BackTable / ENT / Podcast / Transcript #25

Podcast Transcript: Sialendoscopy

with Dr. David Cognetti

We talk with Dr. David Cognetti about sialendoscopy including the importance of patient selection as well as tips and tricks for success. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Presentation and Workup of Sialendoscopy Patients

(2) Differential of Inflammatory vs Obstructive Causes of Salivary Gland Pathologies

(3) Physical Exam Techniques with Ultrasound Augmentation

(4) Pre-Procedure Sialendoscopy Equipment and Scope Preparation

(5) Sialendoscopy Surgical Techniques and When to Use Them

(6) In-Office Sialendoscopy Considerations and Limitations

(7) Important Surgical Considerations Intra-operatively for Sialendoscopy: Techniques, Location, and Stone Size

(8) Stone Recurrence and Management

(9) Complications of Sialendoscopy and Subsequent Management

(10) Management of Inflammatory Causes of Salivary Gland Symptoms

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[Ashley Agan MD]
Hey, everyone. Welcome to the show. This is the BackTable ENT Podcast. For our returning listeners, thanks for coming back, stopping by again today. For those of you who are new, our goal here is medical education, and we seek to accomplish this through conversations with brilliant people from all over the world and we hope that you can take this information and apply it to your everyday practice. Quick intros before we get started. I'm Ashley Agan and I'm a general otolaryngologist practicing in an academic setting at UT Southwestern in Dallas, Texas.

[Gopi Shah MD]
I'm a pediatric otolaryngologist practicing at Children's Health here in Dallas at UT Southwestern, and we have a really, really awesome show for you today because we have an awesome guest. We have Dr. David Cognetti. He's the Chairman of the Department of Otolaryngology at Thomas Jefferson University Hospital in Philadelphia. He obtained his medical degree from the University of Pittsburgh. He completed his residency in otolaryngology at Thomas Jefferson and returned to the University of Pittsburgh for his fellowship in advanced head and neck oncology.

When I was a second year resident at Jeff, Dr. Cognetti came back as a new attending, and he came back ready to operate, teach, and lead. He developed programs in transoral robotic surgery, as well as sialendoscopy. Both of which are innovative technologies that eliminate the need for radical open surgery.

On a personal note, Dr. Cognetti was my favorite attending at Jefferson. He taught me so much. At Jeff, we ran his service at that time when we were the PGY4, and he inspired me to be a better human being as I watched him take care of his head and neck cancer patients.

So, welcome to the show, Dave. We're going to talk about sialendoscopy today. Before we get started, can you tell us just a little bit about your practice?

[David Cognetti MD]
Gopi, thank you and Ashley, thank you. I'm so excited to be here. Yeah. So, I'm a head and neck surgeon by trade and training. So, I do all ablative side of oncologic head and neck surgery. I sometimes tell people that my hobby is sialendoscopy, but it's grown to be a large part of my practice over the years.

(1) Presentation and Workup of Sialendoscopy Patients

[Ashley Agan MD]
So, how do these patients end up in your practice or how do they present? Is it a lot of recurrent infections or tell us more about that.

[David Cognetti MD]
Yeah. So, it's interesting to look back and I know, Gopi, in the introduction talked about our sialendoscopy program to think back of what my experience was as a resident and now as an attending because quick, frankly, in an academic center, there was not a whole lot of ... I don't recall doing that many submandibular gland excisions as a resident because we didn't see a whole lot of this because it was mostly managed in the community.

Since sialendoscopy has become a treatment option, the practice has flourished, and the referral patterns have grown. To answer your question directly, how do patients typically present? For the most part, they have obstructive symptoms. So, they have swelling of the affected gland around the time of meals, and that can get to the point of every meal, and the swelling goes up and it goes down after 10 or 20 minutes. It can be relatively intermittent, where people in retrospect will report that they've had obstructive symptoms every once in a while going back over years, maybe even decades, but for the most part, we're dealing with obstructive patients.

Of course, once you have a large salivary practice, then you're going to see all the other inflammatory things that go with salivary gland disorders and xerostomia, et cetera, but for the most part, we're dealing with obstructive.

[Ashley Agan MD]
So as this patient comes into your office, what other workup are you doing? Are you doing a lot of in-office ultrasound? Are you getting other imaging? Talk to us about that.

[David Cognetti MD]
Yeah. So, oftentimes, patients arrive with imaging. So, it's not uncommon for a patient to show up with their CT scan in hand or something, which is helpful and you could look at, certainly if they have a stone, but I'm also doing a lot of in-office ultrasound. If people don't have imaging when they arrive, an ultrasound is a very good spot to start. In fact, I think we'll talk about this a little bit later. I think this is one of those areas where my practice has evolved over the years.

In terms of selecting imaging, it really comes down to what your suspicion is based on your history and their symptoms and your physical exam. So, if people come in with no imaging and you don't have the option to do the in-office ultrasound, the people who you feel most likely have a stone and perhaps you even palpate a stone, are ideal for CT imaging. Whereas the people who are more likely to have some inflammatory disorder, if you're going to end up imaging them, those are the ones where you would consider an MRI.

There's a lot of overlap in between there, and sometimes it's not really clear. So, there's not a wrong answer here, and the different imaging types complement each other.

[Gopi Shah MD]
Is there ever a time where ultrasound is all you get? Is ever that a patient presentation where you just need an ultrasound?

[David Cognetti MD]
Sure. Again, in my practice, most people already had some sort of imaging, but if somebody comes in with very classic symptoms and I do the ultrasound and I can feel the stone and I can see the stone, I mean, there's no reason to put them through a CT if I'm comfortable with the location in the examination.

[Ashley Agan MD]
I tell patients that 20% of stones are radiolucent and may not be seen on CT. Is that accurate?

[David Cognetti MD]
Respectfully, no. I don't think it is.

[Ashley Agan MD]
I don't know where that came from. I heard that somewhere. Thank you for setting the record straight.

[David Cognetti MD]
Yeah. That's probably in older school belief back before we had more modern imaging and techniques, right? If you think about, before sialendoscopy or people doing sialography or other things, it was easy to blame a radiolucent stone as their source, when in actuality, it's probably a stricture or some other inflammatory process.

