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Gunshot injuries to the parotid gland: Patterns of injury and primary management
British Journal of Oral and Maxillofacial Surgery 45 (2007) 571–572
Short communication
Gunshot injuries to the parotid gland: Patterns of injury and primary management Omer W. Majid ∗ Department of Oral & Maxillofacial Surgery, College of Dentistry, Mosul University, Nineveh, Iraq Accepted 16 March 2006 Available online 5 May 2006
Abstract We have treated 16 patients with gunshot injuries to the cheek, 10 of whom had damage to the parotid. There were nine men and one woman, mean age 40 (range 15–65). All injuries were high velocity, and eight had other injuries. We followed them up for a month; three patients required further operation, three had facial palsy, and one lost his hearing on that side. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Parotid duct injuries; Facial gunshot injuries; Parotid fistula
Introduction Gunshot injuries to the buccal region of the face may be associated with many complications because of the complex anatomy of the area. The parotid gland is one of the structures that may be involved. Damage to the parotid is often overlooked or underestimated in patients with facial injuries. Failure to recognise such injuries may result in sialoceles, cutaneous fistulas, or cysts of the salivary duct.1 Such complications are inconvenient for the patients, difficult to treat, and can cause facial scarring.
Patients and methods At the casualty department of the Al-Zahrawi Teaching Hospital, Mosul, 16 patients with gunshot injuries to the cheek were treated over a period of a year, 10 of whom had parotid injuries. On admission all patients had the airway and vital signs stabilised, an intravenous line inserted, and appropriate radiographs taken of the face. The diagnosis was made after direct ∗
Tel.: +00 964 60 812910. E-mail address: omerw [email protected].
exploration of the wound, and injecting normal saline through the orifice of the parotid duct. All patients were operated on within 3 h of admission. Two were treated under local anaesthesia, the others being under general anaesthesia by intraoral tubes. Copious irrigation and careful debridement was required in all cases. Drains were used in five cases. Wounds were closed in layers and pressure dressings applied. All patients were given antibiotics before or during operation.
Results We identified 10 patients with parotid injuries 9 of whom were male and 1 female, aged between 15 and 65 years (mean 40). All injuries were high-velocity. Two parotid injuries were isolated and eight were associated with other facial injuries. Associated local injuries are shown in Table 1. Exit wounds were present in the parotid region in six cases, entry wounds in two, and two injuries were tangential. Systemic non-facial injuries included one in the abdomen and one in the chest. Patients were followed up for one month. Two developed salivary fistulas and one developed a sialocele; all were treated conservatively. Three patients had facial scars that required secondary revision. Three patients developed facial palsies and one lost his hearing.
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.03.015
572
O.W. Majid / British Journal of Oral and Maxillofacial Surgery 45 (2007) 571–572
Table 1 Associated local injuries of gunshot wounds to the parotid Injuries
Number
Associated fractures Maxilla Mandible Zygoma Temporal bone
5 4 3 1
Soft tissue Lip Facial nerve Ear Eye
4 3 3 2
Discussion Gunshot injuries to the parotid region are a special problem, because unlike other penetrating wounds, they are often associated with missing or severely damaged tissue, and a greater likelihood of infection and tissue necrosis.2 Many reported series have advocated the early repair of facial gunshot wounds3,4 and parotid injuries seem to be no exception. Better functional and aesthetic results are obtained by early definitive management. Although the late complications of untreated parotid injuries can be managed conservatively,5,6 they can have devastating aesthetic consequences and add to the morbidity in patients who, in many instances, have multiple injuries. To improve the management, different classification systems have been proposed for parotid injuries based on the site of injury,7 or on the results of sialography.8 However, these classifications do not apply to most gunshot wounds because they are so complex. Clinical judgement is more affected by the patterns of injury of which we identified three. Type I or tangential injury involves the superficial part of the parotid gland, and is similar to a sharp laceration except for the additional need for thorough irrigation and debridement of the wound. The parotid capsule should be closed carefully or approximated. Primary repair of the parotid duct over a stent may be feasible. We had one such injury. A Type II injury occurs when the entrance of the bullet is through the parotid itself. A relatively small external wound is commonly associated with a larger intraoral wound. In addition to careful closure of the external wound, intraoral drainage is required. In Type III injury, the exit wound is through the parotid region with the site of entry being either transoral or through the back of the neck. There is a complex, multiple, and large external wound with a variable extent of tissue lost. High-velocity projectiles tend to cut straight through soft tissue and to fracture bones with relative ease.
