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POST TRAUMATIC SIALOCELE:A CASE REPORT AND LITERATURE REVIEW.

Byline: MUSLIM KHAN, SANA WAZIR, ASHFAQ WAZIR and YASIR REHMAN

ABSTRACT

Sialocele is an acquired lesion due to extravasation of saliva into the subcutaneous tissues due to trauma or surgery in the glandular region. Sialocele typically develops 8 to 14 days. Ultrasound of neck can be helpful in diagnosis of facial swelling. A case of 25 year old male patient with progressive facial swelling in the sub mental regionwith history of fire arm injury, which was diagnosed as sialocele is being reported. Sialography can be helpful in the diagnosis, but can increase further pressure in sailocele. In this case, diagnosis was made on history, clinical examination, aspiration of contents and ultrasound. The objective of the study is to present a case of post traumatic sialocele developing after fire arm injury. A detailed description of the condition and its management along with literature review is presented.

Key Words: Oral and Maxillofacial Surgery, post traumatic sialocele and fire arm injury.

INTRODUCTION

A sialocele (also called salivary mucocele or sali- vary retention cyst) is an accumulationof saliva sur- rounded by tissue reaction to the saliva. The result is a fluid filled sac which can occur under the tongue (a ranula), in the neck or buccal regions, or adjacent to the pharynx.1 It is a pseudocyst, without a distinct epithelial lining. It usually becomes apparent 8-14 days after an injury but maybe delayed.2,3 Facial lac- erations or an operative procedure such as a mandibu- lar osteotomy are frequent initiating factors.4 Other causes for these accumulations of saliva are obstruc- tion (usually caused by inflammation, sialolithiasis) and foreign bodies.5 It can become infected and form an abscess. Extra-oral fistula formation is a possibility, as is the secondary infection.1 Diagnosis of sialocele is based on history and clinical assessment of the pa- tient. Often history of surgical wound or trauma will be present before development of swelling,6 as was present in this case.

Management of sialocele has been contro- versial. Both surgical and nonsurgical treatment mo- dalities are reported in the literature.7,8

The objective of this case report is to give a detailed description of post traumatic sialocele developing af- ter fire arm injury in a young male patient, along with literature review.

CASE REPORT

A 25 years old male patient, reported to Oral and Maxillofacial Surgical Unit, Khyber College of Den- tistry with communited fracture of mandible extend- ing from left parasymphsis and right angle due to firearm injury (FAI). He was a diagnosed case of tuberculosis and was on anti-tuberculose treatment. A detailed intraoral and extra-oral examination was performed. On intraoral examination he had satisfactory oral hygiene and was fully dentate. Lower left first premolar and central incisor were mobile with a dis- turbed occlusion and hematoma in the floor of the mouth. Gingival laceration was also found in the region of communited fracture. Mouth opening was limited. Extra-oral examination revealed an entry wound on left side of mandible in angle region and exit wound on right side of the neck. The lower border of the mandible was tender on palpation. Marginal man- dibular branch of facial nerve was intact on examina- tion. Base line investigations including hepatitis B and hepatitis C were negative.

Blood sugar and urea were within the normal range. After consultation with patient physician and assessment for fitness of gen- eral anaesthesia patient was scheduled for seqeustrectomy and maxillomandibular fixation for 8 weeks.

After one month, patient presented with a soft, fluctuant and mobile swelling in the sub mental region plunging in the midline. Patient complained of a vague pain along the right side of mandible and respiratory problem but he did not mention any increase in size of swelling during oral intake nor decrease in swelling during decrease salivary flow rates. The overlying skin was intact with no change of temperature or other signs of inflammation. On physical examination pa- tient was generally well and afebrile. On palpation the swelling was soft and mobile. On bimanual palpation the swelling was lobulated with smooth margins. The patient denied any discharge from the swelling. No extra-oral or intraoral fistula was detected. Swelling measured about 9 cm in length and 7 cm in width. No skin discoloration, erythema and sensory or motor deficits were found. Right submandibular node was palpable.