Almost all stones in salivary stones are calcium carbonate, and they're going to be seen on CT scan. One of the analogies I give some patients that you might miss a tiny stone depending on the thinness of your cuts on CT scan. I'll tell people that a CT scan is like slicing them up like a loaf of bread, and if you imagine slicing a raisin bread, you don't always cut through every raisin. So, you might miss a small stone that way, but by and large, stones will be visualized.

[Ashley Agan MD]
Interesting.

[Gopi Shah MD]
In terms of sialography, I just think of it as an esoteric imaging study because it requires somebody to cannulate this mandibular duct or the parotid duct, whatever one you're looking at, inject the dye and get imaging. Also, is that a belief that's, "No, we do that," and people do it and that's a gold standard? I mean, I read about it, but I don't know if in practice I've actually ever ordered it.

[David Cognetti MD]
Yeah. So, people do do it and believe in it. One firm believer is Harry Hoffman in Iowa, and he's an otolaryngologist who does it himself. I think that's the difference of why he has so much belief in it because he has control over the success of it, the patient's comfort during it, and can directly get the value and the feedback from it. What he teaches is that there's therapeutic benefit just from the dilation and the irrigation of the contrast, et cetera.

Most of us outside of Harry, we don't do it ourselves. So, doing it requires finding somebody who has experience to do it, and as you referred to, Gopi, it's technician-dependent, right? As you start doing sialendoscopy and trying to cannulate the ducts and you've realized that it's not easy certainly for the submandibular gland to expect the interventionalist or whosever doing it who rarely does this procedure to be successful, it's a balance of your return on your investment there. So, many of us will go straight to sialendoscopy.

(2) Differential of Inflammatory vs Obstructive Causes of Salivary Gland Pathologies

[Ashley Agan MD]
You mentioned MRI for maybe if you're suspecting inflammatory disorders. So, would that make you more or less likely to perceive a sialendoscopy after you get the MRI or can you talk more about what types of things you see and how that changes your management?

[David Cognetti MD]
Yeah. No. It wouldn't necessarily make me more or less likely as much as it will make me feel a little bit more prepared, one, for what to expect at the time of the procedure and, two, in how to counsel the patient in terms of their expectations for after the procedure.

So, if we look back at now outcomes data, and we've looked back at our early outcomes and then there's a lot of work out of UCSF with a patient survey scale, it's pretty clear that parotid glands intervention, in general, has a lower success rate than submandibular gland. So, more likely to require more intervention or they'll have some residual symptoms.

It's also pretty clear that inflammatory patients are, in general, more likely to have continued or residual symptoms than obstructive patients, and it makes sense. If you have a simple obstruction, you remove the stone, you remove the obstruction, everything else works. If you have an inflammatory situation like radioactive iodine, Sjogren's syndrome, the whole system is out of whack. So, it's harder to fully resolve the issue.

So, the MRI in that situation might show multiple strictures or the parenchymal disease and other things that just temper the expectations of what you can achieve.

[Gopi Shah MD]
That makes sense. In terms of going back to workup, talking about the inflammatory differential, do you order labs? Do you just send them to room? I mean, when I think of pediatric patients, A, it's not as common. B, if it is, it's in kids depending on how old they are, the younger they are I think of recurrent juvenile parotitis. Perhaps in my adolescence, perhaps a submandibular stone, and those are the two things that I usually see, but in adults you have perhaps Sjogren's, maybe a history of xerostomia. Do you get those basics out of labs every time or what workup or referrals do you think other than imaging for these patients?

[David Cognetti MD]
Yeah. So, again, differentiating between obstructive and inflammatory, if it's obstructive, there's really no labs. I mean, you know what the problem is and there's nothing that contributes from a laboratory standpoint. If it's inflammatory, and it's not an obvious source like radioactive iodine exposure, then you would do that rheumatologic workup and test for Sjogren's, et cetera, just to give them that underlying understanding of what etiology is.

(3) Physical Exam Techniques with Ultrasound Augmentation

[Ashley Agan MD]
When you're examining these patients in clinic, can you talk about what that looks like? I mean, I think, frequently, obviously, we're trying to feel to see if we can feel a stone, massaging the glands to see what the saliva looks like as it's coming out. Is it cloudy? Is it clear? Anything else that we need to be doing?

[David Cognetti MD]
Yeah. So, absolutely. Couple of things. Yes, you want to palpate the glands. The size of the glands, normal size. Can you express saliva? So, not only where does the saliva come out, is it coming out, and then as you mentioned, the quality of the saliva. Is it viscous? Is it cloudy, et cetera?

I would then urge you to pay close attention to the papillae themselves, and really, because you can predict how difficult it may or may not be to cannulate the punctum when you go on to do sialendoscopy. That's probably, I believe, more important from the submandibular standpoint. So, if you can express saliva, you can actually sometimes visualize the punctum, how big does it look, is it sitting up on a really floppy papilla or is it behind a really tall incisors, is it under mandibular tori, all sorts of stuff that just have you a little bit prepared of your success of cannulation.

Then finally, palpating for stones, and most importantly in the submandibular gland, you want to do bimanual palpation. You really want to make sure because, to me, a major branch in the treatment algorithm, certainly for people who are beginning this is how easy the stone is to palpate, and your best success at palpation is with bimanual palpation. You push the gland up and you deliver it to the finger in the mouth and the submandibular stones are almost always on the intermedial aspect of the gland where the duct originates out of the gland at the hilum there. Of course, you would want to feel the entire floor of mouth and check the entire ductal system, but that's where you'll find most of them.

Then finally, we talked about ultrasound before. Ultrasound augments the examination because it allows you to visualize first and direct your palpation, and then there's a great technique that Arjun Joshi has talked and written about called sonopalpation, where instead of bimanual palpation, you use the ultrasound probe to deliver the gland and push it up and you can look and see your finger on ultrasound and there's times that you can't feel the stone without the ultrasound guiding you to it, and then you can feel it with sonopalpation, which is a great technique.

