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BackTable / ENT / Podcast / Transcript #229
Podcast Transcript: Sialendoscopy: Office-Based Techniques & Best Practices
with Dr. Wais Rahmati
The sour candy myth: why it’s not always the right Rx for salivary gland obstruction. In this episode, Dr. Wais Rahmati, a board-certified otolaryngologist at Mass Eye and Ear and Harvard Medical School, discusses the development of a comprehensive salivary gland center and the focus on office-based sialendoscopy with host Dr. Ashley Agan. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
Sialendoscopy Overview & Indications
Patient Selection
Preoperative Patient Preparation
Office Setup and Workflow
Procedural Details
Stenting & Adjuvant Salivary Gland Interventions
In-Office Sialendoscopy for Salivary Duct Stenosis
Pearls & Patient Aftercare
Billing & Reimbursement Considerations
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[Dr. Ashley Agan]:
Hey, everybody. Welcome to the Backtable ENT Podcast. My name is Ashley Agan, and I'm so excited today to bring you Dr. Wais Rahmati. He's a board-certified otolaryngologist, head and neck surgeon at Mass Eye and Ear and Harvard Medical School, and has developed a comprehensive salivary gland center with a clinical and research focus on the endoscopic management of salivary gland disorders. Today we're going to talk about office-based sialendoscopy, and I'm so excited. Welcome to the show, Wais.
[Dr. Wais Rahmati]:
Thank you so much. It's great being here with you.
[Dr. Ashley Agan]:
We did an episode on sialendoscopy with Dr. David Cognetti back Episode 25, so it's been a while. Gopi and I talked about just office management of stones back in Episode 88. This episode I'm excited about because this merges those two topics, and we're going to talk about bringing sialendoscopy into the office. I'm super stoked, and you and I connected earlier this year or last year because you wrote the article for Otolaryngologic Clinics. We have August 2025, so this August, there's an issue coming out that's all about office procedures. I reached out to you to contribute, and everyone, check out the article because there's going to be-- we probably don't have enough time to cover everything in this hour, but I'm super stoked to get into it.
[Dr. Wais Rahmati]:
Yes. Thank you for actually getting me involved in that. I quite enjoyed writing it, and this is a great segue. It's like the video and transcript to the article in a way.
[Dr. Ashley Agan]:
Yes, for sure. Tell me a little about you and your background. How did you find yourself in this position, as far as doing office-based sialendoscopy?
[Dr. Wais Rahmati]:
Yes, this is great because about 15 years ago, I completed fellowship training for head and neck surgical oncology. That's what I had been doing actually for the last 10 years or first 10 years of practice. Very early on, I was exposed to sialendoscopy during residency training, and I really enjoyed the procedure. I thought, "This is exactly something that I would want to implement in my practice," and I did. I did very quickly, within probably like the first 6 to 12 months, I brought it into my clinical practice with the support of the department that I was in at the time. At the same time, very early on, I thought, "Wow, this is something that makes sense if we were to do it in the office setting, and in certain circumstances, of course, and in the right patients."
We'll obviously get into that in more detail, but I couldn't do it at my first job. It was not a hospital-based practice. It was an academic practice, but we weren't physically situated. Our private offices weren't situated in the hospital. My second job was, I was in a cancer center, and we had direct access to the operating room, so I was able to bring the sialendoscope. I immediately started doing office-based sialendoscopy, and I was like, "Oh, this is perfect. This is exactly as I envisioned. This is something that works. It's very straightforward, especially for someone who's done sialendoscopy in the operating room setting for years. It's easy to transition, and the patients absolutely love it."
I was minding my own business, and I get this email one day if I would like to build a program around sialendoscopy. I thought, "Well, let's see. I'm good where I am, but I like the idea. I like the idea of diving in deep and building a focused program around something that I'm actually very passionate about." I thought, "Well, if there's a place to establish such a program, the Mass Eye and Ear would absolutely be that place." It's actually exactly how I thought it would be.
I've been here at the Eye and Ear for the last four and a half years, and the practice has completely ramped up. Support from not just the internal academic community, but basically all of New England. That's the other thing. It's become a center for all of New England otolaryngologists and other physicians who now are aware of the services to provide referrals so that their patients can be treated. It's been great. That's where I am now.
Sialendoscopy Overview & Indications
[Dr. Ashley Agan]:
We're going to dig in a little bit into just the administrative aspect of building a program like you have, but first, let's just set a foundation about sialendoscopy in general. 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.
[Dr. Ashley Agan]:
Yes. I feel like removing, now that sialendoscopy is widely known, and I don't know if I would say widespread use, but there's a lot more people using it than there were 10 years ago, but taking out a submandibular gland seems, I think for a lot of patients too, seems extreme. It's like, "Wait, you're going to take my whole gland out? I'm going to have a surgery? I'm going to have an incision here?" Having that more minimally invasive option is nice. I think patients really appreciate that option.
