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TRAUMATIC INJURY OF PAROTID GLAND MANAGEMENT

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REVIEW
TRAUMATIC INJURY OF PAROTID GLAND-
MANAGEMENT
Amar Bhuibhar1, Jeevan Prakash2, Shubharanjan Dutta3, Rohit Punga4, Abhinay Deshmukh5
1,3,5
Post Graduate Student, 2Prof. and Head, 4Senior Lecturer
Dept. of Oral & Maxillofacial Surgery, Vyas Dental College and Hospital, Jodhpur
Corresponding Author: Dr. Amar Bhuibhar, Email : dr.amar.bhuibhar@gmail.com
ABSTRACT
Parotid gland and duct injuries are common
complications following surgery of parotid
gland, temporomandibular joint & panfacial
trauma. Various other causes of parotid injury
are rupture of parotid abscess, complication of
superficial Parotidectomy & gunshot wounds.
Injury to the parotid duct may be difficult to
diagnose and treat. If not recognized will lead to
salivary fistula and sialocele formation which
will not heal spontaneously because of
continuous flow of saliva. Persistent salivary
fistula may be most troubling to the patient.
Successful treatment depends on early
recognition and appropriate early intervention
Key Words: Parotid fistula, Stensen's duct
INTRODUCTION
Parotid gland and duct injury have been described in
the literature for several hundred years and
published surgical treatments begin to appear in
1890s. Nicoladoni reported the first primary
anastomosis of the parotid duct in 1896. Morestin
reported ligation of the proximal stump in 1917 and
formation of an oral fistula was described in 1918.1
Both surgical and non surgical treatment modalities
have been used in the management of salivary gland
and duct injury and post traumatic sequelae. The
purpose of this article is to review different
treatment modalities mentioned in the literature for
the same which helps the clinician in diagnosing as
well as treating the condition accurately.
Dental Impact Vol. 5, Issue 2, Dec. 2013
ISSN 2249-5436
Surgical anatomy of the parotid region
The parotid gland lies superficial to the posterior
aspect of the masseter muscle and the ascending
ramus of the mandible. The deep part of the gland
may extend forward between the medial pterygoid
process. The parotid gland is a lobulated mass
surrounded by a connective tissue capsule, and
enclosed by a dense fibrous capsule derived from
the investing layer of deep cervical fascia showing
in (Fig.1).
Fig. 1. Gross anatomy of parotid gland
The facial nerve exits the cranium via the
stylomastoid foramen and courses through the
substance of the parotid gland. The facial nerve
branches within the substance of the parotid gland in
a highly variable pattern.
The parotid duct is approximately 7 cm long and is
composed of an inner epithelium, a smooth muscle
coat, and an outer adventitial layer much like a
blood vessel. The parotid duct exits the parotid
gland anteriorly and crosses the superficial border
of the masseter. It then turns medially and pierces
the buccinator muscle. It enters the oral cavity
through a papilla in the buccal mucosa opposite the
second maxillary molar (Fig. 1). The course of the
parotid duct generally follows a line drawn from the
109
 tragus to the midportion of the upper lip. Any injury
that crosses this line should be considered to involve
the parotid duct until proven otherwise. Parotid duct
injuries are often overlooked because of more
severe concomitant injury or difficulty in obtaining
the diagnosis.
Etiology 2
Penetrating injuries in the parotid region.
?
Blunt trauma.
?
Complication of parotid duct cannulation for
?
sialography .
Intraoperative iatrogenic injury.
?
TMJ surgeries.
?
Parotidectomy.
? cutaneous salivary gland fistula, sialocele
Classification of parotid injuries
An injury classification system has been devised by
Van Sickels.3 This system divides the parotid
injuries into three regions showing in (Fig. 2) .
Fig. 2. Classification of Sites of parotid
gland injury
A. Posterior to the masseter or intraglandular
B.Overlying the masseter
C. Anterior to the masseter
Dental Impact Vol. 5, Issue 2, Dec. 2013
Treatment options
Aspiration and pressure dressings
?
Anti-Sialogogues
?
Radiation therapy
?
?Parasympathetic Denervation (Tympanic
Denervation)
Cauterization of the Fistulous
?
Reconstruction of the duct
?
Superficial or Total Parotidectomy tract
?
