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Saving Face With Sialendoscopy

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JACKSONVILLE, Fla. (Ivanhoe Newswire) - If you suffer from salivary gland stones, you know how irritating they can be. The standard treatment is surgery, which can be risky and leave a huge scar. For a teenage girl, that can be emotionally scarring. Now, there is a new, super tiny technology that allows surgeons to remove those stones without using the scalpel.

13-year-old Seara Schoenbeck enjoyed a healthy childhood, until about two years ago, when she started having pain in her mouth.

"I thought it was a cold sore," Seara Schoenbeck told Ivanhoe. "But then it kept on getting bigger and burst, and it kept on doing that over and over."

A stone was stuck in one of her submandibular glands and had to come out. The standard procedure is to surgically remove the entire gland.

"I was so scared about them going inside my neck," said Seara.

That's because there are several important nerves nearby that could get damaged. The thought of having an inch and a half long scar was also tough for Seara to swallow.

"To see her scared and worried hurt me," Richard Schoenbeck, Seara's father, told Ivanhoe.

That's when Richard went online and discovered a minimally-invasive alternative called sialendoscopy, performed by Doctor Gary Josephson at Nemours Children's Clinic.

"We can leave the glands alone and we can go in and take care of the problem," Doctor Josephson told Ivanhoe.

Doctor Josephson entered the salivary duct and gland through the floor of the mouth using a diagnostic scope with a camera the size of a toothpick.

"While you're doing this, you're watching," said Dr. Josephson. "You're doing it off the monitor, so it looks to me like it's a giant."

Once the camera is in, saline is run through the duct to keep it open, and a tiny drill is inserted to break up the stone and flush out the pieces.

If needed, a tiny wire basket is used to catch and pull out any remains.

"When we're done with this, there's minimal pain and you usually just need Tylenol or Motrin for a day and they're good to go," Doctor Josephson explained.

Good to go, and extremely grateful.

"Grateful that I live in a technology world," said Seara.

Seara was put under anesthesia for the procedure, but was able to leave the hospital the same day. She was back to normal in less than 24 hours. Compare that to the standard procedure that would require at least one or two days in the hospital and a longer recovery due to the incision and removal of the gland.

Doctor Josephson said Seara is his oldest sialendoscopy patient to date. He's performed the procedure on children as young as six-years-old.

If a surgeon is unable to remove the stone endoscopically, the gland would still have to be removed. If you suffer from salivary gland stones, talk to your specialist about the best options for you. Insurance companies typically cover this procedure.

RESEARCH SUMMARY

BACKGROUND: A salivary gland stone, also called salivary duct stone, is a calcified structure that may form inside a salivary gland or duct. It can block the flow of saliva into the mouth. The majority of stones affect the submandibular glands located at the floor of the mouth. Less commonly, the stones affect the parotid glands, located on the inside of the cheeks, or the sublingual glands, which are under the tongue. Many people with the condition have multiple stones. (SOURCE: www.mayoclinic.com/health/kidney-stones)

CAUSES: The cause for salivary gland stones is unknown, but factors contributing to less saliva production and/or thickened saliva may be risk factors for salivary stones. These factors include: dehydration, poor eating, and use of certain medications, such as antihistamines. Trauma to the salivary glands may also raise the risk for salivary stones. (SOURCE:www.mayoclinic.com/health/kidney-stones)

SYMPTOMS: The stones cause no symptoms as they form, but if they reach a size that blocks the duct, saliva backs up into the gland, causing pain and swelling. Inflammation and infection within the affected gland may follow. (SOURCE: www.mayoclinic.com/health/kidney-stones)

TREATMENT: More and more, doctors are using a newer and less invasive technique called sialendoscopy to remove salivary gland stones. Developed and used successfully in Europe for a decade, sialendoscopy uses tiny lighted scopes, inserted into the gland's opening in the mouth, to visualize the salivary duct system and locate the stone. Then, using micro instruments, the surgeon can remove the stone to relieve the blockage. The procedure is performed under local or light general anesthesia, which allows the patient to go home right after the procedure. (SOURCE: www.mayoclinic.com/health/kidney-stones)

INTERVIEW

Dr. Gary Josephson, Chairman of Surgery at Nemours's Children's Clinic, and Pediatric Ear, Nose, Throat, Head, Neck Surgeon, talks about sialendoscopy; a new method for treating glands.

Tell me what is sialendoscopy?

Dr. Josephson: A sialendoscopy is a little tiny camera that we now can use to go into the duct, the opening of the glands that secrete your saliva into your mouth. We have four big glands, two in your cheeks and two underneath your jaw. The two under your jaw are called the submandibular glands and the two in the cheeks are called the parotid glands. Sometimes those glands either have a little narrowing in the duct or they may form a stone for various reasons. Some people form stones in their glands or in their duct of the gland and that would cause swelling and infection.

