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 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 [].