Therapeutic sialendoscopy

# Guidance
Current evidence on the safety and efficacy of therapeutic sialendoscopy appears adequate to support the use of this procedure provided that the normal arrangements are in place for consent, audit and clinical governance.# The procedure

# Indications
Therapeutic sialendoscopy is used in the treatment of suspected salivary gland obstruction. Obstruction of the ducts is most commonly caused by sialolithiasis (stones).
Symptoms of salivary gland obstruction are varied and include swelling of the face or neck, swelling in front of the ear, pain in the face or mouth and decreased ability to open the mouth.
Treatment of salivary gland obstruction depends on the underlying cause and location. For most benign ductal disorders such as sialolithiasis treatment includes surgical excision of the stone from within the mouth if it is easily accessible. Interventional sialography and extracorporeal or endoscopic lithotripsy may also be used. Removal of the affected salivary gland may be required for large or less accessible stones.

# Outline of the procedure
The procedure is typically performed under local anaesthesia. Progressive dilatation of the salivary duct, with or without stents, is performed until the opening is large enough to allow the introduction of an endoscope. The duct is irrigated initially with a local anaesthetic solution and then with saline as the scope is passed through the ductal system. Instruments (such as wire retrieval baskets) are then introduced through the endoscope to remove stones. A stent may sometimes be left in the duct postoperatively.

# Efficacy
The evidence of efficacy was based on five case series. Across these studies therapeutic sialendoscopy relieved duct obstruction in between 82% (90/110) and 87% (47/54) of cases.
In a study of 72 patients, 8% (6/72) had continuing symptoms or other clinical problems which did not improve after the procedure and required removal of the gland (sialadenectomy). In another study of 129 patients, 110 of whom underwent therapeutic sialendoscopy, the treatment was considered a failure in 18% (20/110) of patients, 5 of whom required gland removal.
Recurrence of obstructive symptoms was reported in two of the studies, with rates of 2% (4/236) and 5% (3/55), respectively. All recurrences occurred between 15 and 24 months after the procedure. For more details, refer to the 'Sources of evidence' section.
The Specialist Advisers did not consider there to be any uncertainties about this procedure. One Adviser noted that high success rates are reported in the published literature.

# Safety
Few complications were reported in the five case series reviewed. Temporary swelling of the gland was common. In one study of 129 patients, ductal wall perforation occurred in 11 patients (9%), with two of these patients requiring hospitalisation and one patient undergoing gland resection. Three other studies reported cases of salivary gland perforation with an incidence of between < 1% and 5% (3/55, 1/103, 1/236). One patient (1/236) developed lingual nerve paraesthesia caused by the perforation. Ductal strictures were also reported in seven patients (3%) in a case series of 236 patients. Five patients underwent successful dilatation but two required open surgery. Other complications included difficulty in retrieving the wire basket after engaging the stone and postoperative infections. For more details, refer to the 'Sources of evidence' section.
The Specialist Advisers stated the potential complications include infection, perforation of the duct, ranula formation, lingual nerve injury and duct stenosis.
Andrew DillonChief ExecutiveMay 2007# Further information

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
'Interventional procedure overview of therapeutic sialendoscopy', November 2006.

# Information for patients
NICE has produced information on this procedure for patients and carers ('Understanding NICE guidance'). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Changes since publication
January 2012: minor maintenance.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2007. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
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