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(c) (d) Figure 15.9. An 8-year-old girl (a) with left submandibular swelling that had been present for 6 months. Imaging with CT identified an ill-defined mass of the submandibular gland region (b) as well as hydrocephalus (c). Oral examination (d)showed fullness in the left sublingual space. With a differential diagnosis of neurofibroma the patient underwent a debulking of this (e and f). Histopathology identified a plexiform neurofibroma (g), indicative of neurofibromatosis. The patient did well postoperatively as noted at her 2-year visit (h and i). No reaccumulation of the tumor was noted on physical examination.

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(i) Figure 15.9. (Continued)

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PAROTID TUMORS of which occurred in children. Fifty-seven (71%) of these tumors developed in the . In their review of the Salivary Gland Register from 1965–1984 at the University of Hamburg, Seifert, accounts for virtually all of et al. (1986) reported on 9883 cases of salivary the benign pediatric neoplasms occurring in the gland pathology, including 3326 neoplasms, 80 parotid gland with the Warthin tumor representing

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(c) (d) Figure 15.10. A 9-year-old boy (a) with a mass of the left hard-soft junction (b). Incisional biopsy identified low-grade . Imaging with CT (c) showed no bone erosion of the hard palate such that the patient underwent wide local excision of his cancer (d). Final histopathology (e) identified intermediate grade mucoepidermoid carcinoma. (Hematoxylin and eosin, original magnification ×100.)

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SUBMANDIBULAR GLAND TUMORS As in adults, submandibular gland tumors are very uncommon in pediatric patients. Of 168 sali- vary gland tumors in the series of Krolls, et al. (1972), submandibular gland tumors included 3 , 4 mucoepidermoid carcinomas, and 10 benign tumors. While there were 12 acinic cell carcinomas in this series, none occurred in the submandibular gland. Lack and Upton (1988) similarly identified their five cases of exclusively present in the parotid gland, but they identified no cases of mucoepidermoid carcinoma in the submandibular gland. These authors identified 4 of 10 cases of pleomorphic (e) adenoma occurring in the submandibular gland. In Figure 15.10. (Continued) Castro’s series of 38 major salivary gland tumors, 5 were noted to occur in the submandibular gland. a minor contribution at this anatomic site. In 166 These included four cases of pleomorphic ade- children with epithelial parotid tumors, 93 (55%) and one case of malignant mixed tumor. were benign and 73 (45%) were malignant (Ord The treatment of submandibular gland tumors in 2004). Of the 73 malignancies, 47 (64%) were children includes excision of the submandibular mucoepidermoid carcinomas and 17 (23%) were gland and tumor en bloc. acinic cell carcinomas. This relative incidence of mucoepidermoid carcinomas and acinic cell MINOR SALIVARY GLAND TUMORS k carcinomas of the parotid gland in children is k distinguished from the near equal incidence of Minor salivary gland tumors in children are rare. these malignancies in the parotid gland in adult Population studies have demonstrated that only 5% patients in the AFIP data (Ellis, et al. 1991). Finally, of minor salivary gland tumors occur in children, although the parotid gland is a less common site with a near equal distribution of benign and malig- for salivary gland tumors in children compared to nant tumors (Galer, et al. 2012). In their study of adults, there is a greater chance for malignancy in 35 minor salivary gland tumors in children, Galer, children. et al. (2012) identified 22 cases of mucoepidermoid The workup of a child with a parotid swelling carcinoma, 9 cases of , does not differ significantly from that of an adult. and 4 cases of . Thirty-one of the Once inflammatory disease has been ruled out, a malignancies were low-intermediate grade. Twenty fine needle aspiration biopsy of a discrete parotid of the tumors were classified as occurring in the mass in a child is useful to establish its cytologic oral cavity and 13 were classified as occurring in character. Structural imaging is also valuable so the hard palate. These authors found an excellent as to establish the anatomic extent of the tumor. prognosis for their patients with an overall survival Superficial or partial superficial of 88.4% and disease free survival of 89.3% at parotidectomy with facial nerve identification and 5 years. Preferred treatment is identical to that preservation are the procedures of choice for pedi- of adult’s diagnosis for diagnosis. In the author’s atric parotid tumors. Facial nerve sacrifice is only unpublished series of 275 minor salivary gland performed when preoperative palsy is noted to tumors, 12 (4.3%) were pediatric cases (age 9–19). exist or when nerve invasion is appreciated intra- Ten cases were malignant (83.3%), of which 7 operatively. The facial nerve is more superficial in (70%) were mucoepidermoid carcinomas and 9 of infants younger than 4 months of age compared the 12 tumors was located in the palate (75%). to older children due to the lack of development A mucoepidermoid carcinoma of the palate of the mastoid process (Ord 2004). Neck dissec- in a child should undergo structural imaging and tion is performed for high-grade malignancies excision of the tumor with appropriate anatomic or when evidence of metastatic adenopathy is barrier inclusion on the deep aspect of the tumor present. (Figure 15.10). Unless the bone is clinically or

