11/6/2014 Disclosures • None Starting Practice Jolie Chang, MD Assistant Professor Department of Otolaryngology, Head and Neck Surgery University of California, San Francisco November 6, 2014 Department of Otolaryngology Department of – Head and Neck Surgery Otolaryngology – Head and Neck Surgery Equipment is Fragile Outline • Sialendoscope • Equipment – 0.75mm fiber • Technical Challenges – All-in-One • Risks/Complications • Staff Training • Caveats • Repair/Replacement costs • Coding • Cases Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery 1
11/6/2014 Technique – the Papilla Challenges • Dilation of Wharton’s duct papilla • Identify the papilla – Rate-limiting step; Up to 20% failure – Gland massage • Dilation over guide wire (Chossegros et al. 2006) – Symmetry • Limited distal sialodochotomy (Chang JL, Eisele – Methylene blue DW. 2012) – Magnification – Identify duct in anterior FOM – Inject papilla – Preserve papilla • Papilla dilation – Start with smallest 0000, go back if needed – Conical dilator when at size 0 – Keep papilla in view Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery Distal Sialodochtomy Distal Sialodochtomy Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery 2
11/6/2014 Distal Limited Sialdochotomy Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery Limited distal sialodochotomy Department of Department of Otolaryngology – Head Otolaryngology – Head Chang JL, Eisele DW. Laryngoscope 2013. and Neck Surgery and Neck Surgery 3
11/6/2014 Technique - Sialendoscopy Postop Care and Complications • Postoperative care • Diagnostic Sialendoscope – Hydration, massage, abtx – Orient camera • Duct stricture (2.5%) – Brightness • Recurrent stones • Introduce sialendoscope: Lab • Duct perforation – Saline irrigation – no air bubbles • Ranula formation (2.5%) – Small movements • Wire basket/instrument – Backing out the camera helps to find lumen impaction – Advance under visualization • Temporary lingual nerve injury (0.4%) • FOM swelling, airway Department of Department of Otolaryngology – Head Otolaryngology – Head • Need for gland removal and Neck Surgery and Neck Surgery Witt RL. Laryngoscope 2012. Tips - Technical Tips - Imaging • Keep your eyes on the papilla • Be careful not to avulse the duct • Laser lithotripsy – may require multiple treatments • Dochotomy often required for extraction • Beware of duct perforation and excessive irrigation • Avoid sublingual tissue manipulation Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery 4
11/6/2014 Retained Stones Sialodochoplasty vs. None: SMG • Park et al. Clin Exp Otorhinolaryngol. 2012. • Roh et al. Oto-HNS. 2008. Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery Future study required Coding • 42699 Unlisted Salivary Gland Procedure • Stent placement – Use as secondary code for diagnosis, discovery of • Steroid irrigation stone or stricture • Sialendoscopy for sialadenitis without stones – Variable reimbursement • Other forms of lithotripsy – Payment: $0-750 (Medicare $116 – primary; charge $1500) • 42606 Ductal dilation and Injection – Office steroid infusion – Payment: ~$130 • 76942 Ultrasound needle guided placement – Payment ~$80 • 76536 Ultrasound diagnostic head and neck – Payment ~$60 (Medicare $25) Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery 5
11/6/2014 Coding Sialodochoplasty Coding: Sialolithotomy • 42500 Primary sialodochoplasty: • 42335 Sialolithotomy, SMG intraoral, complicated – Diagnostic procedure – Does not bundle with sialodochoplasty codes – Payment: ~$700 (Medicare $258) – Payment: ~$350 (Medicare $122) • 42505 Complicated sialodochoplasty: • 42340 Sialolithotomy, Parotid intraoral, secondary/Complex complicated – Document complexity: time, why it took longer – Payment: ~$600 (Medicare $160) – Does not bundle with complex intraoral stone codes – Payment: ~$1170 (Medicare $390-434) Department of Department of Otolaryngology – Head Otolaryngology – Head and Neck Surgery and Neck Surgery Cases Department of Otolaryngology – Head and Neck Surgery 6
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