SIALENDOSCOPY
The Endoscopic Approach to
Salivary Gland Ductal Pathologies
Francis MARCHAL, MD, FACS
Professor of Otorhinolaryngology, Head and Neck Surgery
Department of ORL, Head and Neck Surgery
University Hospital of Geneva, Switzerland
Director of the European Sialendoscopy Training Centre, Geneva, Switzerland
Founder and General Secretary of the European and International Salivary Glands Societies
Contact:
16, Cours de Rive
CH-1204 Geneva, Switzerland
Phone: +41 227 35 72 47
Fax:
+41 227 35 70 58
E-mail: francis.marchal@sialendoscopy.com
Internet: www.sialendoscopy.com
Preface
Sialendoscopy is a prime example of the shifting paradigms in surgery which
have irrevocably changed the landscape of our specialty. Other minimally invasive
procedures such as: transoral CO2 laser surgery of the larynx, endoscopicassisted thyroid surgery, functional endoscopic sinus surgery, and robotic surgery
have been made possible through the close co-operation between surgeons and
industry. These remarkable advances in our specialty, driven by the development
of innovative technology, have made minimally-invasive surgery readily available
for the benefit of our patients.
The development of the flexible endoscopes, tiny enough to be inserted into salivary ducts was pioneered by Karl Storz. Professor Marchal, in close collaboration
KARL STORZ, developed a series of miniaturized instruments which can be inserted through the endoscope to accomplish a variety of important tasks, such as:
pulverizing calculi with a laser, retrieving calculi with a forceps or a basket, biopsy
of lesions, removing granulation tissue, dilating stenotic ducts, and irrigating ducts
clogged with mucous such as those that develop secondary to treatment.
The new paradigm in the management of sialadenitis and calculi has in large
measure eliminated the need to remove salivary ductal stones or non-malignant
salivary glands by open surgery. This new approach has modified our thinking
about these problems and has resolved many of the complications inherent in the
open approaches.
Successful application of sialendoscopy, as with all minimally invasive procedures,
requires a well-organized training program. Surgeons from around the world have
attended the many courses that Professor Marchal has organized in Geneva and
many other countries around the world.
In these courses, didactic material is supplemented by a robust “hands-on” animal
laboratory experience as well as observation of live surgery dispensed in 3D in
the conference room. Such an intensive educational experience is necessary to
assure a firm foundation for the surgeon wishing to perform sialendoscopy.
Research is another important element in this area of our specialty. The European
Salivary Gland Society (ESGS) was formed to promote research in this area,
and includes members from: Basic Sciences, Dental and Oral and Maxillofacial
Surgery, Otolaryngology – Head and Neck Surgery, Pathology and Radiology all
of whom have a particular interest in salivary gland disorders. The ESGS organizes
courses and conferences, promotes teaching and designs consensus protocols
for European Standards through multi-disciplinary efforts.
Eugene Myers, M.D., F.A.C.S., F.R.C.S., Edin (Hon)
Distinguished Professor of Otolaryngology
University of Pittsburgh School of Medicine, Pittsburg, PA, U.S.A.
6
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Sialendoscopy – The Endoscopic Approach to
Salivary Gland Ductal Pathologies
Francis MARCHAL, MD, FACS
Professor of Otorhinolaryngology, Head and Neck Surgery
Department of ORL, Head and Neck Surgery
University Hospital of Geneva, Switzerland
Director of the European Sialendoscopy Training Centre,
Geneva, Switzerland
Founder and General Secretary of the European Salivary Gland
Society and the International Salivary Gland Society
Editorial Board of: ‘The Laryngoscope’ and ‘The Annals of Otology,
Rhinology, and Laryngology’
Address for correspondence:
Francis Marchal, M.D., FACS
16, Cours de Rive
CH-1204 Geneva, Switzerland
Phone: +41 22 735 72 47
Fax:
+41 22 735 70 58
E-mail: francis.marchal@sialendoscopy.com
Internet:www.sialendoscopy.com
Cover illustration and image processing
of Figs. 1a–d:
Harald Konopatzki, Grünewaldstrasse 3a
D-69126 Heidelberg, Germany
E-mail: konillu@t-online.de
Please note:
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editors, or publisher of the work herein, or changes in
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and other health care professionals. This material is not
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Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Table of Contents
1.0 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
1.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1.1 History of Endoscopy . . . . . . . . . . . . . . . . .
1.1.2 History of Sialendoscopy . . . . . . . . . . . . . .
1.2 Disease Process of Sialadenitis . . . . . . . . . . . . .
1.3 History and|Physical Examination of
Sialadenitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
8
8
9
2.0 Standard Diagnostic Approaches. . . . . . . . . . . . . . .
10
3.0 Diagnostic Sialendoscopy. . . . . . . . . . . . . . . . . . . . .
11
3.1 LSD Classification System . . . . . . . . . . . . . . . . .
3.2 Normal Anatomy of the Salivary Duct System .
3.2.1 The Ductal System . . . . . . . . . . . . . . . . . . .
3.2.2 Submandibular Sialendoscopy . . . . . . . . .
3.2.3 Parotid Sialendoscopy . . . . . . . . . . . . . . . .
3.2.4 Sialendoscopy in Case of Sialadenitis . . .
3.3 Pathological Findings . . . . . . . . . . . . . . . . . . . . .
3.3.1 Mucous Plugs . . . . . . . . . . . . . . . . . . . . . .
3.3.2 Sialolithiasis – Multiple Stones, Various
Morphologies of Salivary Stones . . . . . . .
3.3.3 Ductal Stenosis. . . . . . . . . . . . . . . . . . . . . .
3.3.4 Polyps and Tumors . . . . . . . . . . . . . . . . . . .
3.4 Classical Approach to Sialadenitis . . . . . . . . . . .
3.4.1 Medical Treatment and External Surgery.
3.4.2 Extracorporeal Lithotripsy . . . . . . . . . . . . .
11
12
12
13
13
13
14
14
4.0 Interventional Sialendoscopy . . . . . . . . . . . . . . . . . .
18
4.1 Stone Removal by use of a Wire Basket . . . . . .
Wharton’s Duct . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stensen’s Duct . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2 Stone Removal by Use of a Wire Basket,
preceded by Laser Fragmentation . . . . . . . . . . .
4.3 Sialendoscopic Treatment of Stenosis. . . . . . . .
4.4 Combined Techniques . . . . . . . . . . . . . . . . . . . . .
4.4.1 Combined Techniques for the
Submandibular Gland. . . . . . . . . . . . . . . . .
4.4.2 Combined Techniques for the
Parotid Gland . . . . . . . . . . . . . . . . . . . . . . .
18
18
19
9
15
16
16
17
17
17
20
21
22
22
22
7
5.0 Technique of Sialendoscopy . . . . . . . . . . . . . . . . . . .
5.1 Indications and Contraindications . . . . . . . . . . .
5.2 Operating Room Set-up. . . . . . . . . . . . . . . . . . . .
5.3 Anesthetic Technique. . . . . . . . . . . . . . . . . . . . . .
5.4 Step-by-Step Technique . . . . . . . . . . . . . . . . . . .
5.4.1 Parotid Sialendoscopy . . . . . . . . . . . . . . . .
5.4.2 Submandibular Sialendoscopy . . . . . . . . .
5.5 Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.5.1 Salivary Probes . . . . . . . . . . . . . . . . . . . . . .
5.5.2 Conic Dilator . . . . . . . . . . . . . . . . . . . . . . . .
5.5.3 Hollow Rigid Bougies . . . . . . . . . . . . . . . . .
5.5.4 Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.5.5 Sialendoscopes. . . . . . . . . . . . . . . . . . . . . .
5.5.6 Disposable Devices . . . . . . . . . . . . . . . . . .
5.6 Inherent Limitations of Sialendoscopy. . . . . . . .
5.6.1 Significance of the Tip Design. . . . . . . . . .
5.6.2 Significance of the Bevelled Tip . . . . . . . .
5.6.3 Significance of Late Marsupialization. . . .
5.7 Post-Operative Care . . . . . . . . . . . . . . . . . . . . . .
23
23
23
23
24
24
24
25
25
25
25
25
25
25
26
26
26
26
26
6.0 Workflow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1 Decisional Algorithms . . . . . . . . . . . . . . . . . . . . .
6.2 Recommended Equipment for Beginners:
Basic Set . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2 Recommended Equipment:
Advanced Set . . . . . . . . . . . . . . . . . . . . . . . . . . . .
27
27
28
28
7.0 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.2 The European Sialendoscopy Training
Center (ESTC) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.2.1 Aims of the ESTC . . . . . . . . . . . . . . . . . . . .
7.2.2 Hands-on Training . . . . . . . . . . . . . . . . . . .
7.2.3 Conferences . . . . . . . . . . . . . . . . . . . . . . . .
7.2.4 Live Surgery in 3D. . . . . . . . . . . . . . . . . . . .
7.2.5 Courses for Beginners and Advanced
Courses . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.3 Course Evaluation . . . . . . . . . . . . . . . . . . . . . . . .
29
29
8.0 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31
29
29
29
29
30
30
30
Sialendoscopy Basic and Advanced Sets for Diagnosis
and Treatment of the Parotid and Submandibular Glands
as recommended by Prof.MARCHAL . . . . . . . . . . . . . . . 34
8
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
1.0 Introduction
1.1 History
Salivary gland diseases were first
described in ancient times by Hippocrates,29 460–370 BC. More than 1000
years later, Abulcasis,75 reported on
a pioneering work and instrumentation for what later became known as
otolaryngology, ophthalmology and
neurosurgery. He described at that time
the ranula and its treatment.
a
1 Hippocrates (460–370 BC).
Further descriptions of salivary gland
diseases focused on parotid tumors,
although the humoral theory was developed already by Paulus Aeginata64 and
by Ambroise Paré,63 a French surgeon of
the 16th century.
The first description of the ductal system
of a salivary gland appeared in the 17th
century, with the pioneering work of
Thomas Wharton, who published a
monograph entitled, ‘Adenographia sive
glandularum totius corporis descriptio’82
in 1659. Ever since, the duct has borne
his name.
The anatomy of the parotid ductal
system was discovered shortly thereafter
in 1660 during an animal dissection by
Nicolaus Stenonius.
Van Horne of Leyden demonstrated
the anatomy in public and named it
after Stenon. Stenon’s main work, ‘De
glandulis oris et novis earundum vasis.
Observationes anatomicae in iclyta
Lugdunensi Academia sub praesidio DD
Johannis van Horne”76 was published in
1661, and the parotid duct also bears his
name.
Casparus
Bartholinus
(1655–1738),
professor of anatomy, first described
the sublingual ductal system, which now
bears his name.26
b
c
d
1 Thomas Wharton (1614–1673).
1 Nicolaus Stenonius (1638–1686),
Wellcome Institute Library, London.
1 Caspar Bartholin (1655–1738).
1.1.1 History of Endoscopy
The first endoscope, of a kind, was
developed in 1806 by Philippe Bozzini
but not introduced in a human until
1853. In 1911, a procedure termed
‘Laparothorakoskopie’ was introduced.
