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Calculous Sialadenitis: Clinic, Diagnostics, Medical Treatment

Calculous Sialadenitis: Clinic, Diagnostics, Medical Treatment

MINISTRY OF HEALTH OF UKRAINE Ukrainian medical stomatological academy

“Approved” On the meeting chair Of Propaedeutics Surgical Stomatology The Head of the Department prof. ovikov V.M. ______“ ____ ” ______20 ____

GUIDELINES Individual work of students During preparation for Practical classes

Educational discipline Surgical stomatology Module № 2 Inflammatory diseases in maxillofacial region. Nonodontogenous inflammatory diseases in Content module № 4 maxillofacial region Calculous : clinic, diagnostics, medical treatment. Fistuls of salivary glands, mechanism of their formation. Examination methods, diagnostics, methods of surgical medical treatment (C.P.Sapozhcov, A.N.Limbexg, G.A.Vasilev and Theme lesson in.). Contribution of chairs of surgical stomatology Ukrainian medicine stomatology academy to working out of questions of an etiology, a pathogenesis and treatment of diseases of salivary glands. Course 3 Faculty Stomatological

Poltava 2018 1. Actuality of the topic: On statistical given to N.D. Lesovoj (1979) compounds 40-61,1 % among all diseases of sialadens. Sialolithiasis - polyetiological disease of sialadens, therefore is a lot of questions of an etiology, a pathogeny, clinic and treatments of this pathology remain thoroughly not investigated to this time (to I.F. Romacheva and joint authors, 1987). 2. The objectives of the studies: To learn students to diagnose and define medical tactics at manifestations a calculus sialadenitis (sialolithiasis). To be able: To make a diagnosis of a calculus sialadenitis (sialolithiasis; To draw up a plan of examination of the patient with a calculus sialadenitis (sialolithiasis); To prescribe proper treatment of a calculus sialadenitis (sialolithiasis).

3. Basic knowledge, skills, skills necessary for study topics (interdisciplinary integration). Name of previous These skills courses Physiopathology Inflammatory processes Anatomical pathology Inflammatory processes Microbiology The infestant, microbic flora of an oral cavity and a secret of sialadens. Operative surgery and Features of an anatomical structure of sialadens. topographical anatomy. Features of a constitution of sialadens. Propedeutics of a surgical Methods of examine of the stomatologic patient. stomatology. Intrasubject integration. Clinic of a calculous sialadenitis (sialolithiasis), acute and chronic inflammatory diseases of sialadens.

4. Tasks for independent work in preparation for the classes. 4.1. A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson:

Term Definition Sialolithiasis refers to the formation of stones in the salivary glands Salivary colic periodic attacks of pain in the region of a salivary duct or gland, accompanied by an acute swelling of the gland, occurring in cases of salivary calculus. Salivary stones crystallized minerals in the ducts or in the body that drain the salivary glands

2 4.2. Theoretical questions to lesson: 1. To give concept - a calculous sialadenitis with localization of a salivary stone in a duct of Ferri lactas. 2. To give concept - a calculous sialadenitis with localization of a salivary stone in a sialaden. 3. To give concept - a chronic inflammation of a sialaden owing to sialolithiasis (and - after a spontaneous casting-off of a stone, - after operative treatment of a stone from a duct).

4.3. Practical works (tasks) are performed in class: - examination of thematic patients; - to fill in case history; - to define of clinical diagnosis; - to perform diagnostic and surgical procedures; - to acquire practical skills, to carry out curate the patient with a calculus sialadenitis at localization of a salivary stone in the main excretory duct of a sialaden and in the sialaden;

5. Theme contents Salivary duct lithiasis is a condition characterized by the obstruction of a or its excretory duct due to the formation of calcareous concretions or sialoliths, resulting in salivary ectasia and even provoking the subsequent dilation of the salivary gland. A further effect may be the of the salivary gland which may result in chronic sialadenitis (1). The clinical symptoms are clear and allow for an easy diagnosis, whenever we take into account that pain is only one of the symptoms and that it does not occur in 17% of the cases (2). Sialolithiasis accounts for 30% of salivary diseases and it most commonly involves the submaxillary glands (83 to 94%) and less frequently the parotid (4 to 10%) and sublingual glands (1 to 7%). Sialolithiasis usually appears around the age of 40, though it can also have an early onset in teenagers and it can also affect old patients. It has a predilection for male patients, particularly in the case of lithiasis (1). Several hypotheses have been put forward to explain the etiology of these calculi: mechanical, inflammatory, chemical, neurogenic, infectious, strange bodies, etc. Anyhow, it seems that the combination of a variety of these factors usually provokes the precipitation of the amorphous tricalcic phosphate, which, once crystallized and transformed into hydroxyapatite becomes the initial focus. From this moment on, it acts as a catalyst that attracts and supports the proliferation of new deposits of different substances (2)

