagnostic details
as compared to the conventional imaging modalities used for obstructive
pathologies. Recently, the introduction of miniaturized endoscopic imaging devices
has brought revolutionary advances in the field of sialendoscopy. Preservation of gland function while relieving the
obstruction forms the principle advantage of sialendoscopy. Currently,
sialendoscopy is utilised for treatment of sialolithiasis, stricture dilation, and
as a therapeutic aid for recurrent juvenile sialadenitis, radioiodine induced
sialadenitis, and patients who
have recurrent sialedenitis from autoimmune processes such as sjogren’s
syndrome and systemic lupus erythematosus. This
paper presents review of literature about sialendoscopy
history, instrument techniques and its significance as diagnostic and
therapeutic aid in salivary gland disorders.

KEYWORDS:
Imaging modalities, Salivary gland diseases, Sialolithiasis, Sialendoscopy.

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INTRODUCTION

Obstructive sialadenitis is the
most common benign salivary gland disease and accounts to almost 50% of non-neoplastic
salivary gland pathologies. 1 Obstructive sialadenitis frequently affects the
saubmandibular gland (80% to 90%) followed by parotid (5% to 10%) and
sublingual (less than 1%) glands. 2 Sialolithiasis, stenosis, mucus plugs,
polyps, foreign bodies, external compression, and variations in anatomical ductal
system forms the major etiological factors. (STRYCHOWSKY AMERICAN MED ASSOC
2012) Initial treatment of obstructive sialadenitis is usually conservative
with hydration, salivary flow stimulation, anti-inflammatory medication and
antibiotics when bacterial infection is suspected. (CAARTA ACTA OTORHINOLOGY
2017) For recalcitrant cases, surgical protocol (including papillotomy and
gland removal) is usually followed. 3 (STRYCHOWSKY AMERICAN MED ASSOC 2012) While
conservative therapy doesn’t provide permanent cure, surgical management may be
associated with potential nerve injury (marginal mandibular nerve, hypoglossal
nerve, lingual nerve and facial nerve), 1 poor cosmetic outcome, gustatory
sweating (auriculotemporal syndrome), and paraesthesias. (DEENDAYAL
OTOLARYNGOLOGY 2016) With the introduction of sialendoscopy, the management of
salivary gland obstruction has undergone a revolutionary change. 5 (CAARTA ACTA
OTORHINOLOGY 2017) 3 Sialendoscopy has evolved as an ideal investigative as
well as therapeutic tool for of salivary gland pathologies over the last two
decades. (PP SINGH IND J OTOLARYNG HEAD AND NECK 2015) Sialendoscopy is a
minimally invasive procedure that incorporates a small -calibre endoscope and
facilitates direct examination of the salivary ductal system. (ATINEZA 2015
BRITISH ASSOC OF ORAL SURG)

HISTORY

The anatomical
description of the major salivary gland ductal system was first accounted as
early as late 17th century. In 1990, Konigsberger et al. were the pioneer in salivary
endoscopy and used a 0.8-mm flexible endoscope.1,2 Katz performed sialendoscopy
using a flexible scope and a basket, and a wide array of sialendoscopy
instruments and methods were further delineated by Nahlieli et al. and
Marchal.3,4 The semirigid sialendoscopes were introduced by  Zenk et al. and Nahlieli et al.  incorporated pediatric sialendoscopy for treatment
of recurrent juvenile parotitis and radioiodine sialadenitis patients in 2004
and 2006 respectively.  6 7 In 2007, the combined
technique of endoscopy and external method for sialolith extirpation was put
forward by Marshall. 8 (ERKUL 2016 LARYNGOSCOPE INVESTIGATIVE OTOLARYNGOLOGY)

INSTRUMENTATION

Sialendoscopes may be
classified as rigid, semi-rigid and flexible sialendoscopes. Flexible endoscopes
are beneficial as their manoeuvering is easier through the tortuous duct system and are
generally atraumatic. The disadvantages include- fragility, shorter lifespan, difficult
handling and they cannot be are not autoclaved 14. Rigid endoscopes employ high-quality
optical lens system and results in improved exploration of the duct system, are
sturdier and autoclaving is possible. These endoscopes show difficulty in
handling because of larger diameters and the camera being directly fixed onto
the ocular attached to the endoscope 14. (CAARTA ACTA OTORHINOLOGY 2017)
These days, semi rigid endoscopes are preferred and considered as the
sialendoscope of choice. They exhibit properties intermediate to rigid and
flexible sialendoscopes. They are easy to manoeuvre through the ductal system as
they possess certain degree of flexibility (45 degrees) and zero degree viewing
angle. (PP SINGH IND J OTOLARYNG HEAD AND NECK 2015)

INDICATIONS

Sialendoscopy
serves as an ideal investigative as well as therapeutic protocol for obstructive
salivary gland pathologies. 3. With the advancements in instrumentation and
acceptance of minimally invasive surgeries, sialendoscopy has emerged as the
principal therapeutic modality for obstructive salivary gland disorders 9. Sialendoscopy
is now widely accepted therapeutic tool for sialolithiasis, stricture dilation,
recurrent juvenile sialadenitis 3. radioiodine induced sialadenitis, 10
intraductal masses 2 (Indian J Otolaryngol Head Neck Surg. 2013  Apr;
65(2): 111–115. Interventional
Sialendoscopy with Endoscopic Sialolith Removal Without Fragmentation Payman Dabirmoghaddam and Rima Hosseinzadehnik) and patients with recurrent sialedenitis due to
autoimmune disorders such as systemic lupus erythematosus and sjogren’s
syndrome ( Wilson-advances in endoscopic surgery intechopen.com)

Sialolithiasis is the major
causative factor for sialadenitis and manifest as diffuse unilateral major
salivary glands swelling. (Marchal F, Dulguerov P. 2003; Nahlieli O. 2006). Generally,
sialendoscopy is successful in surgical extirpation of salivary stones less
than 4 mm in the submandibular gland and less than 3 mm in the parotid gland
respectively. Further disintegration of sialoliths (with holmium laser or lithotripsy)
may be required before endoscopic procedure for salivary stones sized between
5-7 mm. Sialoliths of diameter greater than 8 mm necessitate a combined
approach technique for stone removal (Karavidas K, Nahlieli O, Fritsch N, et
al. 2010). The combined approach technique incorporates a sialendoscope for stone
localization and either an intra-oral or an external approach for extirpation
of a large submandibular or parotid stones, respectively (Bodner L. 2002;
Lustmann J, Regev E, Melamed Y. 1990; Marchal F. 2007; Raif J, Vardi M,
Nahlieli O, et al. 2006; Seldin HM, Seldin SD, Rakower W. 1953; Walvekar RR,
Bomeli SR, Carrau RL, et al. 2009).