Sialocutaneous fistula to the external auditory canal repaired with superficial parotidectomy and temporoparietal flap: A case report

RATIONALE

Gustatory otorrhea can lead to cutaneous changes, recurrent infection, and social disruption. We present a case of a late, evolving sialocutaneous fistula to the external auditory canal, managed surgically after failing conservative therapies. This case is unique by late evolution, whereby the symptoms presented with significance 27 years after her operation and 19 years after mild symptoms initially arose.

PATIENT CONCERNS

Gustatory, left-sided clear otorrhea with acutely increased volume over 8 months causing social disruption.

DIAGNOSES

Sialocutaneous fistula to the external auditory canal.

INTERVENTIONS

Superficial parotidectomy and temporoparietal flap for closure of fistula.

OUTCOMES

No postoperative complications and resolution of gustatory otorrhea at one-year follow-up.

LESSONS

This rare, but important, postoperative complication can present late with evolving symptoms, causing significant social disruption. It can be treated with conservative medical management and several surgical approaches.

Quality of life after surgery for benign disease of the parotid gland

Objective:

To evaluate quality of life after surgery for benign neoplastic disease of the parotid gland.

Patients and methods:

A quality of life questionnaire, which was created from the Hebrew version of the University of Washington Quality of Life prototype, was applied to 55 patients who underwent surgery for benign neoplastic parotid disease. All patients were examined in Baskent University Adana Teaching and Medical Research Center, where all except 10 subjects (who responded by phone) completed the quality of life questionnaire.

Results:

The highest overall score was 96.3 indicating no salivary fistula. Only one patient complained of salivary secretion through the wound scar. The lowest overall score was 59.5 indicating loss of sensation. Although no post-surgical pain was reported by 32 (58 per cent) patients, 16 (29 per cent) patients reported a post-surgical change in their appearance. Scarring and surgical site depression were reported by 26 (47 per cent) and 17 patients (30 per cent), respectively. Facial nerve impairment was reported by seven patients (13 per cent) during the early post-operative period; these patients recovered from that impairment. The only significant statistical correlations were noted between general health and gender, and between post-surgical pain and gender. There was not any statistical correlation between all data and age, tumour type and education level.

Conclusion:

The general status of patients who have undergone surgery for a benign parotid neoplasm can be assessed with a quality of life questionnaire. Patients' post-surgical quality of life can be improved by the correct choice of surgical approach and reconstructive method.

Complications after parotid gland surgery Our experience

AIM

Complications after parotid surgery include deficit of the facial nerve, wound complications, as sialocele and salivary fistula, and Frey syndrome; the goal of this study was to evaluate the relationship between the type of parotid surgery performed and the incidence of each of these complications.

MATERIAL OF STUDY

A total of 184 patients were evaluated and 158 were included in the study. Four different kinds of intervention were made: extracapsular dissection, partial superficial parotidectomy; superficial parotidectomy and total parotidectomy. The incidence of each complication was studied and correlated to the type of surgery performed. Statistical analysis was done using the chi-square test of independence.

RESULTS

From all cases examined, 86 patients developed facial nerve complications with 59 minor asymmetry, 19 partial weakness and 8 complete weakness. Forty patients had wound complications, 28 sialocele and 12 salivary fistula. Sixteen patients developed Frey syndrome.

DISCUSSION

Facial nerve complications and Frey syndrome were significantly related to superficial or total parotidectomy, differently extracapsular dissection and partial superficial parotidectomy had more cases of wound complications.

CONCLUSION

The kind of complications that occur after parotid surgery depends on surgery performed. Chi-square test has a statistically significant result and confirms this kind of relationship (P <.0001).

KEY WORDS

Facial nerve, Parotid glands, Parotidectomy.

Transdermal scopolamine in the management of postparotidectomy salivary fistula

Parotid fistula represents an uncommon complication in parotid surgery. Its early recognition contributes to successful management. The condition is distressing for both the patient and the surgeon, since conservative and operative treatment frequently fail. There is no consensus on the optimal management of parotid gland fistula. The aim of this study is to describe a new, simple procedure in the treatment of this condition using transdermal scopolamine. We report 3 cases of salivary fistulae occurring after parotidectomy. The patients were admitted to our department with swelling in the parotid region and an output of clear drainage from the drain site during oral intake. The patients were treated with a scopolamine transdermal release system applied to hairless skin overlying the parotid region. A prompt and remarkable decrease in daily salivary output was observed. Fistulae healed completely within 3 days. No collateral effects were observed. Parotid fistulae do not generally occur as a complication of parotidectomies. Their management can be difficult, and several methods of treatment have been attempted. We believe that the use of transdermal scopolamine is a valid option in the treatment of parotid fistulae without causing collateral effects.

