ORIGINAL ARTICLE
Parotid Duct Relocation in Buccal Mucosa Cancer Resection Sandeep Mehta, MBBS, MS, Juhi Agrawal, MBBS, MS, Ajay K. Dewan, MBBS, MS, and Tapaswini Pradhan, MBBS, MS (ENT) Abstract: Buccal mucosal cancer is commonly seen in India with patients presenting in advanced stages of the disease. Its excision commonly mandates division of parotid duct as a part of disease or its margin. We have adopted a simple method to salvage the parotid gland by cannulating the duct and rerouting the saliva into the oral cavity at a different site. This has now become a protocol at our center. A total of 562 patients from 2002 to 2012 have undergone this procedure. This has markedly reduced the incidence of sialocele and parotitis in early postoperative period, which may delay wound healing and subsequent radiotherapy. Key Words: Stenson duct, oral cancer, cheek cancer (J Craniofac Surg 2014;25: 1746–1747)
C
arcinomas of the buccal mucosa seen in India are extensive lesions and are not just limited to upper or lower gingivobuccal sulcus. During excision of these lesions, parotid duct is invariably cut either as a part of the lesion or as a part of the margin for tumor clearance. Ligation of the parotid duct causes complications like sialoceles, fistulas, delayed wound healing, and delay in subsequent radiotherapy. These complications were seen in as high as 75% of cases where parotid duct was not addressed. This prompted us to innovate a simple method to salvage the gland by relocating the duct to open up in the oral cavity.
METHODS Under general anesthesia, tumor resection is done with adequate margin and the parotid duct is identified and dissected. The duct is preserved for relocation during reconstruction of the defect (Fig. 1). The periductal tissue is held with the help of 2 skin hooks and is irrigated with warm saline stream poured directly over the duct opening to relieve its spasm, and the lumen is visualized. The duct is cannulated with 20G intravenous catheter (Volex; Hindustan Syringes & Medical Devices Ltd, Faridabad, Haryana, India) or 5 Fr infant feeding tube (Romsons Scientific & Surgical Industries Pvt Ltd, Agra, Uttar Pradesh, India) depending upon the diameter of the duct. When 5 Fr feeding tube is used, it is From the Division of Reconstructive Surgery, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India Received December 4, 2013. Accepted for publication April 7, 2014. Address correspondence and reprint requests to Juhi Agrawal, MBBS, MS, MCh, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, B22, Brahma Apartments, Sector-7, Plot no 7, Dwarka, New Delhi 110075, India; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000998
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spatulated by cutting it at an angle which makes cannulation easier (Figs. 2 & 3). When 20G intravenous catheter is used. The hub of the catheter is cut to remove the butterfly attachment of the catheter and reduce the bulk. The opening of the duct is relocated in the oral cavity through the buccal mucosa or at the margin between mucosa and the flap or even through the flap depending upon the available length of duct and the location of the defect. The cut end of the duct with the catheter in situ is brought out and sutured with the surrounding mucosa/skin with 4-0 PDS as an everting ostomy (Fig. 4). At the end of the procedure, the parotid gland is manipulated to express secretions from the relocated duct to confirm its patency. The catheter is periodically cleaned by irrigating its opening to avoid blockade in the postoperative period. The patients are advised to massage the parotidomasseteric area to express the secretions on a regular basis, which further ensures its patency. The catheter is kept until completion of radiotherapy (Fig. 5). The removal of catheter is done at the end of 10 weeks (Fig. 6). We have adopted this technique as a routine for the last 10 years.
RESULTS Parotid duct relocation has been performed in 562 patients in the last 10 years. Sialocele was seen in 30 patients (5.3%), parotitis in 17 patients (3.02%), and catheter blockade in 11 patients (1.9%). Ten patients (1.7%) were lost to follow-up with the catheter. Duct was accidently removed in 18 patients (3.2%). Follow-up of the patients has been for 6 to 26 months (mean 9 months).
DISCUSSION Parotid gland has an important role in salivary secretion. It accounts for 60% to 65% of the total salivary output.1 Its salvage during cheek carcinoma resection is hence important. The parotid duct is 7 cm in length and starts from the anterior border of the parotid gland and passes over the masseter muscle to open in the oral cavity opposite the maxillary second molar. A line drawn from tragus to the middle of the upper lip describes its
FIGURE 1. parotid duct preserved for translocation.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Parotid Duct Relocation in Buccal Mucosa
FIGURE 6. Matured duct opening after catheter removal.
FIGURE 2. Feeding tube spatulated for cannulation.
