Eur Arch Otorhinolaryngol DOI 10.1007/s00405-015-3497-9
CASE REPORT
Parotid injury due to penetrating and blast injury Marrigje Aagje de Jong • Jonathan Cohen Miriam Lorberbaum • Menachem Gross
•
Received: 1 December 2014 / Accepted: 3 January 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Introduction Fortunately, trauma to the parotid gland is rare. As the gland is well protected by a thick capsule and situated behind the mandible. The parotid, as a rule, can only be breached by a penetrating wound or violent external force, e.g. blast trauma, which causes fracturing of the mandible. In these instances, trauma to the gland parenchyma is usually superseded by trauma to other, more vital structures, necessitating surgical intervention.
bodies were embedded throughout the right-sided aspect of the skull and upper neck; no bone fractures or other injuries to major vessels of the head and neck were demonstrated. The patient was admitted to the otolaryngology department for observation and treatment. Four days following the injury, the patient developed right facial nerve paresis, primarily of the marginal mandibular branch. The patient underwent urgent surgical exploration of the right parotid region to remove the metallic foreign body on the fourth day of admission. Following surgery, the patient was treated with antibiotics and steroids. Treatment resulted in gradual, yet complete resolution of the facial weakness.
Case report A 27-year-old male was admitted to our trauma unit after sustaining a blast injury with penetrating trauma to the right parotid region. On admission, the patient was conscious and hemodynamically stable. Physical examination revealed periorbital hematoma with severe swelling of the right eye. Eye movement was normal. Bilateral acute tympanic membrane perforations were noted on otoscopic evaluation. On the right side, numerous penetrating blast particles and debris were noted in the parotid, with no facial nerve paresis or paralysis observed. The remainder of the physical examination was normal. Computer tomography (CT) angiography scan of the head and neck revealed a penetrating metallic, radio-opaque foreign body in the parotid gland located in the superficial and deep lobes (Fig. 1). In addition, numerous metallic, small foreign
M. A. de Jong (&) J. Cohen M. Lorberbaum M. Gross Department of Otolaryngology/Head and Neck Surgery, Hadassah Hebrew-University Medical Center, Jerusalem 91120, Israel e-mail: [email protected]
Discussion Trauma to the parotid gland is rare, usually the result of a penetrating wound, such as in war or following an assault. The most comprehensive published reports of such injuries date back to World War I, when Morestin [1] reported a series of 62 cases of parotid fistulae following battlefield wounds. Possible complications include: hemorrhage, intraparotid hematoma, sialocele, and salivary fistula. The most devastating complication is facial nerve paralysis or paresis, due to direct neural injury or to edema of the parotid parenchyma with subsequent pressure on the nerve. Historically, treatment consisted of surgically draining the fistula into the oral cavity. Subsequently, it was found that conservative management of parotid duct injuries was adequate. In a trial series of 14 cases of penetrating injuries, Landau and Stewart concluded that systemic probanthine, intravenous fluids, and an NPO (nil per os; nothing by mouth) regimen, combined with external pressure, produced resolution of symptoms, even in the presence of a
123
Eur Arch Otorhinolaryngol
Fig. 1 Computer tomography angiography scan of the head and neck revealing a penetrating metallic, radio-opaque foreign body in the right parotid gland located in the superficial and deep lobes
fistula or sialocele. [2] In their trial series, antibiotics were administered only to patients with clinical evidence of infection. Surgical exploration was reserved for those patients presenting within 24 h of injury. A subsequent trial series by Lewis and Knottenbelt [3] also concluded that conservative management was adequate for parotid duct injuries. Trauma to the salivary glands in the absence of a penetrating injury is particularly rare. The force required is considerable and there is usually an associated skeletal injury, either to the mandible or the temporomandibular joint [4, 5]. Roebker et al. [6] reported a case in which the submandibular salivary gland was ruptured following a blunt trauma sustained in a motor vehicle accident. However, there have been no case reports in which the parotid gland has ruptured following minor external force or in the absence of a penetrating wound. Perhaps the most clinically significant aspect of penetrating injury to the parotid gland is damage to the facial nerve. Given that early surgical exploration of an injured nerve can produce a favorable outcome, it is essential, when managing such patients, that facial nerve function is carefully documented and recorded. Youngs and Walsh-
123
Waring [7] reported three patients with facial palsy after open trauma, all of whom underwent surgical exploration of the nerve, and all of whom subsequently had good recovery. This case presents us with a zone III penetrating neck injury. As the patient was hemodynamically stable at presentation, the next step in the management of this patient was to perform an imaging study of the head and neck. The tomography scan did not demonstrate acute bleeding and as such, the patient was placed under observation without undergoing initial surgical intervention. However when facial nerve paresis developed, the patient was urgently taken to the operating room for surgical exploration. This, in combination with post-operative continuation of antibiotic and steroid treatment, resulted in a gradual regain of the facial nerve function. Presence of damage to the facial nerve is the primary factor to be considered in determining the management of parotid injury. If there is no facial nerve paresis or paralysis, the patient only needs to be observed. When signs of nerve involvement should subsequently appear, immediate surgical exploration is indicated for decompression or repair purposes. If the patient initially presents with signs of facial nerve injury, the exploration cannot be postponed and must be performed immediately. Conflict of interest support.
