Trauma stensen duct.pptx

8/14/2019 Trauma stensen duct.pptx

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I'm a surgeon. I make an incision, do what

needs to be done and sew up the wound.

Richard Selzer Professor of Surgery of Yale University


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History

RIOLAN 1648: Identified the glandular substance ofparotid

NIELS STENSON 1660: Identified the parotid duct insheep

THOMAS WARTON 1656 Identified the submandibulargland and duct

HEYFELDER 1825: Avoided the facial nerve afterparotidectomy

VELPEAU 1830: Identified trunk of facial nerve

BELL AND VELPEAU: Determined the facial nerve wasresponsible for facial animation. Determined facialsensation was from CN V.


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Anatomical Considerations

Twosubmandibular

Two Parotid Two sublingual

> 400 minor

salivary glands


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Minor salivary glands

These lie just under mucosa.

Distributed over lips, cheeks,palate, floor of mouth & retro-

molar area. Also appear in upper

aerodigestive tract

Contribute 10% of total

salivary volume.


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Parotid Gland

The parotid gland represents thelargest salivary gland

The following lists the boundaries ofthe parotid compartment:

Superior border Zygoma

Posterior border ExternalAuditory CanalInferior border Styloid Process,Styloid Process musculature,Internal Carotid Artery, JugularVeins

Anterior border a diagonal linedrawn from the Zygomatic root tothe EAC


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courses anteriorly fromthe parotid gland over the

masseter muscle

it pierces the buccinator

muscle to enter throughthe buccal mucosa,

usually opposite the

second maxillary molar.

The Stensen duct can be

found approximately 1.5cm below the zygoma.

The parotid duct, or

Stensen duct,

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Facial nerve

divides the gland into

the superficial (80 %)and deep lobe (20%)

www.similima.com 8


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Parotid Gland

Cranial Nerve VII divides it into 2 surgicalzones (the superficial and deep lobes).

After exiting the foramen, it turns laterallyto enter the gland at its posterior margin.

The nerve then branches at the Pes

Anserinus (gooses foot) approximately 1.3cm from the stylomastoid foramen. Thenerve then gives rise to 2 divisions:

1)Temperofacial (upper) 2)Cervicofacial (lower)


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Cranial Nerve VII

Followed by 5terminal branches:

1)Temporal

2)Zygomatic3)Buccal

4)Marginal

Mandibular5)Cervical


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Parotid Gland

80% of the gland overlies theMasseter and mandible. Theremaining 20% of the gland

(the retromandibular portion

This portion of the gland lies inthe Prestyloid Compartment of

the Parapharyngeal space
http://en.academic.ru/pictures/enwiki/71/Gray1024.png


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Parotid Gland

Stensens duct arises from the anteriorborder of the Parotid and parallels theZygomatic arch, 1.5 cm inferior to theinferior margin of the arch.

It runs superficial to the massetermuscle, then turns medially 90degrees to pierce the Buccinatormuscle at the level of the second

maxillary molar where it opens ontothe oral cavity.


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Parotid Gland

Neural compartment

VII, Great Auricular, Auriculotemporal

Venous compartment Retromandibular vein

Arterial compartment

Superficial Temporal/Transverse Facial


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The parotid gland has two layers ofdraining lymph nodes.

The superficial layer (periparotid ) lies

beneath the capsule, and

The deeper layer (intraparotid) lies within

the parotid parenchyma.

Lymphatic drainage

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Functions of saliva include the following:

It has a cleansing action on the teeth

It moistens and lubricates food during mastication andswallowing

It dissolves certain molecules so that food can be tasted

It begins the chemical digestion of starches through theaction of amylase, which breaks down polysaccharides intodisaccharides.

The saliva from the parotid gland is a rather thin, wateryfluid, but the saliva from the sublingual and thesubmandibular glands contains mucus and is much thicker.


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PAROTID DUCT INJURIES

Pasien pasien yang mengalami cedera pada duktusparotikus, 47% diantaranya dapat sembuh tanpaadanya komplikasi. Komplikasi awal pada pasiendengan cedera duktus parotikus yaitu 21% dapat

berupa sialocele yang dapat terbentuk dalam 4 jampertama paska trauma


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Classification of Injuries

Tipe 1 : terjadi kompresi dari duktusstensen pada kurvatura di sekitarm.masseter akibat dari tekanan dariSuperficial Muscular Aponeurotic System( SMAS ). Jenis cedera ini menyebabkanpembengkakan yang bersifat sementarapada kebanyakan pasien ( Gambar 1 S )

Tipe 2 : laserasi dari kapsula kelenjarparotis. Tipe cedera ini menyebabkanpembengkakan pada lokasi dimanaterjadinya laserasi. ( gambar 1 b )

Tipe 3 : kompresi dari duktus stensenpada kurvatura di sekitar m.masseterakibat dari tekanan yang berasal dariSMAS dan laserasi dari kapsula kelenjarparotis ( Kombinasi tipe 1 + tipe 2 ).

