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Table of Contents   
CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 2  |  Page : 336-339
Sialocele: An unusual case report and its management


Department of Oral Medicine & Radiology, Al-Ameen Dental College and Hospital, Bijapur, Karnataka, India

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Date of Submission17-Sep-2009
Date of Decision02-Jul-2010
Date of Acceptance26-Aug-2010
Date of Web Publication27-Aug-2011
 

   Abstract 

A post traumatic parotid sialocele is an acquired lesion that arises from extravasation of saliva into glandular or periglandular tissues secondary to disruption of the parotid duct or parenchyma. Facial trauma and surgery in the parotid region are the most common causes of this rare condition. This paper presents an unusual incidence of post traumatic parotid sialocele after Le-Fort II fracture reduction and its management by relatively simple and cost-effective technique which can be carried out in routine dental surgery suite. The results achieved justify our recommendation of scalp vein cannula for the treatment of sialocele in clinical practice.

Keywords: Scalp vein cannula, sialocele, traumatic injury

How to cite this article:
Sulabha A N, Sangamesh N C, Warad N, Ahmad A. Sialocele: An unusual case report and its management. Indian J Dent Res 2011;22:336-9

How to cite this URL:
Sulabha A N, Sangamesh N C, Warad N, Ahmad A. Sialocele: An unusual case report and its management. Indian J Dent Res [serial online] 2011 [cited 2014 Oct 21];22:336-9. Available from: http://www.ijdr.in/text.asp?2011/22/2/336/84314
Facial swellings commonly present to the clinician on a regular basis and can be due to wide range of causes. [1] Parotid injuries are usually not so obvious and they may go unseen till complications are seen. Parotid effusion, sialocele and fistula are some of those complications. [2] Sialocele is an acquired lesion that occurs when there is a collection of saliva beneath the skin if duct leaks out but no fistula forms or it may also result when glandular substance of parotid is disrupted but parotid duct is intact. Sialocele is an intermediate length complication, early being the parotid effusion. [3]

Both surgical and nonsurgical approaches are accepted as modalities of treatment for sialocele, as untreated sialocele may develop into significantly large facial swelling. Fistula formation usually occurs often draining extraorally. [4]

Reports of parotid sialocele after mid facial surgery are scanty in the literature. Therefore, the purpose of this article is to present such an unusual case report and its management by a relatively simple technique. Treatment that allows drainage and quick resolution of the pseudocyst is necessary to minimize the damage that might ensue. [5]


   Case Report Top


A 28-year-old male patient was referred to the out-patient department with a large progressive swelling on right side of the face (preauricular region) of 6-7 days duration [Figure 1]. Patient's history revealed that he had road traffic accident 7 days back.
Figure 1: Preoperative photograph of the patient showing swelling on the right side of the face following road traffic accident

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Clinical and radiological examination confirmed Lefort II fracture with no intraoral communication on left side [Figure 2]. His medical history was unremarkable. The patient was taken for surgical reduction of Lefort II fracture. An intraoral vestibular degloving incision was given and subperiosteal dissection was done to expose the fracture fragment. After adequate reduction of fracture fragments the rigid fixation was achieved using two miniplates and wound was closed in two layers using resorbable vicryl (3-0) suture material.
Figure 2: Radiograph showing Lefort II fracture on the right side

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After 12 days the patient presented with a huge painful swelling on left side of the face [Figure 3]. On physical examination patient appeared generally well and was afebrile. Swelling measured 5 cm×5 cm. On palpation swelling was soft, slightly tender, with no significant change in the color of the skin. It was provisionally thought to be postoperative oedema and patient was put on a course of antibiotics and anti- inflammatory drugs. Three days later, the swelling did not subside and patient also reported an increase in the size of the swelling during meal time. There was no associated lymphadenopathy.
Figure 3: Postoperative photograph showing the swelling on the right side

