BackTable / ENT / Podcast / Episode #25
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.
BackTable, LLC (Producer). (2021, June 22). Ep. 25 – Sialendoscopy [Audio podcast]. Retrieved from https://www.backtable.com
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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.
In this episode, Dr. David Cognetti joins Dr. Gopi Shah and Dr. Ashley Agan to discuss the workup for salivary gland obstruction and inflammation, the emerging use of sialendoscopy, and different approaches to sialolithotomy.
First, the doctors highlight key aspects of physical examination: observing swelling around the glands, bimanually palpating for stones, and massaging the glands to observe the quantity and quality of saliva produced. For imaging, Dr. Cognetti typically orders CT for suspected stones and MRI for suspected inflammatory disorders. He describes the process of sialography, noting that the outcome may be technician-dependent. The doctors also discuss inflammatory cases where laboratory tests may be appropriate and can reveal autoimmune disorders.
Then, Dr. Cognetti describes his preferred sialendoscopy tools and how he uses them to cannulate and dilate the parotid and submandibular ducts during surgery. He emphasizes the fragile nature of the scopes and the need to protect them from damage. For sialolithotomy, he describes various methods of lithotripsy and ways to prevent thermal damage. He also discusses how he deals with duct perforation and how he decides whether or not to use stents.
The doctors bring up management of patient expectations throughout the episode, as outcomes may vary depending on the individual’s history of stone recurrence.
“Sonopalpation: A Novel Application of Ultrasound for Detection of Submandibular Calculi” - https://journals.sagepub.com/doi/10.1177/0194599814545736?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
“Limited Distal Sialodochotomy to Facilitate Sialendoscopy of the Submandibular Duct” - https://onlinelibrary.wiley.com/doi/full/10.1002/lary.23801
4th Annual Jefferson Sialendoscopy Course- https://cme.jefferson.edu/content/sialendoscopy2021#group-tabs-node-course-default1
[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.
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