All of these things help you predict your success in the operating room and/or your approach in the operating room, and then it's also important as you're doing the massage to deliver the saliva that the patients understand as well. I will say it is sometimes remarkable to me that by the time patients get to me and have had multiple bouts of sialadenitis and had symptoms for a long time that they've never really recognized or been shown how to massage and express their own saliva, which is such an important part of symptom management.

[Gopi Shah MD]
Before we move on to talking about the procedure itself, another thing that comes up in clinic with these patients is risk factors and why did this happen, and is there anything I can be doing to prevent these, and that sort of discussion. Can you talk about how that goes with your patients?

[David Cognetti MD]
Yeah, sure. I wish I had a great answer. What I'm about to say is quite simplistic, and I usually tell people we believe it's related to dehydration at some point in their lives, and I tell people that saliva is salty and when you get dehydrated, it precipitates a small piece of salt, and when that gets caught, even though I'm not sure it actually gets caught, it's like an oyster making a pearl that will just get bigger and bigger and bigger with time.

There's probably more sophisticated risk factors that we're not recognizing at this point, but in general, stone formation is, we believe, related to dehydration. Of course, anybody who makes one stone is more likely to make more stones in the future. I counsel them about that in terms of recurrence, and that's then different than the inflammatory risk factors, which include radiation exposure, specifically radioactive iodine exposure, and all the autoimmune disorders that contribute to sialadenitis.

(4) Pre-Procedure Sialendoscopy Equipment and Scope Preparation

[Gopi Shah MD]
Going into talking about equipment because I remember I think I called you from one of my first cases and it's ingrained in my mind you got to know your equipment, what scopes you have, which ones have the side ports. Can you go into just initially about equipment and setup, I guess? What do you usually think about what you are taking when your patient is at the OR?

[David Cognetti MD]
Yeah. There's a whole lot there, Gopi. So, the equipment, first is you do want to know your scopes. You want to know that they're fragile. You want to make sure you're caring for them and everybody else who touches them cares for them because these are not like rigid sinuscopes that most otolaryngologists have handles. Those are pretty resilient. With a sialendoscopy scope, if you wipe the tip or dab it like you do in sinus surgery, that sometimes could be enough to break it. I mean, we're talking 1 mm scope size. So, that's number one.

Number two, there are various sizes of the scope starting at 0.9 mm with no working channel to 1.1 to 1.3 and 1.6 mm. Those will impact what you can do through them, but you can't just say larger is better because if you tried to cannulate somebody with the 1.6 scope, most people doesn't have a duct that's big enough. So, the real work courses are the 1.1 and the 1.3 scopes. Some companies' baskets, and baskets are fairly frequently used, fit through the 1.3 and not the 1.1. so, that's important, but I would emphasize the fragility of the scopes and how important it is to protect them.

Then there's all sorts of different options for dilation. Early on in the learning curve, I think dilation may be a point of frustration. So, you want to understand what those options are and the algorithm to get cannulated.

You asked me, I think, about setup. My setup emphasizes really protection of the scope. So, the scope has a handle, and then it has the actual scope itself. I'll roll a little towel so that when it's placed down there's only weight on the handle and that the scope itself is elevated and pointing away and protected from the people. I try to keep the mayo stand as uncluttered as possible so there's not a lot of competition with the scope in terms of protection in real estate and then the back table will have the stuff that you're not using that often. So, the dilators and other things will be on the mayo stand.

There's all sorts of little things to pay attention to like the orientation of the camera once you attach them to the scope because if you're not paying attention to that, you finally get cannulated and you can't find the lumen. It might just simply be that you don't have the camera attached appropriately. There are settings on the tower that people ... Our towers at Jefferson have a setting called ENT, and people will love to go to that, but you actually need the flex filter on, otherwise you get a very pixelated view, and tips and tricks like that.

(5) Sialendoscopy Surgical Techniques and When to Use Them

[Ashley Agan MD]
Can you talk more about cannulating the duct and dilating and different techniques and how you do that?

[David Cognetti MD]
Yes, happily. So, let me start with this. In general, people are going to have an easier time cannulating the parotid duct because the papilla is friendlier and the opening is a little bit bigger. However, they will likely, in general, have a more difficult time navigating the parotid duct because there's usually a sharp turn at about a centimeter, centimeter and a half where the duct crosses the masseter muscle, and the parotid is more likely you're dealing with strictures or small duct and then the branches into the parenchyma.

The converse is true for the submandibular gland. In general, it's more difficult to cannulate the duct. The papilla can be floppy. The punctum is tiny. It can be a struggle, but once you're in it, navigation is easy. It's essentially a straight shot down to the hilum, and most stones occur there and not further down in the gland that's much smaller. So, those are just some general rules to think about.

There are two types of dilators. One I'll call the Storz dilator, which is they come in sizes ranging from four zero, 0000, up until I think seven or eight. I never get to sizes that big. They're the ones I started with. So, the first several years of my practice and, Gopi, when you were here, I'm sure that's all we were using, and I've gotten very used to their weight and navigating with them.

The shaken dilators have the advantage. They're much shorter, but they're tapered in a different manner. What's the advantage of their tapered end, and there's just five of them, they go from one, two, three, four, five, when you pass the one to the black line that's on them, the black line is bigger than the tip of the two. So, if you're able to cannulate with one of them, the subsequent pass of each one is a little bit easier because the maximum dilation of the previous one was bigger than the tip of the next one. Whereas with the Storz dilators, they're basically straight dilators.

What I'll typically do is start with either the 0000 or the 1, always the small size. You want to know where the punctum is. You want to express saliva to know where it is. So, you certainly don't want any drying agents given by the anesthesia staff because you want the saliva. You don't want to sit there and massage out all the saliva before you're ready to go because there's only so much saliva each gland has. You don't want your resident preparing and pushing out all the saliva before you get there.

[Gopi Shah MD]
I may have done that, and I think for our first case, I maybe even tried to inject the four and you're like, "How am I going to find the punctum?" I did that.