Its use in the abdomen was extended by
Heinz Kalk in 1930. In 1953, Karl Storz
(1911–1996) developed and produced
the first endoscope. In January 1957,
Basil Hirschowitz (*1925) invented the
glass fiber for use in flexible and rigid
scopes, and in this way pioneered flexible endoscopy. The first laparoscopic
cholecystectomy was performed in 1984
and further generalized in the 90’s.
e
1 Karl Storz (1911–1996).
*) see References: 1–3, 5–7, 9, 12, 14, 17–21, 24, 31, 34–45,
55–57, 62, 65–67, 69–73, 78–81, 83–86
1.1.2 History of Sialendoscopy
The first attempts to perform salivary endoscopy in the early 1990’s by Katz33 and
Gundlach25 were not followed by wider
clinical applications, either on account
of poor vision or due to lack of specific
instrumentation. The first blind retrievals
of salivary stones were performed by
radiologists in submandibular (1990) and
parotid (1994) glands. In 1994, Nahlieli
et al.61 reported on endoscope-assisted
retrieval of stones using a hazel-type of
scope. In the following period, dedicated
instruments were simultaneously developed in two different centers (Marchal,
Switzerland – Nahlieli, Israel). Once
feasibility of the technique was demonstrated,48, 59 and particularly after start-up
of regular training programs at the European Sialendoscopy Training Center in
2002, physicians have been trained using
the new method and members of ESTC
began to adopt the technique, which is
reflected in an abundance of literature.*
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
9
1.2 Disease Process of Sialadenitis
Salivary gland pathology can be divided
into two categories: tumoral and ductal
diseases. The latter is the predominant
group comprising mainly stones,
strictures, and polyps wheras salivary
gland tumors are more rarely seen.10 The
etiology of sialadenitis in case of stones
remains unclear and various hypothesis
have been described. Ductal strictures
can be encountered mainly in juvenal recurrent parotidis, in Sjögren syndrom, or,
in the absence of an underlying disease
process, their cause remains unclear.
Strictures can be localized, thin or thick
or more generalized in the ductal tree.
1.3 History and|Physical Examination of Sialadenitis
Stones and strictures do obstruct the
salivary duct and patients present with
recurrent glandular swelllings during
meals, which can remain transitory or
be complicated by bacterial infections.
In this case, patients ocassionally have
fever, complain of inappropriate taste
in the mouth due to purulent discharge,
often accompanied by continuous pain-
ful swelling of the gland. On physical
examination, the gland is swollen and
massage of the gland is painful and
expresses thick saliva or pus through the
papilla (Figs. 2, 3). Manual palpation of
the submandibular gland is also painful
and sometimes a stone can be palpated
intraorally or, more rarely, in the parotid
gland by bimanual or external palpation.
a
3 Purulent exudate emerging from Stensen’s
parotid papilla.
4 Deeply located salivary stone necessitating submandibular resection.
Salivary probe in the primary passageway of
Wharton’s duct.
2 Acute parotitis, with spontaneous abcess
drainage.
b
Transoral removal of a palpable salivary stone
located in the floor of the mouth.
*) Figs. 4a, b by courtesy of Prof Willy Lehmann, ORL Department, University of Geneva,
Switzerland.
10
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
2.0 Standard Diagnostic Approaches
5 CT scan showing a 4 mm calculus (¤)
located in the distal portion of Wharton’s
duct, as it enters the submandibular gland.
The classical investigation methods
of salivary glands are radiography,
including X-rays, ultrasound, CT scan
and sialography, which up to now is
considered as the gold standard37 for
evaluation of the ductal system.74 Ultrasound remains an excellent primary
diagnostic method for the detection of
salivary stones, however calculi with a
size of less than 3 mm cannot be visualized.74 Another non-invasive diagnostic
option is nuclear magnetic resonance
tomography, MR-sialography,3 which
provides scans of the salivary ducts by
7 MR-Sialography in chronic sialadenitis,
showing a significant stenosis of
Stensen’s duct (¤) as well as massive dilation
of the intraglandular ductal system.
6 Conventional X-ray image of a 6 mm calculus (¤) at the level of the anterior third of the floor
of the mouth (a).
Ultrasound examination (b) in the same patient as in (a) shows the calculus (¤) with a characteristic acoustic shadow. The calculus is located in the anterior portion of Wharton’s duct.
a
opacification of the natural salivary pathways without the need for administration
of contrast medium and without exerting the patient to ionizing irradiation.
As shown in the figures below, these
procedures aim to visualize the ductal
system for the diagnosis of obstructive
pathologies, typically stones or other
rarer diseases. New diagnostic options
like 3D-sialography using the technique
of cone beam CT with flat panel (CPCT)
have been described recently, opening
new vistas that certainly are of interest to
the field.32, 77
b
a
Conventional sialography shows a 4 mm
calculus (¤) located near the orifice of
Wharton’s duct. Note the marked dilatation
of the ductal system after administration of
contrast media in a retrograde fashion.
b
MR-sialography of the same patient as in (a)
shows the anteriorly located calculus (¤). The
ductal system is visualized due to the presence
of saliva inside the ductal system (shown in
white on T2-weighted sequences) without
the need for retrograde injection of contrast
medium.
a
b
8
*) Figs. 5–8 by courtesy of Prof. Minerva Becker, Department of Radiology,
University of Geneva, Switzerland.
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
3.0 Diagnostic Sialendoscopy
3.1 LSD Classification System
In recent years, sialendoscopy has
gained in popularity, which is reflected
by the increase of related publications in
that period (Table 1). The only existing
classification was based on sialographic
findings and did not include stones or
dilatations. Therefore, the author and
team felt the need to develop a classification of pathologies involving the salivary
duct system. The acronym LSP stands
for ‘lithiasis’ (L), ‘stone’ (S) and ‘dilatation’ (D). The LSD classification system
was approved by all members of the
ESTC and further ackowledged by other
sialendoscopists.12,58 * The classification
system is based on endoscopic findings,
which is why it can be applied for assessment purposes only after diagnostic
sialendoscopy (see Tables 2–4).
* (Consensus Meeting on Salivary Gland
Diseases, Paris, 2007)
11
Table 1
Number of sialendoscopy-related
publications in the past 18 years.
12
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
3.2 Normal Anatomy of the Salivary Duct System
3.2.1 The Ductal System
The new endoscopic techniques
described47, 49 and the specific instrument set designed and developed by
the author in close collaboration with
KARL STORZ allow almost complete
exploration of the ductal system of both
the submandibular and parotid glands.
The main duct of both glands, as well
as secondary, tertiary, quaternary and
even quinary branches, can be explored
in a vast majority of cases. Rare limita-
tions include convoluted sections that
are impassable with a rigid endoscope.
Mobility of the endoscope is also limited
at the distal end of the gland due to the
mouth opening. Sialendoscopy provides
direct, reliable information about most
pathologies and reduces the need
for radiological investigations. In the
author’s opinion, the bevelled-tip multipurpose endoscope is extremely important as it facilitates exploration of smaller
branches by smooth dilatation. The option of customizing the semi-rigid multipurpose endoscope (at the risk of the
user!) is a key feature, that has shown to
be very helpful in exploring wide-angled
ramifications. This is the reason why the
‘all-in-one scopes’ at our institution are
of semi-rigid type.
9
a
b
c
d
e
f
g
a
First centimeters of the Wharton’s duct.
b
Endoscopic view as seen in Wharton’s duct
when reaching the sublingual duct junction.
c
Main duct.
d
Primary branches.
e
Secondary branches.
f
Tertiary branches.
g
Terminal branches (same endoscopic aspect
in both the submandibular and the parotid
gland).
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
13
3.2.2 Submandibular Sialendoscopy
10 Salivary duct probe in the papilla.
11 Salivary dilator inserted in the papilla.
12 Dilated papilla (
duct.
b
c
3.2.3 Parotid Sialendoscopy
a
13 The tip of the sialendoscope can be visualized in Stensen’s duct due to transillumination.
3.2.4 Sialendoscopy in Case of Sialadenitis
a
b
c
14 Endoscopic view of an inflammed ductal system suring removal of a sialolith (which should be avoided, if possible).
) of the left Wharton’s
14
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
3.3 Pathological Findings
3.3.1 Mucous Plugs
Unlike with urolithiasis and cholelithiasis, the etiology of sialolithiasis is
unknown. Various hypotheses have
been proposed. The first is based on the
existence of intracellular micro-calculi,
which when excreted in the canal, become a nidus for further calcification28, 50.
The second theory supposes that
‘mucous plugs’ in the ductal system may
represent the nidus. Both hypotheses
suggest an initial organic nidus that pro-
gressively grows by deposition of layers
of inorganic and organic substances.
Another hypothesis for the formation of
sialolithiasis is that aliments, substances
or bacteria within the oral cavity might
migrate to the salivary ducts and stimulate further calcification.
Mucous plugs are found in cases of
sialolithiasis, but also in cases of Sjögren
syndrome and in several cases of
chronic parotitis in children.
15
mp
a
Thick mucous plug floating in the main duct.
Blurred image due to mucosal plug.
d
The mucosal plug is mechanically detached
by gently tapping on the stone with the laser
fiber tip.
b
Extraction of this plug using a wire basket.
e
Mucous plug is detached from the stone ...
c
A mucous plug is attached to the stone which
impairs intraductal vision
– sialolith
mp – mucous plug
f
... and ensuingly removed.
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
15
3.3.2 Sialolithiasis – Multiple Stones, Various Morphologies of Salivary Stones
16
a
Floating stones.
b
Multiple stones.
c
Stone trapped behind a bifurcation.
17
a
b
Floating stones.
Multiple stones.
According to past autopsy studies60
sialolithiasis is supposed to affect 1 % of
salivary glands. However, its frequency
is most probably underestimated due to
the poor sensitivity of outdated detection methods and absence of treatment
options for intraglandular stones, leading
to more conservative approaches.
18
According to most published data,
salivary stones are localized in the
submandibular gland in 80 % to 90 % of
cases. In our experience, parotid glands
are affected more frequently (30 % to
40 %), a difference possibly explained
by the sensitivity of the new detection
methods.
Sialoliths are composed of organic and
inorganic substances, in varying ratios.
The organic substances are glycoproteins, muco-polysaccharides and
cellular debris. The inorganic substances
are mainly calcium carbonates and calcium phosphates.47 Salivary stones can
be either solitary or multiple, particularly
in the parotid gland. As seen before, their
location can be proximal, distal or intra-
a
c
Multiple stones.
b
Various morphologies depending on the site of the stone(s).
Oval-shaped parotid stone (a). Ball-shaped submandibular stone (b).
glandular. They vary in shape, being either round or irregular. The annual growth
rate of established salivary stones has
been estimated at 1 mm per year.68
Depending on the size of the stones,
they can either float (Fig. 16a) in the
lumen, become partially fixed due to
irregular shapes or even attach to the
ductal wall. In some cases, they are
trapped behind a bifurcation (Fig. 16c).
