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Parotid Sialocele and Fistulae: Current Treatment Options

Srinidhi D,1 Shruthi R, 2 Madhumati Singh,3 Shouvik Choudry4
ABSTRACT
Parotid gland and duct injuries are rare complications following surgery of parotid gland and temporomandibular joint. Various other causes of parotid injury are rupture of parotid abscess, inadvertent incision of parotid abscess, complication of superficial Parotidectomy, gunshot wounds and trauma. Injury to the parotid duct may be difficult to diagnose and treat. If not recognized will lead to salivary fistula and sialocele formation which will not heal spontaneously because of continuous flow of saliva. Persistent salivary fistula may be most troubling to the patient. Successful treatment depends on early recognition and appropriate early intervention Keywords: sialocele;parotid fistula;stensen's duct

continuously discharge saliva and spontaneous healing is very rare. Classification of parotid injuries An injury classification system has been devised by Van Sickels2. This system divides the parotid injuries into three regions: 1.Posterior to the masseter or intraglandular (site A), 2.Overlying the masseter (site B), and 3.Anterior to the masseter (site C). Examination of parotid injuries should include assessment of location , size ,shape , type (e.g., puncture, laceration, avulsion, crush, abrasion) , asymmetry, drainage (i.e., quality, character, odor) tenderness , surrounding erythema, oedema, cellulitis, or crepitation and facial nerve status The most straightforward way to diagnose a parotid duct injury is to cannulate the intraoral parotid duct papilla with a small silastic tube and observe if the tube is visible in the wound. This test does require patient cooperation; therefore, it may be difficult or impossible in children, individuals with intoxication, or individuals with mental disabilities. If any question regarding the diagnosis remains, a small amount of saline may be injected through the tube and observed for flow through the wound. Methylene blue probably should not be injected 1 through the tube because it terribly discolours tissues and makes subsequent operation even more challenging. Sialography3 may be performed but is usually not necessary to establish the diagnosis of parotid duct injury. If performed, watersoluble contrast material should be employed because it is more easily drained and absorbed, and it does not remain as an irritant to the gland. In doubtful cases fluid can be sent for laboratory analysis; raised salivary amylase levels confirm the diagnosis4. Computed tomography fistulography can be performed to look for the extent of the fistula.5

Introduction
A parotid fistula is a communication between the skin and a salivary duct or gland, through which saliva is discharged.1Parotid gland and duct injuries are rare complications following surgery of parotid gland and temporomandibular joint. Various other causes of parotid injury are rupture of parotid abscess, inadvertent incision of parotid abscess, complication of superficial Parotidectomy, gunshot wounds and trauma. 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. If not recognized will lead to salivary fistula and sialocele formation which will not heal spontaneously because of continuous flow of saliva. Successful treatment depends on early recognition and appropriate early intervention.

Clinical features include salivary extravasations into the tissues causing swelling over or adjacent to parotid gland (sialocele), expanding neck mass and cutaneous fistula formation. In glandular fistulas Management discharge is less and tends to heal spontaneously with Nicoladoni reported the first primary anastomosis of conservative treatment, where as ductal fistulas the parotid duct in 1896. Morestin reported ligation of continuously discharge saliva and spontaneous healing IJCD JANUARY, 2011proximal stump in 1917, and formation of an oral the 2(1) is very rare. 9 2011 Int. Journal of Contemporary Dentistry fistula was described in 1918. Acute parotid injuries