How often do people get stones; is this a common problem?

Dr. Josephson: It's more common in adults than in children. The reason why kids or adults would get stones is a myriad of possible reasons but no one knows a hundred percent why.

What was the standard of care before this technology?

Dr. Josephson: If someone got a stone in their gland; if it was a big stone, they would end up with swelling of their cheek or swelling below their jaw.  The saliva would be stuck there and when it's blocked, you can get swelling, pain and possible infection. Usually we would try to treat with maybe an antibiotic or a steroid, but if those things didn't work, then you would have to remove the gland if you couldn't get the stone out.

How invasive is the traditional; the standard procedure compared to sialendoscopy?

Dr. Josephson: The traditional procedure, if someone got recurrent infections and recurrent stones, first it would be diagnosed by a CAT scan, ultrasound or some other type of imaging procedure.  If the stones were large and did not pass by themselves, we would consider removing the gland.  There would be an external incision on the face or on the neck, whereby there are important nerves and vessels that are in those areas. An experienced surgeon would know how to go in to the neck or in to the cheek to remove those glands safely. However, it would require a fairly reasonable size incision. Obviously, there is postoperative care for the incision line and there is more pain.  Many times they need to stay in the hospital for a day, particularly children.  With sialendoscopy, which is really neat, we can leave the glands alone. We go with tiny telescopes through the natural duct and we can take care of the problem by either dilating a narrowing of the duct that causes the recurrent infections or we can remove a stone if present without incisions, so that the flow of the saliva can then resume normally.

How did you even know about this, it's in Europe?

Dr. Josephson: I read a lot and I do a lot of minimally invasive surgery. I do a lot of sinus surgery and use endoscopes and I love endoscopic techniques, because it's less invasive. It certainly gets people back to their routine activities much more quickly. I read about sialendoscopy, and I knew that it was performed in Europe.  I asked the equipment representative that works for the company that makes this equipment when it was coming to the United States.  I was anxious to go ahead and get that equipment here so I can offer this to my patients in need. It became available here in the United States and I happened to have a child that needed it. We ordered the equipment and went ahead and did the procedure. It was a great experience for the child and for the family and the child went home the same day after we did the procedure with no incisions and a successful outcome.

Why is this a big deal for you?

Dr. Josephson:  Anytime we can do something that we call "minimally invasive" that we're able to do without incisions that gets people back to their routine more quickly is great. It also offers less post-operative pain. When we're done with this there's minimal pain, and you usually just need Tylenol, or Motrin for a day and they're good to go, but the other thing is for the surgeon it's really neat innovative stuff. I mean for someone like me who loves endoscopes and minimally invasive type things this is exciting. And to see a camera that's this small, point eight millimeters in diameter, like the size of a toothpick; it's really cool and amazing.

So run through what we'll be looking at for the viewers at home, each of the pieces and how you use them.

Dr. Josephson:  The camera is so small. We actually have it connected to a video camera and that magnifies our picture or our view.

How tiny is the drill bit?

Dr. Josephson: If you think about it the camera is point eight millimeters. This is probably about 0.1-0.2 millimeters.

Equivalent to what?

Dr. Josephson: Maybe a little bigger than a hair. It's absolutely tiny, it's amazing. And what's really neat too is while you're doing this you're watching. You're doing it off the monitor, which magnifies it so it looks like it is giant. By going in with these cameras and removing these stones or dilating a narrowing in the duct, you're getting children back home the same day with minimal pain, not needing many pain medicines or antibiotics and going back to their routine activities the next day.

How long is this procedure versus the standard, time wise?

Dr. Josephson: Well it's variable. This potentially could be an extremely short procedure.  One of the rate limiting steps of this procedure is dilating the opening to the duct because it is so small that sometimes that takes a bit of time to get that cannulated.  However, once you get that dilated it can move forward fairly quickly. You can get this done in thirty minutes to forty five minutes on the shorter time sideIf it's an easily cannulated duct you can get it done fairly quickly and obviously longer than that for more complicated cases.

What's next?

Dr. Josephson: I can't imagine something smaller. Next is no more scopes and somehow poof it goes away. We now have angled scopes, scopes that can go in different directions and allow us to see up and down. Also, before we never had a scope that was this small that you'd be able to get such good resolution and good picture quality to be able to work from.

I guess it's nice for kids too, if you don't have to take something out so early in their life that's got to be a good thing.

Dr. Josephson:  We love to never take anything out of anybody if we don't have too. Also with kids it's really wonderful because when you show them some of these things, and we do go over that with kids as well, they get excited about coming to the operating room and seeing all these video game type things.

FOR MORE INFORMATION, PLEASE CONTACT:

Erin Wallner
Nemours Children's Clinic
Erin.Wallner@nemours.org

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