FIGURE 3. Parotid duct cannulated with feeding tube.
course.2 This has to be kept in mind while resecting the tumor from the depth and the duct should be identified and tagged to avoid its inadvertent injury during tumor excision. If the duct is transected without repair, subsequent stricture, cheek swelling, fistulas, and obstructive sialadenitis may occur.3,4 Here, by this technique, we are diverting the salivary flow by providing it a way into the oral cavity and hence its obstructive sequel are avoided. The literature search reports only 1 case report of Stenson duct relocation after cheek mucosa cancer resection, although there are many reports for submandibular duct relocation and parotid duct injury repair.5–7 We have been doing parotid duct relocation for the past 10 years in all the cases of buccal mucosa resections except in cases where duct has been completely excised as a part of tumor or its margin along with resection of parotid gland. This technique improved the postoperative recovery of the patients in the form of less number of parotitis, cheek swelling, and sialoceles. Thus, we have made it a routine to perform duct relocation in all cases of buccal mucosal resections where parotid duct opening is resected with the tumor. Ligation of parotid duct causes parotid gland atrophy.8 Parotid duct relocation, by means of preserving its function, aids in reviving the parotid gland function after radiation therapy. This hypothesis is currently being studied by the authors and results are awaited.
CONCLUSION Parotid gland function salvage can be done by relocating the duct to the oral cavity following this simple technique. It makes the postoperative recovery of the patient easy and with less number of complications. This should be a routine when the duct is transected in cases of buccal mucosal carcinoma.
REFERENCES FIGURE 4. Duct brought out through buccal mucosa near the upper gingivobuccal sulcus.
FIGURE 5. Catheter in situ after completion of radiotherapy, 11 weeks after surgery.
1. Dirix P, Nuyts S, Bogaert WV. Radiation induced xerostomia in patients with head and neck cancer. Cancer 2006;107:2525–2534 2. Heymans O, Nelissen X, Medot M, et al. Microsurgical repair of Stenson’s duct using an interposition vein graft. J Reconstr Microsurg 1999;15:105–107 3. Etoz A, Tuncel U, Ozcan M. Parotid duct repair by use of an embolectomy catheter with a microvascular clamp. Plast Reconstr Surg 2006;117:330–331 4. Liang CC, Jeng SF, Yeh MC, et al. Reconstruction of traumatic Stenson duct defect using a vein graft as conduit: two case reports. Ann Plast Surg 2004;52:102–104 5. Longo B, Germano S, Laporta R, et al. Stenson duct relocation after cheek mucosa tumour resection. J Craniofac Surg 2012;23:e250–e251 6. Ord RA, Lee VE. Submandibular duct repositioning after excision of floor of mouth cancer. J Oral Maxillofac Surg 1996;54:1075–1078 7. Yura S, Kato T, Ooi K, et al. Oral tumour resection and salivary duct relocation with an ultrasonic surgical aspirator. J Craniofac Surg 2009;20:1250–1251 8. Scott J, Liu P, Smith PM. Morphological and functional characteristics of acinar atrophy and recovery in the duct-ligated parotid gland of the rat. J Dent Res 1999;78:1711–1719
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1747
Parotid Duct Relocation in Buccal Mucosa Cancer Resection Sandeep Mehta, MBBS, MS, Juhi Agrawal, MBBS, MS, Ajay K. Dewan, MBBS, MS, and Tapaswini Pradhan, MBBS, MS (ENT) Abstract: Buccal mucosal cancer is commonly seen in India with patients presenting in advanced stages of the disease. Its excision commonly mandates division of parotid duct as a part of disease or its margin. We have adopted a simple method to salvage the parotid gland by cannulating the duct and rerouting the saliva into the oral cavity at a different site. This has now become a protocol at our center. A total of 562 patients from 2002 to 2012 have undergone this procedure. This has markedly reduced the incidence of sialocele and parotitis in early postoperative period, which may delay wound healing and subsequent radiotherapy. Key Words: Stenson duct, oral cancer, cheek cancer (J Craniofac Surg 2014;25: 1746–1747)
C
arcinomas of the buccal mucosa seen in India are extensive lesions and are not just limited to upper or lower gingivobuccal sulcus. During excision of these lesions, parotid duct is invariably cut either as a part of the lesion or as a part of the margin for tumor clearance. Ligation of the parotid duct causes complications like sialoceles, fistulas, delayed wound healing, and delay in subsequent radiotherapy. These complications were seen in as high as 75% of cases where parotid duct was not addressed. This prompted us to innovate a simple method to salvage the gland by relocating the duct to open up in the oral cavity.
METHODS Under general anesthesia, tumor resection is done with adequate margin and the parotid duct is identified and dissected. The duct is preserved for relocation during reconstruction of the defect (Fig. 1). The periductal tissue is held with the help of 2 skin hooks and is irrigated with warm saline stream poured directly over the duct opening to relieve its spasm, and the lumen is visualized. The duct is cannulated with 20G intravenous catheter (Volex; Hindustan Syringes & Medical Devices Ltd, Faridabad, Haryana, India) or 5 Fr infant feeding tube (Romsons Scientific & Surgical Industries Pvt Ltd, Agra, Uttar Pradesh, India) depending upon the diameter of the duct. When 5 Fr feeding tube is used, it is From the Division of Reconstructive Surgery, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, Delhi, India Received December 4, 2013. Accepted for publication April 7, 2014. Address correspondence and reprint requests to Juhi Agrawal, MBBS, MS, MCh, Department of Surgical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, B22, Brahma Apartments, Sector-7, Plot no 7, Dwarka, New Delhi 110075, India; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000998
1746
spatulated by cutting it at an angle which makes cannulation easier (Figs. 2 & 3). When 20G intravenous catheter is used. The hub of the catheter is cut to remove the butterfly attachment of the catheter and reduce the bulk. The opening of the duct is relocated in the oral cavity through the buccal mucosa or at the margin between mucosa and the flap or even through the flap depending upon the available length of duct and the location of the defect. The cut end of the duct with the catheter in situ is brought out and sutured with the surrounding mucosa/skin with 4-0 PDS as an everting ostomy (Fig. 4). At the end of the procedure, the parotid gland is manipulated to express secretions from the relocated duct to confirm its patency. The catheter is periodically cleaned by irrigating its opening to avoid blockade in the postoperative period. The patients are advised to massage the parotidomasseteric area to express the secretions on a regular basis, which further ensures its patency. The catheter is kept until completion of radiotherapy (Fig. 5). The removal of catheter is done at the end of 10 weeks (Fig. 6). We have adopted this technique as a routine for the last 10 years.