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the parotid duct in 1896. Morestin reported ligation of the proximal stump in 1917, and formation of an oral fistula was described in 1918. Acute parotid injuries should be explored & repaired primarily. Patients with wounds that involve the oral cavity or require manipulation of the parotid duct through the oral cavity should probably receive prophylactic antibiotics after primary closure.4 Treatment options Aspiration and pressure dressings Anti-Sialogogues Radiation therapy Parasympathetic Denervation (Tympanic Denervation) Cauterization of the Fistulous Reconstruction of the duct Superficial or Total Parotidectomy tract the duct, and fistulisation of the duct into the oral cavity.11 Injuries of the proximal duct near the parotid substance, at site A, are usually best treated by ligation of the duct. Duct ligation causes Physiologic Death of the gland.12 Duct ligation may lead to early oedema 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. Tympanic Neurectomy Para sympathetic secretomotor fibres carried to the gland from inferior salivatory nucleus via tympanic plexus (branch from glossopharyngeal nerve) to otic ganglion. Supplied to parotid gland by auriculotemporal nerve. Transtympanic sectioning of the Jacobsons nerve by drilling into temporal bone at hypotympanium has been reported. Glandular atrophy occurs in 6 months. High failure rate due to varied anatomy of nerve reinnervation.13, 14 Recently treatment of salivary fistula with botulinum toxin BOTOX type A has been described. 15 Fistulas and sialocele are managed with botulinum toxin injection after conventional conservative management techniques fail. Botox A inhibits secretion of acetylcholine at presynaptic nerve ending. Cologne protocol contains 25 mU of botulinum toxin / 0.1ml intraglandularly 0.1 -0.2 ml to be injected at 4 to 10 points under sonographic control.16, 17 Repair of the Stensens duct Distal lacerations, occurring at site C, may be treated by repair of the duct. If the papilla is uninjured, the proximal portion may be dissected free and reimplanted into the papilla and cannulation of the duct with a silastic tube.18 If the surgeon is able to repair the duct over a stent, the stent is trimmed at the level of the oral papilla and sewn to the oral mucosa or around the maxillary second molar with a chromic suture. This is designed to hold the stent in place for the recommended 2-3 weeks while the injured duct heals and to help prevent stenosis at the repair site. It may also prevent postoperative oedema in the region from collapsing the fragile duct. Patient tolerance of the stent is highly variable. Some patients require stent removal early or remove it themselves without untoward consequence.18 Dochoplasty Creating intraoral fistula-advocated by Demetriades for internalization of the salivary flow. A novel technique of sialodochoplasty using buccal-mucosa pedicle flap is described.19

CONSERVATIVE MANAGEMENT A conservative modality is based on regular aspiration of the content and compression dressing. Some authors 4,6,7,8 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) Sialocele, i.e., 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. The anticholinergic drugs have many undesired side effects such as xerostomia, constipation, photophobia, tachycardia and urinary retention.9 Radiation therapy induces fibrosis & atrophy of the gland. Approximately 1800 rads for more than 6 weeks is required .Especially considered for refractory salivary fistulas.10 SURGICAL THERAPY Surgical excision of the fistulous tract followed by tight pressure dressing of the wound is an effective management option. Three operative techniques have been described include repair of the duct over a stent, ligation of the duct, and fistulisation of the duct into the oral cavity.11

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Injuries of the proximal duct near the parotid