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(a) (b)

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(c) Figure 15.11. A 12-year-old girl (a) with a long history of a slowly growing mass of the palate (b). Axial T2 weighted MRI (c) identifies a hyperintense multilobulated mass consistent with a pleomorphic adenoma that was confirmed by incisional biopsy. Source: Reproduced with permission of John Caccamese.

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radiologically involved the bone does not require in infant and its review. Case Reports in Dentistry,article resection for low grade mucoepidermoid carci- ID 723130. noma in children (Caccamese and Ord 2002). The Bradley PJ, Hartley B. 2011. Salivary Gland Neoplasms. In: periosteum appears to be an effective oncologic Bradley PJ, Guntinas-Lichius O (eds), Salivary Gland barrier and its inclusion on the deep surface of the Disorders and Diseases: Diagnosis and Management. tumor permits a margin-free cancer surgery with Stuttgart, Thieme, p. 94. Caccamese JF, Ord RA. 2002. Pediatric mucoepidermoid high rates of cure. carcinoma of the palate. Int J Oral Maxillofac Surg The surgical management of benign palatal 31(2):136–139. salivary gland tumors, like that of malignant sali- Canzi P, Occhini A, Pagella F, Marchal F, Benazzo M, vary gland tumors is identical to those surgeries et al. 2013. Sialendoscopy in juvenile recurrent ; performed in adult patients (Figure 15.11). Specifi- a review of the literature Acta Otorhinolaryngol Ital cally, the inclusion of the periosteum on the deep 33(6):367–373. surface of the tumor provides effective cure of Castro EB, Huvos AG, Strong EW, Foote FW. 1972. these benign tumors. The superiorly located max- Tumors of the major salivary glands in children. Cancer illary bone need not be included with the tumor 29:312–317. specimen. Chiaravali S, Guzzo M , Bisogno G, De Pasquale MD, Migliorati R, De Leonardis F, Collini P, Casanova M, Cecchetto G, Ferrari A. 2014. Salivary gland carcinomas in children and adolescents: The Italian TREP project Summary experience. Pediatr Blood Cancer 61(11):1961–1968. Chitre VV, Premchandra DJ. 1997. Recurrent parotitis. Arch • Salivary gland are rare in the pediatric Dis Child 77:359–363. population that is variably defined in terms of Chung MK, Jeong HS, Ko MH, Cho HJ, Ryu NG, Cho DY, Son age. YI, Baek CH. 2007. Pediatric : What is differ- • The mucocele is the most common salivary ent from adult sialolithiasis? Int J Pediatr Otorhinolaryngol k gland lesion encountered in pediatric patients. 71(5):787–791. k • has historically been the most com- Craver RD, Carr R. 2012. Paediatric salivary gland pathology. mon form of diagnosed in children. Diagn Histo 18:373–380. • Chronic recurrent parotitis is the second most Drolet BA, Esterly NB, Frieden IJ. 1999. Hemangiomas in common form of sialadenitis in children. children. NEnglJMed341:173–181. • The pleomorphic adenoma is the most com- Ellies M, Laskawi R. 2010. Diseases of the salivary glands in infants and adolescents. Head & Face Medicine 6:1–7. mon pediatric salivary gland tumor and the Ellis GL, Auclair PL, Gnepp DR. 1991. Surgical Pathology most common benign tumor in children. of the Salivary Glands. Philadelphia, WB Saunders Co., Together with the hemangioma, these benign Ch. 9. tumors account for nearly 90% of all benign Enjolras O, Rich MC, Merland JJ, Escarde JP. 1990. Manage- salivary gland tumors in children. ment of alarming hemangiomas in infants: a review of 25 • The mucoepidermoid carcinoma is the most cases. Pediatrics 25:491–498. common malignant pediatric salivary gland Ezekowitz RAB, Mulliken JB, Folkman J. 1992. Interferon tumor. Together with the acinic cell carci- alfa-2a therapy for life-threatening hemangiomas of noma, these two malignant tumors account infancy. NEnglJMed326:1456–1463. for approximately 60% of malignant salivary Fang QG, Shi S, Li ZN, Zhang X, Liu FY, Sun CE. 2013. gland tumors in children. Epithelial salivary gland tumors in children; a twenty-five year experience of 122 patients. Int J Pediatr Otorhino- laryngol 77:1252–1254. Galer C, Santillan AA, Chelius D, et al. 2012. Minor sali- References vary gland malignancies in the pediatric population. Head Neck 34:1648–1651. Ajike SO, Lakhoo K. n.d. Salivary Gland Diseases in Chil- Gallia LJ, Johnson JT. 1981. The incidence of neoplastic ver- dren and Adolescents. Ch. 39, available at www.global- sus inflammatory disease in major salivary gland masses help.org/publications/books/help_pedsurgeryafrica39. diagnosed by surgery. Laryngoscope 91:512–516. pdf (accessed March 10, 2015). Gangopadhyay AN, Sinha CK, Gopal SC, et al. 1997. Role of Bhargava N, Agarwal P, Sharma N, Agrawal M, Sidiq M, steroids in childhood haemangioma: a 10-years review. Narain P. 2014. An unusual presentation of Int Surg 82:49–51.

