sialoendoscopy balaji
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SIALOENDOSCOPY – ASSISTED
SIALOLITHECTOMY FOR SUBMANDIBULAR HILAR
CALCULI
BY A.BALAJI ,.DEPT OF OMFS
INTRODUCTION
CLASSIFICATION OF SALIVARY GLANDS
FUNCTIONS ANATOMY DISEASES
CLASSIFICATION OF SALIVARYGLANDS
MINOR
They are numerous widely distributed in the oral cavity.
600 to 1000 in no. mostly located at junction of soft and hard palate
MAJOR
They are paired glands
parotid
sub mandibula
r
sublingual
SecretionsAre
SerousIn
nature
MixedBut
MostlySerous
MixedBoth
MucousAnd
Serous,Mostly
Mucous.
ParotidGland
Sub mandibular
gland
Sublingual
gland
SALIVA
1500 ML per day PH VALUE: RESTING GLAND -
7 ACTIVE
SECRETIONS IS ABOUT 8
FUNCTIONS Lubrication for
speech Helps in
swallowing and mastication Digestive properties
Antibacterial Immunological properties
COMPOSITIONS
ORGANIC proteins urea uric acid
lysozymes IgA
Amylase
INORGANIC Sodium potassium chloride bicarbonate calcium phosphate
EMBROYOLOGY
All salivary glands develop from embryonic oral cavity as buds of epithelium that extends into underlying mesenchymal tissues
These epithelial ingrowths or anlages ,are apparent at 8 weeks gestation and then branch to form a primitive ductal system and eventually become canalized to provide structural salivary gland unit for drainage of salivary secretions.
This unit consists of a myoepithelial cell , intercalated duct , striated duct ,excretory duct.
Around 7 th or 8 th month in utero secretary cells called acini begin to develop around ductal system.
Acinar cells are classified as serous cells –produce thin watery
serous secretions. mucous cells-produce thicker
mucous secretions.
Anatomy of submandibular salivary gland Divided into Superficial and deep part Location-digastric triangle(formed by
anterior and posterior belly of digastric muscles and inferior border of the mandible)
Surfaces- medial surface rests anteriorly-mylohyoid muscle middle part-hyoglossus posteriorly-wall of pharynx
ANATOMY OF SUBMANDIBULAR SALIVARY GLAND
surfaces
Inferior surface-is superficial, seen in digastric triangle, directed downwards and laterally.
Lateral surface-is hidden from view of mandible, divided into anterior and posterior part.
Anterior part –lies in contact with medial surface of body of mandible below the attachment of mylohyoid muscle.
Posterior part-separated from body of mandible by medial pterygoid muscle.
PICTURE SHOWING SUBMANDIBULAR SALIVARY GLAND ,WHARTONS DUCT AND ITS CORELATION WITH
ADJOINING STRUCTURES
Stylohyoid ligamentInferior alveolar nerve,
vesselsNerve to mylohyoid
Submandibular salivary gland
Sublingual salivary glandMedial pterygoid
MylohyoidgenioglossusLingual nerve
Anterior belly of digastric
Deep part - passes in interval between the mylohyoid ( laterally ) hyoglossus (medially)
NERVE SUPPLY -Submandibular gland is innervated by the facial nerve through submandibular ganglion via chorda tymphani nerve.
BLOOD SUPPLY -Branches of facial and lingual arteryLYMPHATICS – drains into submandibular lymph nodes ,through them into deep cervical lymphnodes ,particularly jugulo-omohyoid node.
INNERVATION OF FACIAL NERVE TO SMS GLAND
INTER RELATIONSHIP BETWEEN DUCTAL SYSTEM AND LINGUAL NERVE
LATERAL VIEW
Additional relationships
Gland is covered by 2 layers of fascia formed by splitting of investing layer of deep cervical fascia.
Superficial layer covers the inferior surface of the gland and attaches to the lower border of the mandible.