[Dr. Wais Rahmati]:
That's a great point because I think patients are a lot savvier now there. When the idea of gland excision is offered, a lot of them take a step back and like, "Is there something better? Is there a minimally invasive option?" Of course, they're always worried about the nerve, the marginal branch being injured during surgery, so it opens that door to investigating other options.
Patient Selection
[Dr. Ashley Agan]:
Thinking about moving sialendoscopy into the office, how long had you been doing it in the OR before you moved it to the office? The first thing that comes to mind for me in doing it in the office is that sometimes they're pretty easy and straightforward, and sometimes it is really hard, and I'm thinking, "Okay, now I'm going to be struggling with an awake patient as opposed to being in the OR." Talk to me about, I'm sure patient selection comes into it, setting yourself up for success if you're doing it in the office.
[Dr. Wais Rahmati]:
Absolutely. As I started early on, I was doing all sialendoscopy in the operating room for seven years. That's when I transitioned to my second job, and I immediately implemented in the office space. If I had the opportunity, and I think, for anyone who does sialendoscopy, they probably can, after 50 cases, even, immediately transition. Even earlier, really, for simple diagnostics sialendoscopy.
In terms of indications, anyone coming in with symptoms suspicious for obstructive salivary gland disease in the absence of any prior imaging that would suggest salivary stone, ductal stenosis, on an MRI or ultrasound in the parotid gland, those are perfect candidates to just take a quick look under local anesthesia. You might have intentions for intervening on the introductive pathology at the same time, but it's really to confirm salivary gland disease.
[Dr. Ashley Agan]:
Are you doing that at the time of their initial consult in the way that you would scope a patient, or it's got to be scheduled as a procedure?
[Dr. Wais Rahmati]:
I thought about having that opportunity for patients who come from outside of Massachusetts, which I have about 30% of my patients are out of state, try to make it available to them to do it in that fashion, but usually, it's an initial consultation to just evaluate the patient and talk about sialendoscopy. Then we schedule it on another day. I usually have a dedicated procedure day. I typically do four sialendoscopies for the day.
[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.
[Dr. Ashley Agan]:
Yes, that makes sense. Referencing your paper as far as size, for the submandibular gland stones, less than 3 millimeters in the short axis, and for parotid, less than 2 millimeters, and mobile is better when we're speaking about stones specifically.
[Dr. Wais Rahmati]:
Correct.
[Dr. Ashley Agan]:
Is that correct? That's ideal.
[Dr. Wais Rahmati]:
Absolutely.
[Dr. Ashley Agan]:
Most of your patients have imaging, or is imaging a prerequisite to have done before doing office sialendoscopy?
[Dr. Wais Rahmati]:
Not necessarily. Again, for me, I use the endoscope as my imaging modality of sorts. I do get a CT scan if the patient has a larger stone that I can palpate, especially the ones that are in the hilum. I just want to make sure that there aren't any other stones. I just want to get a sense of the size and shape of the stone and the exact location. Often, those patients will probably end up in the operating room anyway, any proximal duct location for the stone. Even those patients, I'm slowly trying to do in the office setting with a sialendoscopy-assisted approach.
[Dr. Ashley Agan]:
If you get imaging, your preference is CT, it sounds like.
[Dr. Wais Rahmati]:
It is.
[Dr. Ashley Agan]:
Is that a non-contrasted CT?
[Dr. Wais Rahmati]:
Yes, it is.
[Dr. Ashley Agan]:
Okay. Just to be able to see that stone and if there's any other ones. Any role for other imaging modalities? You've got your ultrasound, you've got your MR sialography, all these other fancy new ways to image the salivary ducts.
[Dr. Wais Rahmati]:
My other go-to is ultrasound. I will routinely check an ultrasound for patients who have multiglandular salivary gland disease, if I'm worried about autoimmune conditions, just to see if the other glands are involved. If I'm doing sialendoscopy for xerostomia, like if xerostomia is a complaint, I'll get an ultrasound just to have some baseline imaging to see if there is any heterogeneity in the gland, anything that would suggest some inflammatory change within the gland.
Beyond that, I might get an MRI in the context of inflammatory disease, but I certainly wouldn't for stones. I get a sialogram only in the context of having done sialendoscopy, seeing a stenosis that I can actually access. I'll do that for further surgical planning, see if it's amenable to potential dilation in the operating room setting. We're actually lucky to have interventional radiology that does sialography. I use that resource quite extensively.
[Dr. Ashley Agan]:
Okay, cool. Your IR partners are doing the cannulating the duct and injecting the dye for you and everything. Okay, that's awesome.
