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BackTable / ENT / Article
Technical Pearls for In-Office Sialendoscopy
Ashton Steed • Updated Aug 1, 2025 • 38 hits
Sialendoscopy has transformed the management of obstructive salivary gland disease by offering a minimally invasive, gland-sparing alternative to excision. By allowing direct visualization of the salivary ducts, surgeons can identify and treat stones, strictures, or inflammatory debris via an endoscopic approach. Furthermore, by transitioning this process to the office setting as opposed to the operating room, patients can benefit from faster recovery and avoidance of general anesthesia, in addition to an overall reduction of healthcare system costs.
This article outlines practical pearls for performing sialendoscopy in the clinic setting, including ideal patient selection, technical considerations of the procedure, and the use of adjunctive measures such as stenting or marsupialization. Together, these strategies help otolaryngologists build confidence in office-based sialendoscopy while maintaining high standards of safety and patient comfort.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• In-office sialendoscopy provides a minimally invasive, gland-sparing alternative for obstructive salivary gland disease
• Careful patient selection is key; ideal candidates have single-gland disease, mobile stones, and minimal anxiety
• Duct access begins with punctum injection, careful dilation, and intraductal anesthesia followed by gentle irrigation
• Maintaining duct access is critical to avoid false passages or loss of entry during scope advancement
• Small papillotomies generally heal without reconstruction, whereas stents are typically reserved for hypofunctional glands or irregular incisions
• Larger mid-duct stones may require extended papillotomy or marsupialization, with selective use of stents to maintain patency
Table of Contents
(1) Sialendoscopy Overview & Indications
(2) Patient Selection for Office-Based Sialendoscopy
(3) Sialendoscopy Procedural Highlights
(4) Stenting & Adjuvant Salivary Gland Interventions
Sialendoscopy Overview & Indications
Sialendoscopy offers a novel level of procedural flexibility in the realm of salivary gland disease, making possible a minimally invasive, gland sparing alternative to the more traditional total excision. Patients with salivary gland disease typically present with classic symptoms of mealtime swelling and pain involving the parotid or submandibular glands, and sialendoscopy allows for direct visualization of the ductal system to both confirm and treat underlying pathology. While stones are more common in the submandibular gland and stenosis tends to occur more frequently in the parotid duct, both can be effectively managed with sialendoscopy.
Beyond stone retrieval and dilation of strictures, the procedure also allows the surgeon to address salivary “sludge” or inspissated secretions that contribute to obstructive symptoms. By preserving and restoring salivary function, sialendoscopy reduces the long-term risks of xerostomia and its oral health complications, while providing a therapeutic option for patients who wish to avoid more invasive procedures.
[Dr. Ashley Agan]
What are the indications, and what is it actually in case there is someone out there who doesn't know what sialendoscopy is?
[Dr. Wais Rahmati]:
Perfect. Great. Yes. Let's first talk about obstructive salivary gland disease. This is benign disease. It's non-neoplastic disease. Classically, patients complain of pain and swelling in their salivary glands, mainly the parotid and the submandibular glands, at mealtime. Those are your simple classic symptoms. Sialendoscopy is basically a minimally invasive approach to evaluating the ductal system and identifying potential intraductal pathology, obstructive pathology. Really, it's stones for the submandibular gland and stenosis for the parotid gland. It's very easy to break it up into those two categories.
There's an initial diagnostic approach with the sialendoscope and then potentially an interventional approach. You see a stone, you try to retrieve it. If a stenosis, you try to dilate that stenosis, put a stent across it, perhaps. I like to always talk about three S's, stones, stenosis, and sludge. Sludge is that salivary buildup in the setting of an inflammatory process. It could happen in the setting of stones, any obstructive process really. Sometimes it's simply just irrigating the ductal system to provide relief to patients experiencing pain and swelling in their salivary glands. Just going back to the sialendoscopy itself, as I said, it's minimally invasive, but the other really important thing about it is it's gland sparing.