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Hackett AM, Baranano CF, Reed M, et al. 2012. Sialoen- Saarinen R, Kolho KL, Davidkin I, Pitkäranta A. 2013. The doscopy for the treatment of pediatric salivary gland dis- clinical picture of juvenile parotitis in a prospective setup. orders. Arch Otolaryngol Head Neck Surg 138:912–915. Acta Paediatr 102(2):177–181. Hayashida AM, Zerbinatti DCZ, Balducci I, Cabral LAG, SalernoS,GiordanoJ,LaTonaG,DeGraziaE,BarresiB, Almeida JD. 2010. Mucus extravasation and retention Lo Casto A. 2011. Pediatric sialolithiasis distinctive phenomena: a 24-year study. BMC Oral Health 10:1–4. characteristics in radiological imaging. Minerva Stomatol Kaban LB, Mulliken JB, Murray JE. 1978. Sialadenitis in 60(9):435–441. childhood. Am J Surg 135:570–576. Scarcella JV, Dykes ER, Anderson R. 1965. Hemangiomas of Krolls SO, Trodahl JN, Boyers RC. 1972. Salivary gland the parotid gland. Plast Reconstr Surg 36:38–47. lesions in children. A survey of 430 cases. Cancer Seifert G, Okabe H, Caselitz J. (1986). Epithelial salivary 30:459–469. gland tumors in children and adolescents. Analysis of 80 Kuperman ME, de la Graza GO, Santillan AA, Williams cases (Salivary Gland Register 1965–1984). ORL J Otorhi- MD,VargheseBT,HuhW,RobertsD,WeberRS. nolaryngol Relat Spec 48:137–149. 2010. Outcomes of pediatric patients with malignan- Seo JH, Park JJ, Kim HY, Jeon SY, Kim JP, Ahn SK, Hur DG, cies of the major salivary glands. Ann Surg Oncol Kim DW, Lee JS. 2010. Surgical management of intraoral 17(120):3301–3307. in children: an analysis of 17 pediatric cases. Int Lack EE, Upton MP. 1988. Histopathologic review of sali- J Pediatr Otorhinolaryngol 74:202–205. vary gland tumors in childhood. Arch Otolaryngol Head Shacham R, Droma EB, London D, et al. 2009. Long-term Neck Surg 114:898–906. experience with endoscopic diagnosis and treatment Laikui L, Hongwei L, Hongbing J, Zhixiu H. 2008. Epithelial of juvenile recurrent parotitis. J Oral Maxillofac Surg salivary gland tumors of children and adolescents in west 67:162–167. China population: A clinicopathologic study of 79 cases. Soumekh B, Adams GL, Shapiro RS. 1996. Treatment of JOralPatholMed37:201–205. head and neck hemangiomas with recombinant interferon Maynard JD. 1965. Recurrent parotid enlargement. Br J Surg alpha-2b. Ann Otol Rhinol Laryngol 105:201–206. 52:784–789. Sultan I, Rodruigez-Galindo C, Al-Sharabati S, Guzzo M, Nahieli O, Ekiav E, Hasson O, Zagury A, Baruchin AM. 2000. Cassanova M, Ferrari A. 2011. Salivary gland carcino- Pediatric sialolithiasis. Oral Surg Oral Med Oral Pathol mas in children and adolescents: a population based k k Oral Radiol Endod 90(6):709–712. study, with comparison to adult cases Head Neck Nahlieli O, Shacham R, Shlesinger M, et al. 2004. Juvenile 33(10):1476–1481. recurrent parotitis: a new method of diagnosis and treat- Syebele K, Butow KW. 2010. Oral mucoceles and ranulas ment. Pediatrics 114:9–12. may be part of initial manifestations of HIV . Aids Ord RA. 2004. Salivary gland tumors in children. In: Kaban Research and Human Retroviruses 26:1075–1078. LB, Troulis MJ (eds). Pediatric Oral and Maxillofacial Tasca RA, Clarke R. 2011. Inflammatory and infec- Surgery. Philadelphia, Saunders. tious diseases of the salivary glands. In: Bradley PJ, Orvidas LJ, Kasperbauer JL, Lewis JE, et al. 2000. Pedi- Guntinas-Lichius O, Salivary Gland Disorders and Dis- atric parotid masses. Arch Otolaryngol Head Neck Surg eases: Diagnosis and Management. Stuttgart, Georg 126:177–184. Thieme Verlag, Ch. 13, pp. 110–120. Ottaviani F, Marchisio P, Arisi E, Capaccio P. 2001. Extra Woo SH, Jang JY, Park GY, Jeong HS. 2009. Long-term corporeal shockwave lithotripsy for salivary calculi in outcome of intraoral submandibular stone removal in pediatric patients. Acta Otolaryngol 121(7):873–876. children as compared to adults. Laryngoscope 119(1): Pandit RT, Park AH. 2002. Management of pediatric . 116–120. Otolaryngol Head Neck Surg 127:115–118. Yoshida EJ, Garcia J, Eisele DW, Chen AM. 2014. Salivary Puttgen KB. 2014. Diagnosis and management of infantile gland malignancies in children. Int J Ped Otorhinolaryngol hemangiomas. Pediatr Clin N Am 61:383–402. 78:174–178. Rutt AL, Hawkshaw MJ, Lurie D, Sataloff RT. 2011. Salivary Zhi K, Wen Y, Ren W, Zhang Y. 2008. Management of infant gland cancer in patients younger than 30 years. Ear Nose ranula. Int J Pediatr Otorhinolaryngol 72:823–826. Throat J 90(4):174–184.

