Sialendoscopy
University of UCSF Update
Stenoses RAI Sjogrens
Access “Iowa H+N Protocols”
Search: Iowa Protocols
Type search term
Disclosures:
- Consultant to COOK Medical
The University of Iowa Research Foundation (UIRF)and Dr. Hoffman filed
- a provisional patent application April 11 2013 “Transilluminating
Obturator” UIK-04301
- a patent March 25 2009 (US Patent) and March 19 2010 (International
Patent: PCT/US2010/027995)
•Portions of possible future profits from devices associated with these
patents will be disbursed through the UIRF with Henry Hoffman listed as
one of the recipients
Google/Bing: “Iowa Protocols”
or
Type “topic term” and “Iowa”
Sodium iodide symporter (NIS)
transports iodide by same mechanism into thyroid and salivary tissue
-- major and minor salivary glands
Immunohistochemical parotid stain for NIS
‘provided by Gainor D*, Chute D# and Lorenz R*, Cleveland Clinic’
*= Dept of Otolaryngology, # = Dept of Anatomic Pathology,
staining absent
in acinar tissue
intense staining of
striated ducts
Radioiodine Sialadenitis
key points:
1. Prevention best by avoiding treatment with I131 when possible
(contemporary use less common)
2. “Cincinnati regimen” reports best results, not duplicated
in other reports
3. Amifostine fallen out of favor
4. Ductal injury logically supports:
a. Early intervention
? Steroid infusion
? Hydroexpansion
? Mechanical expansion w or w/o sialendoscopy
b. Considerations for research study
? Prophylactic ductal infusion (botox/steroid/other)
5. Treatment after injury detected (xerostomia / salivary swelling
and pain) may be too late
“Cincinnati regimen”
intense sialorrheic management with hydration during and after I131 treatment
Silberstein 2008 [vi]
oral 8 mg of dexamethasone and 100 mg of dolasetron 2 hours before therapy and
every 12 hours for 5 doses after I131 ingestion
2,400 mL of nondairy liquid per day for the week after therapy
Sugar-free gum or candy in the mouth at all times when awake for a week and for
the first 3 nights, awaken every three hours to reapply sialogogues and then
brush mouth with soft toothbrush and water for one minute
Remarkably low incidence of salivary problems supports further investigation of
this approach.
Unclear as to contribution provided by dexamathasone (anti-inflammatory) and
dolasetron (secretogogue) which were given primarily for their anti-emetic
properties
Silberstein EG: Reducing the Incidence of I131 –Induced Sialadenitis: the role of
Pilocarpine TheJournal of Nuclear Medicine vol 49 No 4 April 2008 pp 546-549
Radioiodine Sialadenitis
key points:
1. Prevention best by avoiding treatment with I131 when possible
(contemporary use less common)
2. “Cincinnati regimen” reports best results, not duplicated
in other reports
3. Amifostine fallen out of favor
4. Ductal injury logically supports:
a. Early intervention
? Steroid infusion
? Hydroexpansion
? Mechanical expansion w or w/o sialendoscopy
b. Considerations for research study
? Prophylactic ductal infusion (botox/steroid/other)
5. Treatment after injury detected (xerostomia / salivary swelling
and pain) may be too late
Primary Sjogren's: requires 4 of the 6 criteria below, including either positive antibodies
or positive lip biopsy
Secondary Sjogren's requires diagnosis of connective tissue disease and one sicca
symptom and 2 out of the 3 objective tests for either xeropthalmia (ocular) or xerostomia
(oral) symptoms
3.Oral
4.Oral
5.Ocular
1.+'v antiSymptoms( Test(1of3)
Symptoms(
2.Lip
6.Ocular
SSA
1of3)
Unstim saliv 1of3)
Biopsy
Tests(1of2)
and/or SSB
Dry mouth > flow
Dry eyes > 3
3 months
<.1mL/min
months
positive
focus score
>0.25 mm2
see Lip
biopsy
Swollen
salivary
glands
Abnormal
parotid
Sialography
Foreign body
+'ve slit lamp
sensation in
exam
eye
Need liquids
to swallow
Abnormal
salivary
scintigraphy
Use of
artificial
tears >3 x
per day
AECG (American-European Consensus Group)
2002
)+'ve
Schirmer's
test
• Lip Biopsy - useful for selected cases but 'noted inconsistency and unreliability with the lip biopsy' (ref Bamba et al)
1.False negative biopsy:
1.common when on immunosuppressive medication (including corticosteroids)
2.False negative in the face of chronic Sjogren's syndrome with atrophy and fibrosis of salivary glands (long standing Sjogren's may not benefit)
3.Cigarette smoking (Manthorpe 2000)
4.Sialography felt to be diagnostically more sensitive but less specific than labial salivary gland biopsy (Daniels et al 1996)
2.False positive
1.Aging, trauma, hepatitis C, lymphoma, graft v host disease, sarcoidosis (Huo et al 2010)
3. Not useful in the face of elevated anti-SSA or anti-SSB antibodies (reliably predict positive results of a lip biopsy)
4. Useful in selected cases of suspected Sjogren's in the face of negative ANA, RF, anti-SSA or anti-SSB antibodies.
5. Suggested by Huo et al that 'lip biopsy be reserved only for patients whose serological tests for ANA, RF, anti-SS-A and anti-SS-B are all negative" (Huo et al 2010)
6. Technique: Lip biopsy for minor salivary gland (biopsy for Sjogren's syndrome)
Sjogrens Syndrome
key points:
1. Optimal approach to establishing diagnosis is controversial
A. Recognize other causes for xerostomia / salivary swelling
1. (e.g.: diabetic (sialosis = salivary swelling)
2. on antidepressants (xerostomia)
B. ? Lip bx vs Sialogram
2. Management warrants Rheumatology involvement
3. In-office vs in-O.R. salivary duct cannulation/dilation/steroid
insufflation
A Likely to benefit swelling and pain
B Less likely to benefit xerostomia
4. Future developments: ? Infusion of restasis (cyclosporin)
43 yo with R parotid painful swelling
with meals beginning 5 years prior to
referral to our clinic 12-01-2011
Minor discomfort ‘all the time’
Major swelling requiring
antibiotics every 3 to 4 months
No rheumatoid problems no
dry eyes or dry mouth
Previous tx elsewhere: effort to
dilate the duct opening;
tympanic neurectomy on R
with no benefit
Right parotid sialogram done 12 19 2011
High-grade stricture of the main parotid duc
6 cm from the duct orifice
causing diffuse sialectasis of
the right intraglandular parotid ducts
Our surgical intervention 12/28/2011 by
way of a right-sided parotid
sialoendoscopy identified the narrowing
with current limitations in technology
manifest by our efforts to use multiple
different devices to enlarge the area of
narrowing by way of dilation, including
use of a basket and a Fogarty catheter
April 2012
4 months after parotiectomy
4 months after parotidectomy
With no symptoms
Ductal Stenoses
key points:
1. In my hands sialography is an important diagnostic study
Imaging of the ductal system difficult with other methods,
including MR sialography
2. Some strictures are easy (thin membrane; distal)
many are difficult
3. Current methods of dilation require improvement
a. The strictures in most need of dilation are
too small to get a dilator in
b. Need for adjuvants to maintain patency – stents
still questions remain about benefit, type, duration