Many dilator options have been devised to ease the introduction of the sialendoscope, yet the learning curve for these techniques has remained arduous.
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August 2021
Once inserted into the papilla, the guidewire is removed and 1 ml of 2% viscous lidocaine gel is slowly infused into the lumen of the duct. The complete elimination of air bubbles within the syringe is vital to enhance the intraductal view during the sialendoscopy. Backpressure will be noted on the syringe with this infusion. It can be helpful to warn the patients at this point of this additional pressure within their duct as this can lead to some discomfort. Once the lidocaine gel is infused, a 30–60 second delay is employed, with the catheter remaining in place within the papilla to allow for full ductal anesthesia. The catheter is then removed, and at this point, the sialendoscope can be inserted via the widely patent duct with minimal luminal resistance for diagnostic or therapeutic purposes. The stenting and dilating action of the viscous lidocaine within the duct facilitates easy insertion and continued visualization of the entire ductal system. The authors have found that often the lidocaine gel can serve as the only necessary irrigant needed for the entirety of the procedure. In total, procedural access to the individual salivary duct can be completed in an outpatient setting, in under two to three minutes, and is effective with either the parotid or submandibular ducts.
RESULTS
The application of the above technique for dilation and anesthesia of the salivary duct has resulted in quicker introduction of the sialendoscope. This has been observed for all levels of expertise, including early training of resident physicians or novices to sialendoscopy. The time to scope introduction from insertion of the guidewire is often less than five minutes for beginners and trends to under two to three minutes for experienced endoscopists. With such a dramatic decrease in time needed to dilate the papillary system, the patience required of the surgeon and the patient is also lessened immensely. Finally, the feasibility to perform these procedures under local anesthetic or moderate sedation increases. In the first full year the primary author (LS) employed this introduction technique in his university practice, 32 patients were treated with 52 sialendoscopy procedures. All 52 ducts (100%) were obtained utilizing the described technique, and 30/52 (57.7%) endoscopies were able to be completed in the office setting. The majority of cases outside the operating room were completed under moderate sedation (80%). The average number of glands treated in the office per patient was 1.5 glands, while the average number of glands treated per patient in the operating room was 1.83 glands.