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Management of Parotid Gland and Duct Injuries
Management of Parotid Gland and Duct Injuries Joseph E.Van Sickels, DDS KEYWORDS Management Injury Parotid duct Parotid gland
DIAGNOSIS Any penetrating injury along a line drawn from the tragus of the ear to the midportion of the upper lip may injure either Stenson’s duct or the parotid gland.1 Van Sickels and Alexander,6 and later Stevenson,7 noted that the glandular system can be injured in three different regions. Region A is the area of the gland (Fig. 2), region B is the site of the duct as it runs superficial to the masseter muscle, and region C is the region from the masseter muscle to where it enters the oral cavity in the buccal mucosa opposite the maxillary second molar.7 The buccal branch of the facial nerve often runs with the duct, which crosses the superficial layer of the masseter after it exits the parotid gland (Fig. 3). When the nerve is injured, the patient may present with weakness of the upper lip when trying to animate. Intraoperatively, the wound should be explored and the duct cannulated. Although some investigators suggest that a toluidine blue
dye should be injected into the duct to help identify the proximal end, the author feels that a transection of the duct can be seen without the injection of a dye.3 Especially with a dark-colored dye, excessive extravasation from the lacerated duct may complicate surgery because of discoloration of the surgical field. Rather than a dye, saline can be injected if difficulty is encountered in finding the proximal end. No fluid seen in the wound indicates that the duct is intact.
Timing of Repair Most investigators believe that the repair should be done early, preferably in the first 24 hours.2,6 This is because late complications, such as a parotid fistula, are difficult to treat (see section below). Cannulation of the duct also becomes more difficult as the swelling increases, making determination of the status of the duct a more complex task. However, some investigators do not feel that immediate repair of the duct is always necessary. Lewis and Knottenbelt8 treated 33 patients seen in a 6-month period who had parotid gland or duct injury, most caused by sharp injury or a low velocity gun shot. All had wound closure without direct repair of the duct, and all but three had follow-up sialograms. There were no clinical complications in nine of the 19 patients who had follow-up. Complications seen in the remaining 10 were salivary fistula (seven patients) and sialoceles (four patients), but all eventually healed without surgical management. Although healing occurred, it involved a prolonged course, and it is likely that most of these complications could have been avoided by early treatment.
Division of Oral and Maxillofacial Surgery, University of Kentucky, Lexington, KY 40536-0297, USA E-mail address: [email protected] Oral Maxillofacial Surg Clin N Am 21 (2009) 243–246 doi:10.1016/j.coms.2008.12.010 1042-3699/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
oralmaxsurgery.theclinics.com
Surgical repair of injuries to the parotid gland and its duct have been described in the literature for more than 100 years.1 Injury to the glandular structures are usually associated with penetrating wounds of the face and often involve concomitant damage to adjacent structures, including the facial nerve, the ear, and the nearby bony structures (Fig. 1).2,3 Most investigators agree that management of these injuries depends on the location of the damage. However, there are differences of opinion as to the proper management of the repair when the injury to the glandular system is discovered early or late.1–6
244
Van Sickels
Fig. 1. Complex laceration of overlying soft tissue, parotid duct and gland (regions A and B) with an auricle laceration and fracture of mandible.
MANAGEMENT OF INJURIES TO THE GLAND AND DUCT Injury to the gland alone generally involves repair of the injury, putting a stent in the duct, and placing a pressure dressing.2,3 The stent keeps the duct patent during the time the pressure dressing is in place. The main surgical options for injury to the duct include repair of the duct over a stent, ligation of the duct, or fistulization of the duct into the oral cavity.4–6 When a stent is inserted, most investigators leave it in place for a period of weeks;4,6 however, Stevenson7 and Sparkman9 suggest that it is not necessary to leave the stent in place once the parotid duct is repaired. When there are extensive injuries to the glandular/duct system and both ends of the duct cannot be found or are macerated, ligation of the proximal portion of the duct is recommended, the
Fig. 2. Penetrating laceration of face over the region of the duct.