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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.18 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. A case of Stensen's duct microsurgical repair using a vein graft has been reported.20Successful treatment of postparotidectomy fistulae with fibrin glue has been reported by Zwaveling S21 et.al. 7.Epker BN, Burnette JC. Trauma to the parotid gland and duct: primary treatment and management of complications. J Oral Surg. 1970 Sep;28(9):657670. [PubMed] 8.Lewkowicz AA, Hasson O, Nahlieli O .Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg. 2002 Jun;60(6):676-80 9.Krausen AS, Ogura JH. Sialoceles: medical treatment first. Trans Sect Otolaryngol Am Acad Ophtalmol Otolaryngol. 1977;84(5):ORL890-5. 10.Christiansen H, Wolff HA, Knauth J, Hille A, Vorwerk H, Engelke C et al. Radiotherapy : an option for refractory salivary fistulas. HNO. 2009 Dec;57(12):13258. 11.Steinberg MJ, Herrra AF. Management of parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Feb;99(2):136-41. 12.Wallenborn WM, Sydnor TA, Hsu YT, Fitz-Hugh GS. Experimental production of parotid gland atrophy by ligation of Stensen's duct and by irradiation. Laryngoscope. 1964 May;74:644655. [Pubmed] 13.Davis WE, Holt GR, Templer JW. Parotid fistula and tympanic neurectomy. Am J Surg. 1977 May; 133(5):587589. [PubMed] 14.Edussuriya B. Parotid fistulae treated by tympanic neurectomy. Ceylon Med J. 1994 Jun; 39(2):86-7. 1.Marchese-Ragona R, De Filippis C, Marioni G, Staffieri A. Treatment of complications of parotid gland surgery. Acta Otorhinolaryngol Ital. 2005;25:174178. [PMC free article] [PubMed] 2.Van Sickels JE. Management of parotid gland and duct injuries. Oral Maxillofac Surg Clin North Am. 2009 May;21(2):243-6. 3.Karas ND. Surgery of the salivary ducts. Atlas Oral Maxillofac Surg Clin North Am. 1998 Mar;6(1):99-116 4.Steinberg MJ, Herrra AF. Management of parotid duct injuries. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Feb;99(2):136-41. 5.Moon WK, Han MH, Kim IO, Sung MW, Chang KH, Choo SW, Han MC. Congenital fistula with ectopic accessory parotid gland: diagnosis with CT sialography and CT fistulography. AJNR Am J Neuroradiol. 1995;16:997999. [PubMed] 6.Parekh D, Glezerson G, Stewart M, Esser J, and Lawson Post-traumatic parotid fistulae and sialoceles. A prospective study of conservative management in 51 cases. Ann Surg. 1989 January; 209(1): 105111. 15.Guntinas-Lichius O, Sittel C. Treatment of postparotidectomy salivary fistula with botulinum toxin. Ann Otol Rhinol Laryngol 2001;110:1162-4. 16.Marchese Ragona R, de Filippis C, Staffieri A, Tugnoli V, Restivo DA. Parotid fistula: treatment with botulinum toxin. Plastic Reconst Surg 2001;107:886-7. 17.von Lindern JJ, Niederhagen B, Appel T, Berge S, Reich RH. New prospects in the treatment of traumatic and postoperative parotid fistulas with type A botulinum toxin. Plast Reconstr Surg 2002;109:2443-5. 18.Lewkowicz AA, Hasson O, Nahlieli O .Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg. 2002 Jun;60(6):676-80. 19.Raveenthiran V. Reconstruction of traumatically avulsed parotid duct using buccal mucosa flap: report of a new technique. J Trauma. 2008 Sep;65(3):732-5. 20.Heymans O, Nlissen X, Mdot M, Fissette J Microsurgical repair of Stensen's duct using an interposition vein graft.J Reconstr Microsurg. 1999 Feb;15(2):105-7; discussion 107-8.

Conclusion
The management of parotid sialoceles and fistulae have been unsatisfactory in the past, and numerous methods of treatment with varying success and morbidity have been described. Persistent salivary fistula may be most troubling to the patient. The treatment depends on the location of the injury and thus should be specifically chosen for each situation.

References

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21.Zwaveling S, Steenvoorde P, da Costa SA. Treatment of postparotidectomy fistulae with fibrin glue. Acta Medica (Hradec Kralove). 2006;49(1):67-9.[PUBMED abstract]

About the Authors

1) Dr.Srinidhi D
Professor, Department of Oral and Maxillofacial Surgery, Rajarajeshwari Dental College and Hospital, Ramohalli Cross, Mysore road , Bangalore-560074, Karnataka, India.

2) Dr. Shruthi Rangaswamy

AssistantProfessor, Department of Oral and Maxillofacial Surgery, Rajarajeshwari Dental College and Hospital, Ramohalli Cross, Mysore road , Bangalore-560074, Karnataka, India. 3)

Dr. Madhumati Singh

Professor, Department of Oral and Maxillofacial Surgery, Rajarajeshwari Dental College and Hospital, Ramohalli Cross, Mysore road , Bangalore-560074, Karnataka, India. 4)

Dr. Shouvik Choudry

Post Graduate student, Department of Oral and Maxillofacial Surgery, Rajarajeshwari Dental College and Hospital, Ramohalli Cross, Mysore road , Bangalore-560074, Karnataka, India. Address for correspondence

Dr. Shruthi R
e-mail: drshruthir@yahoo.co.in

International Journal of Contemporary Dentistry http://edentj.com/ijcd is an independent, international general dental journal supporting academic freedom and open access.

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