3 Salivary calculi affecting the parotid gland are usually unilateral and are located in the duct. Their size is smaller than submaxillary sialoliths, most of them < 1 cm. (3, 4). Different conditions should be considered when carrying out the differential diagnosis of salivary duct lithiasis. The unilateral enlargement of the parotid region is characterized by the presence of a discreet, palpable mass or either a diffuse swelling. Sialodenitis may be considered in the absence of this mass. A superficial mass in the salivary gland may suggest either a case of lymphadenitis, preauricular cyst, sebaceous cyst, benign lymphoid hyperplasia or extraparotid tumor. A mass inside the salivary gland may suggest either a neoplasia (benign or malignant), an intraparotid adenopathy or a hamartoma (5). The clinical symptoms of malignant tumors include rapid growth, facial palsy, petrous texture, pain and a higher incidence rate among elderly patients. The differential diagnosis of the asymptomatic bilateral enlargement of the parotid region includes benign lymphoepithelial lesions (Mikulicz syndrome), Sjogrenis syndrome and sialadenitis secondary to alcoholism, long-term treatment with different drugs (iodine and heavy metals) and Whartin´s tumor. Painful bilateral enlargements may result from radiotherapy or may be secondary to viral sialadenitis (including ) whenever they co-occur with other systemic symptoms. Among the conditions presenting with diffuse facial swelling of the parotid region, but unrelated to the glands, we must mention masseter muscle hypertrophy, lesions in the temporomandibular articulation and osteomyelitis affecting the ascending maxillary branch. It is also important to differentiate sialoliths from other soft tissue calcifications. Whereas the former are characterized by pain and swelling of the salivary gland, other calcifications such as those of the lymphatic ganglia are symptom free. In the case of small calculi it is advisable to try a non-surgical treatment (spasmolitics, diet, antibiotics, etc) (6). Odontologists and stomatologists are in charge, together with other sanitary professionals, of the diagnosis of salivary glands diseases. They must be aware of them and must be able to apply modern imaging techniques for their diagnosis and, if necessary, manage and treat these diseases. Salivary fistula. Distinguish an external fistula of a sialaden at which the follows through an aperture located in the region of integuments, and internal when its opens on a surface of a mucosa of mouth. Internal, opening in a mouth salivary the fistula does not cause any disorders and does not demand treatment. External salivary the fistula represents burdensome suffering owing to constant wetting by saliva of integuments of lateral departments of the face following from it and neck, a maceration of skin, dermatitis occurrence. At an of a fistulous course probably painful augmentation of sialaden. Fistulas submandibularis sialaden, as a rule, settle down on a course of its duct in an oral cavity. Dermal fistulas of this gland and its duct are localised in submandibularis region and represent an appreciable 4 rarity. Dermal fistulas of a sublingual sialaden to us to observe on it were necessary, though in the literature there are such reports. Usually on a skin parotid gland fistulas (its parenchyma) and its duct open. Under duct fistulas understand fistulas outside glandular parts , and as parenchyma fistulas - fistulas of ducts of separate lobes of a gland. Fistulas part on full and incomplete. Full fistulas are formed as a result of duct rupture; thus all saliva is allocated through a fistula. Communication of a gland with peripheric department of a lead-out duct is absent. Incomplete fistulas arise at wound of a wall of a duct. Constant partial outflow of a saliva natural by (through a duct mouth) in this case remains. Some authors consider, that and incomplete fistulas parotid a duct can be full only. However both kinds of fistulas as well peripheric (intraglandular) ducts parotid sialaden were observed also. Usually at parenchyma fistulas parotid sialaden on skin to front from an auricle, sometimes below an ear lobule of an ear or on other sites within anatomic borders of gland the punctual aperture from which the transparent liquid is allocated is defined. This fistula has a short course and goes in direction of a tissue of a gland. Feature of sialosyrinxes is absence in the region of their locating protruding granulations and inflammatory infiltration of skin. For a full fistula allocation of small amount of secret as outflow occurs only from a gland part is characteristic, is frequent from its one lobe. In intervals between food intakes allocation of a secret from fistula is not observed or happens insignificant. During time of food intake the liquid from fistula can follow drops. At incomplete fistulas of gland saliva allocation can be plentiful owing to hit in a fistula of secret of other lobes of a gland. An spaces locating on skin of in the region of masseter or ahead from it, efflux saliva significant amount are characteristic for a fistula parotid duct. If thus from a mouth of a duct the saliva is not allocated, there are bases to speak about a full fistula of duct. To diagnose salivary a fistula and to define its character it is possible at sounding of fistula and introduction in a duct of a gland of the painted liquid through its mouth. The fullest representation about character and a fistula locating can be received, entering into a fistula or a duct mouth radiopaque substance and carrying out roentgenography - a sialography. At incomplete fistulas the contrast mass entered into a fistula, follows through a duct mouth in an oral cavity and, on the contrary, at introduction in a duct mouth is allocated through a fistula. Iodolipolum fills all functioning (remained) part of a gland and duct in cases of introduction both in the main duct, and through salivary a fistula. However, it is necessary to consider, that on a sialogram short and narrow sinus tract bottoms a background of ducts of a gland it is defined insufficiently accurately, therefore at incomplete sialosyrinxes it is necessary to paste lead label on mouth of a fistula and only after that to make roentgenography. At full fistulas Iodolipolum introduction in a mouth parotid a duct is not accompanied by its allocation from a

