A 1-yr-old girl presented with a salivary discharge at the facial skin of her right cheek. CT sialography was done and a sialo-cutaneous fistula from an accessory parotid gland was diagnosed (). She also had a skin tag on the tragus of the right ear. At that time, surgical excision was considered at a later age. At the age of five, she visited the outpatient clinic for definitive treatment. The clinical examination demonstrated a 1 mm-sized opening located at the facial skin 1 cm lateral to the angle of mouth. The salivary discharge was clear and serous. The salivary flow rate was calculated by a cotton ball test. It revealed that the flow from the accessory gland was about 10% of the total flow of a parotid gland. According to our previous experience (), fistulectomy was scheduled, but aesthetic considerations for the young girl made the surgical plan change to more conservative management. Under general anesthesia, the 6 cm-long fistula tract was identified with a lacrimal probe. Intraoperative ultrasonography was done to demarcate the accessory parotid gland. Although the accessory gland was too small to be clearly identified, 16 IU of botulinum toxin was injected to the accessory gland under ultrasound guidance. After thin adhesive film was attached on the buccal skin around the fistula opening to prevent spillage of corrosive agent from unwanted skin injury, about 2 mL of 40% TCA solution was injected into the tract with a small metal suction tip (). Thirty seconds later, all the solution was removed with suction and squeezing. This procedure of TCA cauterization was repeated twice. There was no immediate complication postoperatively.\nAfter several days, a tensely inflated sialocele formed and the opening was found to be completely closed up. Aspiration was done with long subcutaneous tunneling from behind so as not to make an iatrogenic sialo-cutaneous fistula. After 4 sessions of weekly aspiration, the sialocele did not recur. During one year follow-up, there was no more salivary leakage or sialocele. Moreover, the aesthetic result was very satisfactory.
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 ().