[David Cognetti MD]
You don't want to inject the floor of mouth with anything even in awake ... Gopi, thanks for bringing that up. Even when I'm doing these patients awake or light sedation, I don't inject with any local anesthesia until after I've cannulated the duct at least with one or two of the smaller sizes.

My algorithm is if I have trouble with the first two sizes, I know it's going to be hard to go up, and so thinking back to my own learning curve, I used to struggle and struggle and keep going and spend all this time, but if I notice that early, I'll switch to wire-guided dilation, and there's different ways to do that. There's commercially available kits that do that. There's some reusable dilators that have lumens in them, but the wire is going to be as small as a 0000 dilator. Once you get that in, you know you have the lumen and then you could do Seldinger technique.

If I can't do that, depending on the scenario, and all of this I just want to clarify for the audience, I'm talking about the submandibular gland. Depending on the situation, if I can't cannulate at all, there is a cutdown approach, a retropapillary cutdown approach that's been described, I believe, by Jolie Chang and Dave Eisele, where you can make a small incision just behind the papilla and get the duct right before it makes that final little curve to the punctum, and it's an easy spot to caught up in the duct and access it. Sometimes it's necessary if the punctum is completely scarred off. Hopefully, that answered the question. In terms of the parotid, it's very rare to need Seldinger technique wire guidance or cutdown. It's just usually a problem.

[Ashley Agan MD]
So, your go-to is to start with the shaken? Is that what you said? Shaken dilators? If that's not working, you can go down to the wire to get something smaller.

[David Cognetti MD]
Correct. If I'm having trouble advancing up in size at that point, I would switch to the wire and do the Seldinger technique.

[Ashley Agan MD]
Once you're dilated up, then do you do a first pass with a small scope that doesn't have a working port or do you just go straight to your work course where you're going to be able to find it and put the basket in and grab it and go?

[David Cognetti MD]
I go straight to my work course. I only have one scope per case. I, frankly, have never used a non-working channel scope, the 0.9. Now, that might be different. Gopi can speak to pediatric experience, but I feel that less scopes on the field, less scopes to break.

[Gopi Shah MD]
Yeah. I think the smallest and the 0.9 I've used for the parotid duct and usually that's just for dilating strictures or irrigating Kenalog, steroid irrigation for the submandibular. I think even in the pediatric patients starting with the 1.1 is okay. As for me, the hardest part is always cannulating the duct and just making sure I'm in and dilating up, and then every once in a while, if I'm not sure, I'll do the Seldinger with the wire through my 1.1 side port and pass my scope that way just to make sure I'm in the right spot because false positives, that kind of stuff, can happen.

I was curious to see what you and Ashley did in terms of in-office sialendoscopy in kids. The only thing I'm doing in-office is scopes, taking out toys and beads from ears and noses, but in terms of sialendoscopy in the clinic, how do you choose your patients and is your technique different at all?

(6) In-Office Sialendoscopy Considerations and Limitations

[David Cognetti MD]
Sure. I think the limitation of office sialendoscopy has nothing to do with the patients, quite frankly. I think it's more to do with resources and equipment. If you look at the places that have more experience or promoting in-office sialendoscopy, it's usually that their clinic is in the hospital with shared equipment, and it gets them over that financial barrier.

My practice is mostly sialendoscopy in our surgery center. Gopi, since you left probably, I switched to one day a month at our surgery center and it's allowed me to focus all of these cases into one spot. It's allowed me to work collaboratively with the anesthesia team, et cetera, to really tailor how we manage these cases. Now, we're actually doing a prospective trial of MAC versus general because I've seen over the years I've migrated to MAC whenever I can. Outside of the deep proximal stones and the submandibular gland, most things can be done under MAC. Quite frankly, even MAC is sometimes an excuse to have the anesthesiologist there because most patients tolerate it.

So, I believe the people who do a lot of office experience that patients tolerate this overall pretty well is just the barriers of the equipment and resources can be the hold up. Ashley, I don't know. What's your experience?

[Ashley Agan MD]
I'm not doing any sialendoscopy in clinic because we don't have equipment. I'm interested to, but I'm not able right now, but I do a lot of sialolithotomy, sialodochoplasty if I have a patient who has an obvious stone there in the floor of the mouth and they just want to just take it out, just take care of it. So, I am doing that a fair amount.

When you are doing these patients under MAC, do you do any anesthetic as far as injecting lidocaine gel into the duct or anything like that?

[David Cognetti MD]
Yeah. Great question. So, before I get to that, I appreciate your comments. All the stuff you normally do in the office, do it like that distal stone sitting right at the submandibular punctum, take it out. People are thrilled. There's no reason to take them to the OR to do sialendoscopy just for something that's staring at you. Sometimes I get referrals and, of course, stones migrate, but I'm like, "Let's just do this right now," and they're very, very appreciative. So, yes, it's similar practice there, Ashley.

In terms of under MAC, yes, typically, we'll do local injection, but as I stated before, I don't do any local injection until after I have identified and at least partially dilated the punctum because I don't want to distort the floor of mouth or create a pseudopunctum with the needle tip, et cetera. Patients tolerate the smaller sizes just fine. Sometimes I forget to inject because they're tolerating it so well and I have the whole thing dilated before I even think to inject.

In terms of in the gland, I will then irrigate. I'll cannulate with a camera and then irrigate with some plain lidocaine down the scope. It's just a couple of cc's, and that I think takes the edge off. It's interesting. Most people don't have any issue with the punctal dilation. Where they do have discomfort is with overexpansion or irrigation of the gland. So, lots of times, for inflammatory cases, I'll irrigate with Kenalog and if you're not careful with the pace and amount of irrigation, they do get uncomfortable from the expansion of the gland.

Then sometimes if you're treating a stricture and dilating the stricture, they have some discomfort with the dilation. Of course, of course, local for anytime you're removing a stone with a hybrid approach, of course. That would be required.

(7) Important Surgical Considerations Intra-operatively for Sialendoscopy: Techniques, Location, and Stone Size

[Ashley Agan MD]
Can you speak to the volume of irrigation? Because I feel like when I first started, I was like, "Irrigate. Go, go, go," and then I feel like I listen to more lectures about it and it was like, "Oh, no. It's this tiny system. You don't need to irrigate that much."

