Fistulas of the salivary glands and their excretory ducts: causes, symptoms, diagnosis, treatment

Fistulas of the submandibular salivary gland in peacetime are extremely rare.

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

What causes fistulas of the submandibular salivary gland?

There are fistulas of the submandibular salivary gland, as a rule, as a result of gunshot wounds of the submandibular region.

Fistulas of the parotid glands and their ducts are relatively often noted in peacetime due to suppuration of the gland, phlegmon of the parotid-chewing area, cancerous or nomatous process, accidental damage to the gland, including during the opening of abscesses and infiltrates.

Especially often there are fistulas of the parotid gland when her gunshot wound is complicated repeatedly by relapsing phlegmon. A consequence of prolonged treatment of such a wound in the gland is epithelization of the wound channel, into which the epithelium of the skin of the face and the gland itself grows. In this case, a firmly epithelialized fistulous course is formed, associated with the gland or its duct.

Symptoms of fistulas of the salivary glands

In the presence of a salivary gland fistula, patients complain of a more or less intense salivary discharge from the fistula, especially during the intake of acidic, salty, bitter food.

Out-of-the-meal salivary secretion decreases or completely ceases.

Especially it worries the patients in the winter (saliva cools the skin, wets the collar). They are forced to wear a bandage all year round or endlessly wipe the saliva with a handkerchief. On the skin around the mouth of the fistula chronic dermatitis is noted.

Objectively, in the area of scarly altered skin, a fistula is detected, from which a clear, slightly sticky liquid is released; sometimes small flakes are mixed with it.

If the inflammatory process in the gland has not yet ended, the saliva has a cloudy hue.

Local fistulas on the cheek or in the chewing area, sometimes - behind the angle of the lower jaw or in the submandibular region. The length of the fistulous course is 10-18 mm.

There are fistulas of the parotid salivary gland and its excretory duct. The wound of the excretory duct leads to the formation of the most resistant fistula, difficult to treat.

Fistulas of the parotid duct can be complete and incomplete. A complete fistula is characterized by complete obliteration of the peripheral end of the duct, as a result of which it is impossible to carry (even from the mouth into the fistula) even the thinnest probe or mandrake with the olive on the end. As a result, all the saliva is drunk outside.

If only the wall of the parotid duct is damaged, an incomplete fistula occurs , in which part of the saliva is released to the skin (outside the skin), and a part to the mouth. In this case, it is possible to probe the peripheral end of the duct and pull the end of the probe into the external fistula.

To determine the nature of the fistula (glandular part or duct, full or incomplete), one of the following methods can be used.

1. Examination from the oral cavity of the mouth of the parotid duct or duct of the submandibular gland: if a part of the saliva enters through it, then the fistula is incomplete, and vice versa.
2. Probing the fistulous course towards the mouth of the parotid duct or through the mouth in the direction of the fistula by using the thinnest eye probe, a polyamide thread (0.2 mm in diameter) or a piece of balalaic string with a tin olive soldered at the end.
3. Contrast sialogram of fistula and parotid duct: if the peripheral section of the duct is associated with a fistula, a strip of contrast medium will be visible between them in the picture. If the fistula is associated only with one of the lobes of the gland, then on the sialogram there is a branched network of ducts of only this lobe.
4. Introduction of a solution of methylene blue (1-1.5 ml) into the fistula: with an incomplete fistula, the paint will appear in the mouth.
5. Two-way functional examination of reflex saliva in response to a food irritant (dry food) or subcutaneous injection of 1 ml of 1% pilocarpine. With incomplete fistula, the amount of saliva collected in the capsule will be more healthy on the healthy side than on the patient. With a complete fistula, saliva on the diseased side will not enter the capsule at all.

Diagnosis of salivary gland fistulas

If the fistula is localized in front of the auricle, it is necessary to differentiate it with a rudimentary external auditory meatus, which, as a rule, blindly ends at a depth of 3-5 mm; saliva from it is not allocated.

If the fistula of the salivary gland is localized in the lower part of the parotid-chewing area, it is differentiated with the congenital lateral fistula of the gill slit. From this fistula saliva also does not stand out.

With the help of contrast radiography with the listed congenital anomalies, there is a lack of a connection between them and the salivary gland.

[7], [8], [9], [10], [11], [12]

Treatment of fistulas of the salivary glands

Treatment of fistulas of the salivary glands is a difficult task. The large number of existing (over 60) treatment methods is explained by the variety of character and localization of fistulous courses, as well as the difficulties of carrying out a number of radical surgical interventions in connection with the possible danger of damage to the trunk or branches of the facial nerve.

