376

Penetrating Trauma to the Parotid Gland

Matthias Tisch, MD, PhD1 Susanne Maier, MD2 Heinz Maier, MD, PhD3

1 Klinik für Hals-Nasen-Ohrenheilkunde, Kopf Halschirurgie,
Bundeswehrkrankenhaus Ulm, Ulm, Germany
2 Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie,
Universität Ulm, Ulm, Germany
3 Privatpraxis HNO, Ulm, Areion Med GmbH, Neu-Ulm, Germany
Address for correspondence Prof. Dr. H.C. Matthias Tisch, Klinik für
Hals-Nasen-Ohrenheilkunde, Kopf-Halschirurgie,
Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, D-89081 Ulm,
Germany (e-mail: matthias.tisch@hals-nasen-ohren.net).

Facial Plast Surg 2015;31:376–381.

Abstract Penetrating trauma to the parotid gland may present unique challenges especially when
Stensen duct, neurovascular structures, and/or collateral organs are involved. Especially
ballistic injuries caused by high-velocity projectiles or fragments of grenades and
Keywords improvised explosive devices are often associated with massive tissue damage and a
► penetrating parotid high risk of infections and other posttraumatic complications. Because penetrating
trauma parotid trauma is not very common, only limited information on the primary treatment

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► ballistic injury of such injuries is available. This article gives a short overview about actual aspects on
► parotid gland diagnosis and treatment strategies especially focusing on ballistic parotid injuries.

Penetrating trauma to the face and/or the upper zone III of the
neck may involve the parotid gland. The parotid tissue and
duct system as well as adjacent structures such as the facial
nerve, the external carotid artery, the retromandibular vein,
the external and the middle ear, and the mandible as well as
the temporomandibular joint may be involved.
Stab wounds to the parotid region usually are uncompli-
cated. Injuries caused by gunshots, mines, or improvised
explosive devices (IEDs), however, are often complex. Pene-
trating trauma caused by high-velocity projectiles or IEDs,
which are widely used in terrorist attacks, is particularly
problematic. The high velocity of these projectiles or frag-
ments causes extensive tissue destruction that presents a
challenge for both emergency physicians and head and neck
surgeons providing acute and definitive care.
Penetrating face and neck injuries caused by guns or
explosive devices play an increasingly important role. An
analysis of data from the U.S. Navy and Marine Corps Combat
Trauma Registry, for example, showed that military casualties
with head, face, or neck injuries accounted for 39% of all injury
casualties during Operation Iraqi Freedom II.1
However, apart from treatment of penetrating ballistic
injuries in war sceneries, the increasing threat of terroristic
attacks such as in Madrid, London, and most recently in
Boston indicates that civilian surgeons in western countries
too should be familiar with the treatment of penetrating
ballistic injuries.
Parotid injuries occur infrequently. Thus, only limited
information is available on this topic. In recent asymmetric
warfare, however, injuries to the face and neck and consecu-
tively also to the parotid gland have gained increasing
importance.2,3
Optimal outcome in such injuries demands early recogni-
tion and proper management. This article aims to provide an
overview on actual aspects of diagnostic measures as well as
primary and definitive treatment in penetrating trauma to
the parotid gland.
Initial Encounter and Diagnostics
The initial management of penetrating injuries to the parotid
region starts with the ABCs of trauma management, which
means especially establishing the airway and controlling of
bleeding.4 However, attempts at arresting hemorrhage by
blindly placing sutures or hemostats should be avoided, as
main blood vessels lie deep to the facial nerve that would be
put at risk of iatrogenic injury.5 We recommend controlling
hemorrhage by pressure until adequate wound exploration
under general anesthesia can be undertaken.
In selected cases, especially if bleeding is extensive and
cannot be controlled by pressure, emergency surgery might
become necessary. Morris et al6 reported a case of massive
hemorrhage from a stab wound to the parotid region necessitat-
ing emergency parotidectomy to get access to the injured vessels.