Fig. 3. Anatomic dissection illustrating the duct running over the masseter approximately along a line drawn from the tragus of the ear to the midportion of the upper lip.
theory being that the gland will undergo atrophy.4,6 Findings of one animal study have suggested that an injury to the duct with a resultant continuity defect can be repaired with an autogenous graft.10 In contrast, others have shown that continuity defects repaired with an autogenous graft generally are unsuccessful.11 Injury of the orifice of the duct where it enters the oral cavity often is managed by insertion of a drain (Fig. 4A, B). The concept is that saliva will drain into the oral cavity, and a new orifice will be created.
COMPLICATIONS Injuries to the parotid glandular system can be missed as the result of extensive trauma, subsequently resulting in sialoceles, parotid fistulae, and infections.3,8,12 They may also occur when repair of an injury is not successful. Medical management of such conditions includes antisialogogues and antibiotics.3 Antisialogogues often are combined with aspiration from a nondependent area and application of a pressure dressing when there is a fluid collection or a sialocele occurs. Botulinum toxin has been used for salivary fistulas caused by a number of different problems.12–14 Breuer and colleagues12 reported two cases of salivary fistula after facial trauma, one of which was from the parotid. In both instances they were successful in treating the fistula with the injection of botulinum toxin into the gland. Some investigators have reported good results treating delayed fistulas and sialoceles by other means.15–18 One course of therapy consisted of restricting all oral intake, giving an antisialogogue, placing a pressure dressing, and keeping the patient on intravenous fluids for 5 days.15 In these
Management of Parotid Gland and Duct Injuries
Fig. 4. (A) Gunshot wound entering near orifice of Stenson’s duct. (B) Drain in place, left for 2 weeks.
different studies it was noted that injuries over the gland region (region A) responded more quickly than those that occurred over the region of the duct (region B). Another approach is to do a tympanic neurectomy or parotidectomy for chronic parotid gland problems; this therapy can also be used for chronic fistulae.17,18
SUMMARY Unfortunately, most of the information on the management of parotid gland and duct injuries is based on relatively small clinical studies. However, the preponderance of these studies suggests that the injuries in this region should be treated early and that that the location of the injury has bearing on the type of treatment. Injuries to the glandular portion (region A) should be treated by meticulous closure and a pressure dressing with or without stenting Stenson’s duct. Treatment of the duct region is slightly controversial, with most investigators suggesting that the wound should be closed with a stent in the duct, even if it is intact, because subsequent swelling can still cause obstruction. In contrast, Lewis and Knottenbelt suggest that this is not necessary.8 However, when examining their data, three of those with a region B injury had a sialocele, and four had a salivary fistula (one patient had both). Only two patients with a region B injury had an uncomplicated course. Although they were able to successfully manage all of their complications, their data suggest that it may be better to recognize and treat the problem when the patient initially
presents for therapy. Injury to the orifice of the duct is usually treated by placing a drain. When chronic conditions arise, such as sialoceles or fistulas, management becomes more complicated. Traditional therapy for sialoceles includes aspiration from a nondependent aspect accompanied by a pressure dressing. In the author’s experience, this may require multiple aspirations, with or without use of adjunctive medications. Fistulas are more challenging to treat. Although multiple surgical and medical therapies have been proposed to treat them, resolving a chronic fistula is sometimes difficult. Use of botulinum toxin injection into the glandular structure alone or with other therapies appears to be very promising.
REFERENCES 1. Revis DR, Seagle MB. Parotid duct injures. eMedicine August 1, 2006; last update. 2. Tachmes L, Woloszyn T, Marini C, et al. Parotid gland and facial nerve trauma: a retrospective review. J Trauma 1990;30:1395–8. 3. Lewkowicz AA, Hasson O, Nablieli O. Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg 2002;60:676–80. 4. Epker BN, Burnette JC. Trauma to the parotid gland and duct: primary treatment and management of complications. J Oral Surg 1970;28:657–70. 5. Steinberg MJ, Herrera AF. Management of parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:136–41. 6. Van Sickels JE, Alexander JM. Parotid duct injuries. Oral Surg 1981;52:364–7.