RESULTS Parotid duct relocation has been performed in 562 patients in the last 10 years. Sialocele was seen in 30 patients (5.3%), parotitis in 17 patients (3.02%), and catheter blockade in 11 patients (1.9%). Ten patients (1.7%) were lost to follow-up with the catheter. Duct was accidently removed in 18 patients (3.2%). Follow-up of the patients has been for 6 to 26 months (mean 9 months).
DISCUSSION Parotid gland has an important role in salivary secretion. It accounts for 60% to 65% of the total salivary output.1 Its salvage during cheek carcinoma resection is hence important. The parotid duct is 7 cm in length and starts from the anterior border of the parotid gland and passes over the masseter muscle to open in the oral cavity opposite the maxillary second molar. A line drawn from tragus to the middle of the upper lip describes its
FIGURE 1. parotid duct preserved for translocation.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 5, September 2014
Parotid Duct Relocation in Buccal Mucosa
FIGURE 6. Matured duct opening after catheter removal.
FIGURE 2. Feeding tube spatulated for cannulation.
FIGURE 3. Parotid duct cannulated with feeding tube.
course.2 This has to be kept in mind while resecting the tumor from the depth and the duct should be identified and tagged to avoid its inadvertent injury during tumor excision. If the duct is transected without repair, subsequent stricture, cheek swelling, fistulas, and obstructive sialadenitis may occur.3,4 Here, by this technique, we are diverting the salivary flow by providing it a way into the oral cavity and hence its obstructive sequel are avoided. The literature search reports only 1 case report of Stenson duct relocation after cheek mucosa cancer resection, although there are many reports for submandibular duct relocation and parotid duct injury repair.5–7 We have been doing parotid duct relocation for the past 10 years in all the cases of buccal mucosa resections except in cases where duct has been completely excised as a part of tumor or its margin along with resection of parotid gland. This technique improved the postoperative recovery of the patients in the form of less number of parotitis, cheek swelling, and sialoceles. Thus, we have made it a routine to perform duct relocation in all cases of buccal mucosal resections where parotid duct opening is resected with the tumor. Ligation of parotid duct causes parotid gland atrophy.8 Parotid duct relocation, by means of preserving its function, aids in reviving the parotid gland function after radiation therapy. This hypothesis is currently being studied by the authors and results are awaited.
CONCLUSION Parotid gland function salvage can be done by relocating the duct to the oral cavity following this simple technique. It makes the postoperative recovery of the patient easy and with less number of complications. This should be a routine when the duct is transected in cases of buccal mucosal carcinoma.
REFERENCES FIGURE 4. Duct brought out through buccal mucosa near the upper gingivobuccal sulcus.
FIGURE 5. Catheter in situ after completion of radiotherapy, 11 weeks after surgery.
1. Dirix P, Nuyts S, Bogaert WV. Radiation induced xerostomia in patients with head and neck cancer. Cancer 2006;107:2525–2534 2. Heymans O, Nelissen X, Medot M, et al. Microsurgical repair of Stenson’s duct using an interposition vein graft. J Reconstr Microsurg 1999;15:105–107 3. Etoz A, Tuncel U, Ozcan M. Parotid duct repair by use of an embolectomy catheter with a microvascular clamp. Plast Reconstr Surg 2006;117:330–331 4. Liang CC, Jeng SF, Yeh MC, et al. Reconstruction of traumatic Stenson duct defect using a vein graft as conduit: two case reports. Ann Plast Surg 2004;52:102–104 5. Longo B, Germano S, Laporta R, et al. Stenson duct relocation after cheek mucosa tumour resection. J Craniofac Surg 2012;23:e250–e251 6. Ord RA, Lee VE. Submandibular duct repositioning after excision of floor of mouth cancer. J Oral Maxillofac Surg 1996;54:1075–1078 7. Yura S, Kato T, Ooi K, et al. Oral tumour resection and salivary duct relocation with an ultrasonic surgical aspirator. J Craniofac Surg 2009;20:1250–1251 8. Scott J, Liu P, Smith PM. Morphological and functional characteristics of acinar atrophy and recovery in the duct-ligated parotid gland of the rat. J Dent Res 1999;78:1711–1719
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1747
