Lacerations and interruptions of Stensen's duct are not uncommon with facial injuries or during drainage of a parotid or facial abscess. 'Z In long- standing cases ...
266
SQUAMOUS
CELL
CARCINOMA
AND
MANDIBULAR
FIGURE 3. Ahovc~. Panoramic radiograph of bone around the right transosseous pin.
BONE
showing
PLATE
resorption
FIGURE 4. Bc/o~t,. Photomicrograph of moderately entiated squamous cell carcinoma, (Hematoxylin and original magnification X2.50.)
differeosin.
References FIGURE sertion.
I.
Ahot~.
Appearance
of staple
bone
plate after
in-
FIGURE 2. Exophytic granular tissue around the transosseous pin (c.rrr~r) and extending onto the floor of the mouth (hrlot~). J Oral Maxlllofac
I. Small IA: Survey of experience with the mandibular staple bone plate. J Oral Surg 36:604. 1978 2. Small IA: Metal implants and the mandibular staple bone plate. Chalmers J. Lyons Memorial Lecture. J Oral Surg
33:.571. 1975
Surg
41:266-267. 1983
Vein Graft Repair of a Chronic Duct Fistula N. ANANTHAKRISHNAN, Lacerations and interruptions of Stensen’s duct are not uncommon with facial injuries or during drainage of a parotid or facial abscess. ‘Z In longstanding cases of complete transection, especially of the masseteric portion of the duct, the distal portion trophies. In such situations ablative surgery has been recommended even though it is associated with significant morbidity.3 A technique is de-
* Lecturer in Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry 605006, India. Address correspondence and reprint requests to Dr. Ananthakrishnan.
Parotid
MBBS, MS, MNAMS* scribed gland.
which
is an alternative
to excision
of the
Report of a Case An 18-year-old male patient had a fistula of the masseteric part of the parotid duct resulting from drainage of a facial abscess at the age of 6 months. Two earlier attempts at direct repair at the ages of 5 and 11 years had failed (Fig. 1). On intraoral examination, the orifice of the duct was identified as a small dimple opening into a blindly ending tract about 5 mm deep. This was confirmed by a sialogram which showed extravasation of contrast medium on injection, whereas the duct system could not be visu-
267
ANANTHAKRISHNAN
FIGURE 1. Top /cfr, Preoperative
photograph showing the Iistula and the scars of previous operations.
FIGURE 2. Top. right. Preoperative ductal system.
sialogram showing extravasation
FIGURE 3. Bortom. left, Postoperative FIGURE 4.
Bort~r.
of contrast medium into the oral cavity and lack of filling of the
photograph showing polyethylene
right. Sialogram obtained a year postoperatively,
(Fig. 2). The proximal portion of the duct was about 6 mm long and could be cannulated through the fistula. As an alternative to parotidectomy, complete replacement of the duct with a 5 cm length of autologous saphenous vein was carried out. The venous segment was obtained through a vertical incision along the course of the vein immediately above the medial malleolus. The vein graft was washed thoroughly with saline. In suturing the vein graft to the parotid duct, care was taken to see that the direction of salivary flow would be the same as the flow of blood in the vein so that any valves in the grafted segment would not cause obstruction. From an extraoral approach, the graft was anastomosed end-to-end to the distal remnant of the duct with 6-O interrupted silk sutures. The vein graft was then placed in a submucosal tunnel extending;0 a site below gnd in front of the Stensen’s duct orifice. A disk of mucosa 5 mm in diameter was removed and the distal end of the vein graft was anastomosed to the periphery of the defect with 6-O silk sutures. An internal stint polyethylene tubing was placed before the suturing was done and was left in olace for a week (Fig. 3). Healing was uneventful. A repeat sialogram a year after repair showed a patent ductal system alized
of
(Fig. 4).
Discussion This technique has the advantages of allowing repair as an outpatient procedure with local anesthesia and not compromising future ablative surgery
tube stent in place.
showing a patent ductal system.
if unsuccessful. It is also an alternative when previous direct suturing of an injured duct has failed. To my knowledge, this is the first report of a successful complete replacement of Stensen’s duct with an autologous vein, although vein grafts have been used to bridge very small gaps in the duct.4 The latter method was successful in only one of two cases in which it was attempted and was not recommended by the authors because of technical difficulties encountered. Summary A long-standing fistula of Stensen’s duct with severe atrophy of the distal duct was repaired successfully by replacement with a 5 cm autologous saphenous vein graft. References 1. Halshand ER, Doku HC, Maloney PL: Parotid duct laceration-report of cases. J Oral Surg 28: 123, 1970 2. Morel AS, Firestein A: Repair of traumatic fistulas of the parotid duct. Arch Surg 87:623, 1963 3. Ranger D: Scott Brown’s Diseases of Ear, Nose and Throat. Vol. 4, London, Butterworths, 1971, pp 44-46 4. Kittamura T, Togawa K: Surgery of Stensen’s duct. Arch Otolaryngol 93: 189, 1971