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.
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.