There is no conflict of interest or financial
References 1. Morestin M (1917) Contribution a` l’Etude du Traitement des Fistules Salivaires Conse´cutives aux Blessures de Guerre. Bulletin et Me´moires de la Societe des Chirurgiens de Paris 43:845–855 2. Landau R, Stewart M (1985) Conservative management of posttraumatic parotid fistulae and sialoceles: a prospective study. Br J Surg 72:42–44 3. Lewis G, Knottenbelt JD (1991) Parotid duct injury: is immediate surgical repair necessary? Injury 22:407–409 4. Ohlson NR (1977) Traumatic lesions of the salivary glands. Otolaryngol Clin North Am 10:345–350 5. Shetty DK, Rink B (1974) Effects of direct blunt trauma on the salivary glands. Deutsch Zahn Mund Kieferheilk 62:148–157 6. Roebker JJ, Hall LC, Lukin RR (1991) Fractured submandibular gland: CT findings. J Comput Assist Tomogr 15:1068–1069 7. Youngs RP, Walsh-Waring GP (1987) Trauma to the parotid region. J Laryngol Otol 101:475–479
CASE REPORT
Parotid injury due to penetrating and blast injury Marrigje Aagje de Jong • Jonathan Cohen Miriam Lorberbaum • Menachem Gross
•
Received: 1 December 2014 / Accepted: 3 January 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Introduction Fortunately, trauma to the parotid gland is rare. As the gland is well protected by a thick capsule and situated behind the mandible. The parotid, as a rule, can only be breached by a penetrating wound or violent external force, e.g. blast trauma, which causes fracturing of the mandible. In these instances, trauma to the gland parenchyma is usually superseded by trauma to other, more vital structures, necessitating surgical intervention.
bodies were embedded throughout the right-sided aspect of the skull and upper neck; no bone fractures or other injuries to major vessels of the head and neck were demonstrated. The patient was admitted to the otolaryngology department for observation and treatment. Four days following the injury, the patient developed right facial nerve paresis, primarily of the marginal mandibular branch. The patient underwent urgent surgical exploration of the right parotid region to remove the metallic foreign body on the fourth day of admission. Following surgery, the patient was treated with antibiotics and steroids. Treatment resulted in gradual, yet complete resolution of the facial weakness.
