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Palatal trauma: an unusual cause of a parotid sinus
INTERNATiONAIJOOWN OF
Pediatric International Journal of Pediatric Otorhinolaryngology
ELSEVIER
34 (1996) 253-251
Palatal trauma: an unusual cause of a parotid sinus P. Pracy b, R. Walshb, D.A.
J.P. Grieve”, “Depmtment
of’ ENT, hDepartment
Lewisham qf’ ENT,
Received 8 February
Bowdler”
Hospital, Lmisham High Street, Lewisham, Guy’s Hospital, St. Thomas’s Street, London
London SEl.3 6HL, SE1 9RT, UK
l/K
1995; revision received 9 August 1995; accepted 12 August 1995
Abstract A case is described of a 3-year-old boy who presented with a seemingly trivial injury to his soft palate, who went on to develop a parotid sinus as a result of a retained foreign body. This is a rare clinical problem and it highlights the difficulty in the clinical assessment of a palatal injury ~ especially in children. The child had the foreign body removed successfully 5 months after the initial injury and made an uneventful recovery. Keywords:
Palatal trauma; Parotid sinus; Foreign body
1. Case report A previously fit 3-year-old boy presented with an injury to his soft palate, after falling onto a wooden chopstick. On examination of the chopstick, a 15 x 2 mm piece appeared to be missing; however, the only visible evidence of injury was a small puncture site on the left side of his soft palate. A plain lateral soft tissue X-ray of the area was reported as normal, but he was admitted for overnight observation. The next day he was apyrexial and eating and drinking normally, and was discharged home.
* Corresponding
author.
0165.5876*96;$15.00 Q 1996 Eisevier Science Ireland Ltd. All lights reserved SSDl 0165-5876(95)01268-G
254
J.P. Grieve et al. / Int. J. Pediatr. Ororhinolaryngol.
34 (1996) 253-257
When he was reviewed in the outpatient department 6 weeks later his mother pointed out a 1 x 1 cm swelling just behind his left pinna. This had developed 2 days following his discharge from hospital but there had been no alteration in its size. It was thought that the lesion was a sebaceous cyst, and as the child was otherwise asymptomatic, it was decided to review the situation at the next outpatient visit. Four months after the initial injury, the cyst ruptured leaving a postaural defect covered with granulation tissue (Fig. 1). The wound failed to respond to conservative treatment including broad-spectrum antibiotics and cauterisation with silver nitrate. Therefore he was admitted for an examination under anaesthesia, which was normal, with no foreign body being found. Postoperatively, a CT scan was performed which showed a linear high density structure lying in the soft tissues just inferior to the external auditory meatus with some surrounding soft tissue swelling (Fig. 2). A diagnosis of a foreign body with secondary parotid sinus formation was made with the assumption that the foreign body was a splinter from the chopstick. He was admitted for exploration of the left parotid sinus and removal of the foreign body. A Y-shaped parotid incision was made, excising the sinus orifice. Skin flaps were raised and the foreign body was removed from the body of the parotid along with its tract of granulation tissue. The foreign body matched the splinter which had been missing from the original chopstick (Fig. 3). Post-operatively his facial nerve was intact and he made an uneventful recovery. 2. Discussion
There have been several reports of unusual foreign bodies within the parotid, including blades of grass, seeds, ballpoint pen tops, pieces of plastic, splinters of wood, bullets and billiard cue tips [3,4,6,9,10]. The majority of these appear to have gained accessvia Stenson’s duct, few gain access by direct external trauma and fewer still by penetration through the soft palate [3]. In the latter situation, the evidence of injury is often small and frequently the patient is asymptomatic and may remain so providing complications do not supervene. Views upon the management of suspectedintraparotid foreign bodies are divided. If complications arise such as infection, cutaneous fistulae, facial nerve damage or sialoceles, all would advocate surgical exploration as soon as possible [6,11]. The difficulty arises when there is no clinical evidence of a foreign body or when the patient is asymptomatic. Foreign bodies which gain accessthrough direct penetration of the soft palate are usually found in children where accurate clinical examination may be difficult [3]. Although simple procedures such as plain X-rays are relatively easily undertaken, more informative procedures such as CT are more difficult and may require a general anaesthetic. Usually, these cases are only investigated more assiduously when complications arise However, some authors suggest that when the foreign body cannot be localised elsewhere, it must be presumed to be within the parotid gland. In such patients they recommend immediate exploration of the parotid, as there is a high complication
rate associated with intraparotid foreign bodies [3]. In addition, they recomi nend radiological localisation, preferably using a CT or MRI scan. The majority of patients with asymptomatic foreign bodies which have g;lined access intraorally have sustained low velocity injuries which are associated with minimal tissue damage [6,7]. It is for this reason that conservative managemt x-it is often advocated. However, infection almost invariably supervenes and persists until the foreign body has been removed so that ultimately the great majority of paltients require surgical management.
