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 white17-year-old female patient presented with a 4-month history of swelling over her\nleft cheek anteriorly to the ear. She referred 3 previous episodes, the last one having\nstarted 1 month before the appointment. She denied trauma to the region, had not have\nepisodes of fever lately and her medical history was not contributory. There was no\nassociated pain or alteration of facial function as well as no motor or sensory deficits\nwere observed.\nThe swelling measured about 6 cm in length and 5 cm in width. On bimanual palpation an\nill-defined and resilient mass was noticed (). This mass was evident extra orally with a considerable bulging of the skin\nin the left parotid region. The lesion was normal and no lymphadenopathy was detected.\nOn intraoral examination, oral mucosa and teeth were healthy. The parotid duct in the\naffected side was normal and salivary flow had normal physical aspects without debris or\npurulent discharge. The presumptive clinical diagnosis was an abscess associated to mild\ninflammation, considering the patient’s history and the previous episodes. Conventional\npanoramic radiography, ultrasonography and sialography were performed. The panoramic\nradiograph showed teeth and bones preserved without any evidence of abnormalities. The\nultrasonographic scan revealed a hypoechoic ovoid well defined image suggesting a cyst\n(). Sialography of the left parotid was\nperformed using Lipiodol® (Lipiodol; Guerbet, Jacarepaguá, RJ,\nBrazil) as a substance of contrast. A partial filling of the gland was enough to show\ncavitary sialectasia in a panoramic ()\nand anteroposterior view (), and the\ncontrast was retained in the gland for at least 24 hours ().\nA percutaneous needle aspiration of the swelling was performed 2 weeks after the\nsialography. It yielded 4 mL of a clear viscous fluid. The material was submitted to\nmicrobiological analysis and showed numerous polymorphonuclear leukocytes. The fluid did\nnot show any bacterial growth and presented high amylase levels (7,810 units/L). The\naspiration procedure was sufficient to empty the cavity. The patient was advertised to\ncompression dressing twice a day. Seven days after the percutaneous aspiration a great\ndecrease of the swelling was observed. The overlying skin showed a discreet erythema on\nthe surface of the mass, without signs of infection, and the patient did not refer pain\n(). At the 30-day follow-up visit,\ncomplete recovery was noticed, and the residual swelling had totally disappeared (). The patient was followed up during two\nyears and a half and no recurrence was detected.