5 fistulous course. At contrast agent introduction in a fistulous course efflux from a duct mouth also it is not observed. Iodolipolum entered through a fistulous course, fills the gland bound to it or its part. At Iodolipolum introduction through a mouth parotid a duct it is filled or its peripheric piece, or also the lobes of a gland bound to a duct. By means of a sialography it is possible to tap also some changes of lobes of the gland bound to a fistulous course. Ducts are usually filled irregularly, sometimes have an unusual direction (a broken line). Not always on a sialogram the parenchyma of lobes is defined also. At the same time in ducts of lobes of the gland informed with parotid by a duct, it does not become perceptible essential deviations from a normal structure. Narrowing of a salivary duct. At cicatrical narrowing parotid or submandibularis a duct patients complain on edema, an arching pain in the region of a sialaden during meal, which slowly (in 1-2 hours) disappear. This symptom is bound to a delay of allocation of the saliva plentifully formed during meal through the narrowed site of a duct. The more narrowing, the keeps gland tumescence more longly. At survey in the region of a corresponding sialaden it is possible to define painless припухание a soft consistence which after meal disappears after a while. If disease lasts some years the gland is a little condensed and can palpation be defined constantly. In due course the duct behind the narrowed site extends and can be palpation in the form of condensed band. The narrowed mouth of a duct can be found out only after gland massaging at a protrusion of a mucosa and allocation of a drop of a secret. Duct narrowing on some distance from a mouth can be taped at sounding. The sialography allows defining the fullest picture of a condition of ducts of a gland, degree of narrowing and localisation of the narrowed site. On a sialogram the lead-out duct in peripheric department in relation to the narrowed site is defined not changed, behind it - in regular intervals dilated. Parotid Duct Injuries The parotid duct, or Stenson duct, is the major duct of the parotid gland, which is the major salivary gland. This duct serves as a conduit for saliva between the substance of the parotid gland and the oral cavity. Injury to the parotid duct may be difficult to diagnose; therefore, the initial examining physician must have a high index of suspicion for injuries occurring in the parotid region. Consultation with a specialist should occur if any question as to the integrity of the parotid duct exists. Successful treatment depends on early recognition and appropriate early intervention. Sequelae of inadequate diagnosis and treatment include parotid fistula and formation, which are inconvenient for the patient and more difficult to treat than the initial injury. Three operative techniques have been popularized over time. These include repair of the duct over a stent, ligation of the duct, and fistulization of the duct into the oral cavity. Radiation has been used in the past to suppress the gland, but use of 6 radiation for benign disease is now avoided. Some authors advocate use of anticholinergics to suppress glandular function during healing, but this is not a frequently used modality. History of the Procedure Parotid duct injuries have been described in the literature for several hundred years, and published surgical treatments of parotid duct injuries began to appear in the 1890s. Nicoladoni reported the first primary anastomosis of the parotid duct in 1896.1 Morestin reported ligation of the proximal stump in 1917, and formation of an oral fistula was described in 1918.2 Experience in the care of parotid duct injuries greatly increased with the outbreak of World War I, which witnessed many penetrating facial injuries. Many present treatment modalities were developed during the war years. Frequency Approximately 0.21% of patients with penetrating trauma in the parotid region experience an injury to the parotid duct. Males are twice as likely to experience parotid duct injury as females, a fact probably related to the more aggressive behavior of males. The mean age of patients with parotid duct injury is approximately 30 years. Etiology Penetrating injuries in the parotid region Blunt trauma Complication of parotid duct cannulation for sialography Intraoperative iatrogenic injury Presentation History A careful detailed history is necessary to facilitate communication between various health care professionals involved in the care of the patient and to document why the plan of care was appropriate. Patients with damage to the parotid duct often have multiple injuries requiring cooperation of several medical specialists. Important aspects of the natural history of the wound include the circumstances surrounding the injury, precipitating event or activity, exact mechanism of injury, time of occurrence, location of occurrence, and treatment initiated prior to presentation. Important signs or symptoms related to the wound include pain, fever, edema, discharge, and/or odor. Other important aspects of the history include tobacco, alcohol, or recreational drug use; medications or allergies to medications; tetanus immune status; ability to comprehend the magnitude of injury; and ability to cooperate with the treatment plan. Comorbid conditions that may place the patient at a higher risk for infection or its sequelae include mellitus, prior splenectomy, liver disease, immunosuppression, and presence of a prosthetic valve or joint. 7 Physical examination A thorough physical examination is necessary in order to evaluate the overall state of health, comorbidities, nutritional status, and mental status of the patient. Following the general physical examination, turn attention to the wound. Assessment of the wound can be quite difficult and is often inaccurately or inadequately performed. Adequate examination of the wound may require administration of intravenous or oral pain medication to ensure patient comfort. Children, intoxicated individuals, and individuals with mental disabilities may require general anesthesia to allow adequate wound examination. Important aspects of wound assessment are listed below. Location Shape Size Type (eg, puncture, laceration, avulsion, crush, ) Depth of penetration Drainage (ie, quality, character, odor) Presence of a foreign body (eg, glass, tooth fragments) Loss of tissue Tenderness Asymmetry Surrounding erythema, edema, cellulitis, or crepitation status Indications