Deeper layer covers the medial surface and is attached to the mylohyoid line of the mandible.
WHARTONS DUCT-•2-4mm in diameter & about 5cm in
length.•It opens into the floor of the mouth thru a punctum. •The punctum is a constricted portion of the duct to limit retrograde flow of bacteria-laden oral fluids.•Duct arises in the deep lobe and runs antero medially ,Lingual nerve crosses the duct inferiorly, after immediately arising from deep lobe.
Some terminologies Sialolith-salivary calculi. Sialolithiasis-process of formation of salivary calculi.
Sialography or sialogram-repeated radiographic examination of salivary glands after injection of contrast medium into the salivary duct.
Sialochemistry-examination of electrolyte composition of saliva
Sialoendoscopy-specialized procedure that uses a small video camera with a light at the end of the flexible canula, which is introduced into the ductal orifice.
Sialometry-is a measure of salivary flow
SCINTIGRAPHY-the production of, 2 – dimensional images of distribution of radio activity in the tissues after internal administration of a radiopharmaceutical imaging agent ,the images are obtained by a scintillation camera,(gamma camera).
LITHOTRIPSY-procedure involving the usage of high energy shock waves to fragment and disintegrate or destruct the calculi.
sialolith
They are calcified structure develop with in ductal system of major and minor salivary glands.
Major cause of both-chronic recurring sialadenitis ,acute suppurative sialadenitis.
Stones composed of inorganic calcium and sodium phosphate salts.
They are believed to arise from deposition of these salts around nides of debris with in duct lumen.
Sialoliths continue ……
These debris may include inspissated mucus , bacteria , ductal epithelial cells or foreign bodies (coagulated).
Prevalent in men than women ratio. 2:1. Peak incidence age = 30-40 years. Submandibular gland involvement is 80 %. PH value of these secretion is 6.8-7 %. Increased concentration of calcium and
phosphate ratio. Mucous Secretions are more viscous.
Pathophysiology
Dehydration Concentration of saliva
Fasting or Anorexia Stasis of saliva
Drugs- Anti-histamines, Anti-cholinergics. Decrease production of saliva
Stone can cause stasis of saliva and subsequent bacterial ascent into the gland. Infection most commonly from S. aureus or
Strep Viridans.
ETIOLOGY OF SIALOLITHS EXACT CAUSE OF SIALOLITH FORMATION IS
NOT KNOWN, But 3 prerequisites stand out as primary
etiology 1) NEUROHUMORAL CONDITION> leading to
salivary stagnation . 2) A nidus or matrix for stone formation. 3)some metabolic mechanism may favors
precipitation of salivary salts into the matrix in the presence of coexisting inflammation.
4) long tortuous duct and situated lower level than its orifice ,so increased salivary stagnation, so increased calculus formation.
Signs and symptoms
Pain and swelling are exacerbated during mealtimes
Check for flow of whartons duct Check for tenderness of
submandibular salivarygland Palpate for stone in floor of the
mouth Check mandibular occlusal
radiograph
TREATMENT
Conservative Warm compresses Sour candy Pain relief- analgesics Oral fluids Discontinue anti-histamines Oral antibiotics- Cefalexin 500mg PO QID X 7d.
Surgical Wire basket retrieval under fluoroscopy. Duct cannulation Gland removal for recurrent cases SIALOLITHECTOMY
Lithotripsy (extra corporeal shockwave lithotripsy)
Sialoendoscope ,lithotriper
PURPOSE
TO ACESS THE CLINICAL EFFECTS OF ENDOSCOPY ASSISTED SIALOLITHECTOMY FOR SUBMANDIBULAR HILAR CALCULI
MATERIALS AND METHODS
STUDY WAS TAKEN IN 70 PATIENTS WITH SYMPTOMATIC STONES IN HILUM OF SUBMANDIBULAR SALIVARY GLANDS.