[Dr. Wais Rahmati]:
Now, every so often, they'll send a patient to me, and I'll cannulate and send them down with a little catheter inside the mouth. It makes life easy.
[Dr. Ashley Agan]:
Nice. Yes. It's nice if you're all in the same place, that way you can help each other out if you need to. You touched on patients who are not good candidates. Any absolute contraindications? Obviously, you mentioned some of it's just patient preference and the type of patient. Some patients are just not good candidates to do in the office, but anything else that you can think of?
[Dr. Wais Rahmati]:
There's the same contraindication for sialendoscopy if you were doing it in the operating room. It's a relative contraindication would be like an acute sialadenitis, where there are ducts inflamed, maybe there's some purulent discharge. There's a higher likelihood of ductal perforation, ductal injury. You might not see much in that setting as well. Beyond that, not really.
Preoperative Patient Preparation
[Dr. Ashley Agan]:
For those patients, if they are acutely infected when you're seeing them, what's your next step? You send them out on a certain course of antibiotics and then they get to come back.
[Dr. Wais Rahmati]:
Correct. I normally go to the routine Augmentin or clindamycin if they're panallergic and I like to give them a 10-day course usually. The other thing which I think is usually underappreciated is steroids. I actually use a good deal of steroids for patients. I give them a simple Medrol Dosepak. If a patient comes in and they have purulent discharge, I'll start off with just antibiotics and I'll give them a prescription for Medrol with the instructions to take it in 48 hours or 72 hours if there is no improvement, if there's progression in symptoms. Sometimes I will actually just give a Medrol Dosepak in the absence of purulent drainage from the duct because it's just inflamed. It just needs to cool down a little and often they respond really well to that.
Just along the same lines as of just simple preliminary management of these patients. The other thing I want to take this opportunity to talk about are sialogogues. I think that the teaching, the classic teaching or instruction everyone gives to patients is sour candy and just do it. There's no conditions around it, parameters around it to safeguard the patient. If the patient is completely obstructed and you're encouraging ongoing salivary production, it's got nowhere to go, so that gland is going to get more and more distended. I tell patients to try a sialogogue, but if it seems like symptoms are worsening, then immediately stop. Switch over to a bland diet and a soft diet because all that mechanical chewing is an additional stimulant for salivary production. That's what I do first, let it cool down, reassess–
[Dr. Ashley Agan]:
Is there a rule for hydration?
[Dr. Wais Rahmati]:
Absolutely.
[Dr. Ashley Agan]:
Do you tell people to drink a lot of water, bland diet, soft diet, massage?
[Dr. Wais Rahmati]:
All the classic teachings, yes. Hydration is key, warm compresses, massage, ice packs help some patients. I let them do what works for them, but those are absolutely Top 3 on the list, plus or minus antibiotics, plus or minus steroids, and then there's the care around the sialogogues.
[Dr. Ashley Agan]:
The way I explain it to patients is it's a plumbing problem. Ultimately, if you have a blockage, that has to be removed so that saliva can flow.
[Dr. Wais Rahmati]:
Exactly. Let it cool down for a few weeks, you bring them back to just reassess, make sure everything is back to normal or near normal, and then get them teed up for a sialendoscopy.
Office Setup and Workflow
[Dr. Ashley Agan]:
Moving on to just talking about your office setup. You mentioned your office is within the hospital. Are you just bringing up the same set that you use when you're in the OR?
[Dr. Wais Rahmati]:
That's exactly it. I have a very small setup. The rooms are cozy.
[Dr. Ashley Agan]:
I like that. Cozy. They're not small, they're cozy. [chuckles]
[Dr. Wais Rahmati]:
Actually, in the article that's coming out, it's a picture of my office setup, and we've got a nice comfortable chair that reclines and the leg is elevated as if you're singing in an ottoman. They're comfortable and they can lean back. I've got my microscope set up there. Then we have a simple tower and a mayo stand. We bring in the sialendoscopy equipment. I even have a mini bovine bipolar setup as well, if I really needed to do a more advanced procedure. It's like really just bringing the operating room to the office.
[Dr. Ashley Agan]:
Yes. Are they lying flat, or are they just reclined a little bit? Does it matter from your comfort level?
[Dr. Wais Rahmati]:
I want them to be comfortable, and also for me to feel like, "Okay, this is ergonomically correct for me." Interestingly, I always stand when I'm doing the submandibular gland as I'm looking down into the floor of mouth. When I do the parotid glands, I'm sitting next to the patient, so it's like an eyes-level view of the parotid duct or the parotid papilla.
[Dr. Ashley Agan]:
That makes sense. Yes. Any particular instruments or items on your mayo that you want to highlight that may not be part of the typical sialendoscopy setup in the OR? For example, what size scope are you using in the office?