[Salivary stone in parotid gland with a cutaneous fistula]

Parotid fistulas are very rare and arise from various causes such as trauma, operative complications, infection, malignancy and stone. They may also be congenital. A rare case of cutaneous salivary fistula is presented. A 59-year-old man had a recurrent inflammatory parotid disease which disappeared after the expulsion of the calculus.

Submandibular hydatid cyst fistulized into the oral cavity

Hydatid cysts of the head and neck are rare, even in regions where echinococcal infestation is endemic. Although complications, like cyst rupture and infection, may occur, an external fistula is extremely rare. This study examined a case of hydatid cyst that had fistulized in the right submandibular region of the oral cavity, which eroded the mandible.

CASE REPORT

A 45 year-old female patient visited our clinic with complaints of a discharge that left a bad taste in her mouth that persisted for 1 month and a painless swelling in the right submandibular region that had slowly expanded over the past 5 months. A physical examination revealed a cystic mass located in the right submandibular region that had fistulized in the oral cavity. The results were consistent with a hydatid cyst. We performed submandibular gland exeresis and a marginal mandibulectomy to excise the hydatid cyst together with the fistulous tract.

An unusual complication following rhytidectomy: iatrogenic parotid injury resulting in parotid fistula/sialocele

Rhytidectomy is a common surgical procedure performed by today's aesthetic surgeons. Newer trends and techniques leading to deeper and more aggressive dissection have placed the parotid gland at increased risk for injury during this procedure. Despite there being a relative abundance of literature on traumatic parotid injury, there is a relative paucity of information on iatrogenic parotid injury after rhytidectomy. In addition, there is no consensus on management of these complications. In this article, the authors discuss 3 case reports, review the relevant literature, and propose a treatment algorithm. Early diagnosis and appropriate treatment are essential to properly manage this complication.

[The use of myocutaneous flap for reconstruction of surgical defects in the oropharyngeal area]

Oncological Dispensary of Leningrad Region, St.Petersburg Our paper deals with evaluation of the results of using distal pectoralis major myocutaneous flap (38) in 37 patients; bilateral dissection of tissue--1. Plastic reconstruction of surgical effects of the oral cavity and pharynx was performed in 27 (skin cancer--8, parotid salivary gland tumor--1). Flap was used to both shield the parotid artery and prevent erosive bleeding following radical cervical dissection, urgent plastic surgery--30, postponed--8. Complication, chiefly slight was reported in 60.5% and treated conservatively. Total necrosis was identified in 2 (5.3%), partial--4 (10.8%), salivary fistula--10 out of 27 reconstructions of the upper intestinal tract (18.4%), cervical suture failure--7 (18.4%), flap avulsion from wound edges--6 (15.8%), wound edge avulsion--2 (5.3%). Nasogastric probe for feeding was used for approx. 23.7 days. Feeding per os after the first operation was restored in 23 (85.2%). Repeat reconstruction using pectoralis major myocutaneous flap has proved effective in patients with surgical effects of head and neck.

Traumatic diseases of parotid gland and sequalae. Review of literature and case reports

Parotid gland injuries are accompanied by a large number of sequelae. The aim of this paper is to highlight the importance of thorough management of these parotid glandinjuries especially at initial presentation in order to minimize the complications that accompany these injuries. A review of the aetiology and management of the existing cases of parotid gland injuries obtained from published journals and internet search as well as a report of two cases managed in our centre is presented in this paper. A total of about 70 cases in the previous literatures were reviewed of which assault was responsible for almost 90% of the cases. Sialoceles and fistulae were the main sequelae of these injuries. More than half of the cases (54%) were managed by conservative methods. Surgical drainage was done in about 44% cases; where the Stenson's ducts were accessible, primary repair was done. Excision of the gland was done in very few cases. The two cases managed in our centre were due to assault from broken bottles and road traffic accident respectively and both were managed by conservative methods. The first patient was a case of sialocele following the injury, which resolved within 3 weeks after the cyst formation with reduction in food intake, aspirations and external surgical drainage; while the second patient was a case of persistent fistula which healed after about 5 weeks following the trauma. Follow-up of both patients for about 3 months revealed no further leakage or accumulation of saliva. Management of these injuries involves a thorough understanding of the structure and function of the parotid gland and closely related tissues.