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Chapter 16 Trauma and Injuries to the Salivary Glands

Outline Penetrating Injuries Introduction Penetrating Injuries TRAUMA TO THE GLAND Trauma to the Gland Salivary Fistula Salivary Fistula Penetrating injury to the substance of a major gland, for example the parotid or submandibular Nerve Injuries gland will cause direct damage to the gland and Frey Syndrome Hollowing possible related structures and may lead to the Trauma to Salivary Gland Ducts formation of an external salivary fistula to the skin Transection (Figure 16.1). When the substance of the gland is Stenosis of the injured suture of the parenchyma is recommended Radiation Injury (Lewkowicz, et al. 2002). In addition to direct External Beam closure of the parotid capsule, a pressure dress- Radioactive Iodine ing is applied for 48 h to reduce the chances of k Barotrauma sialocele formation. In 51 cases of parotid com- k Summary plications following trauma, 15 (30%) developed References parotid fistula, treated by intravenous fluids and nil by , with faster healing of parenchymal injuries alone than when the ductal system was Introduction involved (Parkeh, et al. 1989). Similarly, Anan- thakrishnan and Parkash (1982) reported that The salivary glands may be subjected to a num- their three cases of fistula from the parotid gland ber of injuries and insults. Trauma to the parotid parenchyma resolved without treatment, unlike is relatively rare, 0.21% of patients in a trauma the 14 fistulas related to parotid ductal injury. unit (Lewis and Knottenbelt 1991). Penetrating In a study of 13 patients with traumatic parotid trauma may be truly uncontrolled or accidental fistulas, 54% resolved with conservative manage- in nature; however, identical complications and ment within 3 weeks and the remaining patients injuries are seen after the intentional controlled were cured by internal drainage with a catheter trauma of surgery. This chapter will therefore (Cant and Campbell 1991). Landau and Stewart deal with the complications of both salivary gland (1985) advocated conservative management of surgery and true traumatic injury. In addition, the post traumatic parotid fistulas and sialoceles found injurious effects of radiation and barotraumas will that parenchymal injuries alone resolved in 5 be reviewed. days whereas ductal injuries took 14 days. While

