Obstructive Zenk et al. and Nahlieli et al.

Obstructive sialadenitis is the most
common non-neoplastic salivary gland disorder and represents approximately
one-half of benign salivary gland disease. 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, or variations in
anatomical ductal systems 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) Surgical protocol (including papillotomy
and gland removal) may be indicated for recalcitrant lesions. 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

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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 This was followed by Katz,
who  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 etiological factor for sialadenitis
and presents as a diffuse unilateral swelling of the major salivary glands. (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 localization of stone 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). (WILSON-ADVANCES
IN ENDOSCOPIC SURGERY INTECHOPEN.COM)

Besides the size, location and mobility of stone
also have a remarkable influence on therapeutic outcome. According to a study
by Nahlieli et al. 14, sialendoscopy was unsuccessful in 13 % of the patients
because of intraparenchymal location of stone, anatomic stenosis or tortuous
duct course.

Sialendoscopy employs the use of a basket and balloons
for free floating stones. Miniforceps or a grasper may be used in those cases where
it is difficult to bypass the sialolith. (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)

Ductal stenosis and kinks is the second commonest
etiological agent for obstructive sialadenitis. Strictures may be seen in
juvenile recurrent parotitis, radiation induced sialadenitis, and Sjogren’s
syndrome. Isotonic saline irrigation is generally satisfactory for dilation of milder
strictures of less than half the diameter of the duct. Intraductal corticosteroid
injection and placement of stent may be required in few cases. (ATINEZA
2015 BRITISH ASSOC OF ORAL SURG)

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