The total wounding capability, therefore, tends to be a combination of the projectile itself plus the effect of secondary projectiles such as fragments of bone, teeth, and dentures.9 In addition, high-velocity projectiles create a temporary cavity behind and lateral to the bullet, that then collapses as a result of recoil. The resulting loss of tissue may preclude the repair of the parotid duct or diversion of the proximal duct into the oral cavity. In all cases, however, it was possible to close the wound using adjacent tissues by careful undermining. Intraoral drainage in this type of injury is essential. A small gauge nasogastric tube passed through the intraoral wound, and through the external wound, and sutured to the buccal mucosa seemed to be effective and beneficial in reducing the rate of postoperative complications. Despite comprehensive primary management, some complications and residual deformities will occur. Both cases of salivary fistula developed in patients with Type III injuries. Salivary fistula should be suspected in every gunshot injury to the parotid region, particularly Type III. The complexity of such wounds facilitates tracking of saliva through injuryinduced planes toward the surface. By conservative management, including application of dressings and prescription of anticholinergic drugs, both cases resolved within the period of follow up. The only sialocele developed in a patient with a Type II injury and was treated by repeated aspiration and pressure dressings, and resolved within 20 days. Loss of the natural bulk of the cheek and facial scarring was noted in three patients with Type III injuries. These problems can be dealt with later with further revisions.
References 1. Steinberg MJ, Herrera AF. Management of parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:136–41. 2. Thorne CH. Gunshot wounds to the face. Clin Plast Surg 1992;19:233–44. 3. Chen AY, Stewart MG, Raup G. Penetrating injuries to the face. Otolaryngol Head Neck Surg 1996;115:464–70. 4. Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a 4-year experience. J Oral Maxillofac Surg 2001;59:277–82. 5. Epker BN, Burnette JC. Trauma to the parotid gland and duct: primary treatment and management of complications. J Oral Surg 1970;28:657–70. 6. Lewis G, Knottenbelt JD. Parotid duct injury: is immediate surgical repair necessary? Injury 1991;22:407–9. 7. Van Sickels JE. Parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1981;52:364–7. 8. Parekh D, Glezerson G, Stewart M, Esser J, Lawson HH. Post-traumatic parotid fistulae and sialoceles: a prospective study of conservative management in 51 cases. Ann Surg 1989;209:105–11. 9. Khalil AF. Civilian gunshot injuries to the face and jaws. Br J Oral Surg 1980;18:205–11.
Short communication
Gunshot injuries to the parotid gland: Patterns of injury and primary management Omer W. Majid ∗ Department of Oral & Maxillofacial Surgery, College of Dentistry, Mosul University, Nineveh, Iraq Accepted 16 March 2006 Available online 5 May 2006
Abstract We have treated 16 patients with gunshot injuries to the cheek, 10 of whom had damage to the parotid. There were nine men and one woman, mean age 40 (range 15–65). All injuries were high velocity, and eight had other injuries. We followed them up for a month; three patients required further operation, three had facial palsy, and one lost his hearing on that side. © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Parotid duct injuries; Facial gunshot injuries; Parotid fistula
Introduction Gunshot injuries to the buccal region of the face may be associated with many complications because of the complex anatomy of the area. The parotid gland is one of the structures that may be involved. Damage to the parotid is often overlooked or underestimated in patients with facial injuries. Failure to recognise such injuries may result in sialoceles, cutaneous fistulas, or cysts of the salivary duct.1 Such complications are inconvenient for the patients, difficult to treat, and can cause facial scarring.
Patients and methods At the casualty department of the Al-Zahrawi Teaching Hospital, Mosul, 16 patients with gunshot injuries to the cheek were treated over a period of a year, 10 of whom had parotid injuries. On admission all patients had the airway and vital signs stabilised, an intravenous line inserted, and appropriate radiographs taken of the face. The diagnosis was made after direct ∗
Tel.: +00 964 60 812910. E-mail address: omerw [email protected].
exploration of the wound, and injecting normal saline through the orifice of the parotid duct. All patients were operated on within 3 h of admission. Two were treated under local anaesthesia, the others being under general anaesthesia by intraoral tubes. Copious irrigation and careful debridement was required in all cases. Drains were used in five cases. Wounds were closed in layers and pressure dressings applied. All patients were given antibiotics before or during operation.
Results We identified 10 patients with parotid injuries 9 of whom were male and 1 female, aged between 15 and 65 years (mean 40). All injuries were high-velocity. Two parotid injuries were isolated and eight were associated with other facial injuries. Associated local injuries are shown in Table 1. Exit wounds were present in the parotid region in six cases, entry wounds in two, and two injuries were tangential. Systemic non-facial injuries included one in the abdomen and one in the chest. Patients were followed up for one month. Two developed salivary fistulas and one developed a sialocele; all were treated conservatively. Three patients had facial scars that required secondary revision. Three patients developed facial palsies and one lost his hearing.