Salivary Gland Pathology: Diagnosis and Management, Second Edition. Edited by Eric R. Carlson and Robert A. Ord. © 2016 John Wiley & Sons, Inc. Published 2016 by John Wiley & Sons, Inc.

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(a) (b)

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(c) Figure 16.1. (a) Penetrating injury of the parotid after being stabbed with a pencil. (b) Exploration via a modified Blair incision to check for damage to the external carotid artery, facial nerve and suture the capsule. (c) The length of the recovered pencil illustrates the depth of the wound.

Morestin (1917), in a series of 62 war injuries epithelialized fistulas require excision with repair with parotid fistula, 30 glandular and 32 ductal, of the parotid capsule and closure. reported good successes with the creation of an The submandibular gland is less liable to be intraoral fistula. In more extensive avulsive injuries involved in the development of traumatic fistulas with gross scarring, conservative treatment may perhaps because it is protected by the be less successful (Figure 16.2) and established and its smaller size. Few cases are reported and in

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(c) Figure 16.2. (a) Extensive avulsive injury from self-inflicted shotgun wound. (b) Post-surgical reduction of facial fractures and wound closure. (c) The patient developed a salivary fistula, which was treated by excision resuturing and a rotation flap as outlined.

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1995 a published case report of a submandibular but may occur through the surgical skin incision. gland fistula secondary to a gunshot wound, which Usually management with antisialogogues, nil by reviewed the literature found only one other case mouth or botulinum toxin will lead to resolution. In from 1976 (Singh and Shaha 1995). In their case, a report of three cases post-parotidectomy treated the fistula resolved without active treatment in 10 with injection of botulinum toxin under electro- days. myographic control, all resolved with no recurrence Rarely internal parotid fistulas can occur 14–21 months after therapy (Marchese-Ragona, presenting as rhinorrhea or rhinorrhea related to et al. 2006). food usually as a result of maxillary fracture with parotid fistula into the maxillary antrum (Scher and Poe 1988; Faussat, et al. 1993). In a recent Sialocele report of parotid fistula into the maxillary antrum A sialocele is formed by the extravasation of (and a very rare case of a sublingual gland fistula into glandular or periglandular tissues due to to the skin), excellent results were achieved with disruption of the parenchymal or ductal structures botulinum toxin injection (Breuer, et al. 2006). of the saliva gland. This is most commonly seen Although the authors state that primary surgical following trauma and the usual sites are the sublin- repair should be carefully considered, they found gual gland (ranula) or minor salivary glands (muco- the injection of botulinum toxin to be effective, cele). Ranulas and mucoceles have been discussed shorten fistula closure time, and be minimally in Chapter 4 and this section will concentrate invasive. largely on parotid sialocoeles. Parotid sialocoeles The current management of fistulas from are usually seen after penetrating trauma to the the parotid gland parenchyma is therefore con- parotid region and will present as painless, cystic servative, as cases that do not involve the duct swellings which are gradually increasing in size. will resolve. In recalcitrant cases botulinum toxin Aspiration of the sialocele with fluid positive for > k appears a good option. True fistula post-surgery, for amylase 10,000 units/liter will confirm the diag- k example, superficial parotidectomy, is not common nosis. CT scan will show a cystic mass with smooth

(a) (b) Figure 16.3. (a and b) Frontal and three-quarters views of patient with right parotid sialocele post-surgery. (c, d and e) MRI views of sialocele with enhancing capsule.