[Submandibular sialolith: case report and review of the literature]

Sialolithiasis is a common disease of the salivary glands and a major cause of salivary gland dysfunction. The dominance of submandibular sialoliths is widely investigated. Giant stones (>15 mm) are rare, approximately every tenth or twelfth of the stones belong to this category. Sialo-oral or sialo-cutaneous fistula formation promotes the growth of an excessive size. In their presentation, the authors would like to introduce the diagnostic and therapeutic process of a giant (27 mm) submandibular sialolith and give a review of the literature.

Prise en charge non chirurgicale des plaies de la glande parotide et du canal de Stenon: intérêt de la toxine botulinique

Salivary fistulas and sialoceles are rare complications of post-traumatic or postoperative parotid gland and duct injuries. Local injections of type A botulinum toxin represent a new and effective treatment for complications of these injuries, which is less invasive, stressful and lengthy than conventional methods. The authors report five cases in which three salivary fistulas and two sialoceles were successfully treated by botulinum toxin injections. The therapeutic protocol is described; it allows simple management of these complications and use of smaller doses than those described in the literature for treatment of sialoceles. The authors recommend use of botulinum toxin injections in first intention for management of salivary fistulas and sialoceles.

[Application of helix water jet to parotid surgery]

BACKGROUND & OBJECTIVE

Dissecting the facial nerves safely is an important guarantee for the accomplishment of parotidectomy and reduction of postoperative complications. This study was to explore the application of helix water jet to parotidectomy.

METHODS

Clinical data of 43 patients with parotid tumors, who received operation with helix water jet from Feb. 2004 to Feb. 2005 at Cancer Center of Sun Yat-Sen University, were analyzed. Meanwhile, traditional techniques in parotidectomy was performed in 36 patients (control group). Duration of operation, postoperative drainage volume, postoperative hospitalization, and occurrence of postoperative complications, such as facial nerve dysfunction and salivary fistula, of the 2 groups were compared.

RESULTS

The postoperative drainage volume was significantly lower in water jet group than in control group [(9.89+/-3.74) mL vs. (12.15+/-2.11) mL, P<0.05]. There were no significant differences in duration of operation [(90.28+/-25.30) min vs. (76.32+/-20.74) min, P>0.05], postoperative hospitalization [(6.39+/-1.38) days vs. (6.45+/-1.05) days, P>0.05] between the two groups. Of the 43 patients in water jet group, 6 (14.0%) had grade II facial nerve dysfunction and 1 (2.3%) had grade III facial nerve dysfunction; of the 36 patients in control group, 5 (13.9%) had grade II facial nerve dysfunction, 2 (5.6%) had grade III facial nerve dysfunction, 1 (2.8%) had grade IV facial nerve dysfunction and 1 (2.8%) had salivary fistula. There was no permanent facial nerve dysfunction occurred in both groups. There was no significant difference in the occurrence of complications between the two groups. Nine patients who retained nervus auricularis magnus suffered from slight numbness symptom of auricular lobule.

CONCLUSION

Use of helix water jet in parotid surgery is safe and confers some advantages over conventional methods of parotid dissection.

Superficial parotidectomy as first choice for parotid tumours

Parotid neoplasms represent 3% of all head and neck tumours, and most are benign. Malignant tumours account for 14-25% of cases. Surgery is the treatment of choice, with options ranging from simple enucleation to radical parotidectomy. Sixteen patients presented with a history of a painless parotid lump. Diagnosis was achieved by ultrasound scan and MRI. Fifteen superficial parotidectomies and 1 nerve-sparing total parotidectomy were carried out. At histology, 10 pleomorphic adenomas, 4 Warthin's tumours, 1 lymphoepithelial cyst and 1 sebaceous adenocarcinoma were detected. In the single case of carcinoma, the 6 peri-glandular lymph nodes included in the specimen were metastasis-free. In 3 patients (20%) a transient paresis of the facial nerve was noted. The capsule appeared breached in only 1 case of pleomorphic adenoma. Four patients (26%) were diagnosed as suffering from Frey's syndrome. A salivary fistula was recorded in 2 patients (13%). During follow-up ranging from 3 to 96 months no tumour recurrence was recorded. Superficial parotidectomy seems to be the best choice of treatment for benign parotid tumours, since it allows complete excision of the tumour with sparing of the facial nerve. A radical procedure is, however, needed if malignancy is confirmed at frozen section.