Fig. 1. The left postaural sinus covered with granulation
tissue
256
J.P. Grircr et ul. I//ht. J. Pediutr. Otorhinoiuryngol.
34 (19%) 253-257
Fig. 2. An axial CT scan at the level of the parotid gland showing the foreign body on the left side.
There are, however, few reports on the management of post-traumatic parotid fistulae, especially in the presence of a foreign body. Post-surgical parotid fistulae and sialoceles can be successfully treated conservatively with a combination of repeated aspirations, compression dressings, anti-sialogogues and parenteral nutrition, particularly when the damage is parenchymal [1,5,8]. However, those arising from a transected duct are more resistant to conservative treatment [1,2,5]. The presence of a foreign body promotes infection such that the fistula tends to persist until the foreign body has been removed [3]. This case highlights many of the problems in managing patients with palatal trauma. In all cases of palatal trauma, there should be a high level of suspicion that a foreign body may be embedded in the soft tissues of the neck. There should be a low threshold for further investigations especially when further symptoms or signs develop, even if these are seemingly remote. We would advocate early exploration in all cases where the object involved in the trauma is not recovered complete. This
J.P. Griece et cd. :I ht. J. Pediatr. O~orl~itdar~ngol.
34 (1996) 25.3-257
Fig. 3. The foreign body ~ the missing splinter from the original chopstick.
is especially true for wooden objects which may splinter, the splinters being particularly difficult to identify on conventional X-rays due to their radiolucency. References [I] Ananthakrishnan, N. and Parkash, S. (1982) Parotid fistulas ~~ A review. Br. J. Surg. 69, 641-643. [2] Demetriades, D. (1991) Surgical management of post-traumatic parotid sialoceles and fistulae. Injury 22, 183-184. [3] Flood, T.R. (1987) An unusual parotid foreign body presenting as recurrent trismus. Br. J. Oral Maxillofac. Surg. 25, 341-347. [4] Harbert. F., Igarashi, M. and Riordan, D.R. (1961) Brome grass seed in parotid duct. Laryngoscope 71. 1597-1599. [S] Landau, R. and Stewart, M. (1985) Conservative management of post-traumatic parotid fistuli and sialoceles: a prospective study. Br. J. Surg. 72, 42. [6] Lonnen, D.M. (1985) A parotid region foreign body. Br. Dent. J. 159, 220 - 221, [7] Mektubjian, S.R. (1981) Low velocity gunshot maxillofacial injury combined with a ‘blind’ wound of the neck. J. Maxillofac. Surg. 9, 85-88. [8] Parekh. D.. Glezerson, G., Stewart, M. et al. (1989) Post-traumatic parotid fistulae and sialoceles. A prospective study of conservative management in 51 cases. Ann. Surg. 209, 105. [9] Raspall. G. and Gonzalez. J. (1990) An unusual case of intraparotid foreign body. J Oral Maxillofac. Surg. 48, 628-630. [IO] Wherry. D.C. and Lee. J.C. (1960) A foreign body simulating a tumour of the parotid gland. Plast. Reconstr. Surg. 25, 59. [l I] Yih, W.. Thoman, R. and Merrill, R. (1993) Removal of a bullet from the parotid gland. J. Oral Maxillofac. Surg. 51, 925-927.