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(c) (d)

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(e) Figure 16.3. (Continued)

margins and a density lower than the surrounding (Landau and Stewart 1985; Parkeh, et al. 1989; tissues. After 2 weeks there will be enhancing Cant and Campbell 1991) with resolution reported borders due to the development of a capsule in approximately the same time period as for fistu- (Cholankeril and Scioscia 1993) (Figure 16.3). las. Most sialoceles develop 8–14 days post-injury Traditional management has been conserva- and the development of a late capsulated sialo- tive the same as for parotid parenchymal fistulas cele is more difficult to treat. Literature reviews

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(a) (b) k k

(c) Figure 16.4. (a) A 41-year-old male post a gunshot wound that entered in the left parotid region and traversed to the right parotid region, with fracture of both left and right condyles developed an increasing sialocele in the right parotid gland. (b) Panoramic film shows the retained bullet in the right parotid gland (arrow). (c) Modified Blair incision and partial parotidec- tomy, with mosquito forceps indicating the bullet. The bullet was located between the superior and inferior branches of the facial nerve which was intact with no weakness. The capsule of the parotid was repaired and the sialocele resolved.

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show that treatments proposed include multiple Nerve Injuries aspirations, pressure dressings, secondary duct The facial nerve is at risk from penetrating injury repair if this is the etiology, creation of an intraoral to the facial region both in the parotid and in the fistula, sectioning the auriculotemporal nerve, distribution of its peripheral branches to the facial the use of antisialogogues (atropine, probanthine, musculature. It is stated that damage to branches glycopyrrolate), duct ligation, and even radia- distal to a line drawn from the lateral canthus to tion or parotidectomy (Canosa and Cohen 1999; the commissure does not require repair and may Lewkowicz, et al. 2002) (Figures 16.4 and 16.5). be managed expectantly. All patients with facial In recent years, the use of botulinum toxin wounds should have a careful clinical examination has caused a paradigm shift in the way these of the facial nerve function. Where this is not injuries can be managed. In 1999, Ragona, et al. possible, for example, in the unconscious patient reported a case of post traumatic parotid sialocele or the uncooperative infant (Figure 16.6), the resistant to conservative therapy that was suc- wound should be carefully explored at the time of surgery to exclude transaction of the branches cessfully cured using botulinum injection. These of the facial nerve. Primary repair soon after the authors used Botulinum F. due to its earlier and injury with end to end anastomosis is the ideal shorter efficacy compared to Botulinum A and scenario, as paralysis of the facial nerve is a dev- injected the gland with electromyographic control. astating injury for the patient, and even when Botulinum toxin works by causing a chemical den- “successful” nerve repair has been carried out with ervation of the gland by blocking the cholinergic satisfying results (based on the House-Brackmann, neurotransmitter. Following this paper, a report Stennert, and May grading), patients experienced on four cases of recurrent post-parotidectomy a reduced quality of life (Guntinas-Lichius, et al. sialoceles treated with Botulinum A. toxin injected 2007) (Figures 16.7 and 16.8). This section will subcutaneously with 100% success was published discuss the management of the primary nerve (Vargas, et al. 2000) as well as other case reports k injury and will not discuss the techniques for facial k (Chow and Kwok 2003). There is a single case reanimation or static slings, which are beyond the of a submandibular sialocele treated with reso- scope of this text. The interested reader will find lution using botulinum toxin A (Capaccio, et al. many recent review articles addressing these topics 2007). (Malik, et al. 2005; Guntinas-Lichius, et al. 2006).

(a) (b) Figure 16.5. (a) Plain film of 20-year-old man following a gunshot wound shows bullet “floating” in parotid. sialocele. (b) Surgical exploration to remove the bullet revealed an abscess cavity where the bullet had lodged. Note pus draining.

