A 41-year-old man presented for mandibular subcondylar fracture which was reconstructed with direct open reduction and internal fixation of the condyle via the retromandibular transparotid approach. Two weeks after the surgery, he revisited our outpatient office with a chief concern of swelling approximately 5×3 cm in size under the surgical incision wound on the left retromandibular area for the past 1 week (). He did not have pain; however, complained of the swelling increased during meals. Physical examination showed a soft subcutaneous cystic mass. These findings suggested a sialocele.\nA 4 mL of aspiration was performed and serosanguinous fluid was observed. Triamcinolone (0.2 mL×40 mg/mL) and bleomycin (0.2 mL×1 mg/mL) were administered. Pressure dressing was applied. However, the 2 weeks of treatment was not effective. After 2 weeks, the sialocele size did not decrease and the skin overlying the sialocele was thinning. A 5 mL of aspiration was performed again and the serosanguinous fluid had become turbid. This fluid analysis showed no bacterial growth and high amylase levels (17,250 units/L). Triamcinolone and bleomycin were administered again, and pressure dressing was applied continuously.\nWe conducted computed tomography and sialogram for the further evaluation. Computed tomography revealed a well-defined thin-walled cyst (32×22×21 mm) below the earlobe and retromandibular area between the body and tail of the parotid gland (). The lateral portion of the cyst was damaged and fluid leakage outside the cyst was noted where the skin was thin. Sialography of the left parotid gland showed no accumulation of contrast media in the sialocele location when the contrast media was injected through the intraoral Stensen’s duct orifice. It revealed no connection between the Stensen’s duct and the sialocele. A cutting edge of the inferior interlobular duct was noted (). Contrast media was percutaneously injected into the sialocele which was located at the tail of the parotid gland where the inferolateral part of the cutting end of parotid duct was positioned (). It revealed an approximately 30×25 mm cyst located at the lateral area of the transected parotid duct lesion as well as fluid leakage outside the parotid fascia. The sialocele had impending sings of trans-cutaneous fistula, which prompted surgical treatment.\nThe patient underwent surgery through the previous incision line. The sialocele was located beneath the skin and encapsulated with thin capsule that was the part of protruded parotid fascia. Dissection was conducted to parotid fascia layer. The parotid gland was dissected along the sialocele wall that was located between the parotid body and tail area (). Two openings of transected ducts were noted at the base of the inside cavity which were 1.5 cm apart and marked. After complete excision of the sialocele wall, we further dissected the both duct openings and ligated the both ends with 5-0 vicryl suture (). Fifty IU of botulinum toxin type A was injected into the parotid gland around and distal to the sialocele to block salivary secretion and preventing recurrence (). The cyst-excised space was packed with surrounded parotid glandular tissue and tightly sutured. A negative suction drain was placed and pressure dressing applied. No discharge was noted 2 days postoperatively, and the drain was removed. The patient was discharged without any symptoms. No complications or recurrence were observed at 7-month follow-up (). Postoperative computed tomography also showed no recurrence of the sialocele.
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 ).