Vol. 99 No.

2 February 2005

ORAL AND MAXILLOFACIAL SURGERY Editor: James R. Hupp

Management of parotid duct injuries

Mark J. Steinberg, DDS, MD,a and Andres F. Herréra, DDS,b Maywood, Ill
LOYOLA STRITCH SCHOOL OF MEDICINE

Injuries to the buccal region of the face can carry multiple complications due to the complex anatomy that lies
within. The facial nerve and the parotid duct can be easily injured by sharp or penetrating trauma to the cheek. The
purpose of this paper is to present the full spectrum of current treatment modalities available to manage these injuries.
The anatomy of the parotid gland and duct are described, and surgical techniques and therapeutic alternatives for the
immediate and delayed treatment of the parotid duct injuries are reviewed. Clinical cases are presented to illustrate the
treatment options outlined. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:136-41)

MANAGEMENT OF PAROTID DUCT INJURIES favorable outcome, it is important to be able to recognize

Sharp penetrating trauma of the face, besides causing
a cosmetic defect, may also injure deeper anatomic
structures. Lacerations in the cheek region may involve
branches of the facial nerve, parotid gland or its duct, and
vascular structures such as the transverse facial artery.
Common causes of parotid duct injury include stab
wounds from knives or other sharp objects such as
a razor, a bottle fragment, and glass from an automobile
accident.1 Gun shot wounds and iatrogenic injuries
secondary to surgical procedures may also damage the
parotid duct.2
Failure to recognize a parotid duct injury may result in
the formation of a sialocele, cutaneous fistula, or salivary
duct cyst. There are many reports in the literature that
discuss the management of parotid duct injury sequelae.
It is frequently pointed out in these papers that parotid
duct injury is often not diagnosed at the time of the initial
injury.3,4 Since restoration of the gland function and
avoidance of the above complications represent the most
a papillae at the level of the second maxillary molar.5 The
Professor of Surgery, Chief, Division of Oral and Maxillofacial
Surgery and Dental Medicine.
b
Assistant Professor of Oral and Maxillofacial Surgery, Division of
Oral and Maxillofacial Surgery and Dental Medicine.
Received for publication Feb 11, 2004; accepted for publication
May 3, 2004.
Available online 23 August 2004.
1079-2104/$ - see front matter
Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.tripleo.2004.05.001
parotid gland or duct injury at the time of laceration
repair. Historically there have been many methods
employed to repair parotid duct injuries. This report will
discuss the most common treatment approaches for
parotid gland injuries.
ANATOMY OF THE PAROTID GLAND
The parotid gland lies superficial to the posterior
aspect of the masseter muscle. The posterior lobe or tail
of the parotid extends posterior and medial to the
posterior border of the mandibular ascending ramus. The
gland is invested by the parotid-masseteric fascia, which
is an extension of the superficial layer of the deep
cervical fascia. The parotid duct or Stenson’s duct is
approximately 7 cm in length.5 It arises from the anterior
aspect of the gland and passes anteriorly superficial to the
masseter muscle. In this region it is in close proximity to
the transverse facial artery and buccal branch of the facial
nerve. At the anterior border of the masseter the duct
turns medially through the buccal fat pad then penetrates
the buccinator muscle and oral mucosa to finish in its
duct follows a path that can be approximated by a line
extending from the tragus of the ear to the vertical
midpoint of the upper lip6 (Fig 1). Van Sickles classified
parotid duct injuries based on the site of injury as A, B, or
C (Fig 2). Site A includes injuries that are proximal to the
posterior border of the masseter muscle. Site B includes
the part of the duct that passes over the masseter. Site C
injuries occur anterior to the masseter muscle.