Case report A 27-year-old male was admitted to our trauma unit after sustaining a blast injury with penetrating trauma to the right parotid region. On admission, the patient was conscious and hemodynamically stable. Physical examination revealed periorbital hematoma with severe swelling of the right eye. Eye movement was normal. Bilateral acute tympanic membrane perforations were noted on otoscopic evaluation. On the right side, numerous penetrating blast particles and debris were noted in the parotid, with no facial nerve paresis or paralysis observed. The remainder of the physical examination was normal. Computer tomography (CT) angiography scan of the head and neck revealed a penetrating metallic, radio-opaque foreign body in the parotid gland located in the superficial and deep lobes (Fig. 1). In addition, numerous metallic, small foreign
M. A. de Jong (&) J. Cohen M. Lorberbaum M. Gross Department of Otolaryngology/Head and Neck Surgery, Hadassah Hebrew-University Medical Center, Jerusalem 91120, Israel e-mail: [email protected]
Discussion Trauma to the parotid gland is rare, usually the result of a penetrating wound, such as in war or following an assault. The most comprehensive published reports of such injuries date back to World War I, when Morestin [1] reported a series of 62 cases of parotid fistulae following battlefield wounds. Possible complications include: hemorrhage, intraparotid hematoma, sialocele, and salivary fistula. The most devastating complication is facial nerve paralysis or paresis, due to direct neural injury or to edema of the parotid parenchyma with subsequent pressure on the nerve. Historically, treatment consisted of surgically draining the fistula into the oral cavity. Subsequently, it was found that conservative management of parotid duct injuries was adequate. In a trial series of 14 cases of penetrating injuries, Landau and Stewart concluded that systemic probanthine, intravenous fluids, and an NPO (nil per os; nothing by mouth) regimen, combined with external pressure, produced resolution of symptoms, even in the presence of a
123
Eur Arch Otorhinolaryngol
Fig. 1 Computer tomography angiography scan of the head and neck revealing a penetrating metallic, radio-opaque foreign body in the right parotid gland located in the superficial and deep lobes
fistula or sialocele. [2] In their trial series, antibiotics were administered only to patients with clinical evidence of infection. Surgical exploration was reserved for those patients presenting within 24 h of injury. A subsequent trial series by Lewis and Knottenbelt [3] also concluded that conservative management was adequate for parotid duct injuries. Trauma to the salivary glands in the absence of a penetrating injury is particularly rare. The force required is considerable and there is usually an associated skeletal injury, either to the mandible or the temporomandibular joint [4, 5]. Roebker et al. [6] reported a case in which the submandibular salivary gland was ruptured following a blunt trauma sustained in a motor vehicle accident. However, there have been no case reports in which the parotid gland has ruptured following minor external force or in the absence of a penetrating wound. Perhaps the most clinically significant aspect of penetrating injury to the parotid gland is damage to the facial nerve. Given that early surgical exploration of an injured nerve can produce a favorable outcome, it is essential, when managing such patients, that facial nerve function is carefully documented and recorded. Youngs and Walsh-
123
Waring [7] reported three patients with facial palsy after open trauma, all of whom underwent surgical exploration of the nerve, and all of whom subsequently had good recovery. This case presents us with a zone III penetrating neck injury. As the patient was hemodynamically stable at presentation, the next step in the management of this patient was to perform an imaging study of the head and neck. The tomography scan did not demonstrate acute bleeding and as such, the patient was placed under observation without undergoing initial surgical intervention. However when facial nerve paresis developed, the patient was urgently taken to the operating room for surgical exploration. This, in combination with post-operative continuation of antibiotic and steroid treatment, resulted in a gradual regain of the facial nerve function. Presence of damage to the facial nerve is the primary factor to be considered in determining the management of parotid injury. If there is no facial nerve paresis or paralysis, the patient only needs to be observed. When signs of nerve involvement should subsequently appear, immediate surgical exploration is indicated for decompression or repair purposes. If the patient initially presents with signs of facial nerve injury, the exploration cannot be postponed and must be performed immediately. Conflict of interest support.
There is no conflict of interest or financial
References 1. Morestin M (1917) Contribution a` l’Etude du Traitement des Fistules Salivaires Conse´cutives aux Blessures de Guerre. Bulletin et Me´moires de la Societe des Chirurgiens de Paris 43:845–855 2. Landau R, Stewart M (1985) Conservative management of posttraumatic parotid fistulae and sialoceles: a prospective study. Br J Surg 72:42–44 3. Lewis G, Knottenbelt JD (1991) Parotid duct injury: is immediate surgical repair necessary? Injury 22:407–409 4. Ohlson NR (1977) Traumatic lesions of the salivary glands. Otolaryngol Clin North Am 10:345–350 5. Shetty DK, Rink B (1974) Effects of direct blunt trauma on the salivary glands. Deutsch Zahn Mund Kieferheilk 62:148–157 6. Roebker JJ, Hall LC, Lukin RR (1991) Fractured submandibular gland: CT findings. J Comput Assist Tomogr 15:1068–1069 7. Youngs RP, Walsh-Waring GP (1987) Trauma to the parotid region. J Laryngol Otol 101:475–479