Classification of the treatment of salivary gland fistulas

Group I - "conservative" methods that can cause prolonged or permanent suppression or termination of parotid gland function. These include:

1. methods that lead to the destruction of the gland tissue or its atrophy (increasing pressure on the gland, injection of sterile oil into the gland, sulfuric acid, alcohol, dressing of the external carotid artery, ligation of the central end of the parotid duct, renggen irradiation of the gland);
2. methods of permanent termination of the gland function (twisting of the ear-temporal nerve, injection of alcohol into the third branch of the trigeminal nerve in the oval hole, removal of the upper cervical sympathetic unit, combination of denervation and radiography of the gland);
3. methods of removing the gland (complete or partial its extirpation);
4. methods of pharmacological suppression of saliva secretion before each meal.

II group - methods aimed at removing the fistula, but not providing for the flow of saliva into the mouth. These include:

1. methods of mechanical bloodless closure of the fistula mouth with a gold plate, sticky plaster; glue fistula collodion; Injection into tissues surrounding the fistula, paraffin;
2. methods of thermal or chemical effects on the fistula, leading to the closure of the lumen of the fistulous course (the use of hot air in combination with deep massage, cauterization of the fistula with a diathermic coagulant, hot needle or thermocauter, monobromoacetic acid, alcohol, lapis crystals, a combination of drug treatment with X-ray therapy, );
3. methods of dull closure of the fistula by surgical means:
   • scraping of the fistula with subsequent application of the cutaneous suture;
   • excision of the fistula with subsequent application of a suture on the gland, fascia and skin;
   • Closure of the duct or gland defect with a piece of fascia with the application of blind seams over the fascia and the skin;
   • excision of the fistulous course, application of a pouch to the damaged portion of the gland of the musculoskeletal suture, closing it with a fascia flap on the foot with the application of a blind seam to the skin;
   • excision of the fistulous course and three-layer closure of the fistula with flaps of fascia with submerged removable metal seams;
   • the imposition of a submerged pouch around the fistula and a blind seam on the skin over the fistula (according to KP Sapozhkov);
   • ligation of the fistula by submerged ligatures:
   • dissection of the fistula and plastic with a flap with a blind seam;
   • excision of the fistulous course with the use of a lamellar suture and counter triangular flaps of skin according to Serre-A. A. Limberg or plastic by Burov.

III group - methods of closing fistulas, providing for the preservation of the function of the gland and ensuring the outflow of saliva into the mouth.

Among them there are several subgroups:

1. the creation of a new path (course) for the outflow of saliva into the oral cavity:
   • puncture cheeks with hot iron or trocar with leaving a rubber tube in the channel;
   • puncture of the cheek with leaving a silk thread in the channel;
   • double cheek puncture with squeezing of the bridge (from soft cheek tissues) with a wire loop, silk thread, rubber band;
   • the formation of a canal in the thickness of the soft tissues of the cheek to drain saliva from the external fistula towards the mouth and ear;
   • drainage of the canal by silicate drainage, strengthened by a lamellar seam;
   • drainage of the wound channel from the oral cavity with a metal or thin rubber (nipple) tube (according to AV Klementov);
2. restoration of the integrity of the damaged parotid duct:
   • stitching the ends of the duct over a polyethylene catheter;
   • stitching of the fragments of the duct after preliminary expansion of their ends with a string or sticks;
   • stitching parts of the duct over the silver wire;
   • mobilization of the peripheral part of the duct and stitching it with the central one over the catgut filament;
   • stitching the ends of the duct with a vascular suture;
3. restoration of the peripheral part of the duct by plastic means:
   • replacement of the missing part of the duct with a segment of the facial vein;
   • replacement of the missing part of the duct with a free skin graft by AS Yatsenko-Tiersch;
   • restoration of outflow of saliva into the oral cavity by puncturing the cheek and inserting into the wound channel an elastic rubber tube wrapped in an epidermal graft according to Yu. I. Vernadsky;
   • replacement of the missing part of the duct with skin from the cheek;
   • restoration of the missing part of the duct with rags of various shapes, cut from the mucous membrane of the cheek, according to GA Vasiliev;
4. removal of the central segment of the damaged duct on the inner surface of the cheek by sewing it:
   • in the incision on the mucous membrane of the cheek;
   • through a notch in the region of the anterior margin of the actual chewing muscle and in front of the branch of the lower jaw;
   • in the mucosa of the cheek between the posterior edge of the actual chewing muscle and the branch of the lower jaw;
   • formation of a blunt path in the buccal muscle and suturing the central segment of the duct into the cleft of this muscle;
   • insertion of the proximal end of the duct into the mucous membrane of the cheek with its preliminary splitting into two semilunar flaps;
5. methods of removing the mouth of the fistula on the inner surface of the cheek or on the bottom of the mouth:
   • transplanting the mobilized fistula mouth onto the inner surface of the cheek and fixing it in this position with sutures to the mucosa;
   • stitching of the fistula mouth with the submandibular duct.