136
OOOOE
Volume 99, Number 2
Fig 1. A line connecting the tragus and the mid portion of the
upper lip delineates the trajectory of the parotid duct on the
buccal region.
PATIENT EVALUATION
All cheek lacerations should be inspected thoroughly
for evidence of injury to Stenson’s duct, the parotid
gland, branches of the facial nerve, and the transverse
facial artery (Fig 3, A). Injuries to these structures are
best repaired at the initial time of laceration closure. A
ductal injury should be suspected if the laceration crosses
the tragal-lip line, previously described. Cannulation of
the duct via its intraoral orifice with a lacrimal probe or
small catheter usually is helpful in locating its distal cut
end, if its identification is difficult during inspection of
the wound7 (Fig 3, B). Once the distal end is identified in
the wound, the proximal stump can be easily located in
clean sharp lacerations by reapproximating the wound
and following the direction of the probe exiting the distal
stump. In wounds that are jagged or involve tissue
avulsion this method is often not possible. In such
situations, the proximal end may be identified by
milking the parotid gland and looking for flow of saliva
in the wound. Antisialogogue medications, such as
atropine or glycopyrrolate, should be avoided as part
of the anesthetic management if this method is to be
used.
Retrograde injection of methylene blue can be used to
aid in the diagnosis of ductal injury when inspection and
probing fail to locate the duct. The parotid duct papilla is
located intraorally and can then be cannulated with
a small angiocatheter (20-22 gauge). A small amount of
methylene blue is injected retrograde while observing
the wound. Areas of extravasation can then be explored
for ductal injury. It is the authors’ experience that only
era 137
Steinberg and Herr
Fig 2. Diagram shows the classification of parotid duct site
injuries according to Van Sickels.7 A = Glandular portion;
B = duct over the masseter muscle; C = duct distal to the
anterior border of the masseter muscle.
a small amount (1-2 mL) of diluted methylene blue
should be used. Use of larger, more concentrated
amounts can discolor the wound and make it difficult
to identify tissue planes and smaller branches of the
facial nerve.
Sialography has also been used to diagnose parotid
injury.5,8 In the acute injury setting this diagnostic
technique may not be practical or possible. Patients with
facial trauma may also have concomitant injuries that
prohibit transferring the patient to the radiology de-
partment for a lengthy study. Sialography is best used in
cases that present some time after the traumatic event
or in cases in which ductal injury may have been
overlooked. Sialography is also useful in the post-
operative period to evaluate the results of treatment
(Figs 3, E and 4). Recent advancements of helical
computerized tomography have allowed its use in the
diagnosis of parotid injuries, especially those in the
gland’s parenchyma.9 This option represents an advan-
tage in the trauma patient scenario, because in many
cases multiple CT studies are required as part of the
initial assessment for other body injuries such as head or
abdomen.
Although not the focus of this paper, some mention to
injuries of the cranial nerve VII should be made. Injuries
to branches of the facial nerve are usually concomitant
with parotid duct injury. When evaluating a patient with
facial laceration for parotid injury it is also incumbent on
the examiner to identify facial nerve injuries. Branches
of the facial nerve trunk that are anterior to a vertical line
 OOOOE
138 Steinberg and Herrera February 2005

