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 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.