Traditionally, when it came to obstructive stone disease for the submandibular glands, it was gland excision if the stone was in a proximal location, so meaning closer to the gland or within a intraglandular location. Surgery is pretty easy, low-risk profile for the most part, but there is a huge functional component to it. Each submandibular gland produces a quarter to a third of our salivary output. Imagine taking it out for an absolutely benign process. It can be devastating to the patient in the long run. As they age, they may add on a variety of medications that may dry them out and they may not initially be aware of the dryness, but it could be evident, and then all the downstream oral health complications that can come with xerostomia.
Really incorporating sialendoscopy, thinking about sialendoscopy opens up this gland-sparing approach to salivary gland disease, really in the setting of the submandibular gland. Then I think that the other side to this is the parotid gland, which is obstructive disease in the parotid gland has always been neglected. Every patient that comes to me always says, "Well, the doctor told me to suck on sour candy." That's it. You have this, I think, a reservoir of patients suffering with parotid gland disease that prior to sialendoscopy had really no intervention for. I think there's tremendous value in sialendoscopy for the parotid gland and the stenotic disease that often afflicts the ductal system there.
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Patient Selection for Office-Based Sialendoscopy
Thoughtful patient selection is one of the most important factors for success in performing sialendoscopy in the office setting. Patients with single-gland disease, small mobile stones, or a classic clinical history for obstructive glandular disease are well-suited for office-based sialendoscopy. Those with multigland involvement or autoimmune inflammatory disease often present more with more pain and tenderness and may be better suited for the OR where they can receive a general anesthetic.
Patient preference also plays a central role in the decision to do sialendoscopy in the clinic versus the operating room. While most patients prefer to avoid anesthesia and appreciate the convenience of an in-office procedure, those with significant anxiety, low pain tolerance, or a history of vasovagal syncope may be safer undergoing sialendoscopy under sedation or general anesthesia. With time and experience, surgeons may be able to expand their practice to offer even more complex cases in the clinic, but starting with carefully selected patients helps ensure a smoother transition and early success.
[Dr. Ashley Agan]:
Got you. Who is a good candidate to do it in the office? Because I'm sure you still do it in the OR a fair amount, depending on the patient. As you're moving patients to the office, who's the best person to do a sialendoscopy in the office?
[Dr. Wais Rahmati]:
Anyone who I'm concerned has an obstructive problem with their salivary gland. Then patients with small stones either found on imaging or where I have suspicion that they have a stone where you can't palpate it, but sometimes you may actually see it. You may see it, so I use a microscope in my office for every patient encounter.
[Dr. Ashley Agan]:
Rather than loops. Microscope instead of loops. Okay.
[Dr. Wais Rahmati]:
Correct. I have the microscope set up there. I immediately just do an oral cavity examination with the microscope and under high power magnification, sometimes you see these small 2, 3-millimeter stones that they're actually mobile. You can see them move in and out to the distal duct at the punctum. Someone like that, where you can see a small stone, or it just seems like it's very classic recurrent symptoms at mealtime, where it's probably a small floating stone that you can't palpate. That's a perfect setup for sialendoscopy. Then almost every patient who has at least a single gland, single parotid gland, who comes in with a story of recurrent swelling or even chronic pain or intermittent pain, these are all patients that I offer office-based sialendoscopy to.
I think that when someone comes in and they have multiglandular involvement and you're worried about an inflammatory autoimmune process, those are patients initially, I would say, are better in the operating room setting to evaluate. They can be quite tender as well due to the underlying inflammation in the glands, but even in my practice, as it's evolved, most of those patients get four-gland sialendoscopy in the office now, unless they're particularly tender or they're very concerned about pain.
[Dr. Ashley Agan]:
Got it.
[Dr. Wais Rahmati]:
I guess just to continue on in terms of patient selection, it's also about patient preference. I offer all my patients the option of local anesthesia, MAC, and general anesthesia with intubation. Whatever suits them. The majority actually prefer the idea of coming in alone and just having it under local anesthesia and maybe returning back to work. If anyone's concerned about the smallest amount of pain, if they're really anxious, if they have a history of recurrent syncope, those are the patients that I would probably reserve the operating room for.
