Limited distal sialodochotomy to facilitate sialendoscopy of the submandibular duct

Salivary gland obstruction can lead to recurrent and painful gland swelling, typically with eating and drinking, and can be complicated by bacterial sialadenitis and abscess formation. The common causes of obstructive sialadenitis are sialolithiasis, stenosis, inflammation, external compression, foreign bodies, or anatomical variation of the major salivary gland ducts. Prior to the advent of sialendoscopy, classic management of salivary duct obstruction involved conservative medical management followed by surgical transoral excision for stones or sialadenectomy. Sialendoscopy is a relatively new technique that is well described in the literature. It provides a minimally invasive, gland-sparing approach for obstructive salivary duct disease diagnosis and management. The advent of endoscopic visualization of the major salivary ducts has reduced the need for sialadenectomy, thus avoiding the associated surgical risks of nerve injury, unattractive scar, salivary fistula, sialocele, and wound infection. Luers et al. showed the learning curve for sialendoscopy was manageable, with a decrease in operative time and an increase in performance rating over 30 to 50 cases. During sialendoscopy, the papilla of Wharton’s duct is typically dilated with probes of increasing diameter. For surgeons just starting to perform sialendoscopy, the time to identify and cannulate Wharton’s duct papilla is longer than for the larger papilla of Stensen’s duct. Submandibular papilla dilation failure has been described in 20% of cases for beginner sialendoscopists. Only a few techniques have been described for managing difficult submandibular papilla dilation and sialendoscope insertion. Application of methylene blue can help with identification of the papilla. Once the papilla has been cannulated, a guidewire can be placed into the duct lumen, followed by progressively larger dilators and the endoscope, which can be inserted over the wire. Others have described incising the papilla approximately 5 mm for duct cannulation; however, papillotomy risks the development of papilla stenosis and secondary iatrogenic obstruction. We describe a technique for limited distal submandibular sialodochotomy to allow for consistent endoscope introduction into the duct when standard papilla dilation is not possible. This technique is intended to provide both beginners and experts of sialendoscopy with an alternative method to allow access to Wharton’s duct without the need for papillotomy. It also allows for endoscopic-assisted stone extraction without the need for a papillotomy to release a stone. We examined our use of limited distal sialodochotomy in 139 consecutive submandibular sialendoscopies performed at our institution.