Fig 3. A, 26-year-old male patient that sus-

tained a gunshot wound on the right buccal
region, involving the parotid duct and terminal
branches of the facial nerve. B, Wound
exploration and identification of the proximal
and distal stumps of the severed parotid duct
using lacrimal probes. C, Anastomosis of the
duct with the use of 8-0 nylon under magnifi-
cation. D, Layered closure of the remaining
facial injuries. E, Postoperative parotid sialog-
raphy 2 weeks after the repair of the right
parotid duct.
OOOOE
Volume 99, Number 2
Fig 4. A, Postoperative parotid sialography 11 months after repair of a left parotid duct injury. This 18-year-old patient sustained
a sharp injury to the left cheek during a motor vehicle accident. B, Panoramic view of the left parotid sialography on the same patient.
Notice the duct stricture at the level of the anastomosis (dotted line).
that passes through the lateral canthus of the eye need not
to be repaired.7 Transection posterior to this line should
be repaired by either direct neurorrhaphy or grafting
techniques. Muscle relaxant medications, as part of the
general anesthetic, should be avoided if nerve testing is
anticipated.
TREATMENT METHODS
The method of treatment chosen is based on the age of
injury, site of injury, and mechanism of injury. There are
3 methods generally employed to manage duct lacer-
ations. These categories of treatment include primary
repair of the duct with microsurgical anastomosis,
diversion of salivary flow by creation of an oral fistula,
and suppression of salivary gland function.
Primary anastomosis, when possible, is the treatment
of choice. This method is suited for site B injuries that
involve sharp lacerations of the duct with minimal or no
tissue loss. After locating the distal and proximal parts of
the duct, the stumps are dissected free of surrounding
tissue to provide for a tension-free coaptation. Care must
be taken to avoid damage to the buccal branches of the
facial nerve and transverse facial artery that may be in
close proximity when freeing the duct from the adjacent
tissue. Stenosis in the area of anastomosis is avoided by
repairing the duct over a stent and leaving the stent in
place during the initial healing period.
A silicone catheter (Silastic RX-50 medical grade
tubing; Dow-Corning, Midland, Mich) or angiocath is
placed through the wound to exit distally through the
parotid orifice. The other end of the catheter is threaded
into the proximal duct just into the gland. The duct is then
directly repaired with 8-0 or 9-0 nylon sutures (Fig 3, C).
The stent is sutured distally to the buccal mucosa just
era 139
Steinberg and Herr
anterior to the parotid papillae to avoid displacement.
The stent is left in position for 10-14 days.10
In cases involving avulsion of tissue or if the injury
involves the distal aspect of the duct, repair may not be
possible. In such situations, the proximal parotid duct
may be diverted into the oral cavity creating a new
orifice. Stenting is not necessary with this technique. The
proximal end of the duct is brought through the
buccinator muscle and oral mucosa. The ductal epithe-
lium is then sutured to the oral mucosa with 8-0 nylon.
Severe tissue loss such as avulsion injuries with loss of
duct structure may preclude the use of the diversion
technique. In these cases, ligation of the proximal duct
will eventually cause the gland to atrophy.7 Initially, the
gland will swell and become quite painful. A pressure
dressing can also be applied over the parotid gland to
further promote gland atrophy.7 Antisialogogue medi-
cations are also employed as an adjunct to this technique
to decrease the salivary gland function.
DELAYED TREATMENT
Treatment of the parotid duct injuries may be delayed
and not accomplished at the time of injury. This may be
intentional or due to failure to recognize the duct injury.
Repair of parotid wounds may be intentionally delayed
in cases with massive tissue destruction or serious
multisystem trauma. In these cases hemostasis and rapid
wound closure are the primary concerns. Since the duct
injury is not attended initially, the saliva produced will
either form a sialocele or drain cutaneously through the
wound (Fig 5). In cases of sialocele, salivary fluid should
be confirmed by amylase identification.7 The biggest
challenge of this type of case is the presence of a dense
fibrous scar over the area of injury making the attempt of

