A 1-year-old girl presented with serous discharge from the right cheek since birth which increased on chewing. On examination, there was a 1 mm × 1 mm cutaneous opening over the right cheek, 2 cm lateral to the angle of the mouth along with bilateral preauricular skin tags []. Intraoral examination and duct opening of parotid and submandibular gland was normal on both sides. Sinogram with a 24G cannula showed a thin tubular tract directed posteromedially from the external opening on the cheek into the region of the Stensen's duct/parotid gland []. There was no communication with the oral cavity or mandible. Under general anesthesia, the external opening was cannulated with a 24G intravenous plastic cannula and methylene blue injected []. With circumferential fine dissection around the external opening, the fistula tract was separated from the skin and subcutaneous fat of the cheek and brought into the oral cavity. Further intraoral dissection showed the tract initially going vertically down for 2 cm then turning posteriomedially for 1 cm to finally opening into the right Stensen's duct near the lower part of the parotid gland []. The fistulous tract was transfixed and ligated at its origin in the duct and excised in toto []. At 1-year follow-up, she has a negligible scar with a good cosmetic outcome [].
An 80-year-old male was referred to us with squamous cell carcinoma of the left pre-auricular area that was confirmed through incisional biopsy (). The patient was suffering from occasional bleeding, discharge, and repeated ulceration of the lesion. We performed computed tomography of the head and neck region before surgery, which showed no evidence of invasion. We performed wide excision of the tumor with a 0.5 cm lateral margin throughout. We obtained a safe margin of depth without parotid gland injury even though the tumor bed was close to the parotid gland fascia (). However, we could not completely rule out micro-injuries to the parotid gland fascia although we reserved parotid gland fascia. After wide excision, the skin defect was covered with a 5×6 cm full thickness skin graft from the left inguinal area. The usual compression dressing with a tie-over suture was applied to maintain the skin graft.\nOn the fifth postoperative day, we discovered exudate from the base of the skin graft through the slit incision site (). The dressing materials were wet and the discharge from the operative site increased during meals. The amount of discharge was approximately 50 mL, and its amylase level was 200,000 unit/L. Accordingly, we confirmed the exudate was salivary discharge and he was diagnosed with a sialo-cutaneous fistula.\nWe decided to use botulinum toxin type A injection because of concern for graft failure due to increased sialorrhea that was not controlled by conventional compression dressings. Using a tuberculin syringe, we administered a transcutaneous injection of 25 IU of the toxin at a point 0.5 cm above the site of the fistula at the surgical incision line and administered another 25 IU injection 0.5 cm anterior from that point. The injections were performed only for the superficial parotid gland in order to avoid post injection facial nerve paralysis. The discharge draining from the sialo-cutaneous fistula was considerably reduced after the second day of injection. The patient fully recovered within a week without any complications such as graft shearing or failure ().