[David Cognetti MD]
Those are true. You do want to be cautious in usage judiciously. I think I'm a little different than most in that I use the Medtronic sinus irrigator attached to my scope to control the irrigation. So, then I have a foot pedal irrigation instead of having an assistant attached by IV tubing and pushing with the syringe. To me, that developed because early on when we're first doing the syringe stuff, I described it as this. I don't know if this is a good analogy. So, you guys would tell me this, but I remember, and so I have a lot of siblings, and I remember when I was a kid we'd go to the grocery store with my mom and we'd all want to hang on to the cart.

So, she'd be pushing around the grocery cart and she had two or three kids with their hands on the cart. When you do that, you can't really steer the cart too well because everyone pulling on it in a different direction, right? So, when I was navigating with the scope, it would bother me that I'd go to take a turn and there'd be tension and pull from whoever trying to irrigate and pulling the IV tubing.

So, what's great about the sinus irrigator is that when I want that little bit of extra, I just tap my foot, just tap my foot, and I know exactly when. It's not a delay like, "More irrigation please," and "Just a little bit more." I don't have to do that. So, to me, that's a big advantage.

The disadvantage is you have to be cautious, as you said, Ashley, with the amount of irrigation. So, you have to change the settings on that irrigator. You have to make sure they're turned all the way down, and you have to be cognizant that you're not sitting there with your foot on the pedal all the time because it can be a closed system if the scope size is bigger than the lumen size, and if it's a closed system, irrigation itself can actually tear the duct and I've seen that happen. If you're not cautious in the submandibular gland, a torn duct and aggressive irrigation can actually lead to a lot of floor mouth edema, which can be problematic.

Now, that being said, usually, if you over irrigate a little bit, the gland swells up, and I always warn people their gland is going to be small. It goes right down. I mean, massage. As long as it's got an exit, it's going to go down.

[Gopi Shah MD]
For the hand system, it's hard on your assistant, too. It requires a lot of force. Like you said, there's a different tug, and it's hard to irrigate as the assistant as well. So, I can't really imagine. Talk about the hybrid approach. It makes me think of my question about stone size. Do you feel like stone size matters in terms of ... Is there a size where you're like, "No, that one's definitely going to be ... Let me take a look at the camera. I have to cut down on it and take it out through the mouth ..." or "Hey, that one is too small. I don't know if I'm going to be able to catch it with my basket. It's just so tiny. It's just floating around"? How does size playing a role and then at what point are you just like, "No, we need to cut down and change direction"?

[David Cognetti MD]
Yeah. So, size definitely plays a role, but it's not just size. It's size and location, and location, by that I mean which gland, but also location within the ductal system of each gland. So, those things all play into the algorithm.

Gosh! There's so much here. Let's take the submandibular system first. The size will tell you whether or not you can retrieve it with the basket, right? So, if it's less than 4 mm, you have a possibility of retrieving it with the basket, and that is the direction of the smaller access. That's important, too, because if you have a really thin cylindrical stone, doesn't matter how long it is. If it's thin enough to be pulled forward down the lumen. If it's really big and you can feel it, you're not going to waste your time trying to pull a watermelon through a tiny tube. You're going to know that you're going to go straight to the cutdown.

So, that's where my comments early about palpation really matter. It's the medium stones, the 4 mm to 7 mm-ish range stones that are the most problematic in the submandibular gland of do you do a cutdown, do you do some lithotripsy, et cetera, et cetera, that come in to play there.

The parotid usually doesn't get very large stones. It's pretty rare. They become symptomatic more often, but the parotid duct is a bigger challenge because, essentially, the entire course of the submandibular duct is against the floor of mouth. So, if you cut into the submandibular duct, you don't even have to close it and if you don't close and it heals close and drains through the normal system, great, and if it heals open and drains into the floor of mouth, great. I mean, it doesn't matter. That's where the saliva is supposed to go.

You don't have that option in the parotid gland. The parotid gland, you don't have the same access to the duct, and you don't have the liberty that if the duct leaks, it's going to make it to the mouth. Only the end of the duct makes it to the mouth. So, really, the location and what we look at is you compare the stone on imaging to the masseter muscle.

So, by and large, everything anterior to the anterior edge of the masseter muscle is going to be accessible transbuccal, and whether that's with the basket or cutdown or whatever, you should be able to feel confident that you're going to get to it. Everything that's along the masseter muscle, between the anterior edge and the posterior edge, you should feel pretty confident that you'd be able to visualize.

Then from there, size and otherwise, you can determine, "Am I going to be able to get it with the basket? Am I going to need to laser lithotripsy? Am I going to do a transfacial cutdown hybrid approach?" Everything posterior to the posterior edge of the masseter, you have to have some concern that you're not even going to visualize it because back there, you're now likely beyond the first branch point and there's just so much more ductal system.

If you think of the duct as the tree trunk, the parotid has just many more major limbs and branches out to the leaves in the submandibular gland. So, there's a good chance that you won't see it. Now, those patients tend not to be as globally symptomatic, and you can have other options or ultrasound-guided approach or an intervention or ... There's all sorts of things, but by and large, the masseter muscle is going to predict what you can expect to accomplish.

[Ashley Agan MD]
You mentioned lithotripsy, breaking the stones up. Can you talk more about that? Are you doing that frequently? How do you do it?

[David Cognetti MD]
Not frequently, but I do do it. Some people don't do it at all. There's upsides and downsides. So, first of all, external lithotripsy, let's start there. It's not available in the United States. Nobody in the United States is doing it. If patients really want it, they have to fly to Europe, et cetera. It's multiple treatments. To me, the question of the value, especially when you're adding a trip to Europe on top is questionable. Endoscopic lithotripsy can be anywhere from there's a little microbur that you can have, which is frustrating at best. I mean, it's not very effective. You have to have the stone stabilized.

So, most people don't do that. There was a pneumatic lithotripsor in development that people were very excited about, that is no longer in development, and is not expected to be available in the United States. Some people in Canada had it and were using it.