140 Steinberg and Herrera
Fig 5. Salivary fistula product of an undiagnosed parotid duct
injury on a patient that sustained sharp trauma in the left buccal
region.
primary repair of ductal injuries almost impossible.
These problems are treated by establishing drainage
through the parotid duct orifice, creating an oral fistula or
suppressing the production of saliva from the gland.
Sialoceles are treated by multiple percutaneous
aspirations and application of pressure dressings to
induce glandular atrophy. During the period that this
treatment takes place, the use of antisialogogues is
recommended.11,12 Some authors also recommend the
use of parenteral nutrition to decrease the autonomic
gland stimulation.11,13 If these conservative options are
not successful treating the problem, surgical exploration
should then be taken into consideration. Primary repair
of the duct should be attempted, and, if not possible,
identification and ligation of the proximal duct should be
the next step. More aggressive approaches include
superficial10 or total parotidectomy and radiation.
Radiation therapy in low doses is intended to induce
glandular fibrosis and cessation of the salivary pro-
duction7; however, its well recognized local side effects
are the reason for its low popularity in these cases.11,16
The tympanic neurectomy is a less aggressive surgical
option than parotidectomy for the treatment of chronic
salivary fistulas.11,13-15 The tympanic nerve provides the
secretory parasympathetic innervation for the parotid
gland. This technique involves the surgical disruption of
the anterior and posterior fibers of the tympanic nerve by
drilling into the temporal bone at the hypotympanum.
OOOOE
February 2005
This technique has been successfully used for the
treatment of recurrent parotitis, with minimal complica-
tions.15 Reinnervation and/or partial resection of the
nerve fibers account for some of the treatment failures or
short-term results.
Recently, botulinum toxin (Botox) has become
popular for the treatment of salivary fistulas,17 sialor-
rhea, and Frey’s syndrome.18,19 Botulinum toxin type A
(BTXA), works locally at the presynaptic neurons to
inhibit the secretion of acetylcholine. At the level of the
parasympathetic nervous system, the blockage of
neurons innervating the secretory system at the major
salivary glands will reduce the salivary production. This
characteristic makes this treatment approach a viable and
conservative technique for the treatment of salivary
fistulas after parotid duct injuries. The proposed
technique for the use of Botox in the parotid gland,
according to the Cologne protocol,18 requires the
reconstitution of the toxin with 4 mL of preservative-
free normal saline to obtain a 25 mU/0.1 mL concentra-
tion. Between 0.1 to 0.2 mL are injected at each point on
the parotid gland. Depending on the size of the gland, 4
to 10 points are injected on the parotid. The injections are
preferably performed under sonographic control with
a 7.5 Hz linear transducer. In general, a significant
decrease of the salivary production is seen within the first
2 weeks after the injections, and the duration of the effect
averages between 2 to 3 months. Minimal side effects are
seen with this protocol.
DISCUSSION
The anatomical location and physiology of parotid
duct makes the treatment of its injuries key in the setting
of a trauma patient. Closely related with vital structures
of the face such as terminal branches of the facial nerve
and transverse facial artery branch of the superficial
temporal artery, the parotid duct constitutes a very
important landmark when treating injuries on this region.
At the same time, reconstruction of duct integrity could
be essential to achieve a successful treatment of the
traumatized patient. Providing a direct communication
with the oral cavity, an unrepaired ductal injury can be
the port of entrance of pathologic microorganisms into
the deep tissues of the buccal space. Late complications
of nonaddressed parotid duct injuries such as mucoceles
and salivary fistulas can carry devastating esthetic results
as they can cause facial scarring.
A thorough knowledge of the anatomy of parotid duct
and its relations with other structures in the cheek are
essential when treating these injuries. It is preferred to
perform ductal repair under magnification to achieve
a predictable result after its repair.11 Advances in
microsurgical technique have allowed improvement of
surgical techniques and materials to repair an injured
OOOOE
Volume 99, Number 2
parotid gland duct.20 In 1999, Chudakov and Ludchik21
proposed the use of autogenous vein grafts to repair
parotid duct injuries in a dog model. In their study, they
compared the use of a vein graft alone with the use of
a vein graft wrapped with masseter fascia to prevent
obliteration of the repaired duct. Long-term patency and