Sialendoscopy Procedural Highlights
Once the duct has been cannulated with a guidewire, a small amount of local anesthetic is injected around the punctum to facilitate dilation. The duct can then be dilated using disposable dilators for efficiency or sequential probes and bougies for a stepwise approach. In cases where the papilla is poorly defined, a small mucosal injection of local anesthetic may provide tension and improve visualization for cannulation.
After dilation intraductal anesthesia is administered – typically 1–2 cc of lidocaine. This not only provides patient comfort but can also help confirm a salivary origin of symptoms if discomfort is reproduced during irrigation. Irrigation should be performed slowly with a small syringe to avoid excessive pressure. Suctioning is rarely needed, as most patients tolerate small volumes by swallowing or expectorating. Bleeding is generally minimal, unless significant inflammation is present. Once the duct is anesthetized and good visualization is obtained, salivary gland stones can be removed using the basket that extends from the endoscope.
[Dr. Wais Rahmati]:
After I do the dilation, and so again, because my routine is to have the disposable salivary duct dilators in place, I take the guide wire out at that moment. The next step is the intraductal anesthesia. I use 1% plain lidocaine, and I will flush between 1 to 2 cc's of lidocaine intraductally. Now this is another benefit of the office-based sialendoscopy for me because this will give me immediate feedback that what we're dealing with, when symptoms are vague, when patients have these vague symptoms in the region of the salivary glands, but we're not sure if it's TMJ or some other musculoskeletal problem. When you do the irrigation, often they'll feel something. It could be actually a little painful, but it's very quick.
I give them advance warning that "You're going to feel something." Now, if it brings on some symptom that localizes to where they normally have their symptoms, then it confirms that it's likely a salivary gland issue that you're dealing with, as opposed to, "Oh, I've never felt this before. It's in a completely different location." You might rule out a salivary gland cause for their symptoms. It's very brief and very well tolerated, and it generally is enough to be able to at least do the diagnostic sialendoscopy. Sometimes I need to re-dose later if we're doing, let's say, a dilation of a stenotic area.
[Dr. Ashley Agan]:
A small volume, you said, right?
[Dr. Wais Rahmati]:
1 to 2 mLs, not any more than that.
[Dr. Ashley Agan]:
As far as, the pressure applied, is it just very gentle, does that part matter?
[Dr. Wais Rahmati]:
It does because if you go very fast, I've had patients jump out of the seat. Not commonly, fortunately, but it catches them off guard. Slow pressure. I always use very small syringes like 3 cc syringes, so you're not generating big force. Just gently instill the solution. Along the same lines, I had my nurse irrigating during the sialendoscopy. I will tell her to, I would say, "Very gentle irrigation. Do you feel like there's a lot of resistance," as you ask if there's resistance to the irrigation, just to see what we're dealing with in terms of the pathology.
[Dr. Ashley Agan]:
Yes. It's small volume. From a standpoint of suction, you're probably just suctioning very infrequently when your irrigation is starting to build up or something in the mouth.
[Dr. Wais Rahmati]:
Exactly. I hardly actually suction. They're either swallowing small amounts. At some point, it's going to mix with the saline solution that you're irrigating the gland with. Every so often, we stop and the patient needs to just spit out.
[Dr. Ashley Agan]:
It's probably pretty bloodless, too. You probably aren't having much bleeding with this, right?
[Dr. Wais Rahmati]:
Yes. You encounter maybe a drop of bleeding if there's an inflammatory process in the duct, but other than that, it's bloodless.
[Dr. Ashley Agan]:
You've done your intraductal lidocaine, and then you can introduce your scope, I assume. That's the next step, and look around and see what to do.
