Primary Surgery Vol.2 – Trauma: STRUCTURES IN THE CHEEK

STRUCTURES IN THE CHEEK

Repair the patient’s muscles of mastication and facial expression with buried chromic catgut.

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Figure 61.5: STRUCTURES IN THE CHEEK. If you fail to repair an injury to a patient’s parotid duct, a salivary fistula will form. A, the anatomy of his parotid gland, parotid duct, and facial nerve. B, cannulating an injured parotid duct. Partly after Hill, with kind permission.

FACIAL NERVE INJURIES

If the laceration is anterior to a line dropped vertically from the lateral canthus of the patient’s eye, only the peripheral branches of his facial nerve can have been injured. Deformity will be minimal and repair impractical.

If major branches of his facial nerve have been cut posterior to the vertical line, explore his wound and try to repair them by the methods in Section 55.9.

PAROTID GLAND INJURIES

If fluid leaks from a posterior wound of a patient’s cheek, his parotid gland has been injured. Suture the wound as usual. If a fistulous leak of saliva does develop, it will probably heal spontaneously within a few days, and almost always does so within a month.

PAROTID DUCT INJURIES

If you fail to repair an injury to a patient’s parotid duct, he will have a persistent flow of saliva from his cheek. The duct runs under the middle third of a line from the tragus of his ear to the commisure of his lips.

If his parotid duct is injured, repair it with fine silk or catgut over a polythene catheter leading into his mouth and fixed to his buccal mucosa. Pass the catheter, as in B, Fig. 61-5, from his wound, or from the opening of the duct inside his mouth. This is opposite the crown of his second upper molar tooth. Passing the catheter will be easier if you retract his cheek outwards to straighten the duct.

Keep the catheter in place by looping it out of his mouth and taping it to his chin to encourage the flow of saliva. Dave it in for a week.

Alternatively: (1) reimplant the proximal end of the duct through a new opening into his mouth, or(2)tie the duct. This will cause the gland to atrophy.

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Figure 61.6: WOUNDS OF THE EARS. A, B, and C, if part of a patient’s ear is missing and there is any hope of referring him for plastic surgery later, you can make an incision in his scalp (A), suture his ear to the edges of this incision (B), and refer him for plastic surgery (C). D, and E, when you suture this kind of laceration, put the first suture in the edge of his ear. With the kind permission of Peter London.