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I'm a surgeon. I make an incision, do what
needs to be done and sew up the wound.
Richard Selzer Professor of Surgery of Yale University
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History
RIOLAN 1648: Identified the glandular substance ofparotid
NIELS STENSON 1660: Identified the parotid duct insheep
THOMAS WARTON 1656 Identified the submandibulargland and duct
HEYFELDER 1825: Avoided the facial nerve afterparotidectomy
VELPEAU 1830: Identified trunk of facial nerve
BELL AND VELPEAU: Determined the facial nerve wasresponsible for facial animation. Determined facialsensation was from CN V.
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Anatomical Considerations
Twosubmandibular
Two Parotid Two sublingual
> 400 minor
salivary glands
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Minor salivary glands
These lie just under mucosa.
Distributed over lips, cheeks,palate, floor of mouth & retro-
molar area. Also appear in upper
aerodigestive tract
Contribute 10% of total
salivary volume.
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Parotid Gland
The parotid gland represents thelargest salivary gland
The following lists the boundaries ofthe parotid compartment:
Superior border Zygoma
Posterior border ExternalAuditory CanalInferior border Styloid Process,Styloid Process musculature,Internal Carotid Artery, JugularVeins
Anterior border a diagonal linedrawn from the Zygomatic root tothe EAC
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courses anteriorly fromthe parotid gland over the
masseter muscle
it pierces the buccinator
muscle to enter throughthe buccal mucosa,
usually opposite the
second maxillary molar.
The Stensen duct can be
found approximately 1.5cm below the zygoma.
The parotid duct, or
Stensen duct,
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Facial nerve
divides the gland into
the superficial (80 %)and deep lobe (20%)
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Parotid Gland
Cranial Nerve VII divides it into 2 surgicalzones (the superficial and deep lobes).
After exiting the foramen, it turns laterallyto enter the gland at its posterior margin.
The nerve then branches at the Pes
Anserinus (gooses foot) approximately 1.3cm from the stylomastoid foramen. Thenerve then gives rise to 2 divisions:
1)Temperofacial (upper) 2)Cervicofacial (lower)
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Cranial Nerve VII
Followed by 5terminal branches:
1)Temporal
2)Zygomatic3)Buccal
4)Marginal
Mandibular5)Cervical
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Parotid Gland
80% of the gland overlies theMasseter and mandible. Theremaining 20% of the gland
(the retromandibular portion
This portion of the gland lies inthe Prestyloid Compartment of
the Parapharyngeal space
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Parotid Gland
Stensens duct arises from the anteriorborder of the Parotid and parallels theZygomatic arch, 1.5 cm inferior to theinferior margin of the arch.
It runs superficial to the massetermuscle, then turns medially 90degrees to pierce the Buccinatormuscle at the level of the second
maxillary molar where it opens ontothe oral cavity.
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Parotid Gland
Neural compartment
VII, Great Auricular, Auriculotemporal
Venous compartment Retromandibular vein
Arterial compartment
Superficial Temporal/Transverse Facial
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The parotid gland has two layers ofdraining lymph nodes.
The superficial layer (periparotid ) lies
beneath the capsule, and
The deeper layer (intraparotid) lies within
the parotid parenchyma.
Lymphatic drainage
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Functions of saliva include the following:
It has a cleansing action on the teeth
It moistens and lubricates food during mastication andswallowing
It dissolves certain molecules so that food can be tasted
It begins the chemical digestion of starches through theaction of amylase, which breaks down polysaccharides intodisaccharides.
The saliva from the parotid gland is a rather thin, wateryfluid, but the saliva from the sublingual and thesubmandibular glands contains mucus and is much thicker.
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PAROTID DUCT INJURIES
Pasien pasien yang mengalami cedera pada duktusparotikus, 47% diantaranya dapat sembuh tanpaadanya komplikasi. Komplikasi awal pada pasiendengan cedera duktus parotikus yaitu 21% dapat
berupa sialocele yang dapat terbentuk dalam 4 jampertama paska trauma
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Classification of Injuries
Tipe 1 : terjadi kompresi dari duktusstensen pada kurvatura di sekitarm.masseter akibat dari tekanan dariSuperficial Muscular Aponeurotic System( SMAS ). Jenis cedera ini menyebabkanpembengkakan yang bersifat sementarapada kebanyakan pasien ( Gambar 1 S )
Tipe 2 : laserasi dari kapsula kelenjarparotis. Tipe cedera ini menyebabkanpembengkakan pada lokasi dimanaterjadinya laserasi. ( gambar 1 b )
Tipe 3 : kompresi dari duktus stensenpada kurvatura di sekitar m.masseterakibat dari tekanan yang berasal dariSMAS dan laserasi dari kapsula kelenjarparotis ( Kombinasi tipe 1 + tipe 2 ).