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246
Van Sickels 7. Stevenson JH. Parotid duct transection associated with facial trauma: experience with 10 cases. Br J Plast Surg 1983;36:81–3. 8. Lewis G, Knottenbelt JD. Parotid duct injury: is immediate surgical repair necessary? Injury 1991; 22:407–9. 9. Sparkman RS. Laceration of parotid duct further experiences. Ann Surg 1950;131:743–54. 10. Chudakov O, Ludchik T. Microsurgical repair of Stensen’s and Wharton’s ducts with autogenous venous grafts. An experimental study on dogs. Int J Oral Maxillofac Surg 1999;28:70–3. 11. Dumpis J, Feldmane L. Experimental microsurgery of salivary ducts in dogs. J Craniomaxillofac Surg 2001;29:56–62. 12. Breuer T, Ferrazzini A, Grossenbacher R. Botulinum toxin A as a treatment of traumatic salivary gland fistulas. HNO 2006;54:385–90. 13. Marchese-Ragona R, Marioni G, Restivo DA, et al. The role of botulium toxin in post parotidectomy
14.
15.
16.
17.
18.
fistula treatment. A technical note. Am J Otol 2006; 27:221–4. Lim YC, Choi EC. Treatment of an acute salivary fistula after parotid surgery: botulinum toxin type A injection as primary treatment. Eur Arch Otorhinolaryngol 2008;265:243–5. Landau R, Stewart M. Conservative management of post-traumatic parotid fistulae and sialoceles: a prospective study. Br J Surg 1985; 72:42–4. Parekh D, Glezerson G, Stewart M, et al. Post-traumatic parotid fistulae and sialoceles. A prospective study of conservative management in 51 cases. Ann Surg 1989;209:105–11. Perera AM, Kumar BN, Pahor AL. Long-term results of tympanic neurectomy for chronic parotid sialectasis. Rev Laryngol Otol Rhinol (Bord) 2000;121: 95–8. Vasama JP. Tympanic neurectomy and chronic parotitis. Acta Otolaryngol 2000;120:995–8.
DIAGNOSIS Any penetrating injury along a line drawn from the tragus of the ear to the midportion of the upper lip may injure either Stenson’s duct or the parotid gland.1 Van Sickels and Alexander,6 and later Stevenson,7 noted that the glandular system can be injured in three different regions. Region A is the area of the gland (Fig. 2), region B is the site of the duct as it runs superficial to the masseter muscle, and region C is the region from the masseter muscle to where it enters the oral cavity in the buccal mucosa opposite the maxillary second molar.7 The buccal branch of the facial nerve often runs with the duct, which crosses the superficial layer of the masseter after it exits the parotid gland (Fig. 3). When the nerve is injured, the patient may present with weakness of the upper lip when trying to animate. Intraoperatively, the wound should be explored and the duct cannulated. Although some investigators suggest that a toluidine blue
dye should be injected into the duct to help identify the proximal end, the author feels that a transection of the duct can be seen without the injection of a dye.3 Especially with a dark-colored dye, excessive extravasation from the lacerated duct may complicate surgery because of discoloration of the surgical field. Rather than a dye, saline can be injected if difficulty is encountered in finding the proximal end. No fluid seen in the wound indicates that the duct is intact.
Timing of Repair Most investigators believe that the repair should be done early, preferably in the first 24 hours.2,6 This is because late complications, such as a parotid fistula, are difficult to treat (see section below). Cannulation of the duct also becomes more difficult as the swelling increases, making determination of the status of the duct a more complex task. However, some investigators do not feel that immediate repair of the duct is always necessary. Lewis and Knottenbelt8 treated 33 patients seen in a 6-month period who had parotid gland or duct injury, most caused by sharp injury or a low velocity gun shot. All had wound closure without direct repair of the duct, and all but three had follow-up sialograms. There were no clinical complications in nine of the 19 patients who had follow-up. Complications seen in the remaining 10 were salivary fistula (seven patients) and sialoceles (four patients), but all eventually healed without surgical management. Although healing occurred, it involved a prolonged course, and it is likely that most of these complications could have been avoided by early treatment.