Relevant Anatomy The gland is divided into superficial and deep lobes with regard to its relation to the facial nerve (ie, cranial nerve VII), which travels through the gland. This division is not truly anatomic but rather is used to facilitate surgical treatment of parotid masses. The facial nerve exits the cranium via the stylomastoid foramen and courses through the substance of the parotid gland. The superficial lobe of the parotid gland rests superficial to or lateral to the facial nerve, and the deep lobe rests deep to or medial to the facial nerve. 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 , 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. After traveling for a variable distance between the buccinator muscle and the , it enters the oral cavity through a papilla in the buccal mucosa opposite the second maxillary molar. The course of the parotid duct generally follows a line drawn from the tragus to the midportion of the upper . Any injury that crosses this line should be considered to involve the parotid duct until proven otherwise. Parotid duct injuries 8 are often overlooked because of more severe concomitant injury or difficulty in obtaining the diagnosis. The parotid duct travels adjacent to the buccal branch of the facial nerve and the transverse facial , which also are at risk in injuries causing damage to the parotid duct. The parotid duct was found to be interrelated with the in cadaveric dissections. In addition, a 26% chance of injuring the parotid duct exists with the removal of the buccal fat pad. The transverse facial artery, if injured, need not be repaired. However, injury to this artery may cause bleeding into the tissues, which may obscure adequate delineation of structures and confuse the diagnosis. Above all, blind clamping of bleeding vessels in the wound is strongly discouraged because of the extremely high risk of further damage to the delicate structures in this region. An injury classification system has been devised for parotid duct injuries. This system divides the parotid duct into the following 3 regions: Posterior to the masseter or intraglandular Overlying the masseter Anterior to the masseter Contraindications Wounds older than 24 hours should probably be managed expectantly because many heal without untoward even Treatment Medical Therapy Wounds in the parotid region generally heal well with a low rate of infection, but patients with wounds that involve the oral cavity or require manipulation of the parotid duct through the oral cavity should probably receive prophylactic antibiotics for a brief time after primary closure. Saliva containing as many as 100,000,000 organisms per mL and representing as many as 190 different species may be inadvertently introduced to the wound. These species are both aerobes and anaerobes, and several of the more common species produce beta-lactamase, rendering them resistant to penicillin. Routine cultures are not necessary because they are costly, demonstrate no growth in over 80% of cases, and rarely alter first-line therapy. Moreover, wounds subsequently manifesting signs of infection often have bacteriologic profiles differing from the initial cultures. Wound care is the cornerstone of therapy; antibiotics cannot avert or cure in the setting of poor wound care. In regards to antibiotic therapy, err on the side of caution because the risk of antibiotic therapy is minimal, while the potential complications of wound infections are considerable. Prophylactic antibiotics should be continued for 5-7 days. Selection of the appropriate antibiotic involves multiple factors, including culture results if obtained and available, drug sensitivities, patient age, drug interactions, expected compliance, and renal and hepatic function. 9 The drug of choice is amoxicillin/clavulanate potassium (Augmentin; adult dosage 500/125 mg PO tid or 875/125 mg PO bid). It is the most effective and economical choice for outpatient therapy, unless contraindicated because of penicillin allergy. Doxycycline is an alternative choice for oral therapy in patients allergic to penicillin (adult dosage 100 mg PO bid). Rocephin 1 g administered intramuscularly or intravenously is useful in patients whose compliance with dosage schedules is questionable. In rare cases, human saliva has been shown to contain and occasionally transmit Clostridium tetani. Assess all patients for tetanus immune status and update their immunization as appropriate. Err on the side of caution when deciding to administer tetanus toxoid or tetanus immune globulin. Some authors choose to employ anticholinergic agents to suppress glandular function during healing or in an attempt to close a fistula or resolve a sialocele spontaneously. A commonly used agent is 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). Surgical Therapy Meticulous wound care is the cornerstone of treatment for penetrating injuries in the parotid region. Copious irrigation has been shown to decrease the incidence of wound infection. Use isotonic sodium chloride solution, dilute Betadine, or dilute hydrogen peroxide to cleanse the wound thoroughly. Irrigation is best performed with a 10-mL syringe with an 18-gauge angiocatheter attached. Take care to avoid injection of the tissues and to prevent additional trauma. Careful debridement of devitalized tissue, particulate matter, and clot is necessary to reduce the infection risk and to improve the cosmetic result. Clean, surgically created wound margins allow for faster wound healing and better scarring. Head and neck wounds, being in a cosmetically sensitive region, may be closed if they are less than 12 hours old and not obviously infected. These have been closed with a low incidence of infection. The low infection rate is probably related to the excellent regional blood supply and infrequency of edema in these regions. Perform closure in a simple interrupted fashion, avoiding layered closure with buried sutures. Preoperative Details Appropriate consent must be obtained, including an explanation of the possible need for duct repair, ligation, or reimplantation into the oral mucosa. Informed consent includes a discussion of the possible complications, including but not limited to infection, hematoma, hypertrophic scarring, nerve injury, parotid fistula, sialocele, and death from anesthesia. Discuss expectant care with the patient as a viable alternate course of treatment that is probably less than ideal. Repair at initial presentation is technically simpler than in the case of delayed presentation with development of complications such as a fistula or sialocele.