[Gopi Shah MD]
Was that going to just pump air to break the stone or a balloon? What does that mean?

[David Cognetti MD]
It's basically that. It's forceful air. It was really impressive to see it, but bottom line, it's not available. Then the final is the laser lithotripsy, which is, again, endoscopic lithotripsy. That's the one I'll use for select patients. Urologists use it all the time. It's a holmium laser. It's good for select patients. I would never choose it over a cutdown for a large stone because a large stone, I mean, it would take you hours to break it up.

So, where I use it are those small to medium stones that I just can't get with the basket, and I'm worried that it's going to be challenging to find or get to with the cutdown for the submandibular gland. Sometimes I'll see that, ironically, Gopi, in some pediatric patients I've had where I'm like, "Well, look, it's just a little too big. If I just zap it a couple of times with a laser, I'd get it out. I don't have to cut down," et cetera or I'll use it in those parotid duct stones along the masseter, where it saves the transfacial cutdown. Again, those are more on the small to medium size.

Why people don't like them is you have to be careful of thermal damage to the duct which leads to the stricture. You have to be careful to remove the entire stone, right? You have a single stone that you're fragmenting into powder and pieces and they float around and then there's inflammation from the thermal stuff. It can be challenging, which I experienced on the first time I used it and my scrub nurse to this day reminds me of how I can damage the scope.

So, if you're not really careful and you fire the laser with the laser too close to the tip of the scope, you will burn the tip of the scope, and then you can't pass anything through that scope and if you're ... Back then, we had one scope, so that ended the case. So, you have to be cognizant of that.

[Gopi Shah MD]
Can we talk about tricks about getting small pieces out? Because I've not used a laser trying to lithotripsy, even just trying to get a stone out because depending on size or fragile, sometimes they break, and then like you said, if you start with 4 mm or 5 mm scope and now you have a little 1 mm piece.

[David Cognetti MD]
Stone.

[Gopi Shah MD]
Yeah, a stone, excuse me, and it's now a small little 1 mm piece that's left floating around, that's not an easy thing to get out always because you have a basket that you open and then, hopefully, you close right on it, but sometimes it just falls through the net of the basket. Do you just send hope that the patient massages it out? Do you ever leave some debris behind?

[David Cognetti MD]
I try not to leave debris, but those sizes, the little powdery stuff or 1 mm things that are too small to grasp with a basket are the ones that you can expect to flush out, but I would try to flush them out right there and then. Meaning, your best chance for massage to work is while doing it. So, irrigate with saline. Take the scope out. Take everything out and really focus on massaging what's in there. So, overfill the gland and then massage it. Sometimes you'll see a lot of particles just come forward, and you can watch them come out of the punctum and then check again.

You can withdraw on your scope and create a vacuum and do some suction to pull some of that stuff forward. So, there are some tricks to that. If you have an open system, and what I mean by that is you already took out a big stone by doing a cutdown into the posterior floor of mouth, so the duct is open up. I'll put an angiocatheter in or the scope itself and just really power flush through because you can. There's an exit for the irrigant, and you can really try to get some of that stuff out.

[Ashley Agan MD]
Speaking about cutting down and doing the sialolithotomy, do you formalize that with sialodochoplasty? Do you put in sutures or do you let it heal?

[David Cognetti MD]
No. Never. Despite Gopi talking about all my patients in the OR, I have no patients for that and you don't. So, let me be clear. For the submandibular gland, for the cutdowns, for the posterior near the hilum, I don't, and it goes back to what we talked about before. If they fistulize, they're fistulizing into the mouth, which is exactly where you want the saliva to go. It is very challenging to suture back there, and hundreds of cases later, I've never felt the need to do it.

That's different. The anterior floor of the mouth or even the mid floor of mouth is a little bit of a different ballgame. Earlier, I described thinking about the parotid in thirds anterior to the masseter, posterior to the masseter, and along the masseter. I think about the floor of the mouth in thirds anterior to the sublingual gland, along the sublingual gland, and posterior to the sublingual gland.

Now, the middle one, along the sublingual gland is very, very rare. You're usually going to find the stone upfront near the duct, either right at the punctum or that little curve of the duct right before the punctum or you're going to find them all the way in the back as they're entering, as the duct is entering the gland.

So, the ones upfront, sure, I might throw a couple sutures to hold open the papilla as a sialodochoplasty. The ones in the back I never do, and in between is where you have to think about the impact of the sublingual gland and granular formation, et cetera. Every once in a while, you think the stone is in the duct itself, but it's not. It's in the sublingual gland or in a branch to the sublingual gland.

So, for those in the mid floor of mouth, I'm prepared to, if needed, remove the sublingual gland or do an actual sialodochoplasty and sew the edges of the duct up to the mucosa. In that area, the duct is so much closer to the mucosa. It's easier to do and I'm not as frustrated.

[Gopi Shah MD]
Do you use a 0000 chromic or what do you-

[David Cognetti MD]
I usually just use Vicryl. I don't think it matters.

[Gopi Shah MD]
Vicryl, okay.

[David Cognetti MD]
Yeah, I don't think it matters.

[Gopi Shah MD]
That's awesome because I've spent a lot of time trying to sew away in the back of the duct.

[David Cognetti MD]
Never again. Never again.

[Gopi Shah MD]
I'm never going to do it again.

[David Cognetti MD]
You're going to be like, "Oh, I'm so glad I did that podcast with Cognetti."

(8) Stone Recurrence and Management

[Gopi Shah MD]
Yeah. So, Dave, for some of the ones that are really big, that are in the back, in the floor of the mouth, I find that I have to cut down on those to take them out and they come back. Do you have any-

[David Cognetti MD]
They come back. Interesting.

[Gopi Shah MD]
Stones can come back, we said, and sometimes even you take this egg out and two years later, the same egg, there's another egg there. I guess my question is, do you do anything different on the revision cases? Two, maybe if we can get into this after, but when do you think about using the shaken stents?

[David Cognetti MD]
I think those are two different topics. Let's start with the first one. I openly admitted earlier that I don't think we fully understand the pathophysiology of sialolithiasis. Gopi, when you're describing these patients, are they all kids, pediatrics?