On intraoral examination there was a mild bulging of the mucosa of the floor of the mouth on the right side, suggesting the increased size of the right sub lingual gland. On aspiration thick straw coloured viscous secretions were found, about 70 cc of fluid was aspirated in the first visit to decompress the swelling and relieve respiratory problem. (Fig. 1)

The patient was sent for ultrasound of the neck as a part of the workup for progressive facial swelling. The ultrasound report stated cystic lesion lying super- ficially in submandibular and submental region with internal septa and contents having echoes. Thyroid gland appeared normal on ultrasound. On basis of history, clinical examination and ultrasound report a provisional diagnosis was made that it was a post traumatic sublingual sialocele.

The patient was treated under general anaesthe- sia. A small stab incision was made in the sub mental region after blunt dissection thick viscous fluid of about 250 cc was drained. The swelling decreased in size. A mucosal incision on the right side of the floor of mouth was made and right sublingual gland was removed in toto. (Fig 2). Right Whartons duct was identified and redirected posteriorly in the mouth. Repair was done with 3/0 silk. A 3 cm corrugated rubber drain was placed in the extra-oral incision and pressure dressing applied. On follow up visit the pa- tient was asymptomatic with no complaint of swelling and pain. (Fig 3)

DISCUSSION

Sialocele, or salivary pseudocyst, is a rare compli- cation. The sialocele is a subcutaneous cavity contain- ing saliva, usually resulting from trauma to the gland parenchyma, laceration of duct or ductal stenosis with subsequent dilation. Extravasation of saliva into the surrounding tissues occurs following injury thus cre- ating the sialocele.2,9 Sialocele is an acquired lesion and an intermediate length complication early being the gland effusion.10

Sialocele typically develops 8-14 days after in- jury.11,12 Unless secondarily infected there is absence of pain and it is soft and mobile on palpation. Infection is an important complication in sialocele and leads to external salivary fistula.12

Diagnosis of sialocele is made by history and clini- cal assessment of patient. An aspirated fluid medium is analyzed for salivary amylase (exceeding 10,000 U/ L in case of parotid sialocele).7,9,11 In this case, sialochemistry revealed salivary amylase of 281 U/L which further confirmed the swelling to be of sublin- gual origin. As salivary amylase tend to be increased in serous secretions, sublingual gland being predomi- nantly mucous the salivary amylase was decreased. Radiological examinations (CT, MRI) have very small role in detecting injuries to area of parotid gland.13CT scan will reveal a single or multiloculated cyst-like mass with less density than the surrounding tissues with smooth margins.14 Ultrasonography is a useful examination to use for diseases of the salivary glands and for confirming the cystic nature and precise loca- tion of a sialocele. Ultrasound scaning commonly dem- onstrates a complex fluid collection sometimes with septation and debris.15

Sialography may be performed, however some authors have claimed that sialography may increase the pressure in sialocele causing rupture and fistula.3,9 In the present case sialography was avoided because of the above mentioned reason and also the previous fire arm injury (FAI) and surgery has distorted the normal anatomy and posed a difficulty in performing sialography. The development of new diag- nostic tools such as magnetic resonance sialography and endoscopic techniques (sialoendoscopy) has led to further improvements in the clinical and diagnostic assessment of this condition.16

Numerous methods described in the literature for sialocele treatment.1 Some authors postulated that minor sialoceles resolve spontaneously by the end of one month because scar tissue formation around transected margins of the salivary parenchyma seals any further flow of saliva from the remaining salivary parenchyma.10 Various non-surgical or conservative approaches are repeated aspiration and pressure dress- ing, 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 noth- ing orally to the patient until fistula closes, anti- sialogogues like atropine or probanthine can be used but their side effects restrict their use.2,7 Botulinum toxin therapy has recently been described as a highly effective, safe, and non invasive method of treatment in the management of parotid sialoceles.17Lapid et al.2 reported the application of transdermal scopolamine resulted in resolution of a postrhytidectomy sialocele within 6 days.

