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Acute sialadenitis is the only reported absolute
contraindication for sialendoscopy. (WILSON-ADVANCES IN ENDOSCOPIC SURGERY
INTECHOPEN.COM) Sialendoscopy, if attempted, during the acute inflammation is
associated with difficulty in cannulation and diminished exploration of the salivary
ductal system. This results in perforation and stenosis of the duct and may intensifying
further complications. (PP SINGH IND J OTOLARYNG HEAD AND NECK
2015) Patients with  microstomia or
trismus may pose a challenge to sialendoscopy and regarded as relative
contraindications for the procedure. (WILSON-ADVANCES IN ENDOSCOPIC SURGERY INTECHOPEN.COM)

TECHNIQUE

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Sialendoscopy is usually done with the
patient either in a sitting or supine position. (SAMUEL SIALENDOSCOPY) For
diagnostic siendoscopy, a sterilized gauze piece soaked in local anesthetia (4
% lignocaine) is placed over the ductal openings (floor of mouth in
submandibular sialendoscopy or along the upper gingivobuccal sulcus in parotid
sialendoscopy) half an hour before the procedure. General anaesthesia is
usually preferred for interventional sialendoscopies. However, local anaesthesia
may be used in certain cooperative individuals and patients who are compromised
for general anaesthesia. (PP SINGH IND J OTOLARYNG HEAD AND NECK 2015) Sialogogues
(lemon or vitamin C tab) may be given prior to the procedure to enhance the
salivary flow. This enables accurate location of ductal opening and efficient exploration
of the ductal system. (PP SINGH IND J OTOLARYNG HEAD AND NECK 2015) Papilla is
dilated using scopes of larger diameter and the lumen is thoroughly irrigated with
local anaesthetic solution or normal saline (in GA cases) (Rashid squd 2010)
Thorough luminal irrigation facilitates efficient manoeuvring of the endoscope
and better surgical exploration of the duct system by clearing the accumulated sludge
and debris. The method to remove the sialolith is decided further after
determining the size of stone. (PP SINGH IND J OTOLARYNG HEAD AND NECK 2015)

Post operative management- A 5 day
course of antibiotics is prescribed to patients following sialendoscopy. Usually
day care procedures are done for patients under local anaesthesia and
discharged after few hours of monitoring. Individuals operated under general
anaesthesia are discharged either the same evening or on the next morning. Soft,
bland and cold diet is advised and emphasis on adequate hydration is made. Patient
is periodically reviewed after a week and month. Stents, if inserted need to be
removed after 2–4 weeks. (PP SINGH IND J OTOLARYNG HEAD AND NECK 2015)

ADVANTAGES

Preservation of
functionality of the gland while relieving the obstruction forms the major
advantage of sialendoscopy. The procedure can be carried out on a day care basis
without local anaesthesia and is minimally invasive with negligible morbidity
9. The procedure is amenable to all age groups and is particularly helpful in
elderly patients who have other age related co-morbidities 10. (DEENDAYAL
OTOLARYNGOLOGY 2016) The status of glandular tissues from appearance of ductal
lining can be appreciated. In the healthy gland, shiny appearance of the duct
and proliferating blood vessels can be appreciated. In chronic sialadenitis,
matted lining, ecchymosis and small blood vessels can be found. Sialendoscopy  holds a superior place to plain films, ultrasound,
sialography, and computed tomography, in detecting radiolucent stones. (JIOMAR
SHASHIKANT 2007)

LIMITATIONS

An extensive experience
and training for operator, difficult manoeuvering of miniature, tortuous and delicate ducts, and the
necessity for a skilled surgeon are the few limitations for sialendoscopy.
10. (DEENDAYAL OTOLARYNGOLOGY 2016) Utmost care and precautions should
be taken to prevent trauma while manoeuvering within the delicate salivary
ducts. This would minimize perforation of the ductal system and later stenosis.
Measures should also be taken to avoid marsupialisation of the duct papillae,
thus minimising retrograde air and aliments passage. (RASHID AL BARI SQUD 2010)

COMPLICATIONS

Post-operative glandular swelling is the
most common complication and usually shows self remission within a day or two. Post
–operative swelling holds significant consideration in submandibular procedures
due to potential risk of airway obstruction. Ductal avulsioin is another serious
iatrogenic complication, and can be minimised by preventing excessive traction
on the stone. Paresthesia of the lingual nerve has been reported in up to 15%
of patients and usually exhibits self resolution. Precautionary measures to
avoid or minimise trauma to the duct or papilla may significantly reduce the
incidence of post-operative strictures (Bowen MA, Tauzin M, Kluka, EA, et al.
2010; Nahlieli O. 2009). Salivary fistulas, sialoceles, minor ductal tears,
development traumatic ranulas, minor bleeding, and infection have been reported
(Nahlieli O. 2006; Walvekar RR, Razfar A, Carrau RL, et al. 2008; Bowen MA,
Tauzin M, Kluka, EA, et al. 2010) (4,21,31).

CONCLUSION

Sialendoscopy has emerged as an
excellent diagnostic and therapeutic aid in the management of obstructive
salivary gland disorders. Major advances in optical technologies and the introduction
of miniaturized sialendoscopes are the key factors accountable for significant evolution
in salivary gland endoscopy. The recent years have witnessed a paradigm shift
in the management of salivary gland pathologies from surgical approaches to a
more conservative approach. 

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