Parotid sialocele in a 10-year-old girl.

Dr. Sataloff again has demonstrated leadership as editor-in-chief of EAR, NOSE & THROAT JOURNAL. During his tenure, he has expanded the ENT Clinics, increased participation among otolaryngologists through the Editorial Board, and, with the addition of the Pediatric Otolaryngology Clinic, has embraced the full spectrum and breadth of our specialty.

My colleagues have generously volunteered their time and their experience to bring interesting cases to the forefront and share them with all otolaryngologists. Enjoy the Pediatric Otolaryngology Clinic. We welcome suggestions and will tailor this Clinic to the needs of our readership. I wish all of you a healthy and prosperous 2007.

--Rande H. Lazar, MD

Clinic Editor

A 10-year-old girl presented with a 2-month history of a swelling over her right cheek. She had been seen at an outside hospital, where the swelling had been aspirated on two different occasions, only to recur within a day both times. There was no associated pain or alteration of facial function. Her medical history included minor trauma to the area from a piece of glass that she experienced while changing a light bulb. The piece of glass had been removed from her cheek uneventfully. The swelling had appeared a week later.

Examination revealed a smooth, translucent swelling in the skin over the right parotid gland (figure 1). The skin over the swelling was attenuated but not inflamed. There was no tenderness on palpation. Aspiration of the swelling yielded clear fluid that had an amylase level of 400,000 U/L. Computed tomography (CT) with sialography revealed a sialocele (figure 2).

[FIGURES 1-2 OMITTED]

The sialocele was approached via a parotidectomy incision (figure 3). The cyst was opened, and the distal end of Stensen's duct was identified. The proximal end could not be found. The proximal part of the cyst was closed with nonabsorbable sutures. The patient's postoperative recovery was uneventful, and follow-up revealed no recurrence 4 months postoperatively. The skin over the swelling healed with minimal scarring.

[FIGURE 3 OMITTED]

Sialoceles are known complications of penetrating trauma to the parotid gland. They can also follow parotidectomy or rhytidectomy. The parenchyma of the gland is usually injured, and Stensen's duct is lacerated or divided. A sialocele typically presents a few days after trauma or surgery as a cystic mass in the area. However, isolated injury of the parotid duct without facial nerve injury is rare, and almost all reported cases have occurred in adults following an assault with a knife, bottle, or firearm. Failure to detect and repair a ductal injury can result in a salivary fistula, sialocele, facial abscess, or atrophy of the involved parotid gland.

Stensen's duct injury is classified according to the anatomic site. A injuries are posterior to the masseter, B injuries are over the muscle, and C injuries are anterior to the muscle. Site B and C injuries are more likely to develop in complications, and hence should be repaired immediately over a stent.

When a Stensen's duct injury is suspected, the duct may be cannulated and methylene blue may be gently injected into it. Extravasation of the dye from the wound would signify ductal injury. Different forms of treatment have been advocated for sialoceles, including repeated aspiration, pressure dressings, rerouting of the duct, reconstruction with a vein graft, tympanic neurectomy, and partial or total parotidectomy. Antisialagogues are frequently used alone or in combination with other forms of therapy; these anticholinergic drugs act on the cholinergic, parasympathetic, secretomotor neurons of the gland and cause a temporary reduction in salivary output. This reduction allows the injured gland or duct to heal, although it might cause side effects such as dry mouth, constipation, blurred vision, headaches, and drowsiness. Botulinum toxin, which causes temporary chemical denervation of the cholinergic nerve fibers, has also been used successfully to manage sialoceles.

Suggested reading

Lewis G, Knottenbelt JD. Parotid duct injury: Is immediate surgical repair necessary? Injury 1991;22:407-9.

Van Sickels JE. Parotid duct injuries. Oral Surg Oral Med Oral Pathol 1981;52:364-7.

Vargas H, Galati LT, Parnes SM. A pilot study evaluating the treatment of postparotidectomy sialoceles with botulinum toxin type A. Arch Otolaryngol Head Neck Surg 2000; 126:421-4.

Kevin D. Pereira, MD; Stacey L. Smith, MD; Ron B. Mitchell, MD

From the Department of Otolaryngology-Head and Neck Surgery, University of Texas-Houston Health Science Center (Dr. Pereira and Dr. Smith), and the Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University, Richmond (Dr. Mitchell).