Management of Salivary Fistulas After Microvascular Head and Neck Reconstruction

Salivary fistulas after head and neck microvascular reconstruction are difficult problems whose treatment remains controversial. Although aggressive, early operative intervention has been suggested by some groups, we have found that many patients respond to conservative management with bedside debridement and aggressive local wound care. The purpose of this study was, therefore, to review our experience with the management of postoperative salivary fistulas.

METHODS

A retrospective review was performed and all patients who developed a salivary fistula after microvascular head and neck reconstruction over a 7-year period at Memorial Sloan-Kettering Cancer Center were identified and evaluated.

RESULTS

Six hundred thirty-seven patients underwent reconstruction during the study period. Of these, 35 patients developed a postoperative salivary fistula (5.4%). The majority of patients (81%) who developed fistulas shortly after the index procedure (<30 days) were successfully treated with conservative management. Similarly, 50% of late salivary fistulas (>30 days) responded to bedside debridement and wound care. There were no significant differences in the rate of total flap loss, carotid artery blowout, delay in onset of adjuvant radiation therapy (>6 weeks), or return to oral feeds between the conservative and operatively managed groups.

CONCLUSIONS

Aggressive surgical intervention in early postoperative salivary fistulas is usually not necessary, although the treatment plan should be individualized. Bedside debridement and aggressive wound care are adequate in most cases of early salivary fistulas. This approach is not associated with an increased rate of complications.

Gunshot injuries to the parotid gland: Patterns of injury and primary management

We have treated 16 patients with gunshot injuries to the cheek, 10 of whom had damage to the parotid. There were nine men and one woman, mean age 40 (range 15-65). All injuries were high velocity, and eight had other injuries. We followed them up for a month; three patients required further operation, three had facial palsy, and one lost his hearing on that side.

The role of botulinum toxin in postparotidectomy fistula treatment. A technical note

PURPOSE

Parotid fistula is a well-known complication of parotidectomy or penetrating injury of the parotid gland. The management of parotid fistula has been controversial, and numerous conservative and surgical treatment methods have been described.

METHODS

We report 3 cases of parotid fistula after partial parotidectomy, which were treated by botulinum toxin injection under electromyographic control into the residual substance of parotid gland.

RESULTS

Complete healing of the fistula was achieved with a single botulinum toxin treatment in all patients. No side effects were observed after the treatment. The patients are disease-free after 21, 18, and 14 months, respectively.

CONCLUSIONS

In the considered cases, the localized injection of botulinum toxin into the parotid gland resulted to an effective and long-lasting treatment of postparotidectomy fistula.

Diagnosis and Management of Salivary Fistula after Surgery for Congenital Aural Atresia

OBJECTIVE

Salivary fistula is an uncommon and unreported yet meaningful complication associated with the repair of congenital aural atresia. The capsule of the parotid gland may be violated during two steps of the operation: the initial dissection around the glenoid fossa or while aligning the auricle with the bony canal at the end of the procedure. We present the first described series of patients with salivary fistula after repair of congenital aural atresia.

STUDY DESIGN

Retrospective case review from 1985 to 2004.

SETTING

Tertiary referral center.

PATIENTS

We included all patients who were diagnosed with a salivary fistula after congenital aural atresia repair.

MAIN OUTCOME MEASURE

The diagnosis of a salivary fistula or salivary tissue in the external auditory canal after atresia repair was based on one of the following criteria: 1) identification of a fistula tract or salivary tissue in the external auditory canal, 2) otorrhea positive for amylase, or 3) intermittent otorrhea associated with eating.

RESULTS

Of 1,500 patients operated on for aural atresia, we identified 6 with salivary fistula after atresia repair. Salivary fistulas were diagnosed from 15 days to 10 years postoperatively, and the duration ranged from 6 months to 14 years. Treatment included observation, medical management, and surgical intervention.

CONCLUSION

Salivary fistulas in the external auditory canal may present with granulation tissue, persistent crusting, or persistent otorrhea; it is therefore necessary to consider salivary fistula when managing these findings in postoperative congenital aural atresia patients. Salivary fistula secondary to repair of congenital aural atresia may be managed conservatively or surgically.