10 Administer 1 dose of intravenous broad-spectrum antibiotics within 1 hour prior to the operation. Intraoperative Details After initiation of general anesthesia, prepare and drape the head and neck in the usual sterile fashion. Plan the initial incision based on the level of suspected injury indicated by preoperative examination of the wound, the oral papilla, and cannulation of the duct with a silastic tube. All but the most distal injuries require a standard approach to the parotid gland. Distal injuries may sometimes be appropriately approached through an intraoral buccal mucosal incision, and often the facial wound is extensive enough to allow adequate visualization of key structures and their repair. The most important initial step is the identification of the buccal branches of the facial nerve and the parotid duct itself. If the buccal branch was transected, repair it with fine sutures (8-0 to 10-0 nylon is appropriate) under microscopic aid. Use of a nerve stimulator intraoperatively and avoidance of the use of paralytic agents by the anesthesiologist can greatly aid in identification of facial nerve branches. The distal end of the parotid duct is identified by the silastic tube, which was placed via cannulation of the intraoral papilla. The proximal parotid duct can usually be identified by the flow of saliva into the wound. If not clearly identified, gentle pressure over the gland may cause an increased flow of saliva, facilitating identification. Once all key structures are identified, a decision is made regarding which repair technique to employ. Distal lacerations, occurring at site C, may be treated in several ways. If the papilla is uninjured, the proximal portion may be dissected free and reimplanted into the papilla. The papilla may be gently dilated if this technique is chosen. Alternatively, if the papilla is injured or if the proximal duct does not reach the papilla, the duct may be reimplanted into the oral mucosa posterior to the papilla. This should be performed with fine interrupted absorbable sutures with meticulous approximation of duct epithelium to oral mucosa. This should probably be performed under loupe magnification because of the difficulty of using the surgical microscope deep in the oral cavity. If the distal injury does not leave enough duct to be reimplanted into the oral mucosa without undue tension, then the best decision is to ligate the proximal duct. Injuries occurring over the masseter muscle, at site B, are the most common injuries to the parotid duct and may be treated by repair or ligation. 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. Reports of attempts to use a graft to replace missing or damaged segments of parotid duct have generally found such attempts unsuccessful.

11 Injuries of the proximal duct near the parotid substance, at site A, are usually best treated by ligation of the duct. The amount of proximal duct remaining is usually insufficient to result in a useful repair. Laceration of the gland itself without disruption of the parotid duct may be oversewn with fine absorbable sutures (5-0 or 6- 0 Vicryl). 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 edema in the region from collapsing the fragile duct. Patient tolerance of the stent is highly variable. Some patients require stent removal early or remove it themselves without untoward consequence. Most authors recommend a drain in the bed of the wound. This serves to drain any residual salivary leak and prevents early sialocele formation. Drains are removed once drainage is minimal and the skin has become adherent to the operative site. The remaining facial and intraoral lacerations, as well as any incisions required for exposure, are then closed in the standard fashion. Postoperative Details Place a compression dressing over the operative field postoperatively for several days. Perform routine drain care. Continue antibiotic prophylaxis for 5-7 days. Antibiotic prophylaxis may be administered orally to prevent retrograde infection if the duct has been repaired over a stent that protrudes into the oral cavity. If ductal injury required ligation of the proximal duct, expect marked temporary swelling of the gland followed by rapid glandular atrophy. If leaking of saliva occurs as in the development of a fistula or sialocele, a pressure dressing should be continued or reinstituted. Intermittent aspiration of sialoceles has led to resolution in many cases. Anticholinergics may be used to temporarily decrease salivary flow in order to effect wound healing. Others have reported dividing the tympanic branch of the glossopharyngeal nerve (ie, Jacobsen nerve) as it runs through the middle ear. This serves to interrupt the preganglionic secretomotor fibers to the parotid gland. This measure only temporarily reduces salivary flow, but it may provide enough time for spontaneous closure of the salivary leak. In the case of a chronic parotid duct fistula, an intraoral diversion technique to reestablish salivary flow in the setting of a nonfunctional parotid duct punctum has been described. In this case report, a fistula tract and the surrounding ellipse of skin were passed in the oral cavity and sutured to the buccal mucosa with 4-0 chromic sutures.3 This allows for correction of a chronic fistula and simultaneous revision of a traumatic scar without need for stenting. Alternatively, chronic fistula and sialocele have been medically managed with botulinum toxin type A.4 In this case, the authors injected only 100 IU divided among 12 3 injection points in the superficial part of the parotid to stop salivary secretion. After 5 days, the sialocele disappeared and subsequent problems were related to the scar. Three months later, because of the reappearance of facial tension and the initial effectiveness of this dosage, 100 IU of botulinum toxin were again injected. Maintenance injections of 100 IU were performed every 3 months. Follow-up No special follow-up is necessary over and above routine postoperative care. Complications Complications may result from inadequate initial diagnosis and treatment or following appropriate care. Persistent salivary fistula may be most troubling to the patient. If fistula occurs in the oral cavity, it is of no consequence and requires no further therapy. If the fistula occurs to the overlying skin, the patient experiences saliva dripping down the cheek. Initial expectant management, with or without anticholinergic medications, has led to resolution in many cases. Other cases have required surgical excision of the fistula tract with repair of the duct as previously described. Some have even required superficial for resolution. Anticholinergics may be beneficial in the treatment of fistulas. Sialocele, is, a collection of saliva beneath the skin, may occur if the duct leaks but no fistula forms. This may also result when the glandular substance of the parotid is disrupted but the parotid duct is intact. This condition usually resolves with intermittent aspiration and compression and rarely requires drain placement. Anticholinergics may be beneficial in the treatment of sialoceles. Duct ligation may lead to early edema of the gland with accompanying pain from stretching of the capsule. This usually subsides spontaneously within 1-2 weeks as atrophy of the gland occurs. Late complications of ligating the duct include chronic infections of the remaining glandular substance. Sialadenitis may result from manipulation of the intraoral papilla or from sialography and may require drainage and antibiotics. Facial nerve injury and sensory nerve injury are well-recognized complications of surgery conducted in the region of the parotid duct, particularly in cases where trauma and blood extravasation have discolored the tissues and disrupted tissue planes. Contribution of chairs of surgical stomatology Ukrainian medicine stomatology academy to working out of questions of an etiology, a pathogenesis and treatment of diseases of salivary glands. Scientific and clinical researches of pathology of salivary glands (SG) are one of leading scientific directions of chairs of surgical stomatology and propaedeutics of surgical stomatology. Probably is it is bound by that on the basis of the Poltava regional stomatologic. Out-patient department and the Poltava regional hospital there is a centre of pathology of salivary glands under the guidance of professor O.V. Rybalova. Among employees of chairs of surgical stomatology and propaedeutics of surgical stomatology it is necessary to allocate the big group of authors which studied a pathology of salivary glands: Lesovaja N.D, 1972; Saccharov Yu.К, 1979; Jatsenko I.V, 1992; Borisova Ye.V., 1994; Mitchenok V.I, 1996; Sajapina L.M, 1998; Skinevich M.G, 2000; Pankevich A.I, 2001; Oblap N.V, 2003 which in the scientific and clinical

