|Year : 2016 | Volume
| Issue : 2 | Page : 155-159
Sialoendoscopy: A new diagnostic and therapeutic tool
Abhijeet Alok1, Indra D Singh2, Shivani Singh3, Mallika Kishore4
1 Department of Oral Medicine and Radiology, Sarjug Dental College and Hospital, Darbhanga, Bihar, India
2 Department of Psychiatry, Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar, India
3 Department of Public Health Dentistry, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India
4 Department of Oral Medicine and Radiology, Yashoda Hospital, Ghaziabad, Uttar Pradesh, India
|Date of Submission||22-Apr-2015|
|Date of Acceptance||17-Nov-2016|
|Date of Web Publication||02-Dec-2016|
Dr. Abhijeet Alok
Department of Oral Medicine and Radiology, Sarjug Dental College and Hospital, Hospital Road, Laheriasarai, Darbhanga - 846 003, Bihar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
One of the most important innovations in last few years is sialoendoscopy. The diagnosis and treatment of obstruction and inflammation of the salivary glands can be problematic because of the limitations of the standard imaging techniques. Sialoendoscopy is a new technique for evaluating salivary obstructive diseases, which allows complete visualization of the ductal system and its disorders. This procedure by allowing the complete exploration of the salivary ductal system is positioned to replace sialography and other radiological studies because of its higher specificity and cost effectiveness.
Keywords: Obstructive diseases, salivary gland, sialoendoscopy, sialolithiasis
|How to cite this article:|
Alok A, Singh ID, Singh S, Kishore M. Sialoendoscopy: A new diagnostic and therapeutic tool. J Indian Acad Oral Med Radiol 2016;28:155-9
|How to cite this URL:|
Alok A, Singh ID, Singh S, Kishore M. Sialoendoscopy: A new diagnostic and therapeutic tool. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2021 Apr 13];28:155-9. Available from: https://www.jiaomr.in/text.asp?2016/28/2/155/195129
| Introduction|| |
Assessment of the quality of life and the degree of patient satisfaction are parameters that are important and increasingly often considered in treatment planning and selection of diagnostic and therapeutic approaches.  Sialoendoscopy is an innovative method for the management of salivary duct diseases.  It was introduced into clinical practice in the late 1990s, after which diagnostic and therapeutic management of salivary gland disease underwent a fundamental change.
Salivary gland endoscopy has been a major step not only in providing an accurate means of diagnosing and locating intraductal obstructions but also in permitting minimally invasive surgical treatment that can successfully manage blockages precluding sialoadenectomy in most cases.  The conventional treatment of salivary gland disease have shifted from open surgical or gland resection procedures to endoscopic or endoscopic-assisted techniques.  The application of endoscopy in salivary gland diseases has enabled a combination of diagnostic and therapeutic processes, with the microinvasive nature of the procedure considerably unburdening the patients.
| History|| |
The approach of diagnosis and treatment for submandibular stones and parotid stones before 1989 was transoral duct slitting up to the first molar and up to the curvature of the masseter, respectively. The recent literature on sialoendoscopy provides an evidence-based background to current multinational expert opinion [Table 1]. 
| Classification|| |
Sialoendoscopy is now used as a routine diagnostic and therapeutic tool by many diagnostic and therapeutic centres, with the help of custom developed instruments (baskets, forceps, laser, drills). Sialoendoscopy procedures are minimally invasive. On account of which morbidity and hospital costs are minimized. Radiographic sialographic classification of ductal pathologies does exist but it does not fit to the recently discovered endoscopic aspects of salivary ductal pathologies.  Marchal  proposed a comprehensive classification of stenosis, stones and dilatations [Table 2] and [Table 3].
Salivary stones are the most frequent pathology encountered in nontumoral diseases of salivary glands. Size and shape of stones may vary in patients. In some patients, stone shapes may vary from round to oval. The location of stone also changes. In some it is in close proximity to the ductal opening, in some it is placed deep inside the duct (submandibular ducts varies between 2 and 4 mm, whereas the size of parotid ducts varies from 1 to 2 mm).  The success of an easy retrieval of salivary stones relies on the ratio between stone diameter and duct diameter. Therefore, stones which are of smaller size compared to duct size have the chance of an easy removal by basket. In case of fixed stones, the main criteria of success of the technique relies on the possibility to view the whole surface of the stone to use fragmentation tools. ,,, When the stone is partially visible, other kind of approaches might be performed, and the success of these procedures depend on clear localization of the stone [Table 3]. 