Potential sequelae of trauma involving the major
salivary glands include infections, facial paralysis,
formation and duct obstruction as a result of scar
formation, with eventual glandular atrophy and
decreased function. The involved gland may
eventually require surgical removal.3,4
Imaging Studies
Sialography may be performed with water soluble
contrast material should be used because it is more
easily drained and absorbed and it does not remain
as an irritant to the gland. Sialography can be used to
detect perforations, fistula tracts, calculi, and tumor,
and it defines the ductal anatomy well. It is rarely
used at present, however. If undertaken, it should be
performed as sterilely as possible to prevent
introduction of intraoral bacteria to the parotid
duct.5
Cannulate the intraoral parotid duct papilla with a
small (ie, 19-gauge) silastic tube and observe if the
tube is visible in the wound. A small amount of
saline may be injected through the tube and
observed for flow through the wound. Methylene
blue probably should not be injected through the
tube because it terribly discolors tissues and makes
subsequent operation even more challenging.6
Medical Therapy
In regards to antibiotic therapy, era on the side of
caution because the risk of antibiotic therapy is
minimal, while the potential complications of
wound infections are considerable. Prophylactic
110
 antibiotics should be continued for 5-7 days.
The drug of choice is amoxicillin/clavulanate
potassium (Augmentin; adult dosage 500/125 mg
PO tid). Doxycycline is an alternative choice for
oral therapy in patients allergic to penicillin (adult
dosage 100 mg PO bid). Rocephin 1 gm
administered intramuscularly or intravenously is
useful in patients whose compliance with dosage
schedules is questionable. Some authors choose to
use anticholinergic agents to suppress glandular
function during healing or in an attempt to close a
fistula or resolve a sialocele spontaneously. Many
undesired side effects such as xerostomia,
constipation, photophobia, tachycardia and urinary
retention.7 Propantheline bromide (Pro-Banthine),
which inhibits the action of acetylcholine at the
postganglionic nerve endings of the
parasympathetic nervous system (adult dose 15 mg
PO qid half an hour prior to meals). Earler radiation
therapy 1800 rad was used for induce fibrosis &
atropy of gland for treanment of siocele & fistula.
But duration of this therapy more than 6 weeks for
the gland atropy to occur. It is potential to induce
malignancy of surrounding staucture.8
Botox A inhibits secretion of acetylcholine at
presynaptic nerve ending. Cologne protocol
contains 25 mU of botulinum toxin / 0.1ml
intraglandularly 0.1 - 0.2 ml to be injected at 4 to 10
points under sonographic control.9,10
Sialocele and salivary fistula can frequently be
managed nonoperatively with antibiotics, pressure
dressings, and serial aspiration. Anticholinergic
medications and the injection of botulinum toxin
type A represent additional measures before
resorting to surgical therapies such as tympanic
neurectomy or parotidectomy. High failure rate due
to varied anatomy of nerve reinnervation.9
Surgical Therapy
Lacerations, involving the salivary glands and their
ducts may accompany a variety of facial injuries,
including fractures. Repair may include ductal
anastomoses, in which the proximal and distal
portions of the duct are identified, a plastic or metal
catheter is placed as a stent, and the duct is sutured
over the stent. The catheter usually remains in place
for 10 - 14 days for epithelization of the duct to
Dental Impact Vol. 5, Issue 2, Dec. 2013
occur. Additionally, nerve anastomoses may be
required and performed by placing epineural
sutures, using magnification, to reapproximate the
nerve stimps. The lacerations are closed in a usual
layered fashion, after debridment of the soft tissue
wounds to cleanse the site of entrapped particles,
such as glass or dirt. Clean, surgically created
wound margins allow for faster wound healing and
better scarring. Injuries of the proximal duct near
the parotid substance are usually best treated by
ligation of the duct. Duct ligation causes
“Physiologic Death” of the gland.10 Surgical
excision of the fistulous tract followed by tight
pressure dressing of the wound is an effective
management option. Three operative techniques
have been described include repair of the duct over a
stent, ligation of the duct, and fistulisation of the
duct into the oral cavity.5
Tympanic Neurectomy
Para sympathetic secretomotor fibres carried to the
gland from inferior salivatory nucleus via tympanic
plexus (branch from glossopharyngeal nerve) to
otic ganglion. Supplied to parotid gland by
auriculotemporal nerve. Transtympanic sectioning
of the Jacobson's nerve by drilling into temporal
bone at hypotympanium has been reported.