Division of Oral and Maxillofacial Surgery, University of Kentucky, Lexington, KY 40536-0297, USA E-mail address: [email protected] Oral Maxillofacial Surg Clin N Am 21 (2009) 243–246 doi:10.1016/j.coms.2008.12.010 1042-3699/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
oralmaxsurgery.theclinics.com
Surgical repair of injuries to the parotid gland and its duct have been described in the literature for more than 100 years.1 Injury to the glandular structures are usually associated with penetrating wounds of the face and often involve concomitant damage to adjacent structures, including the facial nerve, the ear, and the nearby bony structures (Fig. 1).2,3 Most investigators agree that management of these injuries depends on the location of the damage. However, there are differences of opinion as to the proper management of the repair when the injury to the glandular system is discovered early or late.1–6
244
Van Sickels
Fig. 1. Complex laceration of overlying soft tissue, parotid duct and gland (regions A and B) with an auricle laceration and fracture of mandible.
MANAGEMENT OF INJURIES TO THE GLAND AND DUCT Injury to the gland alone generally involves repair of the injury, putting a stent in the duct, and placing a pressure dressing.2,3 The stent keeps the duct patent during the time the pressure dressing is in place. The main surgical options for injury to the duct include repair of the duct over a stent, ligation of the duct, or fistulization of the duct into the oral cavity.4–6 When a stent is inserted, most investigators leave it in place for a period of weeks;4,6 however, Stevenson7 and Sparkman9 suggest that it is not necessary to leave the stent in place once the parotid duct is repaired. When there are extensive injuries to the glandular/duct system and both ends of the duct cannot be found or are macerated, ligation of the proximal portion of the duct is recommended, the
Fig. 2. Penetrating laceration of face over the region of the duct.
Fig. 3. Anatomic dissection illustrating the duct running over the masseter approximately along a line drawn from the tragus of the ear to the midportion of the upper lip.
theory being that the gland will undergo atrophy.4,6 Findings of one animal study have suggested that an injury to the duct with a resultant continuity defect can be repaired with an autogenous graft.10 In contrast, others have shown that continuity defects repaired with an autogenous graft generally are unsuccessful.11 Injury of the orifice of the duct where it enters the oral cavity often is managed by insertion of a drain (Fig. 4A, B). The concept is that saliva will drain into the oral cavity, and a new orifice will be created.
COMPLICATIONS Injuries to the parotid glandular system can be missed as the result of extensive trauma, subsequently resulting in sialoceles, parotid fistulae, and infections.3,8,12 They may also occur when repair of an injury is not successful. Medical management of such conditions includes antisialogogues and antibiotics.3 Antisialogogues often are combined with aspiration from a nondependent area and application of a pressure dressing when there is a fluid collection or a sialocele occurs. Botulinum toxin has been used for salivary fistulas caused by a number of different problems.12–14 Breuer and colleagues12 reported two cases of salivary fistula after facial trauma, one of which was from the parotid. In both instances they were successful in treating the fistula with the injection of botulinum toxin into the gland. Some investigators have reported good results treating delayed fistulas and sialoceles by other means.15–18 One course of therapy consisted of restricting all oral intake, giving an antisialogogue, placing a pressure dressing, and keeping the patient on intravenous fluids for 5 days.15 In these
Management of Parotid Gland and Duct Injuries
Fig. 4. (A) Gunshot wound entering near orifice of Stenson’s duct. (B) Drain in place, left for 2 weeks.