Stone shapes vary between the parotid
and submandibular glands; stones found
in the parotid (Fig. 18a) are often smaller,
longer and smoother than the more calcified submandibular stones (Fig. 18b).
16
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
3.3.3 Ductal Stenosis
19
a
Endoscopic view of a concentric stenosis in
the second branch of Stensen’s duct.
b
c
Close-up view of the same site as in (a).
Stenosis of a third generation Wharton’s duct.
According to the LSD classification,
strictures can either be localized and
thin, large or diffuse. These can be
encountered in juvenile recurrent
parotidis,17, 19, 21 34, 57, 67 Sjögren syndrom,
radiation-induced sialadenitis65 (either
after external radiation therapy or as a
sequela of radioactive iodine treatment
for thyroid carcinoma and precipitating
further salivary symptoms and strictures
of one or multiple salivary glands).
3.3.4 Polyps and Tumors
20
a
Polyps and tumors of the ductal tree are
of very rare occurrence. They can be benign or malignant. In case of malignant
tumors,22 the prognosis is relatively poor
and any suspicious sign on endoscopy
eliciting doubts about the nature of the
lesion should prompt the sialendoscopist
to have histologic analysis be made of
the collected specimen.54
b
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
3.4 Classical Approach to Sialadenitis
17
21
3.4.1 Medical Treatment and External Surgery
Proximal stones close to the papilla are
extracted, whereas glandular resection46
is indicated for deeply located stones
(Fig. 4b).
In submandibular glands, sialolithiasis
still represents 70 % to 90 % of all actual
indications13, 23 for glandular resection.
Although resection of the submandibular
gland is a frequent operation, several
reports27 demonstrate a rather high rate
of complications – up to 37 %. In rare
cases, this may include neurological
damage.
Parotidectomy is rarely performed for inflammatory conditions in parotid glands,
because it remains a tedious procedure
and is associated with a higher incidence
of post-operative paresis.8, 11, 16 Because
of this operation’s higher morbidity,
surgeons and, more often, patients are
reluctant to proceed with surgery.
In case of strictures, usually no other
treatments are applied than the medical
therapy employed prior to sialendoscopy
which consisted of anti-inflammatory
medication, massages and administration of sialagogues.
One possible reason behind the high rate
of submandibular resections may be the
common opinion that submandibular
glands with sialolithiasis (chronic infections) should be removed because they
are non-functional.
In a clinical-histological study47 on 48 patients with sialolithiasis who were treated
by resection of the submandibular gland,
the clinical history was correlated with
the histological alteration of the gland.
a
The authors found out that up to one-half
of the patients had subnormal histology
patterns, and that there was no correlation between the number of infectious
episodes and the alteration of the gland.
Therefore, numerous infectious episodes
or a long duration of symptoms cannot
be used to predict the degree of glandular alteration, and thus a conservative
attitude toward sialolithiasis appears
justified.
b
Normal histological appearance of a
submandibular gland specimen (a).
Histologically confirmed alteration of glandular
tissue (b).
3.4.2 Extracorporeal Lithotripsy
22
In search of conservative approaches
toward the treatment of sialolithiasis, a
new technique was developed in the
1990s, namely extracorporeal shock
wave lithotripsy30 (e.g., by use of the
extracorporal lithotriptor MINILITH® SL;
STORZ MEDICAL AG, Kreuzlingen,
Switzerland). Success rates vary from
40 % to 75 % for the submandibular
(Fig. 22) and parotid glands, respec-
tively. Performed on an outpatient basis,
this technique is now widely practiced
but often requires multiple sessions. The
main problem remains the clearance
of fragments, which, if incomplete, can
become the cause of recurrent sialolithiasis.
With its precise focus zone (0.2 x 2 cm)
and an in-line ultrasound scanner the
MINILITH®SL1 lithotriptor is specifically
designed for extracorporeal shock wave
lithotripsy (ESWL) of salivary stones.
The optimum stone size for effective treatment
varies between 2–8 mm in diameter. Even
though disintegration of calculi larger than
8|mm in diameter can be accomplished, the
gland may reach the limits of its excretion
capacity if the amount of residual fragments is
too large to be washed out spontaneously by
salivation induced by medication. In this case,
stone clearance can be protracted and may
require repetitive treatment sessions and/or
adjunctive minimally invasive sialendoscopic
stone removal.
Interventional sialendoscopy allows to
avoid these problems, as described
hereafter.
18
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
4.0 Interventional Sialendoscopy
4.1 Stone Removal by use of a Wire Basket
Following diagnostic sialendoscopy and
exposure of the sialolith, the adopted
strategy is the same for the submandibular53 and parotid glands,54 although the
diameter of the ductal system is smaller
in the parotid duct.87
For small stones, less than 4 mm in diameter in submandibular cases and less
than 3|mm in parotid cases, extraction is
performed with wire baskets of various
sizes. The basket is advanced through
the working channel of the scope and
opened behind the stone. It is then
closed over the stone and basket and
endoscope are removed altogether
in one movement. Papillotomy is performed at the end of the procedure, and
it should be kept as minimal as possible.
Wharton’s Duct
23
a
b
c
d
e
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
f
19
g
h
b
c
i
Stensen’s Duct
24
a
Stone extraction in Stensen’s duct (a–c).
20
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
4.2 Stone Removal by Use of a Wire Basket,
preceded by Laser Fragmentation
In cases of bigger stones, prior fragmentation is necessary using a laser system.
The first successful endoscopic-guided
laser lithotripsy of salivary stones was
reported by Gundlach in Germany,26
who, until now, uses two types of lasers
for stone fragmentation with a success
rate of above 90% for L2 stones of less
than 10 mm. Limitations are stones that
are only partially visible, or calculi too
large in size.
Various types of laser systems are suited
for laser lithotripsy of sialoliths: The Dye
Laser at 350 nm is very useful, as well
as the Holmium-YAG Laser at 2104 nm.
Laser irradiation may inadvertently cause
damage to ductal walls and hidden
structures. Therefore, it is mandatory
that the laser be operated only under
clear vision, continuous flow irrigation
and in close contact with the stone while
carefully sparing the ductal walls.
25
a
b
c
d
e
f
g
h
a–h
Laser fragmentation and extraction of stone
debris by use of a wire basket through a
minimal incision made in Wharton’s papilla,
followed by complete clearance of the duct.
NB:
Stone removal should only be performed
after complete fragmentation of the sialolith.
Attempting to retrieve large stone fragments
poses the risk of wire basket entrapment, a
situation that cannot be resolved by applying
firm traction to the instrument, which – under
any circumstances – must be avoided!
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
21
4.3 Sialendoscopic Treatment of Stenosis
Strictures are more common in the
parotid than in the submandibular gland.
The main issue with stricture treatment
is the overall diameter of the duct, which
is generally less than 1.5 mm. The best
way to dilate the stricture is to choose
the multi-purpose sialoscope. Following
diagnostic sialendoscopy, a guide wire
is first introduced through the channel
of the scope. The shaft is then removed
leaving the guide wire in the duct. The
interventional sialendoscope is then
passed over the guide wire allowing the
scope to be securely advanced. Dilata-
tion is accomplished by the beveled
type of the scope without causing any
trauma. In principle, the same technique
can be applied via the guide wire when
using the all-in-one scope, however, in
order to achieve adequate dilatation, the
surgeon needs to have available several
scopes of increasing diameter. In clinical
practice, we were frequently faced with
difficulties to achieve dilatation, though
using scopes of increasing diameter
(because the all-in-one scope does not
have a beveled tip).
26
a
Endoscopic view of the stenosis before …
d
Endoscopic view of the stenosis before …
b
… and after dilatation.
e
… and after dilatation.
c
Close-up view of the completely filled
balloon-tip at the catheter’s distal end.
f
Bougies of various sizes for dilation of
stenoses.
22
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
4.4 Combined Techniques
Large salivary stones or impassably
dense strictures have always posed a
therapeutic challenge that could not
be solved by sialendoscopy alone.
The advent of external lithotripsy in the
early 1990’s opened up the prospects
that all stones may become amenable
to conservative treatment, however the
relatively poor success rates in case of
large stones were disappointing. The use
of intraductal laser fragmentation had
also its limitations in case of large stones.
In all these cases, removal of the gland
was the last-resort option, which as we
all know, is associated with a significant
rate of morbidity. Therefore, we proposed
a new combined approach using both
sialendoscopy and external surgery45 as
described below. In close collaboration
with KARL STORZ Tuttlingen, Germany,
the author has designed specific instruments for use in combined approaches.
This set of instruments is currently in
production and will be available soon.
4.4.1 Combined Techniques for the Submandibular Gland
The sialendoscope is positioned in front
of the stricture / stone, which owing
to the diaphanoscopic effect provides
adequate orienation for the combined
external-intraoral approach. First, an
accurate mucosal incision is made with
meticulous care, followed by a ductal
incision, which enables careful dissection of the duct following visualization
of the lingual nerve to remove the stone.
Concurrent sialendoscopy of the distal
part of the gland is extremely important
and has proven useful in removing more
distally located stones. At the end of the
procedure, the duct is approximated by
placing one or two nylon sutures. A stent
may be introduced in the papilla in order
to avoid improper scaring.
4.4.2 Combined Techniques for the Parotid Gland
At the author’s insitution, sialendoscopy
is also performed with the 1.3-mm allin-one sialendoscope or the diagnostic
multi-purpose scope. The sialendoscope
is inserted in the duct, stabilized in a
position proximal to the lesion, which
may be a stricture or a stone. Throughout the next steps of the procedure, the
scope may be fixed to the angle of the
mouth. The patient is then prepared
for a classical parotid approach. We
commonly use a facelift approach
assisted by intraoperative facial nerve
monitoring15, 45 but as an alternative
option, a ‘lazy-S’-shaped incision may
also be used. The skin is then elevated
and a SMAS* flap raised and the U- or T* Superficial Muscular Aponeurotic System
shaped SMAS flap is then created along
the area defined by transillumination. The
salivary tissue is then very carefully dissected free with the help of a binocular
loup or a microscope in order to expose
Stensen’s duct. Constant awareness of
proximity to the facial nerve branches is
extremely important and particular care
must be paid while cutting over the duct
avoiding under any circumstances to
cause iatrogenic damage to the nerve.
Once the incision in the duct has been
made, the stone may be removed and/
or the stricture be treated by use of a
venus patch. Constant irrigation of the
duct is crucial to confirm patency of the
ductal sutures. Following wound closure,
a pressure dressing is applied.
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
5.0 Technique of Sialendoscopy
5.1 Indications and Contraindications
The indications for sialendoscopy are
all salivary gland swellings of unclear
origin.51, 60 There are no specific contraindications, mostly because sialendoscopy is a minimally invasive outpatient
procedure performed under local anesthesia. Even elderly or unstable patients
unable to undergo general anesthesia
can benefit from this technique.
potential risks of causing perforation and
vascular or neural damage. The sialendoscope should only be advanced under
adequate vision. Perforations of iatrogenic origin can lead to diffuse swellings
of the floor of the mouth. Meticulous
attention has to be given to this anatomical area because of the potential risk of a
life-threatening increase of the swellings.