[Gopi Shah MD]
For me, adolescents. When I'm thinking submandibular stones, they are usually in my 13+.

[David Cognetti MD]
Yeah. So, I wonder if that's a little different than some of the adult patients I see in terms of risk factors because I always tell people and usually tell the younger people, "Look. We can do all this and you can make a stone again. You've already made one. You're more likely than another person to make a stone, and you have 'decades of life' ahead of you. So, stay hydrated," et cetera.

So, I don't know that the ones who create stones younger have more propensity because of whatever, the makeup of their saliva to have recurrent stone formation, and it is what it is. Obviously, ideally, we get the stone out and we have as much flow as possible to prevent stagnation and future stone formation, if you will.

By definition, the fact that they've had a stone and we're intervening, they're probably more likely to make another. In terms of different approaches in recurrent stones, well, you just have to be cognizant of the potential for scarring. You have to be extra cognizant of the lingual nerve. You have to be more realistic of what the expectations are because they might have their third and fourth stone, and at some point, the patient may prefer to have the gland out.

(9) Complications of Sialendoscopy and Subsequent Management

[Ashley Agan MD]
Yes. Speaking of complications, things that can happen, things that can go wrong, what happens if you perforate the duct, if you create a false passage, you're in the case, what do you do?

[David Cognetti MD]
It depends. So, complications, I've given talks in complications and I think I've seen, meaning I've caused just about every complication you can imagine. I'm usually going to talk with, "Has anybody else experienced anything more than what I've done?" So, I mean, the dreaded complications, which, again, I've had in people with experience I've described is complete transection of the duct by pulling on a stone that you shouldn't be pulling on. So, you have to be really careful of that.

Ductal perforation is relatively common. It shouldn't be common, but you're going to see it if you do it and you're going to perforate either with the dilators because you're pushing them too far or you're pushing against resistance. You might perforate with Seldinger technique. You might perforate when you're trying to get through a stricture with the tip of the scope. There's all sorts of times you can perforate.

If it happens, probably the most important thing is to not overirrigate because once there's a perforation, everything you irrigate has access to infiltrate the surrounding soft tissue and you can end up with too much edema.

Beyond that, it's usually not that big of a deal. If you can still finish what you're there to finish, carefully remove the stone. It's ideal to not have to come back, but the duct will likely heal up and go on with life. I don't know if that answered your question.

[Ashley Agan MD]
Yeah, absolutely. There's nothing special you have to do. You don't have to freeze and stop and abort. You just carefully move on easy with your irrigation and do what you set out to do. It should heal up.

[David Cognetti MD]
Now, depending, you might not be able to move on depending on how big the false passage is and can you still cannulate beyond it, et cetera, et cetera, but in and of itself, it's usually not a huge deal.

[Ashley Agan MD]
Do you routinely put patients on antibiotics after the case and if not, would you be more likely to if you did perforate the duct?

[David Cognetti MD]
So, in the beginning, I think I put everybody on antibiotics because that's just what we did. We sent them home with their antibiotic script, their pain medicine script, and this, and that, and the other thing. Then I was like, "Why am I putting these people on antibiotics?" Got enough courses and talked with other people. So, then I was like, "All right. Let's put the ones that I do cutdowns on on antibiotics because I'm violating the mucosa, they're at higher risk," et cetera.

I would even say preoperative antibiotics, but going into a case, I wasn't able to predict necessarily and now, I've migrated to essentially to nobody gets antibiotics. They all go home with a [inaudible 00:53:10] or something like that and by and large, they do fine. Every once in a while, I might have an extensive submandibular gland intervention come in with a little infection and you put them on antibiotics a few days later and they end up doing fine. So, I don't think antibiotics are critical in this situation.

[Ashley Agan MD]
Even if you've perforated the duct or anything like that, it shouldn't matter.

[David Cognetti MD]
No. I don't think. Unless you have a huge concern, no. Again, more than the small perforation is what else is going on in the case will drive that decision.

[Ashley Agan MD]
Do you irrigate with some Kenalog or some steroid at the end?

[David Cognetti MD]
I only do that for inflammatory cases. So, I don't do it if I go and find a stone and take out a stone, I do not routinely use Kenalog. It's questionable how much the Kenalog adds, but I think if we're there, we're taking somebody for an inflammatory case, I want to give them the best chance of improvement on symptoms. So, I will irrigate with Kenalog 10, usually between 5 cc and 10 cc for inflammatory cases.

[Gopi Shah MD]
This is a good segue, I think, to get into the inflammatory patients. So, let's say you have that thyroid cancer patient that's had the radioactive iodine. What does that case look like?

(10) Management of Inflammatory Causes of Salivary Gland Symptoms

[David Cognetti MD]
I think one of the things we were going to talk about was how do I present sialendoscopy to patients, right? I do it in a pretty simplistic manner. So, every one of our exam rooms has a sink in it, right? I usually describe myself as a plumber. If you look at the sink, I explain to them that their gland makes saliva, and the drain to the sink is backed up, right?

So, for a stone, they have a hairball or something in the drain, it's clogged, and then the sink overflows when you run the water. So, the overflowed sink for them is the gland swells and they get pain. They understand that.

So, I say to them, "My job is I go in like a Roto-Rooter and I take out the clog." The analogy works because sometimes they were offered removal of the gland, and I say to them, "If you had a clogged sink in your house and you called the plumber and they came and said, 'I'll take care of your problem. Let me just take away your sink,' you wouldn't really want that, right? So, let's take away the clog and that's a fix."

Then I'll say to the inflammatory people the problem with your situation is you don't just have a clog, you have a rusty sink. The entire thing is ruined, right? It affects not just the drain, the sink itself, the faucet, the water source, et cetera. So, it's a different problem. It's less likely to get full resolution, and we have to ask ourselves what our expectations and goals are.

So, it's easiest to address obstructive symptoms and even inflammatory radioactive iodine, patients can have instructive symptoms because they have strictures and they have mucous plugs and they have other things on top of their underlying rusty sink. Sialendoscopy does a pretty good job.