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A provisional diagnosis of post operative parotid sialocele was made. Aspiration was carried out which yielded 25 ml of fluid which was slightly straw colored clear fluid with watery consistency [Figure 4]. The diagnosis of salivary fluid was confirmed by elevated salivary amylase content (40,000 units/L) of aspirated fluid. The patient was instructed to abstain from intake of sour food or drink. Daily percutaneous aspirations of fluid under antimicrobial therapy (Amoxicillin, 500 mg TID by oral route) for 1 week did not improve the condition. After each aspiration, the swelling subsided, but reappeared some hours later.
Figure 4: Photograph showing the aspirated fluid

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On the post-operative day 12, scalp vein cannula (N0 22) was introduced into the swelling intraorally [Figure 5]. After the induction of local anaesthesia, the incision was made on right buccal mucosa near the duct opening. Scalp vein cannula was inserted into the cavity and was secured with buccal mucosa with sutures (Vicryl 5-0), which allowed continuous drainage of the fluid into the oral cavity via the tube [Figure 6]. The tube was maintained for 2 weeks to allow epithelization of the track surrounding the tube after which it was removed. The patient was under the antibiotic coverage (Amoxicillin/Clavulanic acid and metronidazole) for 2 weeks. The subsequent healing was uneventful and a follow up of 1 year postoperatively revealed no recurrence of the lesion [Figure 7].
Figure 5: Photograph showing the scalp vein cannula

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Figure 6: Intraoral photograph showing the inserted cannula

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Figure 7: Photograph of patient after 1 year follow up

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   Discussion Top


Sialocele, or salivary pseudocyst, is a rare complication. [5] The sialocele is a subcutaneous cavity containing saliva, usually resulting from trauma to the parotid gland parenchyma, laceration of the parotid duct or ductal stenosis with subsequent dilation. Extravasation of saliva into the surrounding tissues occurs following injury thus creating the sialocele. [1]

Parotid injuries usually present within 24 h of parotid effusion which presents as an extensive soft tissue swelling of the face on the side of the injury. Parotid effusion is not well recognized entity and often misdiagnosed as hematoma. Diagnosis of parotid injury at this stage may allow primary repair of the duct. If parotid injury is missed at this stage, an inflammatory pseudo capsule limits further extravasation of saliva into the neck tissue planes and the patient goes on to develop sialocele or an external parotid fistula. [6]

Sialocele typically develops 8-14 days after injury. [4],[6] Similar finding was noticed in the present case. Unless secondarily infected there is absence of pain and on palpation it is soft and mobile. Infection is an important complication in a sialocele and usually leads to an external salivary fistula. [6]

The parotid duct can be imagined as being in the middle third of line drawn from tragus of ear to a point midway between vermillion border of upper lip and ala of nose. Any laceration crossing this line must be suspected of having a damaged parotid duct or its accompanying neurovascular bundle and should be meticulously assessed. [4],[6] In the present case surgical procedure during the fracture reduction might have caused trauma to the parotid area indicating probable iatrogenic ductal disturbance and certain communication between the duct and residual cavity as there was rapid return of the swelling to large size following the aspiration, thus indicating the relationship of trauma to the sialocele formation, which was similar to the finding reported by M C Bater. [1],[7]

Diagnosis of sialocele is usually straightforward and can be made by history and clinical assessment of patient. Often history of trauma or surgical wound before the onset of the swelling will be present as was seen in the present case. An aspirated fluid medium is analyzed for salivary amylase (exceeding 10,000 U/L). [1],[4],[6] Radiological examinations (CT, MRI,) have very small role in detecting injuries to area of parotid gland. [2] Ultrasound may help to assess sialocele. Common linear transducers did not give us any significant diagnostic information in the present case. Sialography may be performed however some authors have claimed that sialography may increase the pressure in sialocele causing rupture and fistula. [1],[8]

Management of sialocele has been controversial. Both surgical and non-surgical treatment modalities are reported in the literature. [6],[9] Some authors postulated that minor sialoceles resolve spontaneously by the end of 1 month because scar tissue formation around transected margins of the salivary parenchyma seals any further flow of saliva from the remaining salivary parenchyma. [3]

Various non-surgical or conservative approaches are repeated aspiration and pressure dressing, radiation therapy at 6-20 Gy but it is no longer popular because radiation doses required for healing are high and may be carcinogenic, administering nothing orally to the patient until fistula closes, antisialogogues like atropine or probanthine can be used but their side effects restrict their use. [5],[6]

Surgical procedures can be divided into two groups.

