Sialoendoscopy is a minimally invasive technique that allows for salivary gland surgery for the safe and effective

treatment of sialadenitis and other conditions of the salivary glands. During sialoendoscopy a small camera is placed into the salivary glands through the salivary ducts that empty into the mouth. Sialoendoscopy is an efficient yet simple mode of treatment for major salivary gland obstructions, strictures and sialoliths (salivary stones). Depending on the obstruction, sialoendoscopy can be conducted under local anesthesia in an outpatient office or in the operating room under general anesthesia.

Conditions indicating sialoendoscopy

Salivary gland stones are one of the major causes of salivary gland infections (sialadenitis). These types of stones can be found in 1.2 percent of the general population. [1] The second leading cause of salivary obstruction is from strictures and adhesions !hich can happen from prior salivary gland infections including childhood infections li"e mumps. #ost strictures could be seen in the parotid duct and mostly in the disease process of chronic recurrent sialadenitis.

Description of the technique

$enerally the salivary duct opening needs to be either dilated or incised prior to introduction of the endoscope. %nce the sialoendoscope is in place saline is utili&ed to dilate the salivary duct and its branching. %nce the endoscopes are introduced into gland the internal anatomy is e'plored either for diagnosis or for treatment of a specific disease entity. The endoscope is introduced into the gland through its natural orifice in the mouth or by a ma"ing a small incision in the duct opening. These techni(ues for introduction are completely intraoral techni(ues.

] Salivary gland stone removal[2]

)hen the diameter of the stone is *mm or less it can be removed purely by an endoscopic techni(ue particularly !hen the stone is located above the muscles that comprise the floor of the mouth. The four common techni(ues used to remove the salivary gland stones are+

1. The grasping techni(ue 2. ,sing a small !ire bas"et retrieval system -. #echanical .ragmentation /. 0aser fragmentation

)hen the diameter is larger than * mm a t!ofold (endoscopic assisted) approach can be utili&ed. The endoscope is introduced and the stone locali&ed and then dissected and removed in an intraoral approach. 1fter a sialolith is removed from an affected

gland a sialastic stent is inserted into the duct for t!o to four !ee"s for the duration of the healing process of the oral region and until normal function of the gland is restored. This prevents scar formation !hich can develop overlying the ductal opening into the mouth.

] Treatment of strictures and adhesions

2n the case of strictures or adhesions the follo!ing techni(ue can be used as a treatment modality. .irst the surgeon !ill ma"es his diagnosis and find the e'act location of the obstruction using a sialogram. .ollo!ing this the surgeon can use the endoscopic method. The first step in this is anestheti&ing and laving the duct !ith 2 percent lidocaine and saline. 2f there is no improvement the surgeon then can insert a dilation balloon !hich can be inflated up to - mm. The pressure created by the inflation can be sufficient to dilate most strictures. 1nother techni(ue for dilating strictures is to e'pand the stricture region !ith grasping forceps used as a dilator.

Instrumentation
The ability to perform this techni(ue is the result of the development of miniaturi&ed endoscopic imaging tools. The majority of sialoendoscopes that are currently in use are of the semirigid type. The semirigid endoscope allo!s for visuali&ation of the diseased process but the stiffness allo!s manipulation and navigation of the internal salivary anatomy. #ultiple types of micro instrumentation are available including grasping forceps biopsy forceps drills needles laser fibers and lithotripters (although the last is currently unavailable in the ,S pending ,.S. .ood and 3rug 1dministration approval). #ultiple companies ma"e various types of sialoendoscopes and instrumentation. There are advantages and disadvantages to all of the systems and none are recommend over the other. 3ifferent practitioners utili&e different systems due to the e'perience and clinical training of the surgeon. Results. The authors overall success rate for parotid endoscopic sialolithotomy is 86 percent, and their overall success rate for submandibular endoscopic sialolithotomy is 89 percent. Their success rate for treating strictures is 81 percent. Clinical Implications. The endoscopic technique opens new hori ons in the field of salivary gland diseases. !alivary gland stones and sialadenitis no longer are absolute indications for sialadenectomy. "wing to growing e#perience and surgical s$ills, new endoscopic techniques are in clinical use, and there is constant improvement in endoscopic treatment success rates. Conclusions. !ialoendoscopy is a promising new method for use in the diagnosis, treatment and postoperative management of sialadenitis, sialolithiasis and other obstructive salivary gland diseases.
%iniendoscopes can be divided into three subtypes& fle#ible, rigid and semirigid. The semirigid endoscope combines the advantages of fle#ible and rigid miniendoscopes& it has a clear view, a small diameter, stiffness and good 'pushability'( hence we believe it may be the best instrument available.

POSTOPERATIVE MANAGEMENT

)fter a sialolith is removed from an affected gland, a sialostent is inserted into the duct for two to four wee$s for the duration of the healing process of the oral region and until normal function of the gland is restored, which normally ta$es two to four wee$s( to prevent obstruction of the ductal lumen by postoperative edema( and to serve as a passive dilator to prevent future strictures. ) total of 1** milligrams of hydrocortisone solution should be in+ected intraductally after any procedure. ,n all submandibular cases, the patient should receive 1.grams of amo#icillin per day for seven days. )fter parotid sialoendoscopy, the patient should receive 1.- g of amo#icillin clavulanate potassium per day for seven days. The only absolute contraindication of sialoendoscopy is acute sialadenitis. Success rate. The success rate for parotid endoscopic sialolithotomy is 86 percent, and the success rate for submandibular endoscopic sialolithotomy is 89 percent. Failures. ,mmediate failures .cases in which the introduction of the miniendoscope into the gland failed or proved not feasible/ totaled 1.1 percent .*.8 submandibular glands, *.0 percent parotid glands/. ,ntraoperative failures .cases in which surgeons were unable to accomplish any of the endoscopic retrieval techniques/ totaled 1.1 percent .0 percent parotid glands, 1.1 percent submandibular glands/, and late failures .cases in which there were symptomatic glands though the stone had been removed/ totaled 1.2 percent .3.6 percent submandibular glands, 3.1 percent parotid glands/. Complications. 4omplications included temporary lingual nerve parasthesia .*.1 percent/, postoperative infection .1.6 percent( 1 percent submandibular glands, *.6 percent parotid glands/, postoperative bleeding .*.- percent all of which were submandibular cases/, development of traumatic ranula .*.2 percent/ and ductal strictures .3.- percent( 3.3 percent submandibular glands, *.0 percent parotid glands/.