0266-4356/$ – see front matter © 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2006.03.015
572
O.W. Majid / British Journal of Oral and Maxillofacial Surgery 45 (2007) 571–572
Table 1 Associated local injuries of gunshot wounds to the parotid Injuries
Number
Associated fractures Maxilla Mandible Zygoma Temporal bone
5 4 3 1
Soft tissue Lip Facial nerve Ear Eye
4 3 3 2
Discussion Gunshot injuries to the parotid region are a special problem, because unlike other penetrating wounds, they are often associated with missing or severely damaged tissue, and a greater likelihood of infection and tissue necrosis.2 Many reported series have advocated the early repair of facial gunshot wounds3,4 and parotid injuries seem to be no exception. Better functional and aesthetic results are obtained by early definitive management. Although the late complications of untreated parotid injuries can be managed conservatively,5,6 they can have devastating aesthetic consequences and add to the morbidity in patients who, in many instances, have multiple injuries. To improve the management, different classification systems have been proposed for parotid injuries based on the site of injury,7 or on the results of sialography.8 However, these classifications do not apply to most gunshot wounds because they are so complex. Clinical judgement is more affected by the patterns of injury of which we identified three. Type I or tangential injury involves the superficial part of the parotid gland, and is similar to a sharp laceration except for the additional need for thorough irrigation and debridement of the wound. The parotid capsule should be closed carefully or approximated. Primary repair of the parotid duct over a stent may be feasible. We had one such injury. A Type II injury occurs when the entrance of the bullet is through the parotid itself. A relatively small external wound is commonly associated with a larger intraoral wound. In addition to careful closure of the external wound, intraoral drainage is required. In Type III injury, the exit wound is through the parotid region with the site of entry being either transoral or through the back of the neck. There is a complex, multiple, and large external wound with a variable extent of tissue lost. High-velocity projectiles tend to cut straight through soft tissue and to fracture bones with relative ease.
The total wounding capability, therefore, tends to be a combination of the projectile itself plus the effect of secondary projectiles such as fragments of bone, teeth, and dentures.9 In addition, high-velocity projectiles create a temporary cavity behind and lateral to the bullet, that then collapses as a result of recoil. The resulting loss of tissue may preclude the repair of the parotid duct or diversion of the proximal duct into the oral cavity. In all cases, however, it was possible to close the wound using adjacent tissues by careful undermining. Intraoral drainage in this type of injury is essential. A small gauge nasogastric tube passed through the intraoral wound, and through the external wound, and sutured to the buccal mucosa seemed to be effective and beneficial in reducing the rate of postoperative complications. Despite comprehensive primary management, some complications and residual deformities will occur. Both cases of salivary fistula developed in patients with Type III injuries. Salivary fistula should be suspected in every gunshot injury to the parotid region, particularly Type III. The complexity of such wounds facilitates tracking of saliva through injuryinduced planes toward the surface. By conservative management, including application of dressings and prescription of anticholinergic drugs, both cases resolved within the period of follow up. The only sialocele developed in a patient with a Type II injury and was treated by repeated aspiration and pressure dressings, and resolved within 20 days. Loss of the natural bulk of the cheek and facial scarring was noted in three patients with Type III injuries. These problems can be dealt with later with further revisions.
References 1. Steinberg MJ, Herrera AF. Management of parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:136–41. 2. Thorne CH. Gunshot wounds to the face. Clin Plast Surg 1992;19:233–44. 3. Chen AY, Stewart MG, Raup G. Penetrating injuries to the face. Otolaryngol Head Neck Surg 1996;115:464–70. 4. Hollier L, Grantcharova EP, Kattash M. Facial gunshot wounds: a 4-year experience. J Oral Maxillofac Surg 2001;59:277–82. 5. Epker BN, Burnette JC. Trauma to the parotid gland and duct: primary treatment and management of complications. J Oral Surg 1970;28:657–70. 6. Lewis G, Knottenbelt JD. Parotid duct injury: is immediate surgical repair necessary? Injury 1991;22:407–9. 7. Van Sickels JE. Parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1981;52:364–7. 8. Parekh D, Glezerson G, Stewart M, Esser J, Lawson HH. Post-traumatic parotid fistulae and sialoceles: a prospective study of conservative management in 51 cases. Ann Surg 1989;209:105–11. 9. Khalil AF. Civilian gunshot injuries to the face and jaws. Br J Oral Surg 1980;18:205–11.