13 researches opened new interesting approaches in diagnostics, clinic and treatment of a studied pathology. Managing chair of propaedeutics of surgical stomatology and reconstructive surgery Mitchenok V.I. (1996) in the thesis for a doctor's degree „Sialosis and chronic sialadenites in the conditions of ecological pollution by fluorides and radionuclides" has taped, that at patients who live in sites of ecological pollution by fluorides and radionuclides, at their examines sialosis and chronic sialadenitis are observed. The author asserts, that ecological environmental contamination (fluorine and ionising radiation), cause stimulation peroxidation of lipids and occurrence immunopathological reactions in an organism in experimental animals who are shown by structural changes in salivary glands of type of a dystrophia and a destruction stromalno-parenhimatoznyh components, with manifestations of an immune inflammation and depression of their function, similar sialosis. Binary action hyper fluorination and ionizing radiation is accompanied by a syndrome of mutual burdening with the expressed structurally functional changes in salivary glands, intensifying freely radical oxidations and an excavation immunopathological reactions with manifestations sial autoaggression against T-supressor an immunodeficiency. Isolated, sial autoaggression in experiment partially realises, genetically caused potential possibilities of development autoimmuniti reactions at the expense of a dysregulation and immunoregulation mechanisms, but, on set of criteria and not to the full answers manifestations of sialadenites. At the combined application hyper fluorination, ionising radiation and sial autoaggression in experiment the author has received optimum model under the characteristics toxico- peroxide-immune sialadenitis. Allergic and autoimmune mechanisms are involved in its pathogenesis metabolic, membrane destructive. The author, for correction of the received changes in tissues of salivary glands, has framed a medical complex from vilozens, Spleninum, orotate a potassium, nuclein sodium, acetate and Propolisum tocopherol. These preparations are compatible and is mutual find antilogarithm antitoxic, radioprotectors, antioxidatic, antiallergenic and immunomodelate action at treatment experimental ecogenic sialadenitis and cause high therapeutic efficiency in normalisation of investigated indicators of blood and salivary glands with restoration of their structure and function. The author has spent epidemiological examines in zones ecologically polluted. At active complex prophylactic medical examination has taped 6,1 % of patients from sialosis and sialadenites, that in aggregate with experimental and known sanitary-and-hygienic data has allowed to define high degree of risk their occurrence of sialosis and chronic sialadenitis which increases to 7,9 % at a lesion radionuclides and to 19,2 % at the combined action of radionuclides and fluorine. The taped patterns of an etiology and pathogenesis of investigated sialosis and chronic sialadenites have allowed to add to the author already existing classification of diseases of salivary glands by the term „ecogenic a toxicosis-peroxido-immune sialosis and chronic sialadenites", therefore generality of the basic moments of a pathogenesis ecogenic sialosis and sialadenites does not exclude carrying out between them differential diagnostics with allocation of different forms which are characterised on stages of a clinical current. However the last is possible only under condition of complex application of the general, private and special researches for patients. Applications by the author the treatment-and-prophylactic complex approbation in experiment is ethiopathogenic expedient for treatment sick ecogenic sialosis and sialoadenitis. The author for the purpose of preventive maintenance ecogenic sialosis and sialadenites recommends to propagandise a healthy way of life among the population; To use potable water from a well about contents of fluorine to 1 mg/l; in nutrition to use products of a phytogenesis with radioprotectors properties, especially the author underlines, that obligatory annual dispensary examines of all population in ecological zones. The candidate of medical sciences, the senior lecturer of chair of surgical stomatology Sayapina L.M in 1997 has protected candidate theses on a theme „Morphofunctional a condition of the big salivary glands at inflammatory diseases of nearby tissues to them". The author in the scientific work underlines, that inflammatory diseases (abscesses, phlegmons) in the surrounding tissues located near salivary glands (parotid, submandibularis) cause in animals in experiment of change in tissues of salivary glands (an edema of stroma and a parenchyma of organs; augmentation of volume of kernels glandulocyte; expansion interlobular and intralobulus ducts, and also stagnation in them of a secret, and at a purulent inflammation near glandular tissues becomes perceptible leukocyte infiltrations of a capsule, stroma and parenchyma of salivary glands, formation of abscesses round sanguineous vessels; an appreciable destruction acinus cells, expansion of ducts, presence in them congestive neutrophilic and eosinophil contents). Morphological changes in salivary glands at an inflammation of nearby tissues were accompanied by changes of indicators freelyradicall oxidation and antioxidatic protection in tissues of these glands. When the author entered a