[Dr. Wais Rahmati]:
Okay, great question. I think you can do a lot with just the 1.1 scope. There are four sizes. There's a diagnostic 0.8-millimeter scope. Then there are three interventional scopes, so they have a working channel, a 1.1, 1.3, and 1.6-millimeter scope. I think the 1.1 has become my workhorse because I can thread a smaller-size guide wire through it, and there are actually baskets that are now designed for the 1.1 as well.
[Dr. Ashley Agan]:
Nice. With the 1.1, you can do everything you need to do because there are smaller baskets that you can thread through that now. Because with the 0.8, you're just looking.
[Dr. Wais Rahmati]:
You're just looking.
[Dr. Ashley Agan]:
You can see, but you can't really intervene.
[Dr. Wais Rahmati]:
Correct. Now, in an ideal world, we'd have all four scopes available to us. Fortunately, I do. We had it set up where all either three or four scopes were packaged into a single bin and then reprocessed. We realized that, "Okay, I'm using one or two scopes, they're reprocessing three or four, and scopes, unfortunately, are breaking in the sterilization process." We now have them individually packaged. I can pick and choose what I need, and I'll have it available.
Because it becomes relevant in terms of sizing up the stenosis and trying to access deeper into the gland, especially in the parotid gland, if you're trying to assess the entire ductal system or as far as possible, approximately into the duct. To have a smaller scope so you can downsize and advance through gives you a better sense of the pathology you're dealing with. Are you dealing with just a focal area of stenosis or a more diffuse area that is really less amenable to any intervention?
[Dr. Ashley Agan]:
You have your scopes available. Do you typically just start with your 1.1 since that's your workhorse, or do you like to start with the 0.8 and look, and then go, or maybe it depends on the patient?
[Dr. Wais Rahmati]:
I start with the 1.1 for a scope with a working channel for every case. I'll tell you one of the critical tips on sialendoscopy is ductal access. If you can't get into the duct, you can't do the procedure. One trick to doing that is Seldingering the scope into the duct. It's not so relevant for the parotid gland. The parotid duct is very easy to access generally, but the submandibular duct, the papilla, the mucosa around it can be very floppy. The first thing I try to do is access the duct with the guide wire. Once I have the guide wire in place, and the other tip here is try not to manipulate the mucosa in that area. If you start to grab it with tooth pickups or anything, it's going to distort the mucosa. Now you're going to see these tiny little holes that look like the punctum and you get lost.
Advice number 1 is just respect the punctum, respect the mucosa around it. Just try to cannulate the duct either with a salivary probe, if you don't want to use the disposable equipment, or, as I like to do it, I like to go through with the smaller size. There's a smaller size guide wire that's 0.015 inches, as opposed to the 0.018, which is more of the standard one. It's a little bit flimsier, but it's great because, with that, you can use the 1.1 scope. If you use a larger guide wire, you can't use the 1.1 scope, you can't thread it over, then you need to at least do the 1.3 or the 1.6.
[Dr. Ashley Agan]:
From a local anesthesia standpoint, how are patients-- You've got them reclined, you've got everything set up, everything is ready, do you do anything to anesthetize that area that's not going to distort, and make it hard for you to see the papilla like we were just talking about? How do you make it comfortable, but also not make it hard for yourself?
[Dr. Wais Rahmati]:
That's a great question. Your anesthetics are your topical anesthetics, your injectable, and your intraductal anesthetics. I hardly ever use a topical anesthetic. If a patient is very fearful of the needle and they're worried about the pain that might come with a little needle prick, then I'll use a little Cetacaine. Be careful with applying Cetacaine onto a gauze and then applying it there because it deforms the mucosa, and it creates this ridge-like change to the mucosa after you've removed the gauze. I'd apply it with a little cotton tip applicator to the area just around the punctum, but probably 95-99% of the time, I don't actually use a topical anesthetic.
The sequence would be that I would access the duct with the guide wire or a salivary probe just to make sure I'm in the duct and that there is no obstruction. You try to advance it carefully with very little pressure and see how far it goes in, okay? Remarkably, most patients tolerate this rather well.
[Dr. Ashley Agan]:
Without anything?
[Dr. Wais Rahmati]:
Without anything.
[Dr. Ashley Agan]:
Okay, just talking them through it, "You might feel a little pressure," this, that.
[Dr. Wais Rahmati]:
Exactly. I think if you let them know that you're going to feel a little something or-- and this is the beauty of doing it in the office, I always tell patients, "If this is uncomfortable, raise your hand, I'll immediately stop and we will reassess."
[Dr. Ashley Agan]:
Do you have to tell them from a positioning standpoint, do you have to coach them as far as parking their tongue in a way where it's not trying to participate? You know what I mean? Sometimes I feel like patients don't realize that they're moving their tongue all over the place when you're trying to do a procedure in their mouth.
