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Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today we're highlighting Sialendoscopy: Understanding the Benefits and Limitations in Treating Salivary Gland Disorders. Joining me is Dr. Thomas Schrepfer. He's an Assistant Professor of Head and Neck Surgery in the Department of Otolaryngology at the University of Florida College of Medicine.

Dr. Schrepfer, it's a pleasure to have you join us today. Before we get into some of the treatments, how common are salivary gland disorders? How prevalent are they? And do we know the most common cause? Are there different types? Tell us a little bit about them.

Dr. Thomas Schrepfer: Yeah. So first of all, thanks for having me. Happy to be here and answer any questions you may have. So, the occurrence of salivary gland disorders, that's actually a really good question. I'm not sure if I can give you like a certain number. It depends on what type of salivary gland disorders you're looking at.

So, the ones I treat, I can just tell you out of my practice, you either have an obstructive disorder like a stone or blockage so that the gland actually doesn't drain anymore and you develop symptoms. And the other big category would be an inflammatory process, like we all know mumps or an infection in a child, but you can have also immunomodulated or inflammatory processes later on as an adult that can cause salivary gland disorders. So, two most common appearances, either there's an anatomical obstruction that's causing an issue or an inflammatory process in your gland that gives you symptoms.

Melanie Cole, MS: Okay. So based on whether it's inflammatory or obstructive, if a patient goes to see primary care, what are the symptoms? What are they looking for? Does the face swell up? What happens?

Dr. Thomas Schrepfer: So first, it can be kind of difficult to distinguish these two. So a stone, you assume a stone is only one-sided. We humans, we're mostly symmetric, and so we have the two big parotid glands. These are in front and below your ears. They're really big glands that kind of make a big part of your cheek. Then ,there's another gland, it's called submandibular gland, it's below your jawline. These are the glands that are usually affected with these issues. So, let's assume we have an obstruction like a stone. It's more common in the so-called submandibular gland. And as we all know, we produce more saliva when we either think of food or when we're actually eating or chewing on something. So, if you have some obstruction or a stone, something blocking it, you may feel a swelling under your jaw. People would describe it like a golf ball blowing up when you eat. And then, if you're lucky, it goes back down. Once you're done eating, you can massage it. These stones, they can be anywhere between the opening, which is right under your tongue, or deep in the gland. And a lot of stones, they develop slowly and they're small and they can be floating. And that's why when you eat, they may flow towards the exit of the gland or the duct, and then, that's when the gland swells up and you have the symptoms.

These stones, if you massage your gland, they may just come out. It may look like a little rice corn coming out under your tongue, or it may get stuck there and you can actually see and feel the swelling. The parotid glands can also develop stones, but they're rare and they usually remain smaller. They're also less symptomatic. So if you go to a primary care and you have like on and off swelling, eating or the food intake-related under your chart, then I think it makes sense to think of a stone and obstructive disorder.

 So most of the time, you have the swelling, but you don't see or have symptoms of an infection. Symptoms of infection would be the usual, like warmth, erythema, tender swelling under the jaw, and pus draining from ductal system. So, those are the ones you really want to do the so-called MASH protocol, which means massaging, warm compresses and antibiotic. And then, once it calms down and symptoms may or may not come back, you want to think of obtaining some imaging.

I'm a big fan of ultrasound as the first modality, just because it shows you really the actual texture and the actual structure of the gland. It can already distinguish between an obstruction versus maybe something else going on, like an autoimmune disorder, an inflammatory process. Although if you really think of a stone, you want to know the extension of the stone and the location of the stone, then a CT scan obviously is better because it shows you the density, because it highlights dense structures like a stone.

When you move on to autoimmune disorders, there can be a whole range of symptoms, because if it's autoimmune related, you have to think of it may or may not affect all the glands, or at least a couple or pair of glands. Those patients may have a constant swelling, but not much pain. They can just have like a swelling in front of the ears affecting the parotid glands or submandibular glands. And if it goes on for a certain time, they may develop systemic symptoms such as dry eyes, dry mouth, and that's when you really want to think of an autoimmune-related disorders like Sjögren's disease.

Melanie Cole, MS: Thank you so much, Dr. Schrepfer. So, let's talk about sialendoscopy. Tell us what it is, how it works as a minimally invasive technique for treating these disorders we're discussing here today.

Dr. Thomas Schrepfer: Sialendoscopy, it's a really interesting intervention or technique that was actually developed in Geneva by Francis Marshall. The idea of putting fiber that you can look through the ductal system into the gland has been around for a while, but then Dr. Marshall, he really kind of brought it to a point where he was able to visualize through the gland without having an open surgery and performing through the duct or through the working channel in the scope of procedure. So, he was the first to visualize a stone through the duct, inside the duct, and then take it out through a little basket.

So basically, picture a tiny straw, only maybe 1.2 millimeter in diameter that you can actually insert into your ductal system. And then, at the end of that straw, you can hook up a camera. And whatever you see through the straw is visualized on a screen in front of you. There is mainly three different sizes. There's a company out there called Storz from Germany. They make those scopes. There's a diagnostic scope. It's only 0.89 millimeters in diameter. It does not have a working channel, so all you can do is actually just go into the duct and see what's going on.

