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TECHNIQUE

Sialendoscopy is usually done with
the patient either in a sitting or supine position. 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. 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.  Papilla is dilated
using scopes of larger diameter and the lumen is thoroughly irrigated with local
anaesthetic solution or normal saline in GA cases. 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.8

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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.8

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.29 The
procedure is amenable to all age groups and is particularly helpful in elderly
patients who have other age related co-morbidities.30 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.31 Sialendoscopy holds a superior place to plain films, ultrasound,
sialography, and computed tomography, in detecting radiolucent stones.

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.
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.30

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.32
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.33
Salivary fistulas, sialoceles, minor ductal tears, development traumatic
ranulas, minor bleeding, and infection have been reported.11,20  

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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