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their foreign body reactions have been advocated. However, the tubes can themselves cause foreign body reactions and possible compression. Regard- ing the tissue glues animal experiments appear to show sutures to be superior. In the rabbit model, axonal growth was faster and greater with epineu- ral suture than fibrin adhesive (Junior, et al. 2004) Although the rate and amount of reduction in conduction velocity was equivalent between the two methods the authors concluded that epineural suture appears the method of choice. In another study in the rat model looking at suture and the effects of platelet rich plasma (PRP) and fibrin sealant, the best return of function for the facial nerve was again with suture (Farrag, et al. 2007). The authors did note a favorable neurotropic effect for the PRP but no benefit for the fibrin sealant. As it is vital that the anastomosis be ten- sion free, difficulty is encountered when a gap between the nerve ends exists. In a cadaver study, Gardetto, et al. (2002) showed that removal of the superficial part of the parotid gland could allow overlap of the cut branches of the facial nerve. They found it possible to bridge gaps of 15 mm in the temporo-zygomatic branches, 23 mm in the k buccal-mandibular branches, and 17 mm in the k nerve trunk. Following this experimental work the Figure 16.6. Infant with laceration from broken glass. No authors reported successful clinical results on three facial nerve damage. patients recommending the technique for gaps up to 15 mm but cautioning against its use in the Classically the nerve is sutured under the presence of infection or nerve defects (Piza-Katzer, microscope using 9-O or 10-O nylon sutures et al. 2004). In another approach the use of a rapid attempting to coapt the nerve ends without tension nerve expander (2 cm/30 min) was used to bridge (Figure 16.9). The suturing can be epineural or gaps up to 3 cm (Ya, et al. 2007). In nine patients, fascicular. In epineural suturing less damage is five achieved good results with EMG peak value caused to the neural bundles with less foreign of mimetic muscles 82–95% of the normal side, body reaction in the fascicles due to the suture three cases were fair with EMG 60–90%, and 1 materials; however, fascicular suturing should case with poor EMG 55%. Other surgical options allow better adaptation of the fascicles and trim- in this situation are the use of a tube as a conduit ming back the epineurium to prevent fibrous tissue and grafting. In seven patients with post-traumatic in-growth. However, anatomic studies have shown defects up to 3 cm, the use of a bioabsorbable the fascicular and anatomy of polyglycolic acid tube was reported as giving very the facial nerve to be complex with the number good results in one case, good in four and fair in of fascicles increasing in a proximo-distal way two (Navissano, et al. 2005). The two commonest from the geniculate ganglion with diminishing sites for donor nerves for the facial nerve are the diameter (Figure 16.10). This variability in number greater auricular, which is adjacent to the surgical of fascicles and structure along the extratemporal field, and the sural nerve. Surgical principles for facial nerve constitute a difficulty in facial nerve repair follow those for direct anastomosis. As repair (Captier, et al. 2005). The use of tubes, for expected facial function from cable nerve graft example collagen, to support the anastomosis and interposition is not as good as end to end anasto- prevent connective tissue ingrowth and also tissue mosis (Malik, et al. 2005). If there is widespread glues, for example fibrin, to replace sutures and destruction of multiple branches from an injury

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(a) (b) k k

(c) Figure 16.7. (a) Entrance wound for bullet below ear lobe. (b) Bougie placed through track of bullet to demonstrate entrance and exit. (c) Frontal and buccal facial nerve paralysis.

such as a gunshot, the entire superficial cervical described after a shotgun injury to the parotid gland plexus can be used to supply multiple grafts. (Frey 1923), however, despite Frey’s landmark paper, gustatory sweating was probably first Frey Syndrome described by Baillarger in 1853 (Dulguerov, et al. Although Frey syndrome is now most commonly 1999). In the trauma arena the obvious problem seen in relation to parotid surgery it was originally is management and treatment of the condition,

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(a) (b) (c)