[Dr. Wais Rahmati]:
Yes. Sometimes I do. I have them retract their tongue midline back and that sometimes brings the the papilla straight up centrally, which is nice. Often other times what I do is I simply just softly retract the tongue with my finger. I have one finger on the teeth and one on the tongue just to get my exposure.
[Dr. Ashley Agan]:
What we forgot to mention, we talked about setup, but what about personnel? Do you have an assistant with you, more than one assistant? What do you need from a personnel standpoint?
[Dr. Wais Rahmati]:
Right, so I have a dedicated nurse who helps me with the procedure. It's really helpful to have one or two trained individuals, a nurse, or a medical assistant that can be there for the procedure. They basically set up, they'll help with the irrigation and I have them document certain things for me as we're doing it. For instance, I will have them document the time to different steps. I'm just gathering all this information and then help with the cleanup afterwards.
[Dr. Ashley Agan]:
Okay, so like the OR.
[Dr. Wais Rahmati]:
Exactly. Yes.
Procedural Details
[Dr. Ashley Agan]:
You've got a nurse and another assistant. Okay. We are at the point where you've used your small guide wire to cannulate, and then what happens next as far as–
[Dr. Wais Rahmati]:
This is where I will inject. I use a 30-gauge needle with a small amount, less than 1 cc of lido with epi, and inject the mucosa around the actual punctum. You see it bleb up, and that should suffice for the next step, which is the dilation. There's two approaches here. You can use the disposable salivary duct dilators to quickly dilate, or you can just sequentially dilate with non-disposable salivary probes, like what are comparable to the lacrimal probes. Alternatives would be to use the non-disposable bougies to do the dilation. I'll do the dilation next.
[Dr. Ashley Agan]:
You're injecting your local after you have isolated your duct and that way you're not at risk of deforming the floor of mouth and then not being able to access the duct.
[Dr. Wais Rahmati]:
Correct. Now the caveat to that is sometimes patients have a really floppy papilla. It's just very poorly defined. I'll actually inject in that situation. After attempting to try to access the duct and failing, I'll inject the mucosa, which gives it tension. Then when there's tension, you can actually see the punctum and then cannulate it at that point.
[Dr. Ashley Agan]:
Do you ever have them have a little bit of a sour candy or a lemon or something to help see saliva coming from somewhere?
[Dr. Wais Rahmati]:
Absolutely. Again, one of the benefits of working with an awake patient, so they can listen to what you ask them to do. Yes, I have all sorts of sour candy.
[Dr. Ashley Agan]:
You have like a selection. You open up your candy drawer–
[Dr. Wais Rahmati]:
Lemon, sour cherry, Warheads, whatever. Actually, I tell patients to eat beforehand. I encourage them not to come in dehydrated, not just have a cup of coffee. Have breakfast, have something to eat, definitely have some water beforehand to come in hydrated. If there is a problem where there isn't real visible salivary flow, and sometimes that's the case because the gland is hypofunctional in the setting of obstruction, I'll use a sialogogue to stimulate flow. The other little trick or tip there is the degree of symmetry between the two papillae is quite great. You can massage the gland on the other side or milk the duct and see where saliva is coming. Then it's approximately on the other side of the lingual frenulum for the duct that you're trying to get into.
[Dr. Ashley Agan]:
That makes sense.
[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? How much do you–
[Dr. Wais Rahmati]:
1 to 2 mLs, not any more than that.
[Dr. Ashley Agan]:
As far as, the pressure applied, is it just a 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. Yes.
[Dr. Ashley Agan]:
Yes, so once you gain access, don't lose it. Always have something. [chuckles]
[Dr. Wais Rahmati]:
Exactly. Yes.
[Dr. Ashley Agan]:
Yes. It is quite a humbling procedure I feel like. Everything is just tiny movements, but it can be so satisfying when you can pull a stone out and patients feel instantly better.
[Dr. Wais Rahmati]:
Oh, it's wonderful.
Stenting & Adjuvant Salivary Gland Interventions
[Dr. Ashley Agan]:
It's the best. 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.
[Dr. Ashley Agan]:
Got you. Even with suturing it in, it just–
[Dr. Wais Rahmati]:
Oh, yes. 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.
[Dr. Ashley Agan]:
If you have a stone that's just too big to pull all the way out, but it's mid-duct right there in the floor of mouth where you can feel it, yes. Do you cut down on your scope, or do you just feel where the stone is and cut down to it? How do you think about having your scope there with you, and how that makes it easier?