14 complex of bioantioxidants experimental an animal with an inflammation of nearby tissues to salivary glands, it assisted in a larger measure to normalisation of indicators of is free-radical oxidation and raised activity of antioxidatic enzymes in tissues of salivary glands, a liver and blood of animals, predetermined subsidence the exudative phenomena in a stroma of salivary glands and normalizated a functional condition glandulocyte, eliminated developments of stagnation in salivary glands. The author asserts, that in clinic of patients depending on severity level and diffusion of the inflammatory phenomena to nearby tissues in salivary glands there are functional changes which are expressed by depression of their secretory function, disturbance of an exit of ions of sodium and a potassium, occurrence in a secret of numerous cells of an epithelium of ducts of different levels and leucocytes in different quantity, lymphoidno-reticular cells; local immunity of a mouth as a result of depression of level of a lysozyme of a secret of salivary glands both a stomatic liquid, and reduction of contents secretory IgA goes down. The author has established, that at an inflammation glandular tissues in a secret of the salivary glands involved in inflammatory process and a stomatic liquid, activity of a catalase that specifies in intensifying of damage of cellular membranes and depression of antioxidatic protection of tissues of salivary glands and an oral cavity changes. Activity of antiproteases in a secret of salivary glands which predetermines a condensation and stagnation of a secret in ducts is enlarged. Developed and entered into clinic the author a method of a reactive (contact) sialadenitis which includes a complex of antioxidatic therapy (preparation „Threeovit", an antioxidant Quercetinum), a bougieurage and instillation in ducts of corresponding glands of 0,1 % of a solution of Quercetinum and 5 % of a solution of Acidum ascorbinicum and physiotherapy (ultrasound on region of salivary glands, fluctuorisating in an average dose for 10-15 minutes daily). The author has improved secretory function of corresponding glands and normalised processes a feather oxidation and antioxidatic protection in them, activated local protective forces of an oral cavity. The complex offered by the author assists in optimisation of medical influence on the basic pathological centre in nearby tissues to salivary glands and reduces terms of stay of patients a hospital to 3-5 days. The candidate of medical sciences, the associate professor of chair of surgical stomatology Skikevich M.G (2000) in the dissertation „Condition of parotid glands and an oral cavity homeostasis at chronic diseases of lungs" investigated a functional condition of parotid glands at lungs sick of chronic not specific diseases (CNDL). The author underlines, that at this category of patients depression of secretory process depending on severity level of disease not only in investigated glands (big and small) is observed, that ascertained depression of volume of a stomatic liquid, the transparency parotides a secret thus decreased, its viscosity was enlarged, the hydrogen indicator was displaced in the acidic party. In connection with disturbance of an egestion of mineral components (Са, Сl, Fе) changed their parity in a stomatic liquid. At studying of a condition of a biocenosis parotid a secret the author has established, that the percent of sowing of microbic flora in patients CNDL increases depending on basic disease severity level (from 18,8 % at patients with easy degree to 86,6 % at patients with serious degree of a chronic pathology in lungs). The similar tendency was observed at research of a material from mucosa. Pathogenicity of flora which sow, increased with disease severity level. Falling of concentration of a secretory immunoglobulin A in a stomatic liquid is thus observed, which reflects disturbance local (in an oral cavity) the immune status and presence of accompanying pathological process in salivary glands. Also the author notices, that at patients CNDL rising of processes peroxiding in a stomatic liquid (and bloods) takes place. Also at patients CNDL depending on disease severity level the hygienic condition of an oral cavity from satisfactory (worsens at easy degree) to bad (at serious clinical course CNDL). Prevalence caries fluctuates from 88,6 % to 95,24 %. Generalised parodontitis serious degree at patients with an easy current of disease it was diagnosed in 20 %, and for patients with a serious current - in 85,8 % of observations; at the thermographic characteristic of parotid glands in patients CNDL intensifying of infra-red radiation over them and growth of temperature reactions to 2°С is observed, that specifies in intensity of physiological secretory process in them; on sialograms of parotid glands at the majority of patients CNDL detected deviations from norm of different character: ectasia of the basic duct, ducts I-V of usages, their narrowing; the pathomorphologic picture of parotid glands at CNDL is characterised lympho hystiocitic by stroma infiltration, growth of connecting and fatty tissues, replacement of a part of acinuses. The given changes in glands are qualified as a chronic productive inflammation. The author has developed and has offered a method of correction of functional activity of parotid glands and a homeostasis of a mouth which allows to recommend it for use at patients with CNDL in pulmonology unit (for restoration of functional activity of a

15 parotid gland of 5 % by Acidum ascorbinicum solution, application of preparations of antioxidatic action, carrying out of planned sanation of a mouth for stomatologists) are shown a bougieurage of the main lead-out ducts, mechanical massage of parotid glands, electrophoresis salivary glands. The author specifies in necessity of dispensary maintenance sick of the surgeon and the therapist-stomatologist. The candidate of medical sciences, the associate professor of chair of propaedeutics of surgical stomatology Pankevich's A.I. plastic surgery (2000) in master's theses on a theme „Radiative sialosis" (clinico- experimental research) has established for the first time, that behind etiological signs there is a version of sialosis that causes influence of ionising radiation on salivary glands during radial treatment of tumours of a head and a neck. The last allows founded to dilate classification of sialosis by terminology „a radiative sialosis". In its pathogenesis the main role is taken away to toxic influence of metabolites перекисного oxidation of lipids on intact salivary glands, and postradiative suppression Т- and B - immunity links. For the first time the treatment-and-prophylactic complex in structure Vilozenum, Dibunolum and infusion of a ginseng which allows leveling сиалозотропный effect of radial therapy at sick of oncologic diseases of a head and a neck in the course of a fractional irradiation in the remote terms after its end is applied. Now on chairs of surgical stomatology of children's surgical stomatology and propaedeutics of surgical stomatology with reconstructive surgery of a head and a neck employees of chairs research work which is devoted questions of an etiology, pathogenesis, clinic, diagnostics and treatment of a pathology of salivary glands proceeds.