FROM : DECEMBER 2005 THROUGH MARCH 2011.
OPERATIVE DATA WERE ANALYZED RETROSPECTIVELY AND FOLLOWED PERIODICALLY POSTOPERATIVELY.
GLAND FUNCTION WAS INVESTIGATED BY POST OPERATIVE SYMPTOMS,CLINICAL EXAMINATIONS,SIALOGRAPHY,AND SCINTIGRAPHY.
DIAGNOSIS
BY, ONE OR A COMBINATION OF RADIOGRAPHIC INDICATORS
CROSS SECTIONAL MANDIBULAR OCCLUSAL FILMS
LATERAL PROJECTIONS OF GLAND CONE BEAM COMPUTED
TOMOGRAPHY
CASE SELECTION
INCLUSION CRITERION WAS THAT ,THE STONES WERE SITUATED AT OR PROXIMES TO THIRD MANDIBULAR MOLAR REGIONS
STONES WERE VERIFIED TO BE IMPACTED AFTER HILIUM OF THE WHARTONS DUCT UNDER ENDOSCOPIC VIEW
AMNEABLE TO BASKET RETRIVAL WERE EXCLUDED
SIALOENDOSCOPY
LADUSCOPE T FLEX PD-HS-0250 ENDOSCOPE
HIGLY FLEXIBLE ,SEMIRIGID ENDOSCOPE WITH NITINOL SHEATH
80 MM LONG 1.1mm OUTER DIAMETER 0.4 mm WORKING LENGTH CHANNEL SEPARATE CHANNEL FOR IRRIGATION
PROCEDURE
Main duct of the gland is explored and induction of endoscope done by persistent irrigation.
Small and mobile stones at distal or middle part of the duct were removed by basket entrapment.
Impacted hilar stones were then removed by as endoscopy assisted sialolithectomy technique.
After the stone was verified ,a 2-3 cm incision was made in the floor mucosa according to the light transmitted through endoscope.
As the assistant raised the floor of the mouth with digital pressure in submandibular triangle.
The duct was isolated from the surrounding tissues with particular care to avoid damage to lingual nerve.
Then the hilum was incised at the precise location of the stone and the stone was removed.
Thereafter the entire duct was re-explored for remnant stones or mucous plugs
Hilum then sutured after 4Fr angio catheter had been inserted as a stent, Stent left in situ for 1-2 weeks after surgery.
TREATMENT
Amoxicillin or cefaclor was administrated for 7 days.
Hydration was achieved by the patient drinking more than 2 liters of water a day , and patient advised to avoid sialogogues and spicy foods.
After stent and sutures were removed ,frequent self massaging and sialogogues were recommended.
FOLLOW UP
post operative Clinical assessment was done, to diagnose, any recurrence and
changes in size of the gland . Consistency of the affected gland. Appearance of the ostium ,and the
amount and the nature(clear or milky) of salivary flow on massage.
Siolography
Sialography of submandibular salivarygland was performed with water soluble contrast agent , diatrizoate meglumine, using a closed intravenous catheter (22 gauge),.
After catheter was introduced ,1.5 to 2ml of contrast solution was injected carefully.
Lateral views and 5-min emptying film were taken , and appearance of main ducts, branch ducts and parenchyma were analyzed.
A-Lateral view x-ray showing large stone
B-Stone was removed through an incision at the genu of whartons
duct
C-Extracted stone fragments
D-Six month follow up sialogram shows
proximal duct dilation (filling film)
E-No persistent contrast opacified on functional
film
Different case reports
CONCLUSION
SIALOENDOSCOPY ASSISTED INTRA ORAL REMOVAL IS SAFE AND EFFECTIVE GLAND-PRESERVATION TECHNIQUE FOR PATIENTS WITH LARGE CALCULI AT HILUM OF THE WHARTONS DUCT .
A short movie…by use of endoscopy assisted lithotripsy with a lithotripter