Glandular atrophy occurs in 6 months. Recently
treatment of salivary fistula with botulinum toxin
BOTOX type A has been described.11
Dochoplasty
Creating intraoral fistula advocated by Demetriades
for internalization of the salivary flow. Injuries
occurring over the masseter muscle, are the most
common injuries to the parotid duct and may be
treated by repair or ligation.13 Perform primary
repair if enough length remains. Trim the edges
cleanly and perform anastomosis over the silastic
stent. A single layer of interrupted fine sutures (8-0
to 10-0 nylon or similar suture) is used to carefully
reapproximate the severed ends with the surgical
microscope or under loupe magnification. If a
portion of the duct is damaged beyond repair or is
missing, the proximal and distal duct should be
ligated.
Repair of the Stensen's duct
Distal lacerations, occurring at may be treated by
repair of the duct. If the papilla is uninjured, the
111
 proximal portion may be dissected free and
reimplanted into the papilla and cannulation of the
duct with a silastic tube.12 Showing in Table 1.
If the surgeon is able to repair the duct over a stent,
the stent is trimmed at the level of the oral papilla
and sewn to the oral mucosa or around the maxillary
second molar with a chromic suture. This is
designed to hold the stent in place for the
recommended 2-3 weeks while the injured duct
heals and to help prevent stenosis at the repair site. It
may also prevent postoperative oedema in the
region from collapsing the fragile duct. Patient
tolerance of the stent is highly variable.
Table1. Showing the sequence of treatment for trauma to parotid duct
Dental Impact Vol. 5, Issue 2, Dec. 2013
Management of Parotid Sialoceles and Fistulae: A
Classification of Reported Methods in the
Literature8
1. Diversion of parotid secretion into the mouth
A. Reconstructive methods
Delayed primary repair of duct
?
?Reconstruction of duct with vein graft Mucosal
flaps Suture of proximal duct to buccal mucosa
B. Formation of a controlled internal fistula
T-tube or catheter drainage into the mouth
?
Drainage of proximal duct by a catheter
?
112
 C. Parotidectomy COMPLICATIONS
D. Local therapy to the fistula Injuries to the parotid glandular system can be
Excision
? missed as the result of extensive trauma,
Cauterization
? subsequently resulting in sialoceles, parotid
fistulae, and infections. They may also occur when
2. Depression of parotid secretion surgical repair of an injury is not successful.Surgical
A. Surgical approaches approach may causes facial nerve weakness.
?Duct ligation Medical management of such conditions includes
?Sectioning of the auricotemporal or Jacobsen's antisialogogues and antibiotics. Antisialogogues
nerve often are combined with aspiration from a
nondependent area and application of a pressure
B. Conservative approaches dressing when there is a fluid collection or a
Administering nothing orally to the patient until
? sialocele occurs. This treatment causes saliva ropy
the fistula closes and thick and chance of xerostomia due to reduced
Drugs: atropine or Pro-banthine
? salivary flow. Botulinum toxin has been used for
Radiotherapy
? salivary fistulas caused by a number of different
Repeated aspiration and pressure dressing
? problems. Complication includes temporary muscle
weakness.

Table 2. Current surgical protocol for the management of post- traumatic parotid gland
and duct injury is shown

Dental Impact Vol. 5, Issue 2, Dec. 2013 113

 CONCLUSION
The management of parotid sialoceles and fistulae
have been unsatisfactory in the past, and numerous
methods of treatment with varying success and
morbidity have been described. Persistent salivary
fistula may be most troubling to the patient. The
treatment depends on the location of the injury and
thus should be specifically chosen for each
situation. Delay in the diagnosis of parotid gland
trauma is common. In case of bleeding from parotid
region use pressure pack; avoid blind attempts with
cautery or clamping; major vessels in this region lies
deep to the facial nerve. Examine for the drooping of
upper lip; Hypotensive anaesthesia with
premedications and blood loss reduces salivary
flow, making diagnosis more difficult.
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How to cite this article: Bhuibhar A, Prakash J, Dutta SR,
Punga R, Deshmukh A. Traumatic injury of parotid gland
duct- Management. Dent Impact 2013;5:109-14.
Source of support: Nil Conflict of interest: None declared
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