6. Materials for self control: А. Assignments for self control (tables, charts, drawings, graphs) Main tasks Recommendations Comment To acquire practical 1. Choronomic survey of maxillofacial skills of examine the patient range. with a calculus sialadenitis at 2. A palpation peripheric regions localization of a salivary nodes. stone in the main excretory 3. A palpation of sialadens. duct of a sialaden. 4. Examine of an oral cavity: a) Vestibules of an oral cavity; b) Dens (the dental formula, probe, percussion); c) sialomethriya, probe main excretory ducts of sialadens; d) A cytology of a secret of sialadens; e) A si alography of sialadens.

B. Self-control tests: 1. Latent period of epidemic is: А) 2-3 days; B) 6-7 days; C) 10-15 days ; D) 25-28 days. 2. What index of diastase averages in urine at children after 2th years: A) 10 mgs (ml/h); B) 50 mgs (ml/h); C) 120 mgs (ml/h); D) 160 mgs (ml/h).

16 3. What quantity of saliva from a parotid gland is selected in a norm after 20 min?: А) 0,5-1 mg; B) 1,1-2,5 mgs; C) 3-6 mgs; D) to 0,5 mgs. 4. Differential diagnostics of epidemic parotitis is conducted with: A) lymphadenitis, B) abscess of parotid gland, C) allergic edema, D) chronic parenchymatous parotitis, E) Sjogren disease. 5. At the patient of 24 years on a skin the funneled excavation before a basis of the big curl of an ear at the left is defined. At pressing mucous contents are allocated. At a fistulography contrast is defined between cartilages of a curl and an ear tragus posterior and medialis, reaches to external acoustical passage where blindly comes to an end. Make the correct diagnosis? A. Parotid a congenital fistula at the left. B. Atheroma parotid a site at the left. C. Retention a cyst parotides region at the left. D. A posttraumatic cyst parotid region at the left. E. Salivary a fistula at the left. The answer standard: A. Parotid a congenital fistula at the left. 6. The patient of 25 years after a primary surgical treatment of a perforating wound of a cheek on a wound place had a fistula, from which (especially at the moment of food intake) the transparent liquid is allocated. From an oral cavity from a duct parotid a sialaden the saliva is not allocated. Diagnose. A. Full salivary a fistula. B. Granuloma which migrates. C. Incomplete salivary a fistula. D. Cicatrical deformation of a cheek. E. Chronic osteomyelitis of the top jaw. The answer standard: A. Amphibolic salivary a fistula. C. Tasks for self-control: 1. At objective examine at the patient the stone in a forward department main excretory duct inframaxillary sialaden is revealed salivary. Question 1. To define a mean and a method of treatment of the patient? Question 2. In what conditions surgical treatment is shown? The answer 1. Surgical treatment is shown the patient: ectomy of a salivary stone from the main excretory duct inframaxillary sialaden.

17 The answer 2. Surgical treatment of the patient is shown in conditions of a polyclinic. 2. At the patient the calculus sialadenitis which is complicated with an abscess of the sublingual platen is revealed. Question. How to treat the patient? The answer. It is necessary to open an abscess of the sublingual platen and to carry out conservative treatment with the purpose of prophylaxis of complications of inflammatory process. 3. At the patient of 40 years after a bullet wound in parotid region the fistula on a skin right parotid region from under cicatrix was generated salivary the secret which at patient causes dermatitis is allocated. What way is necessary for applying surgical treatment?

7. Bibliography. Basic: 1. Contemporary Oral and Maxillofacial Surgery//Larry J. Peterson, Edvard Ellis III, James R.Hupp, Myron Tucker/ 2003, MOSBY, – 776 p. 2. Hupp JR, Williams TP, Vallerand WP: The 5 minute clinical consult for dental professionals PDA, Baltimore, 2002, Williams & Wilkins Additional 1. Lustran J, Regev E, Melamed Y. Sioalolithiasis: a survey on 245 patients and review of the literatura. Int J Oral Maxillofac Surg 1990;19:135-8. 2. Bodner L. Parotid sialolithiasis. J Laryngol Otol 1999;113:266-7. 3. Seifert G, Miehlke A, Hanbrich J, Chilla R, eds. Diseases of the salivary glands: pathology, diagnosis, treatment, facial nerve surgery. Stuttgart:George Thime Verlag; 1986. p. 85-90. 4. Ottaviani F, Galli A, Lucia MB, Ventura G. Bilateral parotid sialolithiasis in a patient with acquired immunodeficiency syndrome and immunoglobulin G multiple myeloma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:552-4. 5. http://emedicine.medscape.com/article/882358-overview

Methodical recommendations is prepared by docent Rezvina Ye.Yu.

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