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GUIDELINES
Individual work of students
During preparation for Practical classes
Educational discipline Surgical stomatology
Module № 2 Inflammatory diseases in maxillofacial region.
Content module № 4 Nonodontogenous inflammatory diseases in
maxillofacial region
Theme lesson
Calculous sialadenitis: 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
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
MINISTRY OF HEALTH OF UKRAINE
Ukrainian medical stomatological academy
“Approved”
On the meeting chair
Of Propaedeutics Surgical Stomatology
The Head of the Department
prof. Novikov V.M. ___________
“ ____ ” _____________ 20 ____
2
1. Actuality of the topic:
On statistical given to N.D. Lesovoj (1979) sialolithiasis 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
courses
These skills
Physiopathology Inflammatory processes
Anatomical pathology Inflammatory processes
Microbiology The infestant, microbic flora of an oral cavity and a secret of
sialadens.
Operative surgery and
topographical anatomy.
Features of an anatomical structure of sialadens.
Histology Features of a constitution of sialadens.
Propedeutics of a surgical
stomatology.
Methods of examine of the stomatologic patient.
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
3
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
salivary gland 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 infection 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 parotid
gland 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)
4
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 nerve 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 mumps) 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 saliva
follows through an aperture located in the region of integuments, and internal when its
mouth 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 occlusion 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
5
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 parotid duct, 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 cheek 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
6
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 sialocele 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
7
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 diabetes mellitus, prior splenectomy, liver disease,
immunosuppression, and presence of a prosthetic valve or joint.
8
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, abrasion)
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
Facial nerve 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
epithelium, 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 oral mucosa, 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 lip. Any injury that crosses this line should
be considered to involve the parotid duct until proven otherwise. Parotid duct injuries
9
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 artery, which also are at risk in injuries causing damage to the
parotid duct. The parotid duct was found to be interrelated with the buccal fat pad 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
infections 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.
10
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.
11
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 vein graft to replace missing or damaged segments of parotid duct
have generally found such attempts unsuccessful.
12
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
13
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 parotidectomy 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
14
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
15
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 fauces 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
16
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
skills of examine the patient
with a calculus sialadenitis at
localization of a salivary
stone in the main excretory
duct of a sialaden.
1. Choronomic survey of maxillofacial
range.
2. A palpation peripheric regions lymph
nodes.
3. A palpation of sialadens.
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 parotitis 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).
17
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.
18
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.