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 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.