[Dr. Wais Rahmati]:
Exactly. I've had instances with the submandibular gland or the submandibular duct where I've taken out the scope or taken out the dilator and couldn't get back in. Depending on how you dilated, sometimes there's friability where the duct and the mucosa meet and you basically create a tear. This is where, after I do the irrigation, I reintroduce the guide wire, have the guide wire in the duct, and then pull out the dilator and then Seldinger the scope over the guide wire into the duct just to secure it because it's basically game over if you can't get into the duct after that.
Worse would be the potential for actually being in a false passage and then you're basically irrigating the floor of mouth, and then you get this floor of mouth swelling at which point you have to stop immediately. Always having access to the duct is what I find critical to getting through the procedure.
Stenting & Adjuvant Salivary Gland Interventions
When stones cannot be removed via the endoscope with a basket alone, a small sialolithotomy is sometimes required to access the duct. In these cases, most incisions are small with just a 2–3 mm papillotomy that generally heals well without further reconstruction. Patients are encouraged to hydrate and use sialogogues post-procedure to maintain salivary flow, which helps prevent stricture formation. Formal sialodochoplasty is rarely necessary.
Stenting is reserved for select cases, such as when the duct incision is irregular, distorted, or when the gland appears hypofunctional and unlikely to maintain patency on its own. Despite suturing the stent into place with fine absorbable material, most stents naturally fall out within a week, and by that time the duct is usually well healed with adequate salivary flow restored.
For larger stones located mid-duct, a more extensive approach may be required. In these cases, the surgeon may use a basket to mobilize the stone closer to the punctum, creating tension on the duct before performing an extended papillotomy. If the stone is within approximately two centimeters of the duct orifice, the incision can be marsupialized to create a permanent drainage opening. In some instances, a stent may be placed and the duct repaired around it to help maintain ductal integrity during healing.
[Dr. Ashley Agan]:
Can we talk a little bit, with stones, it's fairly straightforward, right? If you encounter a stone and you use a basket, you remove it. I guess one thing to ask would be when you're removing stones and you need to do a little sialolithotomy to be able to get the stone out, are you formalizing that with a sialodochoplasty at the time of, or how do you think about that?
[Dr. Wais Rahmati]:
Right. If I were to do anything, I would favor putting in a stent. I use a hood lab stents, and that's often in a setting where I'm worried that the gland is a little under-functioning or hypofunctional. If there isn't enough saliva flowing through that's going to keep it patent, or even if in the process of perhaps doing the sialolithotomy, it wasn't a nice linear incision, as the stone is in the basket or coming out, it just seems a little distorted, I'm worried that it might stricture. Then I'll put a stent in for those, but that's actually rather infrequent. Oftentimes, I just leave it open. It's a 2, 3-millimeter incision. It's like basically a little papillotomy. Then I just really encourage them to hydrate and use sialagogue to just keep the saliva flowing through there, that area. Generally, it's fine. I can't recall when there was an issue with it.
[Dr. Ashley Agan]:
Yes. If you do put a stent in, how long does that need to be there?
[Dr. Wais Rahmati]:
I generally tell them as long as it will stay in, I'm happy with it. It usually pops out within one to two weeks, but really it's more around seven days that these stents fall out.
I always wonder, is it the way I sutured it? I've tried different suture materials. I used Prolene initially, now I use a very fine 4-0 Vicryl. It comes out. I think it gets agitated, and as the patients are eating, I ask them to stay on a soft diet and avoid or be very careful when they're brushing and flossing their teeth, but usually around Day 7 it falls out. By that time it should be fine.
[Dr. Ashley Agan]:
Right. Things are healed up and the saliva is flowing, so it's all good.
[Dr. Wais Rahmati]:
Yes. Just along the lines of a sialodochoplasty, if I've made a mid-duct incision, mid-duct sialolithotomy, often those are larger stones. Those I marsupialize.
Podcast Contributors
Dr. Wais Rahmati
Dr. Wais Rahmati is a head and neck surgeon and otolaryngologist practicing at Mass General Brigham in Boston, Massachusetts.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2025, July 1). Ep. 229 – Sialendoscopy: Office-Based Techniques & Best Practices [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.
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