Issue Theme Contemporary Copyright © 2015 by Thieme Medical DOI http://dx.doi.org/

Management of Facial Trauma; Guest Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1563535.
Editors, Ralph Litschel, MD, and Abel-Jan New York, NY 10001, USA. ISSN 0736-6825.
Tasman, MD Tel: +1(212) 584-4662.

Whenever possible, a thorough history has to be obtained,
including time and nature of the injury. Then the parotid
gland and the surrounding structures, that is, the overlying
skin, the oral mucosa, the mandible, the zygomatic arch, the
temporomandibular joint, and the ear are examined. In an
awake and alert patient, facial nerve function should addi-
tionally be investigated via facial expression and mastication.
Initial evaluation involves quantification of motor deficits. A
facial grading on the basis of an established clinical grading
system such as the House-Brackmann scale should be under-
taken and documented via video.7
In open lacerations to the parotid region damage to the
glandular parenchyma, the duct system as well as to the facial
nerve has to be suspected. The integrity of the duct system
can be checked simply by pressing the gland and examining
for any pooling of saliva. If this is not possible, such as in
extensive lacerations, or if the status of the duct system
remains unclear, cannulation of the duct via the natural
ostium should be performed.4 The wound is then checked
to see whether the probe is visible. If this is not the case, saline
or methylene blue solution may be injected into the ductal
system.8,9 When there is no extravasation of fluid into the
wound, a ductal injury is unlikely. While using methylene,
care must be taken not to overinject, as this could discolor the
surgical field and impede identification of injured tissue
structures such as branches of the facial nerve.10,11 Especially
in victims of bomb attacks with only minor injuries in the
parotid region caused by splinters of shrapnel, precise infor-
mation about suspected ductal lesions can be obtained by
using a plain X-ray sialogram.12
An electric nerve stimulator10 may be used for testing
facial nerve integrity or identification of damaged nerve
branches. In the clinical setting, electroneurography repre-
sents an important tool for determining the need for surgical
exploration of the facial nerve.13
In ballistic injuries to the parotid region caused by gun-
shots, mines, or IEDs, a computed tomography (CT) angiog-
raphy should routinely be performed14 to exclude trauma to
the aforementioned surrounding structures and especially to
large vessels and for the detection of foreign bodies.
Treatment
Injuries to the parotid gland should be repaired early, prefer-
ably within 24 hours.11 This is important because swelling
and alterations of the tissue, caused by extravasation of saliva,
make identification and surgical repair of relevant structures
such as facial nerve branches or the parotid duct increasingly
difficult. Furthermore, it seems likely that a delayed treat-
ment is associated with a higher risk of complications such as
sialoceles, parotid fistulas, and infections.
Injuries to the Parotid Parenchyma
If lacerations involve the gland without damage to the facial
nerve or larger salivary ducts, the wound is cleaned by
irrigations with polyhexanide solution and the parotid cap-
sule is closed by sutures.9,15 A pressure dressing is applied
Penetrating Trauma to the Parotid Gland Tisch et al. 377
postoperatively to prevent formation of a sialocele or a
parotid fistula. For reduction of saliva secretion, treatment
with antisialagogues and a restriction of oral intake have been
recommended by other authors. Injection of botulinum toxin
A into the gland (50–100 units of botulinum toxin type A) has
proved to be more efficient and less uncomfortable for the
patient.16 To avoid paralysis of the masseter muscle, the
injection should be performed under sonographic or electro-
myographic surveillance. Injection of botulinum toxin A is not
only effective for preventing traumatic sialoceles or salivary
fistulas but also can be used for treating these posttraumatic
complications.17
Injuries to the Parotid Duct System
According to Van Sickels and Alexander,18 injuries to the
ductal system can be separated into three anatomical areas:
those occurring in the glandular area (type A), those over the
masseter muscle (type B), and those anterior to the masseter
muscle (type C).
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Type A injuries usually are treated similarly like injuries to
the parotid parenchyma.
In type B injuries a microsurgical reconstruction of the
duct19,20 should be performed early, preferably within
24 hours.11 The first step is to insert a soft catheter via the
salivary orifice (►Fig. 1A). For this purpose, a lumbar catheter
sized Charrière 5 or a lacrimal canal catheter (Canaliculus
Intubation Set, Xomed-Treace, Jacksonville, FL) may be used.
The tip of the catheter is localized at the distal stump of the
duct and then introduced into the proximal stump (►Fig. 1B).
Both stumps are dissected free of surrounding tissue, pulled
together, and sutured over the catheter (►Fig. 1C) using
nonresorbable sutures (nylon 8–0, 9–0). The catheter helps
maintain the diameter of the duct and to permit the obstruc-
tion of its lumen by inadvertent suturing of the posterior
wall.9 In case of a tissue loss that does not allow a tension-free
coaptation, an end-to-end anastomosis interposition of an
autogenous venous graft may be necessary.21 If the catheter is
positioned properly, parotid saliva should drain into the oral
cavity after stimulation or massage of the gland. We recom-
mend stenting the duct for at least 2 weeks.2 To avoid
dislocation of the catheter, for example, during chewing, it
should be sutured distally to the oral mucosa just anterior to
the parotid papilla (►Fig. 1D).10
After 2 to 3 months a sialography may be performed to
exclude ductal stenosis at the place of anastomosis.
In type C injuries, which involve the distal aspect of the
duct, repair might be difficult or even impossible. In such
cases, the proximal duct may be diverted into the oral cavity
creating a new orifice.22,23 The proximal stump of the duct is
dissected free of the surrounding tissue and brought through
the buccinator muscle. Then it is split and the ductal epitheli-
um is sutured to the oral mucosa using 8–0 nylon sutures. The
newly created ductal orifice has to be stented for at least
2 weeks.
Ballistic trauma to the parotid gland by gunshots or IEDs
presents a special problem, because unlike other penetrating
injuries, it is often associated with avulsion of tissue or severe
Facial Plastic Surgery Vol. 31 No. 4/2015
378 Penetrating Trauma to the Parotid Gland Tisch et al.
Fig. 1 (A–D) Penetrating injury to the parotid gland type B according to Van Sickels and Alexander.18 (A) The distal end of the dissected duct is
dilated by a metal probe. (B) A catheter is introduced into the dilated duct. (C) After cannulating the proximal part of the duct, microsurgical
reconstruction is performed. (D) The intraoral part of the catheter is sutured to the oral mucosa.
damage to the parenchyma as well as to the intraglandular
duct system.
A wide variety of factors influence the behavior of projec-
tiles in the human body. The extent of injury is mainly
determined by the amount of energy transmitted to the
tissues. Long guns usually develop higher muzzle energies
than handguns so that the damage they cause can occur at a
distance from the actual bullet track, which may play a major
role. In addition, the shape and other characteristics of the
projectile are important determinants for tissue damage.
Most full metal-jacketed bullets transfer their energy at a
penetration depth of 12 to 20 cm, which means that at least in
types I and II injuries kinetic energy is not entirely trans-
ferred. Semi-jacketed bullets, however, transfer their energy
immediately after entering the body. Fragments from gre-
nades or IEDs possess kinetic energy similar to those of bullets
fired from handguns or long guns. In contrast to bullets,
however, they usually transfer their complete energy to the
tissue and thus in most cases cause more severe injuries with
a variable extent of tissue loss.24 Depending on the distance
from the detonation, additionally thermal and pressure-
induced concomitant injuries such as burns and barotrauma
are common. Ballistic injuries show an increased risk of
infection and tissue necrosis.
Successful ductal reconstruction thus might be rather
difficult or even impossible. If facial nerve branches have
additionally been dissected, we recommend a subtotal paro-
tidectomy with primary repair of the facial nerve. In cases
without facial nerve after careful debridement and irrigation
of the wound with saline and Lavasept, ligation of Stensen
duct and pressure dressing should be performed.10,24 In
Facial Plastic Surgery Vol. 31 No. 4/2015
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addition, an intraoral drainage is recommended, such as in
sialoceles.10,25 To improve management, a special classifica-
tion system for ballistic injuries to the parotid gland has been
proposed by Majid,3 which is not based on the site of injury
like the system by Van Sickels and Alexander18 but on the
patterns of injury.
A tangential injury that involves the superficial part of the
gland is classified as type I (►Fig. 2A). The treatment is
identical to the one described before for nonballistic pene-
trating parenchymal injury plus thorough wound irrigation
and debridement.
If the projectile entrance is through the parotid itself with
the wound of exit in the oral cavity, the injury is classified as
type II (►Fig. 2B). In type III injuries, the site of entry of the
projectile is either transoral or through the back of the neck
and the exit wound is through the parotid region ►Fig. 2C). In
most of such cases, especially if caused by high-velocity
projectiles, we find a complex wound that results from the
projectile itself plus the effect of secondary projectiles such as
fragments of the teeth, dentures, and/or bone.
In types II and III injuries an additional intraoral drainage is
recommended. This can be achieved by a small-gauge naso-
gastric tube that is passed through the intraoral wound and
the external wound and sutured to the buccal mucosa.3
Injuries to the Facial Nerve
Facial nerve branches that are injured anterior to a vertical
line extending from the lateral canthus of the eye to the
mental foramen need not to be repaired, as spontaneous
recovery is likely. Transection proximal to this line should be

Fig. 2 (A–D) Ballistic injuries to the parotid gland caused by gunshots or improvised explosive devices of different types according to the
classification of Majid 3: (A) type I, (B, C) type II, and (D) type III.
considered for repair by direct anastomosis or grafting
techniques.
Injuries to the extratemporal facial nerve should be re-
paired under magnification using the microscope if possible
and microsurgical equipment. The preferred technique for
repair is end-to-end neurorrhaphy.13 If this is not possible
because of extensive damage, an interposition nerve graft
from the sural nerve, the greater auricular nerve, or the lateral
cutaneus nerve of the thigh can be used.15 To avoid extensive
tension on the graft, it should be longer than the damaged
segment. To achieve proper alignment of large-caliber nerve
stumps, three triangulated epineural sutures of 10–0 Prolene
should be used. Perineural sutures are usually reserved for
peripheral branches, containing only a single-nerve fascicle.
Frayed nerve ends should be cut and especially excess epi-
neurium has to be trimmed because it may become a source
of fibrous in-growth. In ballistic injuries we have to expect
thermal damage to the nerve stumps that might impair
healing.4 Thus before direct neurorrhaphy or grafting, 1 to
2 mm of the nerve stumps should be resected.
Today most authors advocate facial nerve repair as soon as the
patient is stabilized.4 If surgery is performed within approxi-
mately 72 hours after injury, a nerve stimulator may be used to
confirm the location of the distal end of the transected facial
nerve.26 Beyond this period, the neurotransmitter stores neces-
sary to depolarize the motor end plates are depleted and cannot
be replenished given the disruption of anterograde axoplasmic
transport after nerve injury.27 Therefore identification of distal
nerve endings might become difficult in delayed nerve repair.
Penetrating Trauma to the Parotid Gland Tisch et al. 379
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In severe ballistic injuries and excessive wound contami-
nation, however, a delayed repair within 30 days of the initial
injury is recommended to permit antisepsis and demarcation
of devitalized neural tissue. In such cases initially identified
nerve stumps should be tagged with hemoclips for later ease
of retrieval.13
Prevention of Infection
Measures for prevention of infection are needed for severe
trauma to the parotid gland. This is especially relevant for
ballistic injuries. The assumption that high-velocity projec-
tiles are sterile as a result of heat generation has been proven
wrong.28 Injuries caused by mines, grenades, or IEDs are
usually bacterially contaminated by soil, clothing, metal frag-
ments, plastic particles, and other foreign bodies that are
transported into the wound cavities together with skin.
Traditionally, gram-positive bacteria and anaerobes predom-
inate in wounds at the time of injury and often are replaced by
multidrug-resistant bacteria after several days or weeks.29
Initially, wounds must be cleaned, and necrotic tissue,
bone fragments, tooth particles, and foreign bodies should be
removed if possible. However, maximum preservation of
facial soft tissue should be attempted. Similar to other authors
we recommend wound irrigation with isotonic saline solu-
tion and/or local antiseptics.25,30 As an ideal antiseptic for
irrigation of ballistic wounds especially if there is already a
contamination with pus, we recommend polyhexanide solu-
tion. Further povidone iodine has proved to be particularly
Facial Plastic Surgery Vol. 31 No. 4/2015
380 Penetrating Trauma to the Parotid Gland Tisch et al.
effective. It shows no gaps in effectiveness, is effective even in
the presence of a protein load, and is rapidly active (within 30
seconds).
Another important factor in infection prevention is appro-
priate surgical treatment that should be implemented as soon
as possible. Several authors were able to show that a delay in
treatment was associated with a significant risk of wound
infection.12,13,31,32 The risk of infection can be reduced by the
early stabilization of fractures, the closure of soft tissue
wounds and especially mucosal defects, and adequate wound
drainage. If these measures cannot be taken at an early stage,
extensive wounds should be treated with vacuum-assisted
closure or packed using gauze soaked in povidone iodine.33 If
available, antimicrobial foam dressings containing polyhexa-
methylene biguanide, which kills even multiresistant bacteria
on contact, can also be recommended.
All patients with gunshot and fragment injuries to the face
should receive perioperative prophylactic antibiotics. This
applies in particular to high-risk injuries, such as penetrating
parotid gland trauma and especially comminuted mandibular
fractures. Studies have shown that perioperative prophylactic
antibiotics reduce the risk of infection from 28–87% to
6–10%.31,34 Antibiotics should be administered intravenously
as soon as possible after injury and should be effective against
Streptococcus spp. and anaerobic pathogens. Cefazolin (a first-
generation cephalosporin; 2 g every 8 hours) or ceftriaxone
(a third-generation cephalosporin; 1 g every 12 hours) are
currently recommended for this purpose. Similarly good
results have been reported with clindamycin (600 mg every
8 hours), which can be used for penicillin-allergic patients
and has the advantage of being also active against β-lacta-
mase producers. The risk of Clostridium difficilis enteritis,
however, is several times higher in patients who receive
clindamycin than in those who are treated with other anti-
biotics.35 This must be considered especially in the manage-
ment of immunosuppressed, severely injured patients.
Broad-spectrum antibiotics do not offer significant advan-
tages but are likely to increase the risk of resistance
development.36
It has been recommended to terminate prophylaxis 24
hours after surgical treatment of maxillofacial injuries. For
parotid injuries, however, we recommend antibiotic treat-
ment for 6 to 8 days, as salivary secretions cause maceration
of the wounded tissue that additionally favors bacterial
infections. Further, there is a substantial risk for ascending
infections from the oral cavity.
Conclusion
Penetrating injuries of the parotid region, especially ballistic
injuries, are often associated with severe bleeding, a com-
promised airway, and lesions of surrounding structures. Thus,
initial management consists of controlling hemorrhage
(avoiding blind placement of sutures or hemostats that would
put the facial nerve at risk) and establishing the airway.
Damage to the glandular parenchyma, the duct system,
and to the facial nerve has to be suspected. In injuries caused
by gunshots, mines, or IEDs, a CT angiography should be
Facial Plastic Surgery Vol. 31 No. 4/2015
performed to exclude trauma to surrounding structures and
especially to the large vessels and to detect foreign bodies.
Perioperative narrower spectrum antibiotics such as third-
generation cephalosporins or clindamycin should be admin-
istered as soon as possible after the injury.
Types B and C injuries of the ductal system should be
repaired surgically as soon as possible. In severe ballistic
trauma ductal reconstruction might be impossible. Then
ligation of the duct, intraoral drainage, or even subtotal
parotidectomy might become necessary.
Facial nerve injuries should be repaired within 72 hours. In
severe ballistic injuries and excessive wound contamination,
however, a delayed repair within 30 days of the initial injury
is recommended.
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