A 13-year-old Indo-Caucasian girl came to our hospital with a history of clear watery discharge from a wound just above and behind the angle of her right jaw for two years. The discharge increased while eating food and chewing. Her medical history revealed a swelling just behind her right jaw associated with a throbbing type of pain and fever two years ago, which burst open with pus discharge. A week later, she started getting a clear watery discharge from the affected site.\nOn examination, there was a pinpoint size opening just posterosuperior to the angle of the mandible with a continuous dribbling of clear serous fluid and scarring of the surrounding area (Figure ). Laboratory analysis of the fluid revealed raised salivary amylase levels (7800 IU/mL), which confirmed the diagnosis of a salivary fistula. Our patient was successfully managed by a simple surgical technique, described below.\nThe procedure was performed under general anesthesia with local infiltration of 1 in 100,000 adrenaline around the fistulous opening to minimize intra-operative bleeding. Methylene blue was then injected into the fistulous opening using a 26-gauge needle (blunt tip) under microscopic magnification. The dye was seen exiting from the natural opening of the Stenson's duct, indicating a patent ductal system. An elliptical incision of 1 cm diameter was taken around the fistulous opening, which included the scar tissue. The skin island was then held with skin hooks and the subcutaneous tissue dissected until the fistulous tract containing dye was visible (Figure ). The fistulous tract was then traced proximally until it entered the thick parotid fascia. The fascia was then incised and the tract was seen entering the superficial lobe of parotid. It did not extend up to branches of the facial nerve. At this level, the superficial lobe of parotid was carefully dissected and the fistulous tract was completely excised (Figure ). The parotid fascia was approximated and sutured with 3-0 vicryl and the wound closed in layers. The skin was closed using 3-0 silk sutures (Figure ) and a tight pressure dressing applied. Following surgery, there was no facial nerve deficit.\nPost-operatively, our patient was kept on nil by mouth for 24 hours and put on intravenous fluids, antibiotics, atropine and analgesics. Our patient was discharged on oral antibiotics and analgesics on the third post-operative day. Her sutures were removed on the seventh day. Histopathological examination of the fistulous tract showed no underlying malignancy or evidence of any specific (granulomatous) disease. Our patient was followed up three months later and was found to have successful healing of her wound with no complications or recurrence (Figure ).
A 25-year-old female patient reported with a complaint of watery discharge from her right cheek region since last 1 year. Patient gave history of fever and malaise associated with swelling in the right cheek region, which increased in size gradually and did not decrease for the next 15 days. Patient applied balm and hot fomentation over the swelling and the swelling started draining with purulent discharge over the cheek region. Patient consulted a local physician and was prescribed some medications for 5 days subsiding the swelling and pus discharge. Since then, watery discharge started from the same region. According to the patient, the discharge increased during meals. Patient received consultation from various places for the same but did not get any relief. Patient also consulted a local dentist for the same complain and underwent surgical extraction of the lower right third molar, which was impacted. Even 10 days after-the extraction, patient had no relief and then she was referred to our institution.\nPatient gave no contributory medical history with a healthy familial background and no personal abusive habits. Extra-oral examination revealed a scar tissue on the right cheek on anterosuperior region of the angle of mandible, oval in shape and approximately 1 cm × 1.5 cm in size. The surrounding skin appeared to be normal. A small pinpoint opening () was seen just above the scar from which watery fluid discharged spontaneously which increased on sucking lemon. On palpation, all inspectory findings were confirmed. The scar was completely healed and attached to the underlying deeper structures. The discharged fluid was watery, non-sticky, and thin in consistency. Right submandibular lymph nodes were palpable, enlarged, freely movable and non-tender, measuring approximately 1 cm in size. Intraoral examination revealed healing extraction socket with 48 with no tenderness present on the same region. The parotid papilla appeared to be normal. Mild salivary flow was seen from right parotid papilla along with more flow from fistula on milking of right parotid gland and rest of the oral cavity showing normal wet ability with saliva ().\nUltrasonographic examination revealed normal echostructure of the right parotid gland with smooth margins, giving no evidence of any solid or cystic lesion. A small collection was seen in the anteroinferior margin of the right parotid, which measured 5 mm × 3 mm approximately. The contents were anechoic, and a small 1.5 mm sinus tract was seen from the collection to the skin.\nOn radiographic examination with insertion of gutta percha point in the fistula revealed in the parotid region (). Fistulography, as well as sialography, was performed using 70% urografin contrast media which revealed its relation with parotid duct. When the urografin solution was injected into the parotid duct intra-orally the solution came out from the fistulous tract extra-orally immediately without entering into the gland tissue. This was seen because of least resistance felt on this route. Hence, a false filling defect in radiograph was noted, and solution could not enter the gland because of direct communication of fistulous tract and duct (). The final diagnosis was given as persistent parotid fistula with right parotid duct secondary to chronic suppurative parotitis.\nPatient was taken under short general anesthesia; methylene blue ink was injected into the fistulous opening using a 26-gauge needle to identify the tract. An elliptical incision of 1 cm diameter was taken around the fistulous opening, which included the scar tissue. The skin island was then held with skin hooks and the subcutaneous tissue dissected until the fistulous tract containing dye was visible.\nThe fistulous tract was then traced proximally until it entered the thick parotid fascia. The fascia was incised, and the tract was traced up to the superficial lobe of the parotid. Superficial lobe of the parotid was carefully dissected, and fistulectomy was done after ligating the attachment of the fistulous tract to the Stenson’s duct (). Closure was done in two layers using vicryl 3-0 and nylon 4-0 sutures () followed by tight pressure dressing. Patient was discharged with oral amoxicillin with cloxacillin, diclofenac sodium, and cetirizine on third post-operative day. Sutures were removed on the 7th day. Regular follow-up was done for 1 year, the fistulous tract healed satisfactory () and no complain of recurrence was encountered by the patient. The salivary flow was also adequate and was periodically checked by sucking lime.