Figure 16.8. (a and b) A 72-year-old man diag- nosed with a stroke in the ER after falling through a plate glass window. The diagnosis was made due to the dense facial nerve palsy. (c) After removing the dressings the deep penetrating wound in the region of the facial nerve trunk is appreciated. (d and e) One-year post-repair of nerve trunk and microneural suture, the patient still has some weakness of the upper lid and cannot “blow out” his cheek on the left side, but (d) (e) has good facial symmetry and function. k k whereas in post-parotidectomy cases much work the 2 MU/cm group, 44% of the total skin areas has been done on prevention. were still sweating and required a second injec- Previously reported treatments of Frey tion, and the authors concluded that 3 MU/cm2 syndrome have included topical and systemic is the recommended dose (Nolte, et al. 2004). anticholinergics, tympanic neurectomy, sectioning Some authors have cautioned that the effect of of the auriculotemporal or glossopharyngeal botulinum in Frey syndrome is often temporary nerves, or interposition of fascia lata between the and further injections may be necessary depend- parotid bed and overlying skin. Currently the use ing upon the initial dose and the length of time of botulinum toxin is the most frequently reported followed (Ferraro, et al. 2005). therapeutic modality for Frey syndrome. A report In regards to parotidectomy patients, proba- of 33 patients with Frey syndrome treated by intra- bly 100% of patients will have gustatory sweating cutaneous injection of 16 to 80 IU of botulinum if tested with starch and iodine (Laage-Hellman toxin A showed all symptoms to resolve within a 1957) (Figure 16.11). However, few patients clini- week (Eckardt and Kuettner 2003). In a prospective cally notice this problem and most do not wish for non-randomized, non-blinded study of 11 patients treatment so that this condition will be underesti- treated with botulinum toxin A with followup at mated in clinical reports. Frey syndrome is rarely 6–23 months, only one patient recurred and was reported after submandibular gland removal. successfully retreated (Kyrmizakis, et al. 2004). Berini-Aytes and Gay-Escoda (1992) reviewed 206 A prospective randomized trial to establish the submandibular gland excisions and found only one ideal dosage and length of effect of botulinum case of Frey syndrome, while Teague, et al. (1998) toxin A was carried out on 20 patients divided reviewed the literature and found seven reported into two groups receiving either 2 MU/cm or 3 cases since 1934. MU/cm. In the 3 MU/cm group, a single injection The techniques described for prevention of resulted in nearly complete absence of gustatory Frey syndrome depend upon placing a barrier sweating during the 12-month followup period. In between the parotid bed and skin to prevent the

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Trauma and Injuries to the Salivary Glands 419

(a) (b)

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(c) (d) Figure 16.9. (a) Penetrating wound through ear and parotid. (b) Exploration of wound reveals transaction of the superior branch of the facial nerve. (Ruler from surgical marker makes a good background for microsuture if custom microsurgical background material is unavailable.) (c) Post microsurgical repair. (d) Post-suturing of wounds. This case was treated by Dr. J Caccamese, Dept OMS, University of Maryland.

growth of the secretory parasympathetic nerves 5–22 years treated with an interpositional SMAS from the parotid into the sweat glands causing a layer at the time of parotidectomy and tested paradoxical innervation. Acellular dermis has been with starch/iodine during follow up (Bonanno, used with success but a higher complication rate et al. 2000). Other reported barriers have been the (Govindaraj, et al. 2001). Temporoparietal flaps use of parotid gland fascia (Zumeng, et al. 2006) and the superficial musculoaponeurotic system and sternocleidomastoid flaps, with mixed results (SMAS) have been used with good outcomes (Kerawala, et al. 2002; Filho, et al. 2004). in 146 parotidectomy patients (Cesteleyn, et al. It would appear that Frey syndrome is pre- 2002). No cases of Frey syndrome were encoun- ventable in most cases and perhaps the use of the tered in reviewing 160 patients followed from SMAS layer is the most convenient for the surgeon.

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420 Chapter 16

(a) (b)

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(c) (d) Figure 16.10. (a) Extensive penetrating wound anterior to the parotid gland, which involves the peripheral branches of the nerve. (b) Nerve branches identified for microneural repair. (c) High power view of completed repair. (d, e, f, and g) Post repair note, upper branch weakness persists. This case was treated by Dr. J Caccamese, Dept OMS, University of Maryland.

Hollowing of which have been discussed in this chapter in This is a complication seen in patients following relation to Frey syndrome and in Chapter 9. Tech- parotidectomy rather than trauma and can be niques include the use of layered acellular dermis, managed in a variety of ways. Reconstruction at free fat grafts (Figure 9.4), use of the SMAS layer, the time of surgery to prevent the defect occurring temporalis, and sternocleidomastoid flaps, as well is preferable to secondary reconstruction when as microvascular free flaps including fascial fore- scarring and the superficial position of the facial arm flaps for larger defects. Choice of technique nerve post-parotidectomy increase the risk of nerve will depend on the size of the defect, the surgeon’s damage. Various techniques have been used some own experience, and the wishes of the patient.

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