Tipe 4 : ruptur komplit ataupun lukapenetrasi dari saluran air liur atau salahsatu dari percabangan utama yangmengakibatkan sialocele yang terdapatpada area penetrasi. ( gambar 1 C )


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Etiologies of Injury

Diklasifikasikan berdasarkan mekanisme, lokasi, dandaya trauma penyebab cedera :

Akut

Laserasi,

Luka tembus

Avulsi ( akibat gigitan binatang ataupun manusia )

Trauma tumpul ( dimana jaringan mengalami kompresi denganataupun tanpa rusaknya duktus parotikus).

Kronis iritasi kronis dari struktur gigi geligi yang mengiritasi lubang

saluran duktus parotikus

Benda asing ( corpus alienum ) di dalam saluran duktus parotikus

Radiasi Eksterna


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Examinations & Evaluations

Status regional :

kulit, mukosa mulut, lidah, dan struktur gigi geligi sertapenilaian adanya fraktur pada tulang di sekelilingnya dan Otototot daerah wajah serta mastikasi

adanya cedera yang biasanya ditandai dengan adanya air liurpada luka trauma.

Fungsi dari nervus fasialis dan percabangannya dan nervuslingualis dan nervus hipoglosalis juga harus diperhatikan pada

pasien pasien yang mengalami cedera di area parotis. Bila terdapat keraguan, dilakukan kanulasi pada duktus

parotikus mealui lubang bukaan alami dengan suatu probelakrimal ataupun kateterisasi


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Penilaian nervus fasialis : Gerakan tersenyum, menyeringai, mencucu bibir dan juga gerakan

meniup. Fungsi sensorik dan motorik pada lidah juga harus dinilai.Pada kasus kasus transeksi nervus, bagian distal perlu dinilaidengan stimulator elektrik.

Trauma pada area wajah dengan melibatkan daya yangcukup untuk menyebabkan fraktur tulang wajah dapatdikaitkan dengan cedera kelenjar liur, terutama kelenjarparotis beserta sistem salurannya.

Terdapat beberapa laporan kasus fraktur maxilla disertai

laserasi dari duktus stensen yang telah mengalami prosespenyembuhan dengan adanya fistula parotid antral.Secara klinis, pasien pasien tersebut mengalamirinnorrhoea prandial.


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Aspirasi cairan dari area area pembengkakan disekitar area parotis. Kadar amylase yang lebih dari10.000 units/liter dapat mengkonfirmasi adanyasuatu cedera pada kelenjar parotis besertasalurannya.


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Radiologic Imagings

Sialografi pemeriksaan sialografi

dengan menyuntikan kontraskedalam duktus kelenjarparotis sehingga jalur darialiran saliva dapat

divisualisasikan melalui fotopolos.

tidak boleh dilakukanapabila pasien menderitainfeksi akut kelenjar liur,

memiliki hipersensitivitasterhadap iodium yangmerupakan salah satukomponen dalampemeriksaan sialografi.


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MRI vs CT


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Concluded:

MRI better at distinguishing intrinsic vs extrinsic

Inaccuracy rate of both MRI and CT was the same

MRI 3x more expensive than CT

CT and MRI are morphologically equivalent studiesand have the same diagnostic tools


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Post-Operative XRT


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Management of Stensons Duct Injuries

1. Magnification of operating areas2. Cannulation of the duct through the orifice

3. Pressing on the gland to express saliva into thewound to identify the proximal portion of the duct

4. Ductal lacerations should be repaired as soon asfeasible

5. Ductal lacerations should be suspected if weaknessof upper lip on puckering with a laceration of thecheek

6. Stensensduct is located on a line drawn from thetragus to the midpoint between the upper lipmargin and the columella


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7. The duct is usually located inferior to a small artery andsuperior to a branch of facial nerve

8. Duct laceration should be suspected in all cheekwounds located lateral to the vertical line of the pupiland inferior to a line at the level of tragus

9. Surgical techinques :

Fixation of the ductal splint Suturing the splint to the oral mucosa

Taping the splint to the face

Combinations

Passing the splint through the parenchyma of the gland andthrough the skin ( Abramson, 1973).

10. Significant injury of stensonsduct rerouting of theremaining duct through the buccal mucosa andcreation of a fishmouthopening to prevent stenosis.


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TERIMA KASIH

Documents

Trauma stensen duct.pptx