Management of parotid duct injury secondary to cow horn in a developing country.

Stensen duct injury has been reported in the medical literature following penetrating injuries of the cheek or by exeresis of tumors of the cheek or of the oral mucosa. This type of physical trauma often arises from injuries as a result being assaulted (e.g. with knife) or from road accidents. The complexity of the damage to the anatomical structures and the causative agent sometimes makes the diagnosis difficult. We report on a clinical case of managemenent Stensen duct injury secondary of goring by a cow horn.

Introduction

Stensen duct injury (or Stensen duct) has been reported in the medical literature following penetrating injuries of the cheek or by exeresis of tumors of the cheeks. We report a clinical case of severing of the Stensen duct by a cow horn. The diagnosis and the treatment were carried out at the Regional Hospital Center of Kolda in Senegal.

Clinical observation

An eight year old patient consulted in regard to saliva flowing from their left cheek that increased during meals. Perusal of their medical history revealed trauma to the left cheek 10 months prior by a cow horn. They had received cutaneous stitches at the healthcare facility of their village. The child insisted on an ENT consultation in light of unkind comments made by their classmates that affected their scholastic performance. The clinical examination noted a scar on the left cheek, saliva seeping from the left cheek, and that while the orifice of the right Stenon duct was normal the left one was shut. The severing of the Stenon duct was classified as type C based on the criteria of Van Sickels and Alexander [1]. Palpation of the cheek with between two fingers did not find any mass indicative of a mucocele. Chewing of gum allowed us to make a diagnosis (Fig. 1). The remainder of the ear-nose-throat examination yielded normal findings. A treatment based on antibiotics was implemented and an indication for surgery was discussed. A reimplantation of the severed duct was performed under general anesthesia with orotracheal intubation. The duct was located by external catherization (22 gauge catheter) and dissection around the cutaneous fistula (Fig. 2). Once the remaining duct was located, a marsupialization was created to reimplant the Stenon duct in the oral cavity. We then proceeded with the mucosal and cutaneous closure on both sides of the surgical site. The post-operative monitoring was straightforward at D8 (Fig. 3) and at one month (Fig. 4).

Fig. 1

Photography of the left cheek: diagnosis by salivary flow upon chewing of gum.

Fig. 2

Perioperative photography: location of the Stenon duct with a 22 gauge venous catheter.

Fig. 3

Postoperative photography at D8: dressing after the chewing gum test.

Fig. 4

Postoperative photography at one month: healing achieved.

Discussion

Severing of just the Stenon duct is rare [2]. A delay in its diagnosis is common, as was the case here. Trauma is the most commonly reported mechanism in the literature [1], [3], [4]. With a pediatric population, being gored by a horn often involves injury to the face. Various diagnostic methods are available (e.g. injection of methylene blue, scialoscopy, and imaging by magnetic resonance). Treatment most often involves surgery. Various materials have been reported for locating the Stenon duct [4], [5], [6], [7]. In our setting, the choice of an intravenous catheter had the advantage of being available and of being less onerous.

Conclusion

Penetrating injuries to the cheek expose important structures such as the Stenon duct. The diagnosis must be made early for a timely treatment. Yet these lesions are often not found until later due to the numerous diagnostic means that are available. The complexity of the afflicted anatomical structures and the causative agent explain the variety of surgical techniques that are used. In our case, a treatment with straightforward diagnostic means allowed good esthetic and functional outcomes to be obtained.

Conflicts of interest

Any competing conflict interest.

Funding

Nil.

Ethical approval

This study has approved by the ethic comity of Kolda hospital (Senegal).

Consent

Consent wrote and signed to publish this case report(father).

Author contributions

Hady Tall, Molinier Charles Edouard and Alshamsi Ahmed conceptualized the project and participated in data analysis and drafting the manuscript.

Diop El Hadj Malick and Fraysse Bernard participated to the correction of the manuscript.

Guarantor

All authors read and approved the final manuscript.