Surgical procedures for parotid sialocele can be divided into two groups: First, methods which de- presses secretion of the parotid gland are duct ligation and section of auriculotemporal or Jacobsen's nerve and second are the methods which diverges the secre- tion into the mouth including gland removal, 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.2

As sublingual sialocele is rarely reported in the literature, in the present case sialocele was associated with difficulty in respiration and was of cosmetic concerns, we opted for gland removal and decompres- sion by pressure dressing.

CONCLUSION

Post traumatic sialocele should be considered in the differential diagnosis of submental and submandibular swelling after excluding infection and other causes of such swellings.

REFERENCES

1 Hashemi, D. Farrokh, M. Mohammadifard J. Delayed post trau- matic parotid sialocele: Report of a case.Iran. J. Radiol., 2006,3(4): 229-33.

2 Lapid O, Kreiger Y, Sagi Aetal.Transdermal scopolamine use for post rhytidectomtomy sialocele. Aesth Plast Surg 2004; 28:24-8.

3 Dierks EJ, Granite EL. Parotid sialocele and fistula after mandibular osteotomy. J Oral Surg 1977; 35: 299-300.

4 Cholankeril JV, Scioscia PA. Post-traumatic sialoceles and mucoceles of the salivary glands. Clin Imaging 1993; 17: 41-45.

5 Saifzedah. S. Sublingual sialocele (ranula) in German shepherd dog. Iran. J. Veter 2004; 5: 117-21.

6 Sulabha AN, Sangamesh NC, Warad N, Ahmed A. Sialocele: An unusual case report and its management. Ind. J of Dent. Res 2011; 22(2): 336-9.

7 Parekh D, Glezerson G, Stewart M, EsserJ, Lowson H H. Post traumatic parotid fistulae and sialocele a prospective study of conservative management in 51 cases. Ann Surg 1989; 209:105-11.

8 Demetriades D, Rabinonitz B. Mangement of parotid sialoceles.A simple surgical technique. Br J Surg. 1987; 74: 309.

9 Bater MC. An unusual case of preauricular swelling: A giant parotid sialocele. Int J Oral Maxillofac Surg 1998; 27: 125-6.

10 Witt RL, Philadelphia PA. The incidence and management of sialocele after parotidectomy. Otolaryngol Head Neck Surg.2009; 140:871-4.

11 Canosa A, Cohen MA. Poast traumatic parotid sialocele report of two cases. J Oral Maxillofac Surg 1999; 57: 742-5.

12 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.

13 Lewkowicz AA, Hasson O, Nahlieli O. Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg 2002; 60: 676-80.

14 Yasumoto M, Nakagawa T, Shibuya H, Suzuki S, Satoh T.Ultrasonography of the sublingual space. J Ultrasound Med 1993; 12(12): 723-9.

15 Cholankeril JV, Ravipati M, Khedekar S, Janeira LF, Villacin A: Unusually large sialocele: CT characteristics. J Comput Assist Tomogr 1989; 13: 367-8.

16 Capaccio P, Paglia M, Minorati D, Manzo R, Ottaviani F. Diag- nosis and Therapeutic management of iatrogenic parotid sialocele. Ann Otol Rhinol Laryngol 2004: 562-4.

17 Vargas H, Galati LT, Parnes SM. A pilot study evaluating the treatment of post parotidectomy sialoceles with botulinum toxin type A. Arch Otolaryngol Head Neck Surg 2001; 127:339-40.

For correspondence: Dr. Muslim Khan

1 Associate Professor Oral and Maxillofacial Surgery, Khyber College of Dentistry, Peshawar. C/O Haji Muhammad Rehman and Sons Shop No. 40 Ashraf Road Peshawar City Email. muslim177@hotmail.com

2 Senior Resident Oraland Maxillofacial Surgery

3 Assistant Professor, Oral and Maxillofacial Surgery, Peshawar Dental College, Warsak Road, Peshawar Cantt.

4 Resident Oral and Maxillofacial Surgery Received for Publication: February 1, 2013 Revision Received: February 15, 2013 Revision Accepted: February 22, 2013
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Publication:Pakistan Oral and Dental Journal
Date:Apr 30, 2013
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