Salivary ductal stenosis occurs more frequently in the parotid ductal system than in the submandibular one.  The success of the endoscopic treatment of these stenosis depends on their severity. Diaphragmatic stenosis are always thin and might be unique or multiple. They can easily be dilated either with a bougie, a larger endoscope, or a balloon catheter. ,,, Thicker stenosis are difficult to dilate. In these cases, long lasting symptoms may lead to further dilatation. Such dilatations can be unique, multiple or generalized [Table 4]. 
| Indications and Contraindications|| |
Current evidences validates sialoendoscopy for the treatment of non-neoplastic disorders of the salivary glands, including sialolithiasis.  Sialolithiasis is one of the most common of these disorders and is a major cause of sialadenitis and unilateral diffuse swelling of the major salivary glands. , Other common indications for sialoendoscopy include diagnostic evaluation of recurrent unexplained swelling of the major salivary glands associated with meals, ductal stenosis and intraductal masses such as mucus plugs, strictures and stenosis, salivary polyps, and foreign bodies. , Patients who are suffering from salivary gland pathology and do not respond to conservative management of salivary gland pathology may benefit from interventional sialoendoscopy, which yields success rate of 50-67%.  Several studies suggest benefit in children with recurrent parotitis as well as in patients who have recurrent sialadenitis from autoimmune processes such as Sjogrens syndrome. It can also be used to diagnose undetected concrements.
Contraindication for sialoendoscopy is acute sialadenitis. , Although this condition is not an absolute contraindication, it makes sialoendoscopy problematic because an inflamed ductal system is more difficult to dilate, and also chances of spread of infection to head and neck are present. Trismus from pathologic conditions of the temporomandibular joint is another contraindication.  Another contraindication is ductal lumen which cannot be enlarged to 1.3 mm, calculi larger than 10 mm which are difficult to crush and remove, and intraparenchymal stones. 
| Types of Endoscopes|| |
Three types of endoscopes have been introduced into the ductal system of the major salivary glands. They are flexible sialoendoscopes, rigid sialoendoscopes, and semi-rigid sialoendoscopes (compact and modular).
Flexible endoscopes are advantageous because they can be moved through ductal anatomy and they are also atraumatic. Disadvantage is that only weak forces can be applied, they are fragile, handling is difficult than other types of endoscopes, and it is not possible to autoclave them. 
They are less fragile and various forceps and other miniature tools could be introduced easily. Quality of light is better. The risk of damage to the salivary duct is more with endoscopes with larger diameters. In some cases, papillotomy is required to insert endoscopes. Main advantage of rigid endoscope is better optical qualities. Rigid endoscopes can be autoclaved. 
They have qualities between rigid and flexible endoscopes. There are two types of semi-rigid endoscopes, i.e., compact and modular endoscopes. Semi-rigid compact endoscopes consist of fiber light transmission, a working channel, fiber image transmission and an irrigation channel within one endoscope. Compact endoscope has very thin irrigation channels. These are difficult to clean.  Less exertion is there in using semi-rigid endoscope. Semi-rigid modular endoscopes use a single probe-like component. This can be used in combination with different sheaths. They have disadvantages such as impaired visualization and difficulty in cleaning. 
| Instrumentation|| |
The diameter of salivary ducts sets a limit on the size of the instruments that can be used within them. Multiple considerations are needed to adapt endoscopes to the salivary ducts and glands, including compact outer diameter, highest number of pixels, durability, effective cleaning and sterilization, large working channel for various instruments, ergonomic handling, and flexible manoeuvrability inside the duct system. Various instruments have been designed to be used with endoscope to make instrumentation more easy and precise. 
