Jacksonville, FL - Nemours pediatric otolaryngologist Gary Josephson, MD, and Mayo Clinic in Florida otolaryngologist David Grant, MD, recently performed a minimally invasive procedure called a sialendoscopy, which allows the surgeon to look into the salivary ductal system and gland. A side (working) port allows the physician to dilate the ducts to open narrowed passages and remove salivary gland stones. The outpatient procedure – the first pediatric sialendoscopy in our region and one of only a few done in the U.S. on a child was performed at Wolfson Children’s Hospital on a six-year-old girl with two salivary gland stones, one 5 mm in size and the other 3 mm.
“We don’t know for sure why salivary gland stones form, but we believe it could be due to a mixture of environmental and patient factors,” explains Dr. Grant. “It could be caused by the chemical properties of the patient’s saliva, as a result of radiation treatment or due to structural problems. Thick, sticky saliva can lead to a lack of flow in the mouth in which the saliva becomes stagnant within the ducts in the glands, which may precipitate the chemicals that make stones over months or years.”
Dr. Josephson, who serves as chief of Pediatric Otolaryngology at Wolfson Children’s Hospital and Nemours Children’s Clinic and also as chairman of Surgery at Nemours, says these salivary gland stones can block the salivary duct. “You don’t get saliva drainage, which results in swelling in the neck and pain,” he explains. “If the child eats, it gets worse because the gland tries to produce saliva and the swelling and pain worsen.”
The child in this specific case had experienced infection after infection in her neck, which were treated with antibiotics on and off for six months. “I ordered a CT scan, which showed she had two very large stones in her submandibular salivary gland,” says Dr. Josephson. “Normally, we would have to remove the salivary gland. If you remove a salivary gland, there are still enough glands to produce saliva, but there’s always a risk of injury to some important structures near the gland, including the nerves that move the lips or tongue. It’s a two-hour surgery and requires an overnight hospital stay. And there’s discomfort resulting from the incision.”
Dr. Josephson had never performed a sialendoscopy, although he has performed many endoscopic procedures, including sinus surgery. He contacted Dr. Grant at Mayo Clinic who had performed several minimally invasive salivary gland procedures in adults while he was with M.D. Anderson Cancer Center in Houston to assist him on this case at Wolfson Children’s Hospital.
“I have used the procedure in adult thyroid cancer patients whose salivary gland ducts have become inflamed and narrowed by fibrosis (excess fibrous connective tissue) that can result from radio-iodine therapy,” says Dr. Grant. “The sialendoscopy technique is widely recognized in Europe, but has not been as widely embraced in the United States. It is gaining acceptance.”
The sialendoscope has a very tiny camera and instruments, including a grasper. Dr. Josephson says, “We went underneath the tongue, dilated the duct in the child’s salivary gland, introduced the camera into the duct and then we could see inside the gland, which was magnified on a monitor in the operating room. We used the grasper to grab the stones and place them into a metallic wire basket that tightens around the stones for removal.”
Sialendoscopy allows the surgeon to spare the salivary gland without an incision. “Normally, removing the stones from this child’s salivary gland would have required an inch to inch-and-a-half incision in the neck,” explains Dr. Grant. “The sialendoscopy allows us to get into tiny spaces while avoiding open surgery. It’s something so simple and yet so effective.”
“The patient’s mom was tickled pink,” says Dr. Josephson. “She became tearful with joy when I told her that we could do this procedure with incisionless surgery. Everything went perfectly and her daughter was able to go home the same day as her procedure and return to her normal activities that afternoon.”
“We are excited to bring this procedure to Northeast Florida for children and adults,” says Dr. Grant.