[Dr. Wais Rahmati]:
I will leave the scope in if I'm in the operating room, sometimes I'll have an extra pair of hands. It's a little easier to do it that way, but usually, I'll pull the scope out. What I'll try to do sometimes in these situations where there's a larger stone where you can't pull it all the way to the punctum, I'll still use a basket, a basket to mobilize it to some point closer to the punctum rather than closer to the hilum. Also, it puts tension on the duct, it immobilizes it, and if I'm within 2 centimeters of the punctum, I'll make an extended papillotomy over the wire and get to the stone there, and then either marsupialize it where I've removed the stone or even sometimes I'll put in a stent and then close it up and repair the duct in that fashion if I'm really close to the punctum.
In-Office Sialendoscopy for Salivary Duct Stenosis
[Dr. Ashley Agan]:
Switching gears and talking about stenosis, so how do you think about and treat stenosis in the office with this technique?
[Dr. Wais Rahmati]:
This is where doing your initial diagnostic sialendoscopy is key. You want to go in and evaluate the duct and see what you encounter. When you're dealing with stenosis, you want to identify the location of the stenosis in relation to the punctum, so how far in? Is it a distal duct stenosis, is it mid-duct stenosis, or is it proximal? Then, how severe is it, in terms of just the degree of narrowing within the duct? Is it like a tiny pinhole, or is it, like, okay, you can't accommodate a 1.1 scope, but it's passable with a 0.8 scope, so it is definitely reduced, but it's still big enough that it's probably not clinically too relevant.
Then also, what is the length of the stenosis in terms of severity? Is it a diffuse stenosis? You go in and all you can evaluate is with a 0.8 scope through the length of the duct. From punctum or a couple of centimeters in, all the way to the hilum, is it like 2, 3, 4 centimeters long? When I have that information in hand, that's where I'm going to decide, "Okay, this is something that I should dilate or not." If I can get in 5 to 7 centimeters into the ductal system, pass some areas of bifurcation, and it's pretty smooth without even a 0.8, I probably will not dilate anything in that situation. If there is diffuse stenosis, I don't touch those patients anymore.
I did very early on. I tried to dilate them, but you're just creating an opportunity for that entire region to re-stenose and potentially re-stenose bad, like more severe than what it was initially. Ideal would be something membranous. You see this little thin membrane of narrowing or 1 to 2 centimeters stenosis that is in a distal or mid-duct location. The other key thing is ideally you'd be able to get beyond the stenosis to an area where it's normal. If I actually dilate a stenosis, I will generally try to put a stent across it. If the stenosis is tapering off and you can't get good proximal exposure or clearance, then I don't stent those patients because if you put a stent there, it's more than likely going to occlude and get infected would be a problem.
What I do after I've identified the stenosis, and often you'll see this little pinhole under direct visualization, I'll advance a guide wire in and irrigate as I'm trying to do this, keep the system patent, and then see if I can advance the guide wire through the stenosis without any resistance. If there is resistance, if you can't, it's like it completely stops or it starts to deform the duct because it's not getting through that. That's where I tell the patients, "I can't do anything more today. It wouldn't be safe to try to dilate this." Those are the patients that I'll send for a sialogram for further assessment.
If there is no obstruction, then what I'll do is dilate using the smallest salivary probe or salivary duct dilator. This is the other thing that I recommend doing is on the sialendoscopes, you have 1-centimeter markings. You want to measure where you are in relationship to the punctum. Then I mark on the salivary duct dilators with a marking pen, "Okay, this is 3, this is 4, this is 5 centimeters." I do a 1-centimeter increment of dilation. I'll go in 1 centimeter beyond the stenosis because I don't know what's 2 centimeters beyond, and then reintroduce the scope and reassess, and then gradually advance and also dilate up, go to the next size up, and then hopefully be able to put a stent in.
[Dr. Ashley Agan]:
You've got your guide wire in the whole time, and then you put your scope in, you look, and then you take it out, and then you do your dilator. You take that out and you look, and you're back and forth assessing.
[Dr. Wais Rahmati]:
Exactly.
[Dr. Ashley Agan]:
Okay.
[Dr. Wais Rahmati]:
Yes. While you have the guide wire in place, you can retract it if you want to get a better unobstructed view. Also, the guide wire can be helpful in getting you in where perhaps the duct is making a sharper turn. It can help navigate and advance the scope if one is finding some difficulty with that.
Pearls & Patient Aftercare
[Dr. Ashley Agan]:
As far as for your office procedures, do you set a time limit for how long you want to-- attempts? Because sometimes, even with stones too, you're doing several attempts, and sometimes it's easy, but sometimes it's taking longer. I would think that with an awake patient, patients might only have a certain amount of tolerance to be able to sit there and allow you to work. Do you think about that at all?