| Procedure|| |
Preoperative assessment of salivary duct opening is done by using various radiological procedures. Once the dilatation or incision of duct opening is done, sialoendoscope is placed. Saline can be used to dilate the ductal opening. After sialoendoscope is inserted into the ductal opening, internal anatomy of the duct is closely monitored. The following techniques are usually performed: (A) Sialolith removal: The four common techniques used to remove the sialolith are (i) grasping technique-In this technique grasper with three prongs is used to hold the calculus from behind, (ii) small wire basket retrieval system, (iii) mechanical fragmentation is done by intracorporeal lithotripter, and (iv) laser fragmentation. (B) Treatment of strictures and adhesions: for such procedures, dilatation is employed. Two types of balloons are commonly used, namely, fogarty 3fr and lacricath fr. The first step in the treatment comprises anesthetizing the duct using 2% lidocaine. After which a dilator is inserted. This dilator can be inflated up to 3 mm inside the duct. This inflation of dilator creates a pressure inside the duct which helps in dilating most strictures. Grasping forceps can also be used as an alternative in treating strictures. The average time needed for sialoendoscopy is approximately 60 min, 57 ± 39 min for an international sialoendoscopy for single sialoliths and 89 ± 42 min for multiple sialoliths. 
Postoperative management is done by temporarily introducing polymeric stent into the duct which is kept in place for 4 weeks to prevent the obstruction of ductal lumen by postoperative edema as well as to serve as a passive dilator to prevent further strictures. A total of 100 mg hydrocortisone solution should be injected intraductally after any procedure. All patients are advised antibiotics and analgesics postoperatively. Success rates of 85% have been noticed for both diagnostic and interventional applications. 
| Diagnostic Sialoendoscope|| |
Diagnostic sialoendoscopy is a procedure in which main principle is to arrive at the pathology by following the duct system. The position of the tip of the endoscope can be determined by palpation, centimetre calibrations, or from the outside by the transillumination effect. To track the endoscope, even more precise guidance can be achieved by simultaneously using ultrasound. Irrigation alone is not sufficient at times for mucous removal. In the case of mucous removal, suction is applied by using small syringes. Suction is applied directly without any tubing to the irrigation channels; because of their small diameter they can get blocked by this procedure, and extracorporeal flushing clears the channel. With respect to diagnostic sialoendoscopy, Marchal and Dulguerov  reported a 98% success rate, whereas Nahlieli and Baruchin  reported a success rate of 96% in their case series.
| Therapeutic Sialoendoscope|| |
Together with stenosis and strictures, stones are the main cause of obstructive salivary disease. Forceps, baskets, graspers, and balloons can be used to remove stones with an endoscopic control. Sialoendoscopy is performed as a treatment option both for chronic sialadenitis and recurrent juvenile sialadenitis. By irrigation saline duct systems are dilated and cleaned. Additional use of corticosteroids, the use of balloons, and perioperative antibiotics might be helpful. 
| Complications|| |
In general, sialoendoscopy is considered to be a safe outpatient procedure and has been validated as a safe technique in several large studies. However few complications have been known to occur [Table 5]. ,
| Future Directions|| |
Diagnostic and interventional sialoendoscopy are safe and effective options for treating non-neoplastic disorders of the major salivary glands. Sialoendoscopy is technically challenging and requires sequential learning in which success rates appear to be proportional to the surgeon's level of experience. The authors recommend that future sialoendoscopist'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. Sialoendoscopy training via hands-on courses and case observations should be pursued prior to initiating a sialoendoscopy practice.
| Conclusion|| |
Sialoendoscopy is a technique sensitive procedure that can be used for the diagnosis and the treatment of obstructive salivary gland diseases. Sialoendoscopy is a safe procedure and can be performed in almost any case (apart from definite contraindications) without risking patients' discomfort, pain, or unpleasant experience.
Sialoendoscopy and its different forms have been a major development in providing an accurate method to diagnose and locate intraductal obstruction as well as helping in permitting minimally invasive surgical treatment. Success is measured by treatment that is efficient, clinically effective, cost-effective and gland sparing in the majority of cases. Advances in the armamentarium are making this procedure more frequent.
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Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]