So, if you look at the papers on it, people get relief from those symptoms after sialendoscopy for inflammatory problems. However, it's not going to fix the entire sink. It's not necessarily going to give them a stronger flow of water from their faucet. So, you have to be realistic. If they're not there for swelling and/or discomfort and they're only there for dry mouth, that you're not giving them the expectation that sialendoscopy is going to improve their xerostomia.

Now, the rusty sink issue comes into play when sialendoscopy doesn't work. You get in there and they're still having problems. You can't get the stricture open. They'll still have swelling because it's good for my next analogy, which is botox, which is often a backup plan or certainly a treatment algorithm for these inflammatory situations. I describe that with botox, we're turning off the faucet. We're turning off the water source, so the sink can't overflow because you're not turning on the faucet at all.

[Ashley Agan MD]
Yeah. I think that's a great analogy. I have to steal that one.

[David Cognetti MD]
No problem.

[Ashley Agan MD]
For these patients, your inflammatory patients, what's a good outcome? Like, "Hey, your symptoms should be better for two years, one year, five years." How do you follow them and what kind of expectations?

[David Cognetti MD]
Yeah, I mean, what is a good outcome is really judged by the patient themself. So, that's hard to say. There's this spectrum of how bad they are at the beginning and how much better they feel. You like to have it be months, measured certainly in months and preferably several months on to a couple of years.

Usually, what happens, if you look at ... So, if we want to go back to radioactive iodine, radioactive iodine has a natural history of ... Radioactive iodine-induced sialadenitis has a natural history in and of itself that most patients will have their obstructive inflammatory symptoms improve. If you look, they usually present at six months or so after their radioactive iodine, and then their worst time frame is in that six months to 12 months or 18 months. From a symptoms standpoint, improved.

I think part of that is that the glad is dying and, again, going back to the analogy, they're producing saliva so they're having less obstructive symptoms. So, perhaps for those patients, the intervention is to take away the acute symptoms and they find their equilibrium later because I don't feel like we're ongoing treating them for years and years and years.

With current strictures, you try to find that happy point where you get it open enough that you don't have to keep doing it, and if you can't, then those patients you might give botulinum or something.

[Gopi Shah MD]
In terms of recurrent strictures, is this where ... Do you use the stents? I keep going back to the stents. When do you ever think about using them? Do you use them?

[David Cognetti MD]
I use stents in select cases. It usually is in the parotid and sometimes submandibular depending on my opinion of the duct and what we did to it. Usually, in parotid cases, oftentimes after laser lithotripsy or something or a stricture where I just want to make sure we're open or a sialodochoplasty a the end of the duct, but it's not that often that I use stents, and I certainly don't routinely use stents for the high layer or the posterior floor of mouth cutdown approaches and all of that type of stuff I don't.

[Ashley Agan MD]
So, I think we could probably talk about this for another hour.

[David Cognetti MD]
I know. I know. It is fun.

[Ashley Agan MD]
We have to land this plane. Can you conclude this by telling us maybe any pearls that we might have missed or forgotten to ask or anything that our listeners just need to make sure they take home?

[David Cognetti MD]
Yeah. Sure. I think for the listeners, because we probably will have a mix of listeners, people with experience, people with no experience, and figuring out where it fits in. I think it's important to know that sialendoscopy has really revolutionized, if you will, how we manage salivary gland disorders in otolaryngology. I think it's here to stay. I think a lot of patients have benefited from it. We all need to figure out exactly where it fits into the future algorithms.

I think sometimes people who are doing it feel like gland excision then is a failure, which I would say it is not, right? So, in some cases like, Gopi, you said, "How many times are you going to let a stone recur? Is the patient going to let you intervene before it's simpler to do the definitive?" So, it's not the end all, but it should be considered the first step prior to gland excision in almost all patients.

So, it's very helpful for people, hopefully, listening to this talk to get better understanding of what can be done with it and learn more about it so that their patients can understand it as an option. Patients themselves are seeking it out appropriately.

[Gopi Shah MD]
Well, Dave, thank you so much for taking the time. It was nice to reconnect today. I miss you. I'm so excited that you're the chair now of the Department of ENT at Jeff. I'm so excited to see all the progress and the excitement that's going to be going on with the residency and the overall head and neck department there. So, thank you for joining us.

[David Cognetti MD]
Gopi, thank you. I'm honored to be here. Miss you as well. It's great to reconnect. Ashley, thank you for your time as well. This was a lot of fun for me.

[Ashley Agan MD]
You guys usually do a course or have in the past, right? Is that going to be coming back?

[David Cognetti MD]
We've been doing a course. We just had our fourth annual course in February. It was virtual, which has disadvantages but some major advantages. The advantages were that we have registrants from I think half the states to 20 something states and 10 countries across the world. So, we had our biggest representation to date and we look forward to future courses as well.

I would encourage people. Here's a good final tip. We all think our learning curve is with our hands and our techniques. A lot of sialendoscopy are techniques that are pretty natural to otolaryngologists. The real learning curve is in patient selection, and understanding the limitations and all that type of stuff.

So, I would encourage people to take courses as they get going because it's very helpful. In fact, I love courses because I still am learning from the other experts who do this a lot, and we get together and we just love bouncing cases off each other and still learning new techniques.

[Ashley Agan MD]
Yeah. Absolutely.

[Gopi Shah MD]
Awesome. So, for our listeners, thank you for tuning in today and joining us. For any new listeners, thank you for trying us out. You can find us on iHeart Radio, iTunes, Spotify, Apple, as well as a new platform called Gaana. I believe it's G-A-A-N-A. It's a little bit more international widely used I think in India. Please remember to rate, select. I think, anything else, Ash?

[Ashley Agan MD]
Hit that subscribe button. It helps us a lot. Rate, share us with your friends. We are on social media as well, Instagram and Twitter, @_BackTableENT.

[Gopi Shah MD]
It's a wrap.

[Ashley Agan MD]
Bye. Thanks for stopping by.

Podcast Contributors

Dr. David Cognetti

Dr. David Cognetti is Chairman of Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University.

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2021, June 22). Ep. 25 – Sialendoscopy [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.