  • Methods which depresses parotid secretion
  • Methods which diverses the parotid secretion into the mouth.
Methods which depress parotid gland secretion are duct ligation and section of auriculotemporal or Jacobsen's nerve.

Methods which diverse parotid secretion into mouth are parotidectomy (The management of sialocele remain controversial, parekh et al have reported this method under the techniques that divert parotid secretion in the mouth as authors pointed out in relevant studies. Sialocele can be seen in superficial parotidectomy if it is associated with ductal injuries.), excision and cauterization of fistula, drainage of proximal duct by catheter thus forming a controlled internal fistula or reconstruction of duct by mucosal flap, suture of proximal duct to buccal mucosa, reconstruction of duct with vein graft. [5]

Most of above procedures are invasive with variable and often poor success rates. [1] Multiple aspirations were carried out in the present case which did not resolve swelling. A technique of intraoral drainage with insertion of scalp vein cannula as done in the present case has been described for the treatment of parotid sialocele when conservative management fails or when overlying skin has become so thin that there is imminent rupture. [1] This procedure creates an intraoral salivary fistula as one end of the tube remains within the sialocele while the other drains saliva into the mouth. This technique maintained more patent opening. [1] Inflammatory response and epithelization of the track surrounding the tube prevented the recurrence till date.


   Conclusion Top


Although parotid gland and duct injuries represent a small percentage of overall soft tissue traumas, dentist must be aware of such injury because failure to recognize it will permit the onset of number of different complications, some of which are difficult to resolve. In addition care must be taken when making incisions in the depth of the upper buccal sulcus to avoid cutting the stenson's duct. (Surgeries in the midfacial region should be meticulous enough to avoid injury to the duct or gland in course of making incision and dissection). Based on the experience in managing the present case we believe intraoral drainage with scalp vein cannula should be considered as a minimally invasive and cost-effective option for the treatment of sialocele.

 
   References Top

1.Bater MC. An unusual case of preauricular swelling: A giant parotid sialocele. Int J Oral Maxillofac Surg 1998;27:125-6.  Back to cited text no. 1
[PUBMED]    
2.Lewkowicz AA, Hasson O, Nahlieli O. Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg 2002;60:676-80.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Witt RL, Philadelphia PA. The incidence and management of sialocele after parotidectomy. Otolaryngol Head Neck Surg 2009;140:871-4.  Back to cited text no. 3
    
4.Canosa A, Cohen MA. Poast traumatic parotid sialocele report of two cases. J Oral Maxillofac Surg 1999;57:742-5.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Lapid O, Kreiger Y, Sagi A. transdermal scopolamine use for postrhytidectomtomy sialocele. Aesth Plast Surg 2004;28:24-8.  Back to cited text no. 5
    
6.Parekh D, Glezerson G, Stewart M, Esser J, Lowson HH. Post traumatic parotid fistulae and sialocele a prospective study of conservative management in 51 cases. Ann Surg 1989;209:105-11.  Back to cited text no. 6
    
7.Jayasuriya NS, Kumara SA, Sabesan T. Parotid sialocele: A rare complication of a fracture of the zygomatic complex. Br J Oral Maxillofac Surg 2008;46:106.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Dierks EJ, Granite EL. Parotid sialocele and fistula after mandibular osteotomy. J Oral Surg 1977;35:299-300.   Back to cited text no. 8
[PUBMED]    
9.Demetriades D, Rabinowitz B. Management of parotid sialoceles: A simple surgical technique. Br J Surg 1987;74:309.  Back to cited text no. 9
[PUBMED]    

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Correspondence Address:
A N Sulabha
Department of Oral Medicine & Radiology, Al-Ameen Dental College and Hospital, Bijapur, Karnataka
India
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PMID: 21891909

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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