Slow Adoption of Sialendoscopy Limits Patient Access

It has been 20 years since the opening of an international training center dedicated to instructing specialists in sialendoscopy, a minimally invasive approach to salivary gland disease developed in Germany, and nearly as long since the technique was approved by the FDA in 2005. According to the International Sialendoscopy Society, today there are less than a thousand medical centers offering sialendoscopy globally.

“Here in the U.S., we have about 100 or so medical centers performing salivary endoscopy with a handful of centers in Florida,” estimates head and neck surgeon Daniel Benito, MD, with Cleveland Clinic Martin Health in Stuart, Florida. He credits the relatively slow adoption of sialendoscopy in the United States to limited training opportunities and the learning curve involved in performing the technique, among other factors.

Prior to joining Cleveland Clinic Florida’s Head and Neck Institute last year, Dr. Benito completed the otolaryngology – head and neck surgery residency at George Washington University School of Medicine in Washington, D.C., where he gained extensive experience performing sialendoscopy. With his recent addition, Martin Health joins a small but growing number of U.S. centers using sialendoscopy to diagnose and treat an array of benign salivary gland disorders.

How it works

Sialendoscopy, also called salivary endoscopy, is a minimally invasive outpatient procedure in which a miniature semi-rigid endoscope, measuring 0.8 millimeters to 1.6 mm in diameter, is inserted into the natural opening of the salivary gland duct to visualize the ductal lumen. It is used to evaluate and treat ductal pathologies, including obstructive sialolithiasis, ductal stricture, intraductal masses, and salivary swelling.

“We use a three-channeled micro-endoscope to access the ducts leading to the parotid glands in front of the ears, submandibular glands under the tongue, and sublingual glands, located in the back of mouth below the jaw,” explains Dr. Benito.

One channel contains a camera and light source used throughout the procedure. An irrigation channel is used for administering fluids and medication, and a third channel can be used to introduce tools to carry out interventional procedures, he describes.

Interventional sialendoscopy

Gilberto Alemar, MD, a board-certified otolaryngologist with Cleveland Clinic Weston Hospital, is an early adopter of sialendoscopy, having trained in the technique in 2010. He was one of the first physicians in Florida to offer this approach.

“Salivary endoscopy is an important tool for diagnostic visualization but improvements in the technology over the last decade, such as the use of stents, balloons and wire baskets, has expanded its interventional application,” says Dr. Alemar, noting it is most effective in treating obstructive salivary conditions.

Today sialendoscopy is used to remove salivary stones (sialoliths) — the primary cause of salivary obstruction — dilate and ablate stenotic ducts, irrigate inflamed ducts with saline and steroid flushes, and treat ductal adhesions. It is not, however, used in the treatment of salivary tumors or in cases of acute sialadenitis, where there is a risk for ductal trauma or the spread of infection.

“Being able to treat calculi endoscopically primarily depends on their size and location,” says Dr. Alemar. “We can typically remove sialoliths smaller than 5mm unless they are located too deep in the gland or positioned in a small ductal branch that cannot accommodate the scope.”

Gland preservation and other benefits

Both Dr. Alemar and Dr. Benito also perform hybrid procedures that combine the use of sialendoscopy for stone localization with transoral incisional sialolithotomy. This approach is most often used for stones in the submandibular or parotid glands and significantly reduces the need for salivary gland excision.

According to Dr. Benito, one of the first cases performed at Martin Health was a 54-year-old woman diagnosed with salivary stones who had undergone multiple previous attempts at removal that resulted in significant scar tissue formation.

“With the scope, we confirmed there was complete scarring of the duct and performed a transoral procedure to re-route the duct into the mouth and restore normal salivary flow,” he recalls. “This saved the patient from having to remove her submandibular gland and resulted in no external incisions.”

Today fewer than 5% of salivary stones result in gland excision. Other benefits of sialendoscopy over traditional surgery include less scarring and bleeding and a reduced risk of infections and nerve damage. “Limiting the need for parotidectomy is especially important as it is the source of greatest risk for facial nerve injury, either temporary or permanent,” adds Dr. Alemar.

Clinic versus OR setting

While typically performed in the operating room under general anesthesia, some sialendoscopy cases also can be conducted under local anesthesia in an outpatient office. According to a study conducted by Dr. Benito and his colleagues at George Washington University, published last year in the American Journal of Otolaryngology, appropriately selected patients can be successfully and more cost-effectively treated in the outpatient clinic without compromising patient safety or quality.

“With the right patient, diagnostic sialendoscopy and certain interventional procedures, such as dilation of stenosis or removal of small, freely mobile stones, can be performed in the clinic under local anesthesia,” explains Dr. Benito, who has experience in both settings. “For my ENT colleagues considering learning this technique, I recommend they first become comfortable and proficient with sialendoscopy in the OR before performing cases in the outpatient clinic.”