Disclosure UCSF Salivary Endoscopy Course 2014 I have the following relationship(s) with commercial interests. Basic Set Up and Instruments Hood Laboratories *Walvekar Salivary Stent Cook Industries Rohan R. Walvekar , MD Department of Otolaryngology & Head Neck Medtronic Xome Surgery Louisiana State University Health Sciences Center A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, New Orleans, LA patients. Basic Sialendoscopy Set Basic Sialendoscopy Set � Dilator System � Schaitkin ’ s Fluted Dilators \ � Marchal Dilator System � Instruments for Exposure of the Oral Cavity � Probes No.0000 to No.8 � Anesthesia – Nasal Intubation is preferred � Epistaxis � No.0 – 5 • Pre-op nasal endoscopy to document spurs, � Conical Dilator deviated septum or other abnormality � Helps to transition between dilators • Afrin and lubricated nasal trumpet while � Useful usually once papilla is dilated up to Marchal patient is in preoperative holding area No.1 or 2 dilator � Disposable Plastic cheek retractor � Bougies (increasing diameter) � Dental splints � Compatible with 0.4 mm guide wire � Jennings's mouth gag � COOK Dilator System with Operating Sheath � Minnesota and Sweetheart � Guide Wire retractors � Cook Dilators 1-8 1
Schaitkin Salivary Dilator Set 2
Kolenda Introducer Set (COOK) Sialendoscopy Sialendoscopy Sialendoscopes � 1.3 mm Marchal* � 1.1 mm Erlangen* � 1.6 mm Erlangen* *Karl Storz, Tuttlingen, Germany Fiberoptic channel Irrigation Port Interventional Port Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin N Am 42 (2009) 1029-1052 Sialendoscopy 3
Basic Sialendoscopy Set Marchal Sialendoscope � Sialendoscopes � 0.8 mm � Pediatric diagnostic sialendoscopy � Fifth generation endoscopes � 1.1 mm “ all in one ” Erlangen Sialendoscope � No interventional channel � Original was flexible � 1.3 mm semi rigid scope with 6000 pixels, � Can be autoclaved 0.25mm rinsing channel and 0.65mm working � Interventional Tools that can be used with the scope channel � 0.4 mm guide wire basket � 0.4 mm stone basket � Laser fiber (Holmium laser) � Hand held microburr � Does not have a protective sheath � Dilate up to No.3 or 4 prior to endoscopy � 1.6 mm “ all in one ” Erlangen Sialendoscope Basic Sialendoscopy Set Basic Sialendoscopy Set � 1.3 mm Marchal “ all in one ” scope � Sialendoscopes � Can be autoclaved � Autoclavable. � Interventional Tools that can be used with the scope � Interventional Tools that similar to 1.1 Erlangen � 0.4/6 mm guide wire basket scope � 0.4/6 mm stone basket � Does have a protective sheath � Cup forceps** � Optics are excellent � Does not have a protective sheath � Dilate up to No.4 / 5 prior to endoscopy � Dilate up to No.5 or 6 prior to endoscopy � Gentle bend at the tip of the scope � Balloon Dilator (Storz) – compatible with all in one scopes 4
Basic Sialendoscopy Set � IV Extension Tubing � 20 cc syringe � Vessel loops � Angled Forces with and without teeth � Standard Endoscopy Tower and Monitor with recording capabilities** Accessories � Disposables � Stone baskets � Guide wires � Cleaning brushes � Stents (Hood Laboratories)* � Balloon Dilator � Not Disposable Three way stopcock/valv e � Hand-held micro burr � Stone forceps Sialendoscopy STORZ WIRE BASKETS COOK WIRE BASKETS - - N Gage 5
LSU Sialendoscopy Course Diagnostic Sialendoscopy Data � 100% Successful endoscopy Diagnostic Sialendoscopy � Ductal or papillary stenosis in 7/15 (47%) � Essentially normal endoscopy in 8/15 (53%) � Symptoms improved in 13/15 (87%) cases Rohan R. Walvekar , MD Department of Otolaryngology & Head Neck Surgery Louisiana State University Health Sciences Center New Orleans, LA Bowen M et al. Diagnostic and Interventional Sialendoscopy: A preliminary experience. 2010 Laryngoscope (accepted for publication) Success of Diagnostic Endoscopy ~ 95-98% Sialendoscope Cannulation Rate Limiting Step : Dilation of Papilla SERIAL DILATION USING THE DILATOR SYSTEM � Progressive dilation � Approaches to the papilla � Marchal Dilator System � Dilation technique (No.0000 to No.6) � Seldinger technique � Conical dilator � With bougies � Seldinger technique � With sialendoscope � Guide wire and bougies � Papillotomy � Papillotomy SELDINGER TECHNIQUE USING GUIDE WIRE AND BOUGIES (adopted from Chossegros et al 2 ) � 25% (7/28) � Proximal papillotomy and sialodochoplasty � Successful endoscopy � 96% (27/28) 6
Distal Papillotomy and Dilation Followed by Sialodochoplasty and Stent Placement Papillotomy for diagnostic endoscopy…consequences.. Acknowledgements � Dan W Nuss MD, Faculty and Residents Department of Otolaryngology Head Neck Surgery, LSU HSC, New Orleans, LA � Barry Schaitkin, MD (University of Pittsburgh) � OR Staff (Our Lady of the Lake Regional Medical Center) � Head Neck Center, (Our Lady of the Lake Medical Center) 7
Avoid Complications Technical Problems � Maceration of the papilla: � Local Anesthesia: � measured traction � -Lidocaine 4.5mg/kg (<300mg) � -Lidocaine/epineprine 7mg/kg (<500 mg) � MAC (sedation): � -Over � Avoid creating pseudo-orifices: � -Under � injection � Local Anesthesia: � forceps � dilators � -Beware of ETT position � -NO atropine or like medication Technical Problems Technical Problems � False Passage (papilla): � Overinjection of NSS: � -do not force the dilator � -do not cut the papilla � -60cc syringe with IV extender � -control your assistant enthusiasm � -maintain one port open � Ductal Perforation: � -in the submandibular area it can � -do not advance blindly lead � to AIRWAY COMPROMISE � -do not force the instrument in � -abort if identified 8
Equipment Failure � Be cognizant of the turns: � -scope is semi-rigid (it is fragile) � -straighten the duct using manual traction and pressure � Be cognizant of the teeth � Have back up gear The Learning Curve 9
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