Pediatric International Journal of Pediatric Otorhinolaryngology
ELSEVIER
34 (1996) 253-251
Palatal trauma: an unusual cause of a parotid sinus P. Pracy b, R. Walshb, D.A.
J.P. Grieve”, “Depmtment
of’ ENT, hDepartment
Lewisham qf’ ENT,
Received 8 February
Bowdler”
Hospital, Lmisham High Street, Lewisham, Guy’s Hospital, St. Thomas’s Street, London
London SEl.3 6HL, SE1 9RT, UK
l/K
1995; revision received 9 August 1995; accepted 12 August 1995
Abstract A case is described of a 3-year-old boy who presented with a seemingly trivial injury to his soft palate, who went on to develop a parotid sinus as a result of a retained foreign body. This is a rare clinical problem and it highlights the difficulty in the clinical assessment of a palatal injury ~ especially in children. The child had the foreign body removed successfully 5 months after the initial injury and made an uneventful recovery. Keywords:
Palatal trauma; Parotid sinus; Foreign body
1. Case report A previously fit 3-year-old boy presented with an injury to his soft palate, after falling onto a wooden chopstick. On examination of the chopstick, a 15 x 2 mm piece appeared to be missing; however, the only visible evidence of injury was a small puncture site on the left side of his soft palate. A plain lateral soft tissue X-ray of the area was reported as normal, but he was admitted for overnight observation. The next day he was apyrexial and eating and drinking normally, and was discharged home.
* Corresponding
author.
0165.5876*96;$15.00 Q 1996 Eisevier Science Ireland Ltd. All lights reserved SSDl 0165-5876(95)01268-G
254
J.P. Grieve et al. / Int. J. Pediatr. Ororhinolaryngol.
34 (1996) 253-257
When he was reviewed in the outpatient department 6 weeks later his mother pointed out a 1 x 1 cm swelling just behind his left pinna. This had developed 2 days following his discharge from hospital but there had been no alteration in its size. It was thought that the lesion was a sebaceous cyst, and as the child was otherwise asymptomatic, it was decided to review the situation at the next outpatient visit. Four months after the initial injury, the cyst ruptured leaving a postaural defect covered with granulation tissue (Fig. 1). The wound failed to respond to conservative treatment including broad-spectrum antibiotics and cauterisation with silver nitrate. Therefore he was admitted for an examination under anaesthesia, which was normal, with no foreign body being found. Postoperatively, a CT scan was performed which showed a linear high density structure lying in the soft tissues just inferior to the external auditory meatus with some surrounding soft tissue swelling (Fig. 2). A diagnosis of a foreign body with secondary parotid sinus formation was made with the assumption that the foreign body was a splinter from the chopstick. He was admitted for exploration of the left parotid sinus and removal of the foreign body. A Y-shaped parotid incision was made, excising the sinus orifice. Skin flaps were raised and the foreign body was removed from the body of the parotid along with its tract of granulation tissue. The foreign body matched the splinter which had been missing from the original chopstick (Fig. 3). Post-operatively his facial nerve was intact and he made an uneventful recovery. 2. Discussion
There have been several reports of unusual foreign bodies within the parotid, including blades of grass, seeds, ballpoint pen tops, pieces of plastic, splinters of wood, bullets and billiard cue tips [3,4,6,9,10]. The majority of these appear to have gained accessvia Stenson’s duct, few gain access by direct external trauma and fewer still by penetration through the soft palate [3]. In the latter situation, the evidence of injury is often small and frequently the patient is asymptomatic and may remain so providing complications do not supervene. Views upon the management of suspectedintraparotid foreign bodies are divided. If complications arise such as infection, cutaneous fistulae, facial nerve damage or sialoceles, all would advocate surgical exploration as soon as possible [6,11]. The difficulty arises when there is no clinical evidence of a foreign body or when the patient is asymptomatic. Foreign bodies which gain accessthrough direct penetration of the soft palate are usually found in children where accurate clinical examination may be difficult [3]. Although simple procedures such as plain X-rays are relatively easily undertaken, more informative procedures such as CT are more difficult and may require a general anaesthetic. Usually, these cases are only investigated more assiduously when complications arise However, some authors suggest that when the foreign body cannot be localised elsewhere, it must be presumed to be within the parotid gland. In such patients they recommend immediate exploration of the parotid, as there is a high complication
rate associated with intraparotid foreign bodies [3]. In addition, they recomi nend radiological localisation, preferably using a CT or MRI scan. The majority of patients with asymptomatic foreign bodies which have g;lined access intraorally have sustained low velocity injuries which are associated with minimal tissue damage [6,7]. It is for this reason that conservative managemt x-it is often advocated. However, infection almost invariably supervenes and persists until the foreign body has been removed so that ultimately the great majority of paltients require surgical management.