Treatment of postparotidectomy fistulae with fibrin glue

Although fistulae resulting from superficial parotidectomy represent a serious problem, there is still little consensus on the optimal treatment. Some suggest management by applying dressings, while others advise surgery. In recent years several other strategies have been proposed. In this manuscript, we present two cases of postparotidectomy fistulae treated by injection with fibrin tissue glue (Tissucol Duo 500, Baxter AG, Vienna, Austria). Furthermore, a review of the literature is presented. In both patients the fistulae completely healed within months without complications. A literature search revealed that this is the first time postparotidectomy fistulae were treated this way. We conclude that postparotidectomy fistulae can be effectively treated with fibrin glue. Moreover, this treatment is simple, safe and has no side effects.

Effect of Salivary Fistulas on Free Flap Failure: A Laboratory and Clinical Investigation

OBJECTIVES

Infection is associated with free flap failure in patients undergoing microvascular flap reconstruction. This study investigates the association between infection arising from salivary fistulas, microvascular thrombosis, and free flap failure.

STUDY DESIGN

Prospective laboratory investigation and retrospective clinical investigation.

METHODS

The effect of saliva-induced infection on the patency of microvascular thrombosis was studied in an experimental animal model and in a clinical series of patients undergoing free flap reconstruction of the head and neck. In the laboratory phase of this study, rat femoral artery anastomoses were inoculated with freshly collected rat saliva to simulate a postoperative salivary fistula. The incidence of femoral artery thrombosis was determined. In the clinical arm of this study, the incidence of salivary fistulas and resulting clinical outcome in 588 head and neck free flap reconstructions were examined.

RESULTS

In the animal experiment, arterial patency was 95% after 10 days for both the control group and the salivary contamination group. In the clinical series, 24 patients developed salivary fistulas during the postoperative period. No cases of microvascular thrombosis were attributed to salivary fistula formation.

CONCLUSIONS

Postoperative salivary fistulas do not appear to be strongly associated as a contributory factor toward free flap failure in head and neck reconstruction. On the basis of our current understanding of this condition, we describe a rational approach for management of patients who develop salivary fistulas after microvascular head and neck reconstruction.

Reconstruction of a circular defect of the hypopharynx and cervical part of esophagus by a free jejunal flap (case report)

Patients with impaired continuity of the upper gastrointestinal tract are dependent on gastrostomy or jejunostomy tube feeds, which significantly reduce their quality of life. Reconstruction of the hypopharynx and esophagus is desirable in cases of congenital deformities, corrosive injuries, or defects after tumor resections. Free flap allows for easier reconstruction of head and neck defects. In this article, the authors present a case of complete hypopharynx closure in an oncology patient with a larynx carcinoma. The patient is a 60-year-old male diagnosed in 2002 with epidermoid carcinoma of larynx. The patient underwent laser resection of the tumor followed by radiotherapy and chemotherapy. In 2003 the patient underwent pharyngo - laryngectomy for relapse of the larynx carcinoma. Postoperatively the patient developed pharyngo - cutaneous fistula, which was reconstructed at the otorhinolaryngology department by a muscle - cutaneous flap from the pectoralis major muscle. During the course of healing the patient developed complete hypopharynx and cervical esophagus closure. Free flap of jejunum was recommended. The surgery team used a 10 cm long section of jejunum; the recipient blood vessels were arteria transversa colli and internal jugular vein. On the second day after the surgery patient developed salivary fistula in the wound. The fistula healed spontaneously in five weeks. Pharyngoscopy revealed that the transplanted jejunum was fully vital. Free flap of the jejunum allowed for upper gastrointestinal tract reconstruction and allowed the patient to restart peroral intake.

[Methods of closure for pharyngocutaneous fistula after laryngectomy]

The majority of salivary fistulas after laryngectomy or after laryngo-pharyngectomy close spontaneously within 2-3 weeks, and the remaining require surgical reconstruction. In the years 1987-2000 the pharyngo-cutaneous fistula was closed in 19 patients. The fistula developed after laryngectomy because of larynx cancer T3 and T4. 13 patients were irradiated before. In all the patients laryngectomy was combined with unilateral or bilateral neck dissection. Salivary fistula was closed in one stage operation using pectoralis major myocutaneous flap: 1) skin island of the flap to replace defect of the neck skin and mobilized mucosa from inside, 2) skin island for lining and deltopectoral skin flap from outside, 3) skin island for lining and free split skin flap for external cover, 4) skin island of the flap divided in two paddeles, one for lining and another for external cover. Indications for each method were discussed. Very good result of total fistula closure was obtained in 15 out of 19 patients. The fistula occurred again in 4 patients, in two of them the failure was caused by cancer recurrence.

Parotid salivary fistula secondary to external pin fixation: case