[Dr. Wais Rahmati]:
Absolutely. I allocate an hour to each procedure and it doesn't take that long. For an interventional procedure, let's say for stones, usually within half an hour, I can take care of it unless it's more involved, it's more proximal location, it can be a little bit more tricky. For stenosis as well, it really takes 20 to 30 minutes, in most instances. Now, you should realize within a reasonable period of time, within 10, 15 minutes, is this doable or not. You're not going to just keep pressing on, and the patient is going to give you feedback. Either they're really uncomfortable perhaps, or they start to complain, maybe that they're having a jaw ache or something like that, in which case you think about an alternative.
[Dr. Ashley Agan]:
Anything else about the procedure specifically, tips or pearls, before we just move on to, I want to talk a little bit about just aftercare from the patient's standpoint.
[Dr. Wais Rahmati]:
No, I think I covered the key, I guess maybe in summary, advice, or recommendations. The patient should be well-hydrated prior to the procedure. They come in salivating, which is good. Then, ductal access is critical. Trying to do it in the most atraumatic fashion just to get the access and then, small amounts of anesthesia are needed to initiate and get through the procedure. Then getting patients' feedback as you're going. My nurses constantly ask, "Are you okay? Is everything fine?" Patients are reassured and it's reassuring to hear back that they're doing well, and you continue to push on until you're done.
[Dr. Ashley Agan]:
Then, so when they're all done and they're headed out, what are your post-op instructions for them?
[Dr. Wais Rahmati]:
All the same things. We encourage hydration, sialogogues, really to get the saliva flowing.
[Dr. Ashley Agan]:
Do they need antibiotics?
[Dr. Wais Rahmati]:
Great question. I will routinely give antibiotics and a longer prednisone taper for patients who I stent. This is really the parotid patients who have stenosis, I'm able to dilate and put a stent in. I've had a couple of patients where they were infected in the absence of antibiotics. I do the antibiotics. I like Doxy. I like the anti-inflammatory properties that come with Doxy. I give that for a couple of weeks unless there's obviously any sensitivity to it. Then I do a prednisone taper. I start with 40 milligrams and taper down to 10. There is some evidence that shows that a longer course of steroids reduces the restenosis rate or the likelihood that they're going to need a second procedure. I'll do that for those patients.
In the absence of dilation and stent placement, for the parotid patients, and very early on, and still, I don't know if the duct goes into spasm or something happens. It's not uncommon for patients to experience a little bout of sialadenitis. They complain of pain and swelling, a little bit similar to what they normally experience, but maybe perhaps more intense. I do give patients a Medrol Dosepak just to keep, just to have in case they have symptoms that are bothersome, and then advise them to take it maybe in 24, 48 hours if they're not feeling well.
Most people are just fine with warm compresses, massage, sialogogues, some NSAIDs for pain relief, soft diet for any incisions in the floor of mouth, mid and proximal duct, sialolithotomies for the submandibular gland. I'll generally place them on some antibiotics that prevent any infection in the floor of mouth.
[Dr. Ashley Agan]:
Yes. In my experience, the stone patients feel so much better with the stone being out that. There's not a lot of postoperative pain because they were in so much pain having that obstructed duct.
[Dr. Wais Rahmati]:
Correct. Right. Pain is hardly an issue and it's hardly ever any worse than what they've experienced from the obstruction. I generally recommend Tylenol and an ibuprofen or something similar, but hardly ever do they need anything stronger than that.
Billing & Reimbursement Considerations
[Dr. Ashley Agan]:
As we're rounding this out, I think we have to talk about where sialendoscopy is from a billing reimbursement standpoint and how you've been able to build this salivary gland center because you and I and patients all find this extremely valuable because it's minimally invasive, they're avoiding having their gland completely removed. With you doing it in the office, they're avoiding anesthesia, so I would imagine there is cost savings with that, but because sialendoscopy doesn't have a code, I think it has not been as widely adopted because it's like, how do we get this paid for? The scopes are expensive, they're delicate, they break. I think a lot of people can make a very good argument for why not to do it, so talk me through it. [chuckles]
[Dr. Wais Rahmati]:
Right. Everything you said, I completely agree with. That is probably one of the greater challenges in establishing a program. I think on my side, having the volume that I do justifies, moving forward with it. Certainly, for I think a lower volume practice, it is inherently challenging, as you said. We don't have a dedicated CPT code for this. The traditional salivary gland codes are, first of all, it doesn't represent what you're doing. If you're doing a diagnostic sialendoscopy, you can't use any of the other codes. Even according to the CMS rules, you can't. You have to use the 42699, the unlisted salivary code for it. Otherwise, you're not appropriately billing.
