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Trauma and Injuries to the Salivary Glands Figure 16.10. (Continued) k Trauma and Injuries to the Salivary Glands 421 (e) (f) k k (g) Figure 16.10. (Continued) k k 422 Chapter 16 TRAUMA TO SALIVARY GLAND DUCTS treated non-operatively, 9 (47%) healed without complications. Although seven patients (36.8%) Transection developed salivary fistulas and four (21.4%) devel- As has already been discussed previously in oped sialoceles, these were described as short the sections on fistulas and sialoceles related to term and resolved without the need for surgery parenchymal trauma, conservative management (Lewis and Knottenbelt 1991). Van Sickels (1981), is usually satisfactory except in those cases where divided the parotid duct anatomically into three the injury involves partial or complete transac- sites of injury, based on implications for treatment. tion of the duct. Under these circumstances most Site A is the intra-glandular portion of the duct papers have indicated that resolution is less cer- and ductal injuries in this location are treated as tain and takes longer with active management described previously for parenchymal trauma. Site frequently required. There are studies that support B represents the duct as it overlies the masseter conservative measures in duct injuries and in one muscle and site C is the duct’s course anterior to report, of 19 patients with duct injury confirmed the masseter muscle through the deep tissues of by methylene blue dye injection in a retrograde the cheek into the mouth. Injuries at both these fashion through the Stenson duct who were sites require exploration and direct repair of the k k (a) (b) Figure 16.11. (a) Lateral view of face of patient complaining of gustatory sweating (Frey syndrome). (b) Bottle of iodine solution that is painted on the face and then covered with corn starch. (c) While the patient eats an apple the corn starch is colored blue-black, indicative of gustatory sweating. k k Trauma and Injuries to the Salivary Glands 423 k k (c) Figure 16.11. (Continued) duct if possible. If repair is impossible, creating saline or a small (1 cc) amount of methylene blue a direct fistula into the mouth is the treatment of through the Stenson papilla. Van Sickels (2009) choice for site C injuries (Lazaridou, et al. 2012). cautions against injecting too much dye which can However, in most cases current management stain the tissues and increase the difficulty of the is directed toward primary repair and the clinician dissection. Identification of the proximal end may must therefore have a high level of suspicion for be technically difficult as it can retract into the injuries involving the region of the parotid duct. gland substance. Milking the gland to obtain sali- The classic anatomic surface markings of the vary flow is helpful in these circumstances and the duct are illustrated in Figure 16.12. However, an anesthesiologist must be cautioned preoperatively ultrasound study has shown that 92% of ducts against the use of anti-parasympathetic agents. If were below the classic anatomic surface markings, the proximal and distal ends of the duct are identi- although 93% of the ducts were within 1.5 cm fied and can be coapted, then microsurgical repair of the middle half of a line between the tragus and can be carried out (Hallock 1992) (Figure 16.14). the cheilion (Stringer, et al. 2012). In this study, The use of stents (usually indwelling the mean internal caliber of the duct was 0.6+/− catheters) for 10–14 days to prevent stenosis is 0.2 mm. Confirmatory evidence for transaction is advocated by some and appears a reasonable obtained by cannulating the distal portion of the hypothesis, although no long term studies of duct through the Stenson papilla and observing the these injuries with and without stenting has catheter in the wound (Figure 16.13) or by injecting been published. A technique of using a 4F Foley k k 424 Chapter 16 When the injury is too proximal, the wound is avulsive or the duct cannot be identified, the clinician can either create an intraoral fistula or ligate the proximal duct. A controlled fistula can be created by suturing the proximal duct through the buccinator into the oral cavity if enough length is present, or by placing a catheter or drain from the area of the wound into the mouth and leaving it to fistualize (Figure 16.15). Although tying off the proximal duct to cause eventual atrophy has been proposed (Van Sickels 1981), in the author’s experience this is unpredictable and, even with the use of pressure and antisialogogues, these patients can have considerable swelling and pain. Chemical denervation using botulinum toxin A may be used to achieve a good outcome in these circumstances (Arnaud, et al. 2006). In the case of the