[13], [14], [15]

Treatment of an incomplete fistula of the duct or a single parotid gland

With this form of fistula, both conservative and surgical treatment can be used.

Conservative methods

Oppression of the secretory function of the gland is achieved by introducing 0.1% of atropine sulfate at the skin (0.5 ml 2-3 times per day) or inside the tincture of the belladonna (5-8 drops 30 minutes before meals). Simultaneously appoint a sparing diet.

Injections into the fistula channel of alcohol, 5% alcoholic iodine or diathermocoagulation of the fistulous course. As a result, the epithelium of the canal dies, aseptic inflammation develops around the fistula and as a result, its walls coalesce. Cauterization of the canal canal should be combined with the administration of atropine or tincture of belladonna.

Cauterization of the fistula. The end of the thin eye probe, wrapped with cotton, is moistened in 30% of the silver nitrate solution and injected into the fistula 2-3 times during one session, repeating them every other day for a week. If the fistula is very narrow and the probe can not be inserted into it, heat the tip of the probe over the alcohol and immerse it in a stick of silver nitrate. Then, around the aponeurotic mouth of the fistula, a suture stitch is applied, passing through the notches a silk thread (No. 7 or No. 8). Then the hot tip of the probe coated with a thin layer of silver is injected (once) into the channel. A thin wire electrode of the diathermic coagulant is inserted into the fistula as deep as possible and the electric current is turned on for 2-3 seconds.

Surgical method KP Sapozhkova

Under the infiltration anesthesia 0.5% of the porn of novocaine or trimecaine, an oval cut of the skin around the mouth of the fistula is made, a thin bellied probe is inserted into it and, guided along it, the fistulous course is developed to the maximum depth, after which the excreted fistular tissue is cut off along with the oval corolla of the skin , formed when it is dissected at the beginning of the operation.

Retreating from the edges of the formed oblong wound up and down 2-3 cm, make the incision of the skin to the aponeurosis.

Using a steeply curved needle through the notches, a circular (pouch) suture is made with a silk thread (No. 7 or No. 8) around the aponeurotic mouth of the hibiscus and tightly knotted, the wound is sutured with submerged sutures with catgut, and deaf sutures with a vein (thin line). For the pouch and immersion sutures, a long-lasting non-resorbable chrome-plated catgut can be used, since in the case of suppuration of the silk suture the entire effect of the operation is reduced to zero.

Treatment of a fresh incomplete fistula

With the fresh traumatic incomplete fistula ducts or individual lobules of the gland, two methods of AA Limberg (1938) or the Serre-A method can be recommended. A. Limberg-Burov:

1. If the fistula is included in a relatively small scar and a little saliva is secreted, the simplest version is used: excision of the scar along with the fistulous motion, mobilization of the edges of the wound, the imposition of a plastic seam and usual nodular sutures on the skin; In the lower part of the wound, leave a non-sewn area for temporary drainage of saliva.
2. If the fistula is located under the ear lobe in the area of a wide scar, where it is impossible to move without difficulty the oncoming triangular flaps, the excised portion of the rumen with fistula resembles the shape of a triangle. The resulting wound surface is covered with a skin mixed by the Burov method; In the corner of the wound, a gap is left for the outflow of saliva.
3. When the swine is localized in the area of the extensive scar, its canal is excised along with the scar tissue, forms two opposing triangular flaps of skin at an angle of 45 °, and in the lower part of the wound a small gap is left for the temporary outflow of saliva /

Thus, by means of an operation by the method of AA Limberg or Serre-A. A. Limberg attempts to create such biological conditions that would promote a favorable wound healing: first, ensuring the possibility of a temporary outflow of saliva in the postoperative period, rather than preventing separation (accumulating saliva) of the wound surfaces; secondly, excision of scar tissue at full depth with the movement of surrounding normal tissues, in particular the skin, to the area of the damaged area of the gland; thirdly, the exclusion in the postoperative period of drugs that depress saliva.

The described methods are most effective at fresh traumatic fistulas, in case of a significant outflow of saliva in the mouth and in the absence of acute inflammatory phenomena in the field of operation.

With long-lasting fistulas, the operation is completed by the imposition of submerged catgut sutures, and on the skin - by the stubby sutures. In the postoperative period, it is necessary to appoint funds that reduce salivation.

Treatment of chronic complete fistulas of the parotid duct

With this kind of salivary fistula, especially in the case of their location in the area of large scars, the methods of plastic reconstitution of the duct should be applied according to GA Vasil'ev, AV Klementov, Yu. I. Vernadsky, SM Solomennoy and co-workers.