Fig. 1. The left postaural sinus covered with granulation
tissue
256
J.P. Grircr et ul. I//ht. J. Pediutr. Otorhinoiuryngol.
34 (19%) 253-257
Fig. 2. An axial CT scan at the level of the parotid gland showing the foreign body on the left side.
There are, however, few reports on the management of post-traumatic parotid fistulae, especially in the presence of a foreign body. Post-surgical parotid fistulae and sialoceles can be successfully treated conservatively with a combination of repeated aspirations, compression dressings, anti-sialogogues and parenteral nutrition, particularly when the damage is parenchymal [1,5,8]. However, those arising from a transected duct are more resistant to conservative treatment [1,2,5]. The presence of a foreign body promotes infection such that the fistula tends to persist until the foreign body has been removed [3]. This case highlights many of the problems in managing patients with palatal trauma. In all cases of palatal trauma, there should be a high level of suspicion that a foreign body may be embedded in the soft tissues of the neck. There should be a low threshold for further investigations especially when further symptoms or signs develop, even if these are seemingly remote. We would advocate early exploration in all cases where the object involved in the trauma is not recovered complete. This
J.P. Griece et cd. :I ht. J. Pediatr. O~orl~itdar~ngol.
34 (1996) 25.3-257
Fig. 3. The foreign body ~ the missing splinter from the original chopstick.
is especially true for wooden objects which may splinter, the splinters being particularly difficult to identify on conventional X-rays due to their radiolucency. References [I] Ananthakrishnan, N. and Parkash, S. (1982) Parotid fistulas ~~ A review. Br. J. Surg. 69, 641-643. [2] Demetriades, D. (1991) Surgical management of post-traumatic parotid sialoceles and fistulae. Injury 22, 183-184. [3] Flood, T.R. (1987) An unusual parotid foreign body presenting as recurrent trismus. Br. J. Oral Maxillofac. Surg. 25, 341-347. [4] Harbert. F., Igarashi, M. and Riordan, D.R. (1961) Brome grass seed in parotid duct. Laryngoscope 71. 1597-1599. [S] Landau, R. and Stewart, M. (1985) Conservative management of post-traumatic parotid fistuli and sialoceles: a prospective study. Br. J. Surg. 72, 42. [6] Lonnen, D.M. (1985) A parotid region foreign body. Br. Dent. J. 159, 220 - 221, [7] Mektubjian, S.R. (1981) Low velocity gunshot maxillofacial injury combined with a ‘blind’ wound of the neck. J. Maxillofac. Surg. 9, 85-88. [8] Parekh. D.. Glezerson, G., Stewart, M. et al. (1989) Post-traumatic parotid fistulae and sialoceles. A prospective study of conservative management in 51 cases. Ann. Surg. 209, 105. [9] Raspall. G. and Gonzalez. J. (1990) An unusual case of intraparotid foreign body. J Oral Maxillofac. Surg. 48, 628-630. [IO] Wherry. D.C. and Lee. J.C. (1960) A foreign body simulating a tumour of the parotid gland. Plast. Reconstr. Surg. 25, 59. [l I] Yih, W.. Thoman, R. and Merrill, R. (1993) Removal of a bullet from the parotid gland. J. Oral Maxillofac. Surg. 51, 925-927.