A 10-year-old male child presented with history of intermittent discharge of watery fluid from an opening in the right cheek since birth. The discharge increased on feeding/eating and was not associated with any swelling or pain. There was no previous history of swelling, redness, pain, or injury to the region. He was otherwise healthy and had normal developmental milestones.\nPatient had normal general/systemic examination with vital parameters. Local examination revealed a small punctum on the right side of the face, at a distance of about 2.5 cm from the angle of the mouth and 1 cm inferior to a line joining the tragus and angle of mouth []. Expression of clear serous fluid on local massage was seen. No associated palpable mass or tenderness was noted. Oral examination was normal with normal Stenson's ducts opening bilaterally.\nBilateral pre-aural appendages were noted on regional examination, two on the right side anterior and anteroinferior to the tragus and one appendage on the left side just anterior to the tragus [Figure and ].\nAs a part of the diagnostic work-up, ultrasonography, sono-fistulography, contrast digital fistulography, contrast digital sialography and contrast CT fistulography [] were done. Laboratory analysis of the fluid revealed raised salivary amylase levels (7800 IU/mL), which confirmed the diagnosis of a salivary fistula. Contrast fistulography revealed an opacified tubular shaped density visualized with opacification of soft-tissue area noted on the plain image. No intra oral spillage of contrast was seen.\nOur 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. An incision-along skin crease enclosing fistulous opening was given. The duct was dissected for about 1.5 cm. Then brought out to the mucosal surface through buccinator muscle opposite the first upper molar tooth. The duct was secured in place using absorbable sutures. Skin incision was closed. Pre-auricular tags were also excised. Figures and are showing the dissection.\nPost-operatively, patient was kept on nil by mouth for 24 h and put on intravenous fluids, antibiotics, atropine and analgesics. On stimulating the accessory gland the saliva was found dribbling from the transposited duct opening. Patient was discharged on oral antibiotics and analgesics on the 3rd post-operative day. Her sutures were removed on the 6th day. Histopathological examination of the tissue/fluid adjacent to fistulous tract showed no underlying malignancy or evidence of any specific (granulomatous) disease. At 2 weeks later sialogram was carried out which confirmed the patency of the duct. Our patient was followed-up 3 months later and was found to have successful healing of her wound with no complications or recurrence. Figures and are showing the post-operative status.
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 ).