Despite its apparent simplicity, interventional sialendoscopy is a technically
challenging procedure. Maneuvering
the rigid sialendoscope is delicate,
requires extensive experience and
involves certain hazards due to the
The main technical limitations of interventional sialendoscopy at the present
time are salivary stones in an extreme
posterior location, or a fibrosed canal
wall with a reduced diameter, which impedes advancement of the endoscope.
5.2 Operating Room Set-up
Sialendoscopy can be done as an
outpatient procedure in the clinic with
the patient sitting in a chair or partially
recumbent.52 The author prefers the
patient sitting in a chair or lying, which
allows for better surgeon mobility. The
disadvantage of a fully upright sitting
position is that it is associated with an
increased risk of vaso-vagal syncope. To
be readily prepared for sensitive patients
or the incidence of difficulties, an anes-
thesia unit should be kept available with
the anesthetist on standby throughout
the entire procedure. A mobile cart with
connections for a video camera, video
monitor, digital video recorder (DVR) and
printer are on the opposite side of the
patient, allowing for direct observation
of the surgical procedure. An assistant
(physician, nurse or technician) is located
on that side and is responsible for performing the perioperative procedures.
5.3 Anesthetic Technique
Sialendoscopy generally requires local
anesthesia of the papilla and the ductal
system. A topical anesthetic paste or
spray (10 or 20%) is applied to either
Stensen’s or Wharton’s papilla at the
beginning of the procedure. After introduction of the sialendoscope, anesthesia
of the ductal system is induced with an
irrigation solution of Xylocain, Lidocain
or Carbostesin 0,5 %. Depending on
age and weight of the patient, the total
a
amount infiltrated should not exceed
40|cc, because of absorption risks.
As a rule, diagnostic sialendoscopy can
be performed under local anesthesia.
Taking into account that interventional
sialendoscopy is usually performed
in the same setting, sedation or even
general anaesthesia can be applied
by the anaesthesiologist. This largely
depends on the level of difficulty of the
individual case.
b
27 The patient can rest in a comfortable upright position during the whole course of treatment.
23
24
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
5.4 Step-by-Step Technique
5.4.1 Parotid Sialendoscopy
1 Local anesthesia of the papilla with an
5.4.2 Submandibular Sialendoscopy
1 Local anesthesia of the papilla with an
anesthetic paste or spray (10 or 20%).
anesthetic paste or spray (10 or 20%).
2 Introduction of salivary probes of
2 Superficial infiltration of the papilla
increasing diameter.
with a local anesthetic solution and
adrenalin / epinephrine.
3 Introduction of the dilator.
4 Placement of dental tampons in the
3 Introduction of salivary probes of
posterior aspect of the vestibule and
gingivo-buccal sulcus. These will later
be replaced with new dry ones during
sialendoscopy.
4 Introduction of the dilator.
5 Placement of dental tampons in both
5 Introduction of the sialendoscope.
6 Introduction of a guidewire in the
working channel (this step is optional,
depending on the experience of the
surgeon. It facilitates reintroduction of
the scope in the duct).
7 Interventional sialendoscopy involves the use of laser fibers, stone
baskets or balloon dilators. The
guidewire may be left in place in the
duct throughout the procedure. By
removing the endoscope and reinserting the sialendoscope parallel to the
guidewire the working channel can
be kept open for the use of additional
instruments. In view of the numerous
ramifications, and the difficulty of
inspecting sharply angulated distal
parts of the gland, initial advancement
of the guide wire in the branch that is
difficult to access usually allows the
endoscope to slip on the wire and
explore the duct.
increasing diameter.
sides of the lateral aspects of the
floor of the mouth. These will later be
replaced with new dry ones during
sialendoscopy.
6 Introduction of the sialendoscope.
7 Introduction of a guidewire in the
working channel. This step is optional
– depending on the experience of the
surgeon – and facilitates reintroduction of the scope in the duct.
8 Interventional
sialendoscopy involves the use of laser fibers, stone
baskets or balloon dilators. The
guidewire may be left in place in the
duct throughout the procedure. By
removing the endoscope and reinserting the sialendoscope parallel to the
guidewire the working channel can
be kept open for the use of additional
instruments. In view of the numerous
ramifications, and the difficulty of
inspecting sharply angulated distal
parts of the gland, initial advancement
of the guide wire in the branch that is
difficult to access usually allows the
endoscope to slip on the wire and
explore the duct.
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
25
5.5 Equipment
5.5.1 Salivary Probes
Access via the papilla may either involve
initial marsupialization60 or by use of a
non–traumatic approach. In order to
systematically catheterize the papilla
without causing any trauma, we developed a complete set of salivary probes
which are made of various types of
alloys with different levels of rigidity (the
smaller diameters are more flexible and
have a lower elastic modulus in order to
prevent perforations).
5.5.2 Conic Dilator
This specially designed dilator should
be used instead of a salivary probe for
gentle dilation of the papilla without any
hemorrhage or trauma.
5.5.3 Hollow Rigid Bougies
These bougies allow a blind dilatation of
gross stenosis of the main duct, parotid
or submandibular duct. The guidewire is
inserted first under endoscopic control,
traversing the stenotic process, and the
sialendoscope removed after having
marked the distance to the stenosis. The
metallic bougie is then gently inserted,
using increasing diameters.
5.5.4 Forceps
Custom-made
forceps
measuring
0.8| mm may also be used to retrieve
small salivary stones (11538 TJ) or for
taking biopsies in the salivary duct
system. Care has to be taken when
handling and maneuvering these instruments since they are small and fragile.
Thus, very little pressure should be exerted when grasping the sialolith to avoid
damage to the instrument.
5.5.5 Sialendoscopes
Two types of miniature endoscopes were
developed for sialendoscopy. The first
generation multi-purpose sialendoscopes
comprised two scopes of different size,
and various sheaths allowing for diagnostic and interventional sialendoscopy.
The second generation sialendoscopes
could be called ‘all-in-one endoscopes’
because they have an integrated irrigation channel that may also be used for
introducing small-sized operating instruments.
Multi-Purpose Sialendoscopes
Diagnostic sialendoscopy requires that
the miniature endoscope be available
in two sizes, 0.75 mm and 1 mm in diameter, for pediatric or stenosed ducts,
and adult / nonstenotic ducts, respectively. The irrigation channel is formed
by the tiny gap between the scope and
the lumen of the examination sheath
(11576 KA and 11577 KA with outer
diameters of 1 mm and 1.3 mm).
Interventional sialendoscopy requires
that the examination sheath be replaced
by a special operating sheath with irrigation channel and one integrated working
channel. Operating sheaths are available
in three sizes, with inner diameters of
0.65 mm, 0.9 mm, and 1.15 mm.
All-in-one Sialendoscopes
These endoscopes may be used for both
diagnostic and interventional procedures
eliminating the need for changing the instrument. They are available in 4 different
diameters.
the 0.89 mm-sialendoscope allows for
exploration of small pediatric ducts, or
fibrous / stenotic ducts. In the hands
of the author the device is also used to
perform dacryocystorhinostomies.
the 1.1 mm-sialendoscope is suited
for both diagnostic and interventional
procedures with a working channel of
0.4 mm.
the 1.3-mm| sialendoscope is the
‘universal’ sialendoscope, as its outer
diameter is sized to allow for diagnostic and interventional sialendoscopy of
the submandibular and parotid ducts.
Its working channel of 0.6 mm allows
the passage of baskets or laser fibers.
However, the size of the working channel does not permit the use of balloon
dilators or forceps.
the 1.6 mm-sialendoscope allows the
use of forceps. Its outer diameter is
designed to allow for endoscopic inspection and treatment of the parotid
and submandibular ducts. It is important to note that the lumen of affected
ducts is often narrowed owing to
inflammatory conditions, making the
use of small-diameter sialendoscopes
necessary. Therefore, the 1.6| mmsialendoscope may not always be
suitable in parotid cases due to the
narrow lumen of Stensen’s duct.
5.5.6 Disposable Devices
Balloon Dilators
Disposable dilators allow for endoscopic-controlled dilatation of localized
stenosis, mainly encountered in the
parotid ductal system but also in the
submandibular gland. In addition, we developed high-pressure balloon catheters
designed to treat particularly dense
strictures that are not amenable to dilatation when using low-pressure balloons.
Great caution should be exercised while
insufflating the balloon to prevent undue
distension of the duct.
Stone Retrieval Baskets
The initial trials to remove salivary
calculi were performed with dormia
baskets designed for use in the field of
urology, however this was fraught with
the drawback that they did not fit into
our scopes, which is why we decided to
develop baskets of very thin diameter.
Today, a wide range of special baskets
are available in different sizes and with
various numbers of strands. The latest
model that has been developed is the
tipless basket including a special handle
that can be adapted to the ‘all-in-one’
sialendoscope.
26
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
5.6 Inherent Limitations of Sialendoscopy
The writhing course of the canal
puts certain limitations on semi-rigid
sialendoscopy, especially if sharply
bent curvatures of the duct prevent the
scope from being advanced. The main
previously described limitation being the
size of the sialendoscope has drastically
changed since the development of the
last generation ‘all-in-one’ sialendoscopes. The variety in sizes now allows
for exploration of almost all salivary
ducts.
Maneuvering within the narrow salivary
ducts has to be absolutely atraumatic
because of the risk of ductal perforation
and unpredictable secondary consequences. Significant trauma to the ductal
wall may result in latter stenosis.
5.6.1 Significance of the Tip Design
The small angulation, a distinguishing
design feature of the tips of all Marchal
sialendoscopes facilitates targeted catheterization of branches, whereas with
a standard on-axis tip, difficulties may
occur when advancing to the branch
ahead. A minor deflection may also be
given to the sheaths of sialendoscopes
11576 and 11577. After inserting the
obturator, the tip may be bent very
cautiously, providing the optimal curve.
The endoscope must never be deflected.
a
b
It usually follow the curve of the sheath
and reverts to its former state after
completion of the procedure.
5.6.2 Significance of the Bevelled Tip
Catheterization of the papilla is a
challenging step of the procedure involving a relatively long learning curve. Once
adequate dilatation has been achieved
by use of bougies of varying sizes, introduction of the operating sialendoscope
is considerably facilitated by the bevelled
tip of the sheath since this design feature
allows the tip to be used as a dilation
probe.
5.6.3 Significance of Late
Marsupialization
Marsupialization should be completely
avoided, particularly at the beginning
of the procedure. The irrigation liquid
has a dilating effect that provides excellent vision of all ductal branches. Early
marsupialization leads to poor visual
conditions and makes the technique
more difficult to master, because of the
irrigation liquid escaping from the ductal
system at its opening. Apart from that,
marsupialization of the ductal papillae
should either be completely avoided,
or kept as small as possible to prevent
retrograde passage of air and aliments.
c
28 The minor deflection of the tip, a distinguishing design feature of all MARCHAL sialendoscopes, facilitates targeted catheterization of branches (b, c), because an on-axis tip (a)
usually difficulties may occur when advancing to the next branch.
