He performs most of his procedures in the office setting, while most others in the U.S. perform them in the operating room. During the procedure, the patient is awake and in a semi-sitting position, and the procedure is occasionally performed using loupes, with just one medical assistant or medical student needed. After the duct is topically anesthetized, Dr. Joshi looks for the papilla visually by finding the interdental impression on the buccal mucosa; the parotid papilla is almost always above that. The submandibular papilla is locted just next to the frenulum.
Explore This IssueMarch 2015
If you can’t find the duct, one option is to paint methylene blue over the mucosa and then use external pressure to force saliva through, giving a better idea of where the papilla is. Also, vitamin C or citric acid powder can cause saliva to flow freely, which will help with identifying the papilla. Injecting lidocaine with epinephrine under the papilla will create tension, which can also help with identification.
Finding and gaining access to the papilla is probably the biggest challenge with the procedure. “It definitely is a steep learning curve,” he said.
Once the papilla is found, it’s carefully probed with a lacrimal probe and dilated gently with a conical dilator. When using the scope, he uses his dominant hand to introduce it and to localize the pathology and stabilizes its position with his nondominant hand.
Indications for sialendoscopy include diagnosis, dilation, irrigation, and steroid instillation for stenosis or chronic sialadenitis, as well as removal of small stones up to 4 mm or 5 mm, depending on orientation and position. It can also be used as an adjunct to transoral sialolithotomy, in helping localize pathology in open techniques, and with ultrasound for localization.
“What I’ve noticed is that there is a trend now toward more treatment for stenosis and less for calculi because the stones that I get are usually too big for purely endoscopic treatment,” Dr. Joshi said. “There’s definitely a lot more room for advancement in this field in terms of studying patients with Sjogren’s syndrome, radioactive iodine sialadenitis, and juvenile recurrent parotitis.”
Earning Patient Trust
Mark Persky, MD, director of the head and neck center at New York University Langone Medical Center in New York City, said that developing trust with patients is all about “honesty, honesty, honesty”—honesty with patients, honesty with colleagues, and honesty with yourself.
Honesty with yourself, he said, is “probably the most difficult honesty to attain.” It’s important to realize when “money interferes with good medicine,” but sometimes that’s not easy to do, he said.