The method of GA Vasil'ev

Under the infiltration anesthesia in the horizontal direction, an arcuate incision is made that fringes the orifice of the fistula, in accordance with the course of the parotid duct, so that the anterior pole of the operative wound is located 1 cm anterior to the anterior edge of the masticatory muscle proper. To dissect the tissues best when inserted into the fistula and parotid duct of thin eye probes.

The central part of the duct is discarded from surrounding tissues, cut off the adjacent area of the skin with a fistulous passage that passes through it.

From the oral cavity an arcuate incision from the mucous membrane of the cheek is formed by a linguiform flap about 1 cm wide. The base of this flap should be at the level of the anterior edge of the actual chewing muscle above the line of teeth closing. The length of the flap depends on the location of the fistula.

Between the anterior edge of the actual chewing muscle and the fatty gland, the cheeks make a puncture (puncture) and through it the cut out flap is removed to the wound on the cheek.

The central end of the prepared duct is dissected along a length of 35 mm and a flap of the mucous membrane is ligated to it (thin catgut). A narrow rubber strip (from the glove) is left along the epithelial surface of this flap, which is hemmed with the catgut to the mucous membrane of the cheek.

A defect on the mucosa of the cheek (in the place where the flap is cut from it) is closed by bringing the edges of the wound closer together and applying the catgut seams so that the screwed flap is not strongly pulled off at the base (where the rubber strip lies).

The external wound is sewn layer by layer, and a solution of antibiotics is introduced into the surrounding tissues, to which the microflora of the oral cavity of the operated patient is sensitive (sensitivity is determined in the preoperative period).

In order to increase the secretory function of the salivary gland after the operation, it is recommended to prescribe inside of 8-10 drops of 1% pilocarpine r-3 times a day, and before meals for the first 3 days to produce a mild parotid gland massage to release it from secretion.

The rubber strip is removed after 12-14 days, when an epithelial course is already formed around it.

The method of A. V. Klementov

Oval incisions dissect fistula with adjacent cicatricial tissue. In the depth of the wound, a narrow (eye) scalpel is punctured into the oral cavity. A drainage rubber tube (nipple) is inserted into the perforation hole.

The external wound is closed by moving counter triangular flaps of the skin.

Rubber tube is fixed in the oral cavity to the edges of the incision of the mucosa by two silk sutures and left in the wound for 2 weeks. During this time, the artificial internal fistula is epithelialized, after which the tube is removed.

In the first days after the operation, saliva can accumulate under the skin flaps under the skin during the meal. To prevent this, it is recommended to apply a pressure bandage after the operation, and inwardly appoint 8-10 drops of belladonna tincture or 0.1% of atropine sulfate 15-20 min before meals. If the saliva still accumulates, do a light massage over the napkin superimposed on the operated area.

The method of Yu. I. Vernadsky

The method of Yu. I. Vernadsky is similar to the method of AV Klementov. The difference consists, first, that a thin epidermal flap, glued from the abdomen or the patient's hand, is glued to the rubber drain tube (glue). At the same time, the outer (epithelial) surface of the flap faces the rubber. Secondly, for this purpose, not a thin nipple, but a thicker and stiffer tube, whose inner lumen is 4-5 mm, is taken. This ensures unobstructed passage of saliva into the mouth and tight adherence of the wound surface of the glued skin to the tube to the wound channel-puncture. Third, to monitor the passage of saliva from the gland, the end of the tube from the mouth is removed. To prevent the ingress of saliva to the neck and chest, you can attach a cotton-cushion pad to the end of the tube, into which the saliva is absorbed and from which it gradually evaporates.

After 14-16 days, the tube is removed. During this time the newly created duct is epithelialized, it will freely pass saliva.

After such an operation, there is no need to prescribe drugs that stimulate salivation or, on the contrary, suppress it. Prophylactic antibiotics (intramuscularly) is mandatory.

The method of SM Solomenniy and co-authors

It differs from the method of Yu. I. Vernadsky in that instead of the epidermal autograft, a venous autograft is used instead of the epidermal autograft, which is sewn to the butt from the stump of the proximal end of the excretory duct of the gland (with the aid of a non-absorbable suture and an atraumatic needle).

Treatment of fresh cut wounds of the parotid duct

With cut wounds of the parotid duct, you can sew its ends according to the Kazanjan-Converse method. To do this, stopping bleeding from the wound, a thin (No. 24) polyethylene catheter is inserted through the mouth of the parotid duct. The end of the catheter that appears in the wound is inserted into the proximal fragment of the excretory duct, the fragments of the duct are brought together with each other and stitched with thin silk on the atraumatic needle. After that, the wound on the face is sewn layer by layer.