submandibular duct tran- section is usually iatrogenic as a result of surgery on the sublingual gland, sialolithotomy from Whar- ton duct, or resection of floor of mouth cancer. In this case sialodochoplasty with repositioning of the duct posteriorly is all that is required. A catheter has been used as a stent (Ord and Lee 1996), fol- lowing reposition of Wharton duct in floor of mouth k cancer; however, now the duct lumen is identified, k one blade of a sharp iris scissors is inserted and a vertical cut through one wall of the duct carried out. The duct is now “fish-tailed” and sutured to Figure 16.12. Surface markings of the parotid duct are a newly created hole in the oral mucosa with 6o shown by a line drawn from the tragus of the ear to bisect nylon sutures. Stenosis and stricture has not been a line drawn from the alar base to the commissure. The a problem with this technique. middle third of this line (arrow) is surface marking of the parotid duct. Stenosis of the Duct When ductal injuries are not surgically repaired embolectomy catheter for identification of the immediately complications, such as fistulas and transaction and then left in place as a stent is sialoceles, may arise and their management has described (Etoz, et al. 2006). When the proximal been discussed. If the duct has not been surgically and distal ends of the duct cannot be coapted due repaired by 72 h conservative or medical therapy to tissue loss, repair using a vein graft has been is recommended (Arnaud, et al. 2006). In the long reported (Heymans, et al. 1999). Steinberg and term stricture of the duct may occur, although Herréra (2005) recommended the use of sialog- most strictures are secondary to inflammatory raphy postoperatively to assess the result of duct or infective conditions. In cases of intra-ductal repair, stating this technique may not always be salivary gland obstruction 22.6% of 642 cases practical or possible in the acute setting. How- were due to strictures, which were more com- ever,wehaveusedsialographyintraoperatively mon in females (Ngu, et al. 2007) (Figure 16.16). (Figure 16.13). A further development in the repair When this occurs at the distal end of the Sten- of ductal injuries has been the utilization of the son duct, excision and diversion of the duct into sialendoscope in some centers, for both repair and the oral cavity may be feasible. When the main followup assessment (Koch, et al. 2013; Kopec,´ duct is involved with strictures, sialendoscopy et al. 2013). may be useful to dilate the strictures using saline k k Trauma and Injuries to the Salivary Glands 425 (a) (b) k k (c) (d) Figure 16.13. (a) Patient with cheek laceration that was primarily sutured now has developed sialocele due to missed duct injury. (b) Wound reopened for re-exploration. The duct is discovered to be transected. Vessel loop around distal end of duct. Lacrimal probe passed from intra-oral through the Stenson duct into the wound (short arrow). (c) After finding the proximal end of the duct by milking the gland the duct is approximated. The duct is cannulated and contrast dye injected for intra-operative sialogram. (d) Fluoroscopic image of intra-operative sialogram with repaired duct (arrow). pressure, balloon dilatation, or the miniforceps five of these patients remained asymptomatic grasper, and even the insertion of a stent to the on followup (Salerno, et al. 2007). If this is un- duct lumen (Nahliel, et al. 2004). Simple balloon successful and the patient continues to have recur- angioplasty was successful in 7/9 patients and rent swelling and sialadenitis, denervation with k k 426 Chapter 16 (a) (b) k k (c) (d) Figure 16.14. (a) A 38-year-old man with a laceration of the right cheek in the operating room in preparation for primary closure and exploration of Stenson duct due to the depth and anatomic location of the laceration. (b) Sterile milk was injected in the distal aspect of Stenson duct that permitted the identification of its laceration. (c) The proximal end of the lacerated Stenson duct is able to be cannulated with a lacrimal probe. (d) The proximal and distal ends of the Stenson duct are primarily closed with 6-0 Prolene sutures with an indwelling catheter in place. (e) The catheter is sutured to the oral mucosa and maintained in place for 2 weeks. (f) The cheek wound is primarily closed in anatomic layers. The location of the laceration is appreciated to exist along the middle third of the line denoting the surface marking of the Stenson duct. Source: Courtesy of Dr. J. Greg Anderson and Dr. Michael Foster, University of Tennessee Medical Center Department of Oral and Maxillofacial Surgery. Reproduced with permission of Dr. Anderson. k k Trauma and Injuries to the Salivary Glands 427 (e) (f) Figure 16.14.
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