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 ().
A white17-year-old female patient presented with a 4-month history of swelling over her\nleft cheek anteriorly to the ear. She referred 3 previous episodes, the last one having\nstarted 1 month before the appointment. She denied trauma to the region, had not have\nepisodes of fever lately and her medical history was not contributory. There was no\nassociated pain or alteration of facial function as well as no motor or sensory deficits\nwere observed.\nThe swelling measured about 6 cm in length and 5 cm in width. On bimanual palpation an\nill-defined and resilient mass was noticed (). This mass was evident extra orally with a considerable bulging of the skin\nin the left parotid region. The lesion was normal and no lymphadenopathy was detected.\nOn intraoral examination, oral mucosa and teeth were healthy. The parotid duct in the\naffected side was normal and salivary flow had normal physical aspects without debris or\npurulent discharge. The presumptive clinical diagnosis was an abscess associated to mild\ninflammation, considering the patient’s history and the previous episodes. Conventional\npanoramic radiography, ultrasonography and sialography were performed. The panoramic\nradiograph showed teeth and bones preserved without any evidence of abnormalities. The\nultrasonographic scan revealed a hypoechoic ovoid well defined image suggesting a cyst\n(). Sialography of the left parotid was\nperformed using Lipiodol® (Lipiodol; Guerbet, Jacarepaguá, RJ,\nBrazil) as a substance of contrast. A partial filling of the gland was enough to show\ncavitary sialectasia in a panoramic ()\nand anteroposterior view (), and the\ncontrast was retained in the gland for at least 24 hours ().\nA percutaneous needle aspiration of the swelling was performed 2 weeks after the\nsialography. It yielded 4 mL of a clear viscous fluid. The material was submitted to\nmicrobiological analysis and showed numerous polymorphonuclear leukocytes. The fluid did\nnot show any bacterial growth and presented high amylase levels (7,810 units/L). The\naspiration procedure was sufficient to empty the cavity. The patient was advertised to\ncompression dressing twice a day. Seven days after the percutaneous aspiration a great\ndecrease of the swelling was observed. The overlying skin showed a discreet erythema on\nthe surface of the mass, without signs of infection, and the patient did not refer pain\n(). At the 30-day follow-up visit,\ncomplete recovery was noticed, and the residual swelling had totally disappeared (). The patient was followed up during two\nyears and a half and no recurrence was detected.