That being said if you did sialendoscopy with a sialolithotomy or a sialodochoplasty, the insurance companies will pay for the traditional codes, and they will again omit the sialendoscopy. What I've done, and there's a learning curve to this, where I initially started with the unlisted code, it wasn't paying, when I thought, "Okay, let's try a combination of the unlisted for the ones that are purely diagnostic and add the traditional codes," and realize that reimbursement is rather poor for this. For the last couple of years now, very consistently, I use 42699 code for almost everything, unless I'm not really doing it, like sialendoscopy is a secondary, just a quick look, and really, it's a large stone, it's right there. It'd be silly to not just do the sialolithotomy.
Everything else gets a 42699 code, and then the charges are based on the extent of surgery. If it's a diagnostic code, it's just we code it as 42699-01, and then everything incrementally goes up in terms of complexity.
[Dr. Ashley Agan]:
You've just created a fee schedule based on all of your expenses and how hard it is, and the time.
[Dr. Wais Rahmati]:
Correct. That's exactly what we've done, and we've stuck to it. In terms of reimbursement, the government payers, unfortunately, don't pay. It's essentially a write-off, but these are patients that need it. Again, I see them and I take care of them, not an issue. The commercial payers ultimately pay, but it requires persistency from your billers and coding team, multiple rounds of appeals. We send a package, I send a paper, a few papers that I've written, some justification and note, we send the patient's documentation and why this is being done, and the benefits to the insurance company, like cost savings.
There's a couple of really good articles that show that there's tremendous cost savings by doing it in the office. The payers pay and it's variable. Some payers pay within two months, and others, I think, I received some reimbursement after 18 months.
[Dr. Ashley Agan]:
Oh my gosh.
[Dr. Wais Rahmati]:
I'm happy to get paid 18 months later, but it's hard to plan your budget in some ways when there is so much in accounts receivable. I think here, the emphasis I want to make is, pick a way of doing this. I think the right way to do this is to do the 42699 code and just follow through with the appeals with the insurance companies and see it come through. Unfortunately, with Medicare and Medicaid, the reimbursement is not great. Now the managed Medicare and Medicaid programs will pay actually. There is a reasonable reimbursement through them.
[Dr. Ashley Agan]:
Correct me if I'm wrong, but for tracking purposes, you want to use that code so that eventually there will be a code for sialendoscopy, right?
[Dr. Wais Rahmati]:
Absolutely. We're trying to work on that through the Salivary Gland Committee with the AAO-HNS. Yes, hopefully in the next few years, maybe there will be a code.
[Dr. Ashley Agan]:
Yes. You feel positive about some momentum that's happening. How long have you been doing it in the office? How long have you had your salivary gland center?
[Dr. Wais Rahmati]:
The last five years.
[Dr. Ashley Agan]:
At this point with the payers, do they know you now, meaning like they've received your packets and your appeals and all that before? Are you sending less appeals? Because now they're like, "Oh, yes, it's that guy."
[Dr. Wais Rahmati]:
That's a good question. I'm not sure. I should check. I feel like with some payers, we see a lot of Blue Cross Blue Shield in Massachusetts, and they seem to be more consistent in payments, probably within a six-month period. They probably are seeing the volume come through on a regular basis and the justifications for it. I put a little sentences in my operative note that sialendoscopy was necessary for these reasons or the procedure couldn't be done in the absence of sialendoscopy. Because if you have a floating stone, you're not going to be able to retrieve it any other way. I think they realized that it's reasonable to provide some level of reimbursement for this.
[Dr. Ashley Agan]:
Yes. I think it's a no-brainer for the people who are intimately involved with it. The surgeons and the patients see the benefit so clearly, especially being able to do it in the office where patients can just come in, and I feel like your patient satisfaction scores are probably through the roof because patients who don't have pain when they eat anymore are really happy patients.
[Dr. Wais Rahmati]:
Oh, they absolutely love it. Yes. As I said, I have patients who come in either before work and go right after the procedure straight to work, and there's really no downtime and back to normal activities, which is great.
[Dr. Ashley Agan]:
Yes. Cool. Cool. I'm super excited for what you're doing, and I appreciate you so much for taking the time to talk to me today and for being a collaborator on the upcoming issue of Otolaryngologic Clinics. Everybody definitely go check that out because there's more pearls in there that we weren't able to even get to today. Anything you want to leave our listeners with?
[Dr. Wais Rahmati]:
Yes. Keep an eye out for our next Harvard Sialendoscopy Symposium. Don't think we're going to have one this year, but hopefully, next year, AHNS meets in Boston. I plan to host it at that time. Then you can make my email available to anyone who wants to reach out to me and like to shadow and come in, and we can set up a day to see how office-based sialendoscopy works. I'm happy to be a host.
[Dr. Ashley Agan]:
Cool. That's awesome. Thank you so much. This was wonderful.
[Dr. Wais Rahmati]:
Thank you so much.
Podcast Contributors
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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