Effectiveness and costs of sialendoscopy in pediatric patients with salivary gland disorders.

OBJECTIVES/HYPOTHESIS: This study aimed to characterize the common salivary gland disorders presenting in the pediatric population and to describe the diagnostic and therapeutic outcomes of sialendoscopy in this population. STUDY DESIGN: Retrospective observational study in a tertiary care pediatric medical center. METHODS: Medical records review of patients under 18 years of age who presented to pediatric otolaryngology with symptoms related to a salivary gland disorder from 2002 to 2014. RESULTS: Fifty patients were identified with an average age of 7.5 years at presentation. Eighty percent (40/50) of cases were diagnosed with juvenile recurrent parotitis (JRP), and 15 underwent sialendoscopy. The other 10 (20%) patients presented with sialolithiasis. These patients had a higher average age at presentation (12.4 vs. 6.3 years), and the majority were successfully removed with sialendoscopic techniques. Juvenile recurrent parotitis patients who underwent sialendoscopy had significantly higher costs of care during the period of observation compared to those who did not have a procedure, without a statistically significant difference in outcomes. CONCLUSIONS: Sialendoscopy is an effective tool for stone retrieval in pediatric sialolithiasis. Juvenile recurrent parotitis patients who underwent sialendoscopy had outcomes similar to those selected for conservative therapy, calling into question whether the substantially higher care costs can be justified. Further prospective studies addressing cost-effectiveness will help define the role of sialendoscopy in JRP. LEVEL OF EVIDENCE: 4.

Cost-effectiveness landscape analysis of treatments addressing xerostomia in patients receiving head and neck radiation therapy.

Head and neck (H&N) radiation therapy (RT) can induce irreversible damage to the salivary glands thereby causing long-term xerostomia or dry mouth in 68%-85% of the patients. Not only does xerostomia significantly impair patients' quality-of-life (QOL) but it also has important medical sequelae, incurring high medical and dental costs. In this article, we review various measures to assess xerostomia and evaluate current and emerging solutions to address this condition in H&N cancer patients. These solutions typically seek to accomplish 1 of the 4 objectives: (1) to protect the salivary glands during RT, (2) to stimulate the remaining gland function, (3) to treat the symptoms of xerostomia, or (4) to regenerate the salivary glands. For each treatment, we assess its mechanisms of action, efficacy, safety, clinical utilization, and cost. We conclude that intensity-modulated radiation therapy is both the most widely used prevention approach and the most cost-effective existing solution and we highlight novel and promising techniques on the cost-effectiveness landscape.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: management strategies and economic impact.

PURPOSE: This systematic review aimed to assess the literature for management strategies and economic impact of salivary gland hypofunction and xerostomia induced by cancer therapies and to determine the quality of evidence-based management recommendations. METHODS: The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. For each article, two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results, and conclusions. RESULTS: Seventy-two interventional studies met the inclusion criteria. In addition, 49 intensity-modulated radiation therapy (IMRT) studies were included as a management strategy aiming for less salivary gland damage. Management guideline recommendations were drawn up for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. CONCLUSIONS: There is evidence that salivary gland hypofunction and xerostomia induced by cancer therapies can be prevented or symptoms be minimized to some degree, depending on the type of cancer treatment. Management guideline recommendations are provided for IMRT, amifostine, muscarinic agonist stimulation, oral mucosal lubricants, acupuncture, and submandibular gland transfer. Fields of sparse literature identified included effects of gustatory and masticatory stimulation, specific oral mucosal lubricant formulas, submandibular gland transfer, acupuncture, hyperbaric oxygen treatment, management strategies in pediatric cancer populations, and the economic consequences of salivary gland hypofunction and xerostomia.

Cost efficiency analysis for fine-needle aspiration in the workup of parotid and submandibular gland nodules.

The utility and cost effectiveness of salivary gland fine-needle aspiration (FNA) is controversial. Some authorities argue FNA has no added value over clinical-radiographic study because most salivary gland nodules occur in the parotid and the tumor's relationship to the facial nerve determines the operative procedure rather than the histology. Other experts contend FNA is of value by reducing the overall number of operative procedures performed. We studied 306 salivary gland nodules (214 parotid and 92 submandibular gland) undergoing FNA. One hundred and seventy one were subsequently surgically resected and the remaining 135 followed clinically. A 16% error rate was associated with the nonoperative group, necessitating later surgical resection. The cost of the FNAs and surgical resections (when performed) was calculated based on Medicare reimbursement rates. Costs were based on all cases undergoing initial FNA. The expense of initial resection was based on the observed percentage of patients undergoing resection in our series. The costs of resections related to erroneous FNA diagnoses were based on the error rate associated with FNA diagnoses clinically followed (i.e., chronic sialadenitis). Costs of FNAs, initial resections, and subsequent resections related to FNA errors were summed and compared with the cost which would have occurred if all nodules had been primarily resected.FNA reduced the number of operative procedures by approximately 65% for submandibular nodules and 35% for parotid nodules. Diagnoses which resulted in nonsurgical management included chronic radiation-induced sialadenitis, intraparotid lymph node, recurrent lymphoma, and accessory nodules or lobes of the parotid gland. Pure surgical management was associated with a cost of $275,750.00 per 100 patients. FNA management was associated with an expenditure of $206,632.00 per 100 patients, representing a savings of $69,118.00 (33% savings over surgical management alone). Based on these data, FNA appears to be cost effective in addition to supplying preoperative diagnoses helpful in counseling, operative planning, and allaying patient anxiety.