different studies it was noted that injuries over the gland region (region A) responded more quickly than those that occurred over the region of the duct (region B). Another approach is to do a tympanic neurectomy or parotidectomy for chronic parotid gland problems; this therapy can also be used for chronic fistulae.17,18
SUMMARY Unfortunately, most of the information on the management of parotid gland and duct injuries is based on relatively small clinical studies. However, the preponderance of these studies suggests that the injuries in this region should be treated early and that that the location of the injury has bearing on the type of treatment. Injuries to the glandular portion (region A) should be treated by meticulous closure and a pressure dressing with or without stenting Stenson’s duct. Treatment of the duct region is slightly controversial, with most investigators suggesting that the wound should be closed with a stent in the duct, even if it is intact, because subsequent swelling can still cause obstruction. In contrast, Lewis and Knottenbelt suggest that this is not necessary.8 However, when examining their data, three of those with a region B injury had a sialocele, and four had a salivary fistula (one patient had both). Only two patients with a region B injury had an uncomplicated course. Although they were able to successfully manage all of their complications, their data suggest that it may be better to recognize and treat the problem when the patient initially
presents for therapy. Injury to the orifice of the duct is usually treated by placing a drain. When chronic conditions arise, such as sialoceles or fistulas, management becomes more complicated. Traditional therapy for sialoceles includes aspiration from a nondependent aspect accompanied by a pressure dressing. In the author’s experience, this may require multiple aspirations, with or without use of adjunctive medications. Fistulas are more challenging to treat. Although multiple surgical and medical therapies have been proposed to treat them, resolving a chronic fistula is sometimes difficult. Use of botulinum toxin injection into the glandular structure alone or with other therapies appears to be very promising.
REFERENCES 1. Revis DR, Seagle MB. Parotid duct injures. eMedicine August 1, 2006; last update. 2. Tachmes L, Woloszyn T, Marini C, et al. Parotid gland and facial nerve trauma: a retrospective review. J Trauma 1990;30:1395–8. 3. Lewkowicz AA, Hasson O, Nablieli O. Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg 2002;60:676–80. 4. Epker BN, Burnette JC. Trauma to the parotid gland and duct: primary treatment and management of complications. J Oral Surg 1970;28:657–70. 5. Steinberg MJ, Herrera AF. Management of parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:136–41. 6. Van Sickels JE, Alexander JM. Parotid duct injuries. Oral Surg 1981;52:364–7.
245
246
Van Sickels 7. Stevenson JH. Parotid duct transection associated with facial trauma: experience with 10 cases. Br J Plast Surg 1983;36:81–3. 8. Lewis G, Knottenbelt JD. Parotid duct injury: is immediate surgical repair necessary? Injury 1991; 22:407–9. 9. Sparkman RS. Laceration of parotid duct further experiences. Ann Surg 1950;131:743–54. 10. Chudakov O, Ludchik T. Microsurgical repair of Stensen’s and Wharton’s ducts with autogenous venous grafts. An experimental study on dogs. Int J Oral Maxillofac Surg 1999;28:70–3. 11. Dumpis J, Feldmane L. Experimental microsurgery of salivary ducts in dogs. J Craniomaxillofac Surg 2001;29:56–62. 12. Breuer T, Ferrazzini A, Grossenbacher R. Botulinum toxin A as a treatment of traumatic salivary gland fistulas. HNO 2006;54:385–90. 13. Marchese-Ragona R, Marioni G, Restivo DA, et al. The role of botulium toxin in post parotidectomy
14.
15.
16.
17.
18.
fistula treatment. A technical note. Am J Otol 2006; 27:221–4. Lim YC, Choi EC. Treatment of an acute salivary fistula after parotid surgery: botulinum toxin type A injection as primary treatment. Eur Arch Otorhinolaryngol 2008;265:243–5. Landau R, Stewart M. Conservative management of post-traumatic parotid fistulae and sialoceles: a prospective study. Br J Surg 1985; 72:42–4. Parekh D, Glezerson G, Stewart M, et al. Post-traumatic parotid fistulae and sialoceles. A prospective study of conservative management in 51 cases. Ann Surg 1989;209:105–11. Perera AM, Kumar BN, Pahor AL. Long-term results of tympanic neurectomy for chronic parotid sialectasis. Rev Laryngol Otol Rhinol (Bord) 2000;121: 95–8. Vasama JP. Tympanic neurectomy and chronic parotitis. Acta Otolaryngol 2000;120:995–8.