5.7 Post-Operative Care
Interventional sialendoscopic procedures
are usually conducted under prophylactic antibiotic medication administered
48|hours or earlier prior to the procedure,
depending on the individual case.
Frequent self-massages of the gland
are recommended. Clinical controls are
performed directly after the intervention.
Patients with ruptures of Wharton’s duct,
or in cases of deliberately extended
marsupialization of the latter, have to be
subjected to careful clinical monitoring
because of the risk of edema diffusion
and/or infection of the floor of the mouth
which poses the risk of developing into a
life-threatening emergency.
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
27
6.0 Workflow
6.1 Decisional Algorithms
Diagram 1
Decisional algorithm of diagnostic and
interventional sialendoscopy.
Diagram 2
Technical algorithms for selecting the appropriate sialendoscopic instrumentation.
28
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
6.2 Recommended
Equipment for
Beginners: Basic Set
The 1.3-mm MARCHAL Sialendoscope
is the universal scope that may be used
for diagnosis and treatment in the majority of cases in an outpatient setting as
well as intra-operatively.
The Basic Set consists of a conic dilator,
bougies of various sizes, and the universal 1.3 mm MARCHAL Sialendoscope.
(Basic Set: see page 34)
29 Compact and functional in design, the MARCHAL Sialendoscope 11575 meets the
demands of the practitioner and may also be used for minor interventional procedures that
require the use of a wire basket or laser fiber.
6.2 Recommended
Equipment:
Advanced Set
The 0.75-mm sialendoscope in conjunction with various sheaths extends the
technical options and may be applied in
the entire field of interventional sialendoscopy:
Optional custom-made bending of the
scope at the risk of the user.
Sialendoscopy
under
stenotic conditions.
pediatric
or
Application of baskets, laser fibers,
forceps and balloon-tipped dilators.
(Advanced Set: see page 35)
30 Another option is to use the small lateral channel (I.D.: 0.9 mm) of operating sheath
11576 KF for introducing the Miniature Endoscope 11576, wheras the biopsy forceps
(11570|ZJ) is inserted through the central channel (I.D.: 1.15 mm).
31 The central channel (I.D.: 1.15 mm) of operating sheath 11576 KF may also be used for
introducing a balloon-tipped catheter, while the Miniature Endoscope 11576 is inserted
through the lateral channel (I.D.: 0.90 mm).
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
29
7.0 Training
7.1 Introduction
Since the initial development stage of
sialendoscopy we have been convinced
that the best way to popularize the technique is teaching. Since 2002, more than
600 physicians from 65 countries have
been trained in the European Sialendoscopy Training Center (ESTC) in Geneva,
Switzerland.
7.2 The European Sialendoscopy Training Center (ESTC)
7.2.1 Aims of the ESTC
The aims of the ESTC are:
to train clinicians in the indications and
procedures associated with diagnostic
and therapeutic sialendoscopy,
to organise and disseminate experi-
ence gained by clinicians in this field,
and
to
conduct international courses
and conferences as appropriate, to
facilitate exchange of knowledge,
experiences and advances gained by
leading clinical physicians who focus
on diseases and conditions of the
salivary glands.
7.2.2 Hands-on Training
In Geneva, a specific training and
demonstration model for sialendoscopy
has been validated. The use of fresh
pigs heads has proven to be ideal, after
extensive trials conducted with other
animal models and human cadaveric
specimen.
During each course, participants are
paired and work on one fresh pig head.
The lectures held during the hands-on
course are divided into two sessions,
one focusing on diagnostic and the other
on interventional sialendoscopy.
32 Sialendoscopy in the operating theatre.
7.2.3 Conferences
The international faculty reports on clinical, radiological, medical and surgical
approaches to salivary gland pathologies. They explain and describe their
techniques of sialendoscopy in a stepby-step fashion using a variety of videos
and interactive presentations that allow
for open discussion and comments.
Recent developments in new materials and designs combined with
advances in instrumentation technology are presented during such
conferences. Abstract sessions are
an outstanding way to disseminate
the results of clinical research or to present and discuss case histories. Round
table format and informal discussions
facilitate reporting on advances and
prospects of research that address the
management of salivary gland duct
pathologies.
33 Hands-on Training on an animal model.
30
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
7.2.4 Live Surgery in 3D
Owing to the availability of an excellent video-conference system linking
the operating room to the conference room, live surgeries can be
viewed on a large central video screen.
Participants are encouraged to ask
questions and discuss with the surgeon during the operation. Through
this real-time approach, the steps of
the procedure, but also the risks and
advantages are made tangible to the
course participants. At the subsequent
hands-on sessions surgical tricks and
tips are demonstrated, expanded upon
and taught. For a few years now, the
courses are recorded with a 3D camera
and transmitted to the auditorium.
7.2.5 Courses for Beginners and
Advanced Courses
At the request of hundreds of participants, we started a few years ago to offer
a beginners course and an advanced
course in order to better address the
individual needs at each level.
34 A video-conference system links the operating room to the conference room and allows live
surgeries to be viewed on a large central video screen
7.3 Course Evaluation
8.0 Conclusion
For retrospective evaluation of the
courses held at the ESTC, questionnaires are distributed on a regular basis
among the participants. As a result,
95% are satisfied with the theoretical
part and 98% with the practical part of
the course, underlining the importance
of hands-on training with fresh pig
heads. All participants agreed that the
trickiest part of the procedure is the
practical handling of the papilla in order
to utilize the technique by ways of a truly
minimally invasive approach. Based on
the conclusions from this evaluation,
we found out that the majority of participants (60%) requested an advanced
course, so we decided to install both
a beginners’ course and an advanced
course, held annually in Geneva (www.
sialendoscopy.com).
Taking into consideration differences in
instrumentation and video-endoscopic
equipment, as well as complexity, duration, and potential complications of the
procedures, a distinction has to be made
between diagnostic and interventional
sialendoscopy.
Diagnostic sialendoscopy is a lowmorbidity minimally invasive technique,
which may become the investigational
procedure of choice for salivary duct
pathologies.
Interventional sialendoscopy allows
for extraction and/or fragmentation in
the majority of cases of sialolithiasis, and
can therefore prevent salivary gland excisions.
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
31
References
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Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Sialendoscopy Basic and Advanced Sets
for Diagnosis and Treatment of the
Parotid and Submandibular Glands
as recommended by Prof. MARCHAL
33
34
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Sialendoscopy Basic Set
for Diagnosis and Treatment of the Parotid and Submandibular Glands
as recommended by Prof. MARCHAL
Miniature Straight Forward Telescope 0°, O.D. 1.3 mm, semirigid, autoclavable, 5° distal angulation,
working channel I.D. 0.65 mm, irrigation channel I.D. 0.25 mm, working length 12 cm, length 100 cm,
remote eyepiece, fiber optic light transmission incorporated, including protection cover 11570 P
11580 B Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11575 A,
11581 A – 11583 A, perforated, lid with silicone bridges,
external dimensions (w x d x h): 275 x 178 x 35 mm
11575 K Stone Extractor, O.D. 0.6 mm, basket with 3 wires, sterile, for single use
11575 L Stone Extractor, O.D. 0.6 mm, basket with 6 wires, sterile, for single use
745847
Salivary Duct Probe, size 0000
745848
Salivary Duct Probe, size 000
745849
Salivary Duct Probe, size 00
745850
Salivary Duct Probe, size 0
745851
Salivary Duct Probe, size 1
745852
Salivary Duct Probe, size 2
745853
Salivary Duct Probe, size 3
745854
Salivary Duct Probe, size 4
745855
Salivary Duct Probe, size 5
745856
Salivary Duct Probe, size 6
745910
Dilator for salivary duct, length 14 cm
745720
Guide Wire, O.D. 0,6 mm, sterile, for single use, package of 10, for use with Bougies 745710 – 745713
745715
Forceps, angled, serrated, length 15 cm
745716
Forceps, angled, with 1x 2 teeth, length 15 cm
745717
Angled Scissors for Salivary Gland, with bulb, length 14 cm
27651 K2 Cleaning Brush, for working channel diameter 0.6 – 0.8 mm, length 40 cm,
for single use, package of 10
27651 K5 Cleaning Brush, for working channel diameter 0.25 – 0.4 mm, length 40 cm,
for single use, package of 10
11575 A
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Sialendoscopy Advanced Set
for Diagnosis and Treatment of the Parotid and Submandibular Glands
as recommended by Prof. MARCHAL
11575 A
11580 B
11576
11580 C
11576 KA
11576 KF
11576 KG
11576 TJ
11576 ZJ
11577 BP
11575 K
11575 L
745847
745848
745849
745850
745851
745852
745853
745854
745855
745856
745910
745720
745715
745716
745717
27651 K2
27651 K5
Miniature Straight Forward Telescope 0°, O.D. 1.3 mm, semirigid, autoclavable, 5° distal angulation,
working channel I.D. 0.65 mm, irrigation channel I.D. 0.25 mm, working length 12 cm, length 100 cm,
remote eyepiece, fiber optic light transmission incorporated, including protection cover 11570 P
Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11575 A,
11581 A – 11583 A, perforated, lid with silicone bridges,
external dimensions (w x d x h): 275 x 178 x 35 mm
Miniature Straight Forward Telescope 0°, O.D. 0.75 mm, semirigid,
working length 16 cm, length 145 cm, remote eyepiece, fiber optic light transmission incorporated,
including protection cover 11576 P
Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11576 / 11577,
perforated, lid with silicone bridges, external dimensions (w x d x h): 373 x 178 x 35 mm
Examination Sheath, O.D. 1.1 mm, working length 16 cm, with blunt obturator,
with lateral LUER-Lock adaptor for irrigation, for use with miniature telescope 11576
Operation Sheath, oval, O.D. 1.1 mm and 1.3 mm, working length 16 cm,
telescope channel O.D. 0.9 mm, working channel O.D. 1.15 mm with 2 obturators,
with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11576
Operation Sheath, oval, O.D. 1.1 mm and 0.8 mm, working length 16 cm,
telescope channel O.D. 0.9 mm, working channel 0.65 mm, with 2 obturators,
with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11576
Foreign Body Forceps, double action jaws, flexible, O.D.1 mm, working length 19 cm
Biopsy Forceps, double action jaws, flexible, O.D. 1 mm, working length 19 cm
Balloon Catheter, diameter 0.9 mm, sterile, single use, package of 10
Stone Extractor, O.D. 0.6 mm, basket with 3 wires, sterile, for single use
Stone Extractor, O.D. 0.6 mm, basket with 6 wires, sterile, for single use
Salivary Duct Probe, size 0000
Salivary Duct Probe, size 000
Salivary Duct Probe, size 00
Salivary Duct Probe, size 0
Salivary Duct Probe, size 1
Salivary Duct Probe, size 2
Salivary Duct Probe, size 3
Salivary Duct Probe, size 4
Salivary Duct Probe, size 5
Salivary Duct Probe, size 6
Dilator for salivary duct, length 14 cm
Guide Wire, O.D. 0,6 mm, sterile, for single use, package of 10, for use with Bougies 745710 – 745713
Forceps, angled, serrated, length 15 cm
Forceps, angled, with 1x 2 teeth, length 15 cm
Angled Scissors for Salivary Gland, with bulb, length 14 cm
Cleaning Brush, for working channel diameter 0.6 – 0.8 mm, length 40 cm,
for single use, package of 10
Cleaning Brush, for working channel diameter 0.25 – 0.4 mm, length 40 cm,
for single use, package of 10
35
36
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
MARCHAL All-In-One Miniature Endoscopes
for Diagnostic and Interventional Sialendoscopy
11581 A
11581 A
11582 A
11575 A
11583 A
Miniature Straight Forward Telescope 0°,
O.D. 0.89 mm, semirigid, autoclavable, 5° distal angulation,
irrigation channel I.D. 0.25 mm, working length 12 cm, length 100 cm,
remote eyepiece, fiber optic light transmission incorporated,
including protection cover 11520 P
Miniature Straight Forward Telescope 0°,
O.D. 1.1 mm, semirigid, autoclavable, 5° distal angulation,
working channel I.D. 0.45 mm, irrigation channel I.D. 0.2 mm,
working length 12 cm, length 100 cm, remote eyepiece,
fiber optic light transmission incorporated,
including protection cover 11520 P
for use with:
– Stone Extractor 11582 M
– Guide Wire 745725
– Laser Probe
Miniature Straight Forward Telescope 0°,
O.D. 1.3 mm, semirigid, autoclavable, 5° distal angulation,
working channel I.D. 0.65 mm, irrigation channel I.D. 0.25 mm,
working length 12 cm, length 100 cm, remote eyepiece,
fiber optic light transmission incorporated
including protection cover 11570 P
for use with:
– Stone Extractor 11575 K / L
– Guide Wire 745720
– Laser Probe
Miniature Straight Forward Telescope 0°,
O.D. 1.6 mm, semirigid, autoclavable, 5° distal angulation,
working channel I.D. 0.8 mm, irrigation channel I.D. 0.2 mm,
working length 12 cm, length 100 cm remote eyepiece,
fiber optic light transmission incorporated
including protection cover 11520 P,
for use with:
– Stone Extractor 11575 K / L
– Micro Burr 11574 MB
– Foreign Body Forceps 11583 TJ
– Biopsy Forceps 11583 ZJ
– Guide Wire 745720
– Laser Probe
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Small-Size Miniature Endoscope for Diagnostic and Interventional Sialendoscopy
as recommended by Prof. MARCHAL
Ideal for assessment of stenotic ducts (juvenile recurrent parotitis, Sjögren, radio-iodine sialadenitis etc.)