low occurrence of obliteration and fibrosis were seen in
those cases in which fascial graft was used in conjunction
with the vein graft.
Others have also advocated the nonsurgical manage-
ment of parotid injuries. Lewis and Knottenbelt8 in 1991
presented data from a 6-month prospective study
evaluating the nonsurgical treatment of parotid duct
injuries. A total of 19 patients with injuries of the parotid
duct were followed up for more than 30 days. Forty-
seven percent had an uneventful postoperative period.
The remaining 53% (10 patients), developed minor
complications including sialoceles (4 patients), salivary
fistulas (7 patients), and wound sepsis (1 patient). All the
complications responded to conservative measures that
included weekly aspirations for the sialoceles and the use
of antisialogogues for fistulas that persisted for more
than 14 days.
If immediate repair of parotid duct injuries is not
feasible, multiple delayed treatment approaches are
available. In most of the cases and depending on the
degree of injury to the cheek, scarring of the area can
complicate the attempts to primarily repair the duct. For
this reason, the use of more conservative approaches
including antisialogogues and pressure dressings can
provide acceptable results in these particular circum-
stances.12
Most recently, the use of Botox has shown good
results reducing salivary production in cases of sialor-
rhea, salivary fistulas, and Frey’s syndrome. With
minimal side effects and relatively easy technique for
its use, Botox should be highly considered as a conser-
vative treatment modality in cases of salivary fistulas.17
CONCLUSION
Injury to the parotid duct, if not repaired, may cause
serious sequelae. Parotid duct injuries are best repaired
early at the time of injury. Direct anastomosis of the
severed ends yields the best outcome. Thorough
knowledge of the local anatomy and high degree of
suspicion for injury are important factors in diagnosing
and treating these injuries.
era 141
Steinberg and Herr
REFERENCES
1. Hemenway WG, Bergstrom L. Parotid duct fistula: a review.
South Med J 1971;64(8):912-8.
2. Neuhaus RW, Baylis HI. Parotid duct injury as a complication of
differential seventh nerve ablation. Am J Ophthalmol 1982;93(1):
124-5.
3. Abramson M. Treatment of parotid duct injuries. Laryngoscope
1973;83(11):1764-8.
4. DeVylder J, Carlo J, Stratigos GT. Early recognition and
treatment of the traumatically transected parotid duct: report of
case. J Oral Surg 1978;36(1):43-4.
5. Joffe N. Some sialographic findings in traumatic lesions of the
parotid duct and gland. Am J Roentgenol Radium Ther Nucl Med
1967;100(3):656-63.
6. Barton NW, Miller SH, Graham WP 3rd. Managing lacerations of
the parotid gland, duct and facial nerve. Am Fam Physician 1976;
13(4):130-4.
7. Van Sickels JE. Parotid duct injuries. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1981;52(4):364-7.
8. Lewis G, Knottenbelt JD. Parotid duct injury: is immediate
surgical repair necessary? Injury 1991;22(5):407-9.
9. LeBlang SD, Nunez DB Jr. Helical CT of cervical spine and soft
tissue injuries of the neck. Radiol Clin North Am 1999;37(3):
515-32,v-vi.
10. Stevenson JH. Parotid duct transection associated with facial
trauma: experience with 10 cases. Br J Plast Surg 1983;36(1):
81-2.
11. Haller JR. Trauma to the salivary glands. Otolaryngol Clin North
Am 1999;32(5):907-18.
12. Cavanaugh K, Park A. Postparotidectomy fistula: a different
treatment for an old problem. Int J Pediatr Otorhinolaryngol
1999;47(3):265-8.
13. Davis WE, Holt GR, Templer JW. Parotid fistula and tympanic
neurectomy. Am J Surg 1977;133(5):587-9.
14. Chitre VV, Premchandra DJ. Recurrent parotitis. Arch Dis Child
1997;77(4):359-63.
15. Vasama JP. Tympanic neurectomy and chronic parotitis. Acta
Otolaryngol 2000;120(8):995-8.
16. Lustig LR, Jackler RK, Lanser MJ. Radiation-induced tumors of
the temporal bone. Am J Otol 1997;18(2):230-5.
17. Guntinas-Lichius O, Sittel C. Treatment of postparotidectomy
salivary fistula with botulinum toxin. Ann Otol Rhinol Laryngol
2001;110(12):1162-4.
18. Guntinas-Lichius O. Increased botulinum toxin type A dosage is
more effective in patients with Frey’s syndrome. Laryngoscope
2002;112(4):746-9.
19. Ellies M, Laskawi R, Rohrbach-Volland S, Arglebe C. Up-to-date
report of botulinum toxin therapy in patients with drooling caused
by different etiologies. J Oral Maxillofac Surg 2003;61(4):454-7.
20. Hallock GG. Microsurgical repair of the parotid duct. Microsur-
gery 1992;13(5):243-6.
21. Chudakov O, Ludchik T. Microsurgical repair of Stensen’s &
Wharton’s ducts with autogenous venous grafts. An experimental
study on dogs. Int J Oral Maxillofac Surg 1999;28(1):70-3.
Reprint requests:
Dr. Mark J. Steinberg
Loyola University Medical Center
2160 S. First Avenue, Bld. 105-18-14
Maywood, IL 60153
msteinb@lumc.edu