Tipe 4 : ruptur komplit ataupun lukapenetrasi dari saluran air liur atau salahsatu dari percabangan utama yangmengakibatkan sialocele yang terdapatpada area penetrasi. ( gambar 1 C )
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Etiologies of Injury
Diklasifikasikan berdasarkan mekanisme, lokasi, dandaya trauma penyebab cedera :
Akut
Laserasi,
Luka tembus
Avulsi ( akibat gigitan binatang ataupun manusia )
Trauma tumpul ( dimana jaringan mengalami kompresi denganataupun tanpa rusaknya duktus parotikus).
Kronis iritasi kronis dari struktur gigi geligi yang mengiritasi lubang
saluran duktus parotikus
Benda asing ( corpus alienum ) di dalam saluran duktus parotikus
Radiasi Eksterna
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Examinations & Evaluations
Status regional :
kulit, mukosa mulut, lidah, dan struktur gigi geligi sertapenilaian adanya fraktur pada tulang di sekelilingnya dan Otototot daerah wajah serta mastikasi
adanya cedera yang biasanya ditandai dengan adanya air liurpada luka trauma.
Fungsi dari nervus fasialis dan percabangannya dan nervuslingualis dan nervus hipoglosalis juga harus diperhatikan pada
pasien pasien yang mengalami cedera di area parotis. Bila terdapat keraguan, dilakukan kanulasi pada duktus
parotikus mealui lubang bukaan alami dengan suatu probelakrimal ataupun kateterisasi
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Penilaian nervus fasialis : Gerakan tersenyum, menyeringai, mencucu bibir dan juga gerakan
meniup. Fungsi sensorik dan motorik pada lidah juga harus dinilai.Pada kasus kasus transeksi nervus, bagian distal perlu dinilaidengan stimulator elektrik.
Trauma pada area wajah dengan melibatkan daya yangcukup untuk menyebabkan fraktur tulang wajah dapatdikaitkan dengan cedera kelenjar liur, terutama kelenjarparotis beserta sistem salurannya.
Terdapat beberapa laporan kasus fraktur maxilla disertai
laserasi dari duktus stensen yang telah mengalami prosespenyembuhan dengan adanya fistula parotid antral.Secara klinis, pasien pasien tersebut mengalamirinnorrhoea prandial.
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Aspirasi cairan dari area area pembengkakan disekitar area parotis. Kadar amylase yang lebih dari10.000 units/liter dapat mengkonfirmasi adanyasuatu cedera pada kelenjar parotis besertasalurannya.
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Radiologic Imagings
Sialografi pemeriksaan sialografi
dengan menyuntikan kontraskedalam duktus kelenjarparotis sehingga jalur darialiran saliva dapat
divisualisasikan melalui fotopolos.
tidak boleh dilakukanapabila pasien menderitainfeksi akut kelenjar liur,
memiliki hipersensitivitasterhadap iodium yangmerupakan salah satukomponen dalampemeriksaan sialografi.
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MRI vs CT
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Concluded:
MRI better at distinguishing intrinsic vs extrinsic
Inaccuracy rate of both MRI and CT was the same
MRI 3x more expensive than CT
CT and MRI are morphologically equivalent studiesand have the same diagnostic tools
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Post-Operative XRT
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Management of Stensons Duct Injuries
1. Magnification of operating areas2. Cannulation of the duct through the orifice
3. Pressing on the gland to express saliva into thewound to identify the proximal portion of the duct
4. Ductal lacerations should be repaired as soon asfeasible
5. Ductal lacerations should be suspected if weaknessof upper lip on puckering with a laceration of thecheek
6. Stensensduct is located on a line drawn from thetragus to the midpoint between the upper lipmargin and the columella
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7. The duct is usually located inferior to a small artery andsuperior to a branch of facial nerve
8. Duct laceration should be suspected in all cheekwounds located lateral to the vertical line of the pupiland inferior to a line at the level of tragus
9. Surgical techinques :
Fixation of the ductal splint Suturing the splint to the oral mucosa
Taping the splint to the face
Combinations
Passing the splint through the parenchyma of the gland andthrough the skin ( Abramson, 1973).
10. Significant injury of stensonsduct rerouting of theremaining duct through the buccal mucosa andcreation of a fishmouthopening to prevent stenosis.
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TERIMA KASIH
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