11576
11576
Miniature Straight Forward Telescope 0°,
O.D. 0.75 mm, semirigid, working length 16 cm, length 145 cm,
remote eyepiece, fiber optic light transmission incorporated,
including protection cover 11576 P
Sheath for Diagnostic Sialendoscopy
11576 KA
11576 KA
Examination Sheath,
O.D. 1.1 mm, working length 16 cm, with blunt obturator,
with lateral LUER-Lock adaptor for irrigation,
for use with miniature telescope 11576
37
38
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Sheath for Interventional Sialendoscopy
11576 KF/KG
11576 KF
11576 KF
11576 KG
11576 KG
Operation Sheath, oval, O.D. 1.1 mm and 1.3 mm,
working length 16 cm, telescope channel O.D. 0.9 mm,
working channel O.D. 1.15 mm with 2 obturators,
with lateral LUER-Lock adaptor for irrigation
for use with miniature telescope 11576
Operating instruments for use through the
working channel of 11576 KF
– Stone Extractor 11575 K
– Stone Extractor 11575 L
– Guide Wire 745720
– Ballon Catheter 11577 BP
– Grasping Forceps 11576 TJ
– Biopsy Forceps 11576 ZJ
– Laser Probe
Operation Sheath, oval, O.D. 1.1 mm and 0.8 mm,
working length 16 cm, telescope channel O.D. 0.9 mm,
working channel 0.65 mm, with 2 obturators,
with lateral LUER-Lock adaptor for irrigation
for use with miniature telescope 11576
Operating instruments for use through the
working channel of 11576 KG
– Stone Extractor 11575 K
– Stone Extractor 11575 L
– Guide Wire 745720
– Laser Probe
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Miniature Endoscopes for Diagnostic and Interventional Sialendoscopy
as recommended by Prof. MARCHAL
11577
11577
Miniature Straight Forward Telescope 0°,
O.D. 1 mm, semirigid, working length 16 cm, length 145 cm,
remote eyepiece, fiber optic light transmission incorporated,
including protection cover 11577 P
Sheath for Diagnostic Sialendoscopy
11577 KA
11577 KA
Examination Sheath,
O.D. 1.3 mm, working length 16 cm, with blunt obturator,
with lateral LUER-Lock adaptor for irrigation,
for use with miniature telescope 11577
39
40
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Sheaths for Interventional Sialendoscopy
11577 KD/KE
Operation Sheath, oval, O.D. 1.3 mm and 1.3 mm,
working length 16 cm, telescope channel O.D. 1.15 mm,
working channel 1.15 mm, with 2 obturators, with lateral LUER-Lock
adaptor for irrigation for use with miniature telescope 11577
Operating instruments for use through the
working channel of 11577 KE
– Stone Extractor 11575 K
– Stone Extractor 11575 L
– Guide Wire 745720
– Ballon Catheter 11577 BP
– Grasping Forceps 11576 TJ
– Biopsy Forceps 11576 ZJ
– Laser Probe
11577 KE
11577 KE
11577 KD
11577 KD
Operation Sheath, oval, O.D. 1.3 mm and 0.8 mm,
working length 16 cm, telescope channel O.D. 1.15 mm,
working channel 0.65 mm, with 2 obturators,
with lateral LUER-Lock adaptor for irrigation
for use with miniature telescope 11577
Operating instruments for use through the
working channel of 11577 KD
– Stone Extractor 11575 K
– Stone Extractor 11575 L
– Guide Wire 745720
– Laser Probe
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Additional Instruments
as recommended by Prof. MARCHAL
Set of Salivary Duct Probes
for Dilation of the Salivary Ducts
Set of MARCHAL Salivary Duct Probes,
745847 size 0000 745853 size 3
745848 size 000
745854 size 4
745849 size 00
745855 size 5
745850 size 0
745856 size 6
745851 size 1
745857 size 7
745852 size 2
745858 size 8
Bougies
for Elimination of Stenosis
745710
745709 745710 745711 745712 745713 MARCHAL Bougie diameter 1 mm,
for use with guide wire 745725
Same, diameter 1.5 mm, for use with guide wire 745725
Same, diameter 2.0 mm, for use with guide wire 745725
Same, diameter 2.5 mm, for use with guide wire 745725
Same, diameter 3.0 mm, for use with guide wire 745725
Same, diameter 3.5 mm, for use with guide wire 745725
745910
Dilator, for salivary duct, length 14 cm
745708
Dilator
41
42
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Stone Extractors, Ballon Catheter and Guide Wires
11582 M
Stone Extractor, O.D. 0.4 mm, basket with 4 wires,
sterile, for single use
11573 T
Stone Extractor, diameter 0.6 mm, basket with 4 wires,
tipless, handle for fixation to endoscope
n
11573 M
n
Stone Extractor, diameter 0.4 mm, basket with 4 wires,
handle for fixation to endoscope
11575 K
Stone Extractor, O.D. 0.6 mm, basket with 3 wires,
sterile, for single use
11575 L
Stone Extractor, O.D. 0.6 mm, basket with 6 wires,
sterile, for single use
11577 BP
Balloon Catheter, diameter 0.9 mm, sterile,
single use, package of 10
11583 BP
Balloon Catheter, diameter 0.7 mm, sterile,
for single use, package of 10,
for use with Telescopes 11574 A and 11583 A
n
745720 Guide Wire, O.D. 0,6 mm, sterile, for single use,
package of 10, for use with Bougies 745710 – 745713
745725 Guide Wire, O.D. 0.4 mm, sterile, for single use,
package of 10, for use with Bougies 745708 – 745713
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Dissecting and Tissue Forceps, Scissors
Grasping and Biopsy Forceps
745715
745715
745716
745715
Forceps, angled, serrated, length 15 cm
745716
Forceps, angled, with 1x 2 teeth, length 15 cm
745717
Angled Scissors
for Salivary Gland,
with bulb, length 14 cm
11576 TJ
Foreign Body Forceps, double action jaws,
flexible, O.D.1 mm,
working length 19 cm
11576 ZJ
Biopsy Forceps, double action jaws,
flexible, O.D. 1 mm,
working length 19 cm
11583 TJ
Foreign Body Forceps, double action jaws,
flexible, O.D. 0.8 mm,
working length 26.5 cm
11583 ZJ
Biopsy Forceps, double action jaws,
flexible, O.D. 0.8 mm,
working length 26.5 cm
43
44
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Sterilizing and Storage Trays
11580 A
11580 A
Metal Tray, for sterilizing Salivary Duct Probes
745847 – 745858 and Dilator 745910, perforated,
lid with silicone bridges,
external dimensions (w x d x h): 178 x 178 x 35 mm
11580 B
11580 B
Metal Tray, for Sterilization and Storage of a Miniature
Straight Forward Telescope 11575 A, 11581 A – 11583 A,
perforated, lid with silicone bridges,
external dimensions (w x d x h): 275 x 178 x 35 mm
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
45
Sterilizing and Storage Trays
11580 C
11580 C
Metal Tray, for Sterilization and Storage of a Miniature
Straight Forward Telescope 11576 / 11577,
perforated, lid with silicone bridges,
external dimensions (w x d x h): 373 x 178 x 35 mm
11580 D
Metal Tray, for Sterilization and Storage of a Miniature
Straight Forward Telescope 11572 A – 11574 A,
perforated, lid with silicone bridges,
external dimensions (w x d x h): 275 x 175 x 37 mm
27651 K1
Cleaning Brush, for working channel diameter 0.4 – 0.6 mm,
length 40 cm, for single use, package of 10
Same, for working channel diameter 0.6 – 0.8 mm
Same, for working channel diameter 0.8 – 1.4 mm
Same, for working channel diameter 0.25 – 0.4 mm
Cleaning
27651 K2
27651 K3
27651 K5
46
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Unique benefits of the KARL STORZ TELE PACK X at a Glance n
Crystal clear image
Easy control combined with highest safety
## 15"
## Membrane
LCD monitor
## Rotatable
keyboard approved for wiping
disinfection
image display
## Hot-Keys
## 24
Bit color intensity for natural color
rendition
## DVI
video input for pristine picture quality
## DVI
video output for connecting HD monitors
assuring fast and direct adjustment
## Arrow
keys for intuitive control
## Pedal
control available
Flexible storage possibilities
Additional information
## SD
## Sturdy,
card-slot allows high storage capacity
## USB-slot
## Picture
for external HDDs and flash drives
## Universal
gallery for records
## Playback
design allows comfortable transport
power supply unit: 100 – 240 VAC,
50/60 Hz
of saved videos
## Print-ready
portable casing
## Ergonomic
patient report documentation
## Measurement
(H x W x D):
450 mm x 350 mm x 150 mm
## Weight: 7 kg
Natural illumination
Ordering Information
## Hi-Lux
20 0450 01-ENTELE PACK X
Endoscopic video unit for use with
KARL STORZ TELECAM 1-Chip
Camera Heads and KARL STORZ
Video Endoscopes, incl. 50 W
Hi-Lux Light Source, integrated
Image Processing Module,
15" LCD TFT Display,
USB/SD-Card Storage Module,
Color System PAL/NTSC,
power supply: 100 – 240 VAC,
50/60 Hz including power cable,
USB flash drive, keyboard with
touch pad, US-English character set
50 Watt high-performance light source
## Natural
colour rendition close to sunlight with a
colour temperature of 5700 K
## Up
to 1000 hours lamp operating time
20 2120 40
20 2121 40
20 2120 40 / 20 2121 40
PAL
TELECAM
NTSC One-Chip Camera Head
color system PAL, autoclavable, soakable, gas-sterilizable,