Then, the next step up will be the 1.1 or the 1.3 millimeter scope. The nice thing about those, they have a side port, so you can insert a small wire or even a tiny basket. So if you see a fragment or a small stone in front of you, if you're lucky, you can catch it and pull it out. Then, the next step up would be the 1.6 millimeter scope. I hardly ever can use the scope just because it's almost too big for every duct that we have. Unfortunately, it's the only scope that can accommodate a laser fiber. So every now and then, I try laser lithotripsy to fragment the stone with a laser. That's when I have to go up to the 1.6 millimeter scope, because only that scope has a side port that's big enough to accommodate that wire.

Melanie Cole, MS: That's so cool, Dr. Schrepfer. What an exciting time in your field. This is a really exciting and fascinating interventional equipment. I mean, it's new. We haven't heard much about it, so speak about the benefits for the patients and, as you were describing the procedure so very well in the technique, the benefit for the provider. How is this making it so much easier for you to identify these things than say 20 years ago?

Dr. Thomas Schrepfer: I think you can divide between benefit for the patient, benefit for the provider. So, the benefit for the patient, if you have a small stone, you can hopefully cure them by going through the duct, find the stone, take the stone out and solve the obstruction. The patient is happy again. In the old days, worst case scenarios, those patients, they were symptomatic, so what we do, you take out the gland. So, pretty invasive open surgery to solve, honestly, a small problem, right? A tiny stone. So, it's a benefit for the patient.

The benefit for the provider, obviously, you make a patient very happy. Reimbursement is extremely poor, so that's why there's not many people out that actually offer the procedure, just because there is no specific code, so providers don't get paid. So, the only way to get paid for the procedure is by using different codes or argue with the insurance that, "Hey, you should pay me like I take out the gland because I do a gland-sparing procedure."

The other problem, the equipment. The equipment's extremely fragile. It doesn't take much like it's so flimsy and small, a little bent too much and it breaks. And each scope is $15,000. It's extremely fragile, difficult-to-handle expensive material for a procedure that you probably as a private provider don't get reimbursed enough to actually make a living and pay all the costs, like the overhead costs.

So, that's for obstructive disorders. Obstructive disorders, they can be extremely gratifying. If you find the right patient with the right stone, right size, you can cure them. if you have an inflammatory process, unfortunately, there's no such thing, because we cannot cure an underlying autoimmune disease or Sjögren's. But they get a lot better, especially children. So, even children, they can have recurrent, inflammatory issues with their glands, it's called JRP or Juvenile recurrent parotitis. StIt startsn early childhood, can go on until they're teenagers. And those kids, they can really suffer, they may receive multiple rounds of antibiotics, steroids. They require a lot of workup. And the tissue, the gland can take a lot of damage if you don't do anything for years. Literature and studies show that with sialendoscopy. So what we do, we go into the gland. It's usually, again, parotid gland, just by flushing with saline and irrigating it, and at the end, I usually have a big love of Kenalog, so at the end we flush it with steroid. There is more than 80% of these kids that do well. So like, you do the procedure once and more than 80% of the children, they basically don't have symptoms anymore.

Melanie Cole, MS: Wow, that's really incredible. You've given us so much to think about. Tell us a little bit about advancements, innovations in sialendoscopy that are currently in development. And you mentioned the equipment itself. Dr. Schrepfer, what do you want to see happen with this type of procedure? I mean, obviously for insurance to recognize it a little bit more clearly because it does have such benefits. But if you were to look for the future and say, as a head and neck surgeon, I would like to see, tell us what that is.

Dr. Thomas Schrepfer: I mentioned the laser lithotripsy, like where you can actually insert a laser fiber and fragment the stone. So, that's off-label. You really have to tell the patient, "Hey, it's off-label use." So, there's no official wire or laser approved for that, which is I'll use the equipment provided by Urology. So, the whole technique kind of was copied from Urology, like the cystoscopes from Urology gave the idea to develop these sialendoscopes, and same with the laser fiber and the actual laser. So, we use the holmium:YAG laser and the fiber from Urology. It works. It works actually really well.

The problem is you end up with two issues. Number one, again, the duct is super small and fragile, so there's almost always thermal damage because of the laser. And if you fire laser too close to the endoscope, you may even damage the endoscope. And then, the other thing, you end up with lots of these little fragments that you have to catch and flush out at the end. So if I could wish something, obviously, that it would be officially approved, that there is a guideline developed, or maybe even a fiber that is like, "Okay, hey, that's officially approved for sialendoscopy. Other than that, we all know technology is advancing. So hopefully one day, we don't need the optical fibers anymore. So, maybe one day, it can be a super tiny microchip at the tip. Like right now, the iPhone cameras or other cameras that we can have chip-on-the-tip scope instead of the fibers, so it's less likely to break the scope. I guess that would be a nice advancement in technology.

Melanie Cole, MS: This was very interesting conversation. Dr. Schrepfer, thank you so much. Your knowledge is so fascinating and you have so much of it, your expertise, in this topic that not that many people know about. So, this was really, really interesting. Thank you for such a lively discussion. And to learn more about this and other healthcare topics at UF Health Shans Hospital, please visit innovation.ufhealth.org or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.