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Intraoral Transposition of Traumatic Parotid Duct Fistula

Vishal S. Doctor, MD; Amir Rafii, MD; Danny J. Enepekides, MD; Travis T. Tollefson, MD

Arch Facial Plast Surg. 2007;9(1):44-47.

ABSTRACT

Parotid duct fistula is uncommon but difficult-to-treat complication that often results from a penetrating trauma. While there is general consensus in the literature as to the management of acute parotid injuries, treatment of chronic fistulas remains controversial. We review the current treatment options for parotid duct fistulas and describe an intraoral diversion technique to reestablish salivary flow in the setting of a nonfunctional parotid duct punctum.

INTRODUCTION

Injury to the parotid gland or duct can lead to a bothersome draining fistula tract. Parotid duct fistulas are often the result of improperly managed injuries and can be challenging to treat. The most common causes of parotid duct injury are penetrating trauma from stab wounds, motor vehicle accidents, and gunshot wounds.1 Other causes include injury during tumor resection, ulceration due to large calculi, complications from middle ear or mastoid surgery, and injury during drainage of parotid abscesses.2

Van Sickels3 classified parotid duct injury by specific site: type A is located within the substance of the gland; type B, where the duct passes over the masseter; and type C, anterior to the masseter where it pierces the buccinator and passes intraorally adjacent to the second maxillary molar. The duct is most susceptible to injury as it passes over the masseter (type B) and is in close proximity to the buccal branches of the facial nerve and the transverse facial artery.4 The current literature recommends that lacerations in this area be explored and the parotid duct probed to rule out injury. A transected duct can be repaired over a silastic catheter; however, proximal ductal injury or extensive tissue loss may preclude primary anastamosis. In these cases, 3 alternatives have been suggested: (1) ligation of the proximal duct to induce atrophy of the gland5; (2) diversion of the proximal segment into the oral cavity6; and (3) microsurgical repair of the parotid duct with an autologous interposition vein graft.7

Delayed treatment of parotid duct injuries is more controversial. Failure to diagnose or treat duct injury soon after it occurs often results in sialocele or fistula formation. Multiple treatment techniques for these complications have been attempted, with varying degrees of success. These range from conservative management with pressure dressings to total parotidectomy. To our knowledge, no reports in the medical literature describe the use of an intraoral diversion of the parotid fistula tract in the setting of a traumatic injury.

Figure 1. The parotid duct fistula tract is passed intraorally before being secured. A, Intraoperative photograph of the fistula tract and the surrounding ellipse of skin being passed into the oral cavity with a silk suture attached to the skin island. B, Illustration of the parotid duct fistula tract as it is passed intraorally and secured to the buccal mucosa (note the facial nerve monitor inserted into the buccal branch distribution).

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