with integrated Parfocal Zoom Lens, f = 14 – 28 mm (2x),
2 freely programmable camera head buttons,
including plastic container 39301 ACT for sterilization
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
IMAGE 1 HUB HD
TM
IMAGE 1 HUB HD Camera Control Unit
TM
## Maximum
resolution and the consistent use
of the 16:9 aspect ratio guarantee FULL HD
(High Definition)
## Endoscopic camera systems are equipped
with three CCD chips that support the 16:9 input
format as well as capturing images with a
resolution of 1920 x 1080 pixels
22 2010 11U1 22 2010 11U1XX
The benefits of FULL HD (High Definition)
for medical applications are:
## High input resolution of the camera head delivers
more detail and depth of field with natural color
rendition
## Using 16:9 format during image acquisition
enlarges the field of view
## The 16:9 format of the widescreen monitor
supports ergonomic viewing
## Enhanced color brilliance for optimal diagnosis
## Progressive scan technology provides a steady,
flicker-free display and helps eliminate eyestrain
and fatigue
IMAGE 1 HUB™ HD Camera Control Unit SCB
for use with IMAGE 1 FULL HD and IMAGE 1 standard one- and three-chip
camera heads, max. resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
color systems PAL/NTSC, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
BNC/BNC Video Cable
S-Video (Y/C) Connecting Cable
Special RGBS Connecting Cable
2x Connecting Cable, for controlling peripheral units
DVI-D Connecting Cable
SCB Connecting Cable
Keyboard, with US English character set
22 2010 11U102 IMAGE 1 HUB HD Camera Control Unit SCB,
with SDI module
TM
for use with IMAGE 1 FULL HD and IMAGE 1 standard one- and three-chip
camera heads, max. resolution 1920 x 1080 pixels, with integrated SDI
(Serial Digital Interface) module, KARL STORZ­-SCB
and digital Image Processing Module, color systems PAL/NTSC,
power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
BNC/BNC Video Cable
S-Video (Y/C) Connecting Cable
Special RGBS Connecting Cable
2x Connecting Cable, for controlling peripheral units
DVI-D Connecting Cable
SCB Connecting Cable
Keyboard, with US English character set
47
48
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
IMAGE 1 HUB HD
TM
HD Camera Control Unit
22 2010 11U110 I MAGE 1 HUB™ HD Camera Control Unit SCB,
with ICM module
22 2010 11U11X
for use with IMAGE 1 FULL HD and IMAGE 1 standard one- and three-chip
camera h
­ eads, max. resolution 1920 x 1080 pixels, with integrated ICM
(Image Capture Module), KARL STORZ-SCB and digital Image Processing
Module, color systems PAL/NTSC, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
BNC/BNC Cable
S-Video (Y/C) Connecting Cable
Special RGBS Connecting Cable
2x Connecting Cable, for controlling peripheral units
DVI-D Connecting Cable
SCB Connecting Cable
Keyboard, with US English character set
2x KARL STORZ USB Stick, 4 GB
22 2010 11U112 I MAGE 1 HUB™ HD Camera Control Unit SCB,
with SDI/ICM module
for use with IMAGE 1 FULL HD and IMAGE 1 standard one- and three-chip
camera h
­ eads, max. resolution 1920 x 1080 pixels, with integrated ICM
(Image Capture Module) and SDI (Serial Digital Interface) modules,
KARL STORZ-SCB and integrated digital Image Processing Module,
color systems PAL/NTSC, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
BNC/BNC Video Cable
S-Video (Y/C) Connecting Cable
Special RGBS Connecting Cable
2x Connecting Cable, for controlling peripheral units
DVI-D Connecting Cable
SCB Connecting Cable
Keyboard, with US English character set
2x KARL STORZ USB Stick, 4 GB
Specifications:
Signal-to-noise ratio
IMAGE 1 HUB™ HD,
three-chip camera systemsM 60 dB
AGC
Microprocessor-controlled
Video output
Input
Control output/input
- FULL HD signal to DVI-D socket (2x)
- SDI signal to BNC socket, (only
IMAGE 1 HUB™ HD with SDI module (2x)
- RGBS signal to D-Sub socket
- S-Video to 4-pin Mini-DIN socket (2x)
- Composite signal to BNC socket
- KARL STORZ-SCB to 6-pin socket
Mini-DIN socket (2x)
- 3.5 mm stereo jack plug (ACC 1, ACC 2),
- Serial port at RJ-11
- USB port
(only IMAGE 1 HUB™ HD with ICM) (2x)
Dimensions w x h x d
305 x 89 x 335 mm
Weight
3.35 kg
Power supply
100–240 VAC, 50/60 Hz
Keyboard for title generator,
5-pin DIN socket
Certified to:
IEC 601-1, 601-2-18, CSA 22.2 No. 601,
UL 2601-1 and CE acc. to MDD,
protection class 1/CF defibrillation-safe
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
49
IMAGE 1 HD
FULL HD Camera Control Unit
22 2020 11U110 IMAGE 1 HD Camera Control Unit SCB,
with ICM module
22 2020 11U1XX
for use with IMAGE 1 FULL HD three-chip camera heads,
max. resolution 1920 x 1080 pixels, with integrated ICM
(Image Capture Module), KARL STORZ-SCB and digital Image
Processing Module, power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
2x Connecting Cable, for controlling peripheral units
DVI-D Connecting Cable
SCB Connecting Cable
Keyboard, with US English character set
2x KARL STORZ USB Stick, 4 GB
22 2020 11U1
IMAGE 1 HD Camera Control Unit SCB
for use with IMAGE 1 FULL HD three-chip camera heads,
max. resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB
and digital Image Processing Module,
power supply 100 – 240 VAC, 50/60 Hz
including:
Mains Cord
2x SCB Connecting Cable
DVI-D Connecting Cable
Connecting Cable, for controlling peripheral units
Keyboard, with US English character set
Specifications:
IMAGE 1 HD, three-chip camera systems
M 60 dB
Dimensions w x h x d
305 x 89 x 335 mm
Weight
3.35 kg
AGC
Microprocessor-controlled
Video output
Power supply
100–240 VAC, 50/60 Hz
FULL HD Signal to DVI-D socket
Input
Certified to
Keyboard for title generator,
5-pin DIN socket
IEC
601-1, 601-2-18, CSA 22.2 No. 601,
UL 2601-1 and CE acc. to MDD,
protection class 1/CF defibrillation-safe
Control output/input
- USB port (only IMAGE 1 HD with ICM) (2x)
- Serial port at RJ-11
- 3.5 mm stereo jack plug (ACC 1, ACC 2)
- KARL STORZ-SCB to 6-pin socket
Mini-DIN socket (2x)
Signal-to-noise ratio
50
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
IMAGE 1 HUB™ HD
Full HD Camera Heads
22 2200 55-3
50 Hz IMAGE 1 H3-Z
60 Hz Three-Chip FULL HD Camera Head
22 2200 55-3
max. resolution 1920 x 1080 pixels, progressive scan, soakable,
gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens,
focal length f = 15 – 31 mm (2x),
2 freely programmable camera head buttons
Specifications:
IMAGE 1 FULL HD Camera Heads
H3-Z
50 Hz
22 2200 55-3 (50/60 Hz)
60 Hz
–
Image sensor
3x 1/3" CCD chip
Pixel output signal H x V
1920 x 1080
Dimensions (w x h x l)
39 x 49 x 114 mm
Weight
270 g
Optical interface
integrated Parfocal Zoom Lens,
f = 15-31 mm (2x)
Min. sensitivity
F 1.4/1.17 Lux
Grip mechanism
standard eyepiece adaptor
Cable
non-detachable
Cable length
300 cm
For use with IMAGE 1 HUB™ HD Camera Control Unit SCB 22 2010 11U1xx and IMAGE1 HD
Camera Control Unit SCB 22 2020 11U1xx
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
51
IMAGE 1 HUB™ HD
Full HD Camera Heads – autoclavable
22 2200 61-3
50 Hz IMAGE 1 H3-ZA
60 Hz Three-Chip FULL HD Camera Head
autoclavable, max. resolution 1920 x 1080 pixels, progressive scan,
soakable, gas-­and plasma-sterilizable, with integrated Parfocal Zoom
Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera
head buttons, for use with color systems PAL/NTSC
22 2200 61-3
22 2200 60-3
50 Hz IMAGE 1 H3-FA
60 Hz Three-Chip FULL HD Camera Head
autoclavable, max. resolution 1920 x 1080 pixels, progressive scan,
soakable, gas-­and plasma-­sterilizable, fixed focus,
focal length f = 17 mm, 2 freely programmable camera head buttons,
for use with color systems PAL/NTSC
22 2200 60-3
Specifications:
IMAGE 1 FULL HD Camera Heads
H3-ZA
H3-FA
50/60 Hz
22 2200 61-3 (PAL/NTSC)
22 2200 60-3 (PAL/NTSC)
Image sensor
3x 1/3" CCD chip
3x 1/3" CCD chip
Pixels output signal H x V
1920 x 1080
1920 x 1080
Dimensions (w x h x l)
39 x 49 x 100 mm
39 x 49 x 93 mm
Weight
299 g
261 g
Optical interface
integrated Parfocal Zoom Lens,
f = 15-31 mm
fixed focus f = 17 mm
Min. sensitivity
F 1.4/1.17 Lux
F 1.4/1.17 Lux
Grip mechanism
standard eyepiece adaptor
standard eyepiece adaptor
Cable
non-detachable
non-detachable
Cable length
300 cm
300 cm
For use with IMAGE 1 HUB HD Camera Control Unit SCB 22 2010 11-1xx and
IMAGE 1 HD Camera Control Unit SCB 22202011-1xx
TM
39301 Z3TS Plastic Container for Sterilization and Storage
of camera heads IMAGE1 H3-Z, H3-ZA and H3-FA,
autoclavable, suitable for use with steam, gas and
hydrogen peroxide sterilization, Sterrad® compatible,
external dimensions (w x d x h): 385 x 255 x 75 mm
Please note: The instrument displayed is not
included in the plastic container.
Only camera heads marked “autoclave” can be
placed in the tray for steam sterilization.
52
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
KARL STORZ FULL HD Monitors n
9619 NB
9626 NB/NB-2
KARL STORZ HD and FULL HD Monitors
Wall-mounted with VESA 100 adaption
19"
26"
26"
9619 NB
9626 NB
9626 NB-2
Inputs:
1x
1x
2x
Fiber Optic
optional
optional
optional
RGBS/VGA
1x
1x
2x
S-Video
1x
1x
2x
Composite/FBAS
1x
1x
2x
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
DVI-D
Outputs:
DVI-D
S-Video
Composite/FBAS
Signal Format Display:
4:3
5:4
16:9
Picture-in-Picture
PAL/NTSC compatible
The following accessories are included:
Mains Cord
External 24VDC Power Supply
Signal cables: DVI-D, BNC
Optional accessories:
9626 SF
Pedestal, for 96XX monitor series
Specifications:
KARL STORZ FULL HD Monitors
19"
26"
Desktop with pedestal
optional
optional
Wall-mounted with 100 adaption
9619 NB
9626 NB/NB-2
Brightness
280 cd/m2
400 cd/m2
Max. viewing angle
178° vertical
178° vertical
Pixel distance
0.29 mm
0.30 mm
Reaction time
12 ms
12 ms
Contrast ratio
700:1
700:1
Mount
100 mm VESA
100 mm VESA
Weight
10 kg
14 kg
Rated power
120 W
120 W
Operating conditions
0–40°C
0–40°C
Storage
-20–60°C
-20–60°C
Rel. humidity
max. 80%
max. 80%
Dimensions w x h x d
469.5 x 416 x 75.5 mm
699 x 445.6 x 87.5 mm
Power supply
85–264 VAC
85–264 VAC
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
53
KARL STORZ HD, HD WIDEVIEW™
and HD LED Backlight Monitors
9524 NB, 9526 NBL, 9726 NB
TFT Flat Screens
15"
Wall-mounted with VESA 100 adaption
HD WIDEVIEW Monitors
19"
24"
26"
9515 NB
9519 NB
9524 NB
9526 NBL
9726 NB
l
l
–
l
l
l
–
l
l
l
l
–
l
l
l
l
l
l
–
l
–
l
l
l
l
l
l
–
l
l
l
l
l
l
l
l
–
l
l
l
l
l
l
l
l
–
–
–
–
–
–
–
l
l
–
l
l
l
l
l
l
–
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
–
–
–
–
l
l
l
–
–
l
l
l
l
l
l
l
l
l
l
l
–
l
l
l
l
l
–
l
l
Inputs:
SDI
HD-SDI
3G-SDI
RGBS
S-Video
Composite/FBAS
SOG
DVI-D
VGA
Outputs:
SDI
HD-SDI
3G-SDI
RGBS
S-Video
Composite/FBAS
DVI-D
Signal Format Display:
4:3
5:4
16:9
16:10
Picture-in-Picture
PAL/NTSC compatible
The following accessories are included:
Mains Cord
External 24VDC Power Supply
Signal cables
Optional accessories:
9526 SF
Pedestal for 15", 19", 24" and 26" monitors from the 95XX- and 97XX-series
54
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
KARL STORZ HD, HD WIDEVIEW™
and HD LED Backlight Monitors
Specifications:
Wall-mounted
with VESA 100 adaption
15"
19"
24"
26"
26"
9515 NB
9519 NB
9524 NB
9526 NBL
9726 NB
Brightness
430 cd/m2
300 cd/m2
400 cd/m2
400 cd/m2
800 cd/m2
Max. viewing angle
178° vertical
178° vertical
178° vertical
178° vertical
178° vertical
Pixel distance
0.297 mm
0.294 mm
0.270 mm
0.3 mm
0.3 mm
Reaction time
10–15 ms
10–16 ms
5–12 ms
8 ms
8 ms
Contrast ratio
500:1
600:1
1000:1
1000:1
1000:1
Mount
100 mm VESA
100 mm VESA
100 mm VESA
100 mm VESA
100 mm VESA
Weight
4.8 kg
6.8 kg
7.3 kg
7.3 kg
8.2 kg
Rated power
40 Watt
65 Watt
115 Watt
60 Watt
130 Watt
Operating conditions
0–40 °C
0–38 °C
0–40 °C
0–40 °C
0–40 °C
Storage
-20–60 °C
-20–60 °C
-20–60 °C
-20–60 °C
-20–60 °C
Rel. humidity
5–85%,
non-condensing
5–85%,
non-condensing
20–85%,
non-condensing
20–85%,
non-condensing
20–85%,
non-condensing
Dimensions w x h x d
386 x 302 x 81 mm
465 x 400 x 98 mm
597 x 401 x 100 mm 73 x 418 x 88 mm
673 x 418 x 88 mm
Power supply
100–240 VAC
100–240 VAC
100–240 VAC
100–240 VAC
100–240 VAC
n
9515 NB
15" Monitor
9519 NB
19" HD Monitor
Wall-mounted with VESA 100 adaption, color systems
PAL/NTSC, max. screen resolution 1024 x 768,
power supply 100 – 240 VAC, 50/60 Hz
Wall-mounted with VESA 100 adaption, color systems
PAL/NTSC, max. screen resolution 1280 x 1024,
power supply 100 – 240 VAC, 50/60 Hz
including:
Power Supply
Mains Cord
Signal cables: S-Video (Y/C), DVI-D
including:
Power Supply
Mains Cord
Signal cables: DVI-D, BNC
9524 NB
24" HD WideView Monitor
Wall-mounted with VESA 100 adaption, color systems
PAL/NTSC, max. screen resolution 1920 x 1200,
image format 16:10, power supply 100 – 240 VAC,
50/60 Hz
including:
Power Supply
Mains Cord
Signal cables: DVI-D, BNC
LED Backlight Monitors n
9526 NBL
26" HD Monitor with LED Backlight
9726 NB
26" HD Monitor
(Highbright with LED Backlight)
Wall-mounted with VESA 100 adaption, color systems
PAL/NTSC, max. screen resolution 1920 x 1080,
image format 16:10, power supply 100 – 240 VAC,
50/60 Hz
Wall-mounted with VESA 100 adaption, optical input,
color systems PAL/NTSC, max. screen resolution
1920 x 1080, image format 16:10, power supply
100 – 240 VAC, 50/60 Hz
including:
Power Supply
Mains Cord
Signal cables: DVI-D, BNC
including:
Power Supply
Mains Cord
Signal cables: DVI-D, BNC
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
55
Cold Light Fountains and Accessories
495 NT
495 NTW
495 NTX
Fiber Optic Light Cable,
diameter 2.5 mm, length 180 cm
Fiber Optic Light Cable,
diameter 2.5 mm, length 180 cm
with 90° deflection to the light source
Same, length 230 cm
Cold Light Fountain XENON NOVA® 175
20134001
Cold Light Fountain XENON NOVA® 175,
power supply:
100–125 VAC/220–240 VAC, 50/60 Hz
including:
Mains Cord
20132026
XENON Spare Lamp, only,
175 watt, 15 volt
Cold Light Fountain HALOGEN 250 twin
20 1133 20
Cold Light Fountain HALOGEN 250 twin,
power supply:
100 – 240 VAC, 50/60 Hz
including:
Mains Cord
105
HALOGEN Spare Lamp, 250 watt, 24 volt
Cold Light Fountain XENON 300 SCB
20 133101-1 Cold Light Fountain XENON 300 SCB
with built-in antifog air-pump, and integrated
KARL STORZ Communication Bus System SCB
power supply:
100 –125 VAC/220 –240 VAC, 50/60 Hz
including:
Mains Cord
Silicone Tubing Set, autoclavable, length 250 cm
SCB Connecting Cord, length 100 cm
20133027
Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028
XENON Spare Lamp, only,
300 watt, 15 volt
56
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
Equipment Carts
29005 DRB Equipment Cart,
rides on 4 antistatic dual wheels, 2 equipped
with locking brakes (rear), 3 fixed shelves,
1 with handles, mains switch in vertical beam,
1 drawer unit with lock, integrated cable
conduits in both vertical beams, 1 set of
non-sliding stands for units, double rear
panel with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable
winding on the outside, 1 camera holder,
2 equipment rails sidewise,
Dimensions:
Equipment cart: 730 x 1490 x 716 mm (w x h x d),
shelf: 630 x 480 mm (w x d),
caster diameter: 150 mm
29005 DRB
29005 HNO Equipment Cart,
rides on 4 antistatic dual wheels,
2 equipped with locking brakes,
main switch at vertical beam,
integrated cable conduit in both vertical beams,
Drawer unit with lock,
2 horizontal cable conduits,
one with cable winding,
1 set of non-sliding stands for units,
1 equipment rail,
1 TFT-Monitor holder (VESA 75/100),
1 camera holder,
2 power cords (100 cm),
Powerbox with 6 mains sockets and
potential earth,
Dimensions:
Videocart 530 x 1090 x 645 mm (W x H x D),
shelf: 430 x 480 mm (W x D),
caster diameter: 125 mm
29005 HNO
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies
57
Headlight KS60
with Cold Light Illumination
Special features:
## Luminous field can be focused – adjustable from
20 to 80 mm at a working distance of 40 cm –
­resulting in brightness of over 175,000 lux
## Double lens system provides outstanding illumination
in the depths of the operating field
## Precise delineation and no luminous field color margins
## Homogeneous illumination of the luminous field
without shadows
## Newly designed, lightweight headband provides
improved comfort, also suitable for a small head size,
can be adjusted both horizontally and vertically
## Sterilizable
handle allows adjustment under
sterile conditions, moveable and height adjustable
## Light cable is divided in the head area,
ensuring even distribution of weight
## Extremely robust and flexible light cable due to
special protective casing
## Convenient light cable length of 290 cm
provides greater freedom of movement
310060/310061
Headlight KS60, with double lens system and Y-fiber optic light cable,
>175,000 lux, illuminated area adjustable from 20 – 80 mm with 40 cm
working distance,
including:
Headlight KS60, with removable and sterilizable Focus Handle 310065
Headband, fully adjustable, with Forehead Cushion 078511,
with cross band, including holder for Headlight 310063
Y-Fiber Optic Light Cable, with special protective casing for Headlight 310063,
length 290 cm
Clip with Band, for attaching the fiber optic light cable to OR clothing
310060
310061
Same, including:
Headlight KS60, with removeable and sterilizable Focus Handle 310065
Headband, fully adjustable, with Forehead Cushion 078511, with cross band,
including holder for Headlight 310063
Y-Fiber Optic Light Cable, with special protective casing for Headlight 310063,
with 90° deflection to the light source, length 290 cm
Clip with Band, for attaching the fiber optic light cable to OR clothing
58
Notes:
Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies