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 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.