A 25-year-old man complained of significant swelling in front of his right ear before and around mealtimes. This swelling was associated with considerable pain, which was provoked by the ingestion of lemon sweets. On examination he had tenderness around the right parotid region and a hard nodule was demonstrated in the buccal mucosa adjacent to the right upper molar teeth.
A diagnosis of parotid duct calculus was made.
The formation of stones in the salivary glands is not uncommon, but it is more likely in the submandibular gland than in the parotid gland because the saliva is more mucinous and the duct has a long upward course from the floor of the mouth. Nevertheless, stones do form in the parotid gland and the parotid ducts. Notably, most parotid duct calculi and submandibular duct calculi occur in mouths with excellent dental hygiene and mucosa.
An ultrasound scan was performed.
An initial ultrasound scan demonstrated a stone in the distal end of the right parotid duct with evidence of ductal dilation (eFig. 8.294). Assessment of the gland also demonstrated dilated ducts within the gland and evidence of intraparotid lymphadenopathy.
The patient was treated with antibiotics.
A course of antibiotics was given to remove the bacteria that had produced the inflammation. On return to the doctor some days later the gland was normal in size and there was no evidence of inflammation or infection.
An operation was necessary.
The stone was at the distal end of the parotid duct and it would seem logical and straightforward to make a small incision at the sphincter in the buccal mucosa and deliver the stone, thus permitting the gland to drain normally. Unfortunately, in this patient’s case the gland was significantly destroyed by the chronic obstruction and bacterial infection. Furthermore, smaller calculi were also demonstrated in the gland at ultrasound. On direct questioning it appeared that the patient had had numerous attacks over the previous 4–5 years and it was decided that the parotid gland should be removed surgically.
The patient consented for removal of the parotid gland and a discussion of the possibility for loss of facial function and facial paralysis was had with the patient at this time.
Within the parotid gland the facial nerve [VII] divides into its five terminal branches. At operation the gland is displayed and extremely careful dissection is necessary to peel away the parotid gland from the branches of the facial nerve [VII]. This procedure was made more difficult by the chronic inflammatory change within the gland. After the procedure the patient made a good recovery, though there was some mild paralysis of the whole of the right side of the face. Importantly, taste to the anterior two-thirds of the tongue was preserved. The taste fibers to the anterior two-thirds of the tongue travel in the chorda tympani nerve, which is a branch of the facial nerve [VII]. This nerve leaves the facial nerve [VII] to join the lingual nerve proximal to the parotid gland; therefore, any damage to the facial nerve [VII] within the parotid gland does not affect special sensation (taste).
Over the following week the paralysis improved and was likely due to nerve bruising during the procedure. The patient remained asymptomatic.
A 60-year-old woman was brought to the emergency department with acute right-sided weakness, predominantly in the upper limb, which lasted for 24 hours. She made an uneventful recovery, but was extremely concerned about the nature of her illness and went to see her local doctor.
A diagnosis of a transient ischemic attack (TIA) was made.
A TIA is a neurological deficit resolving within 24 hours. It is a type of stroke.
Neurological deficits may be permanent or transient. Most transient events resolve within 21 days; any failure of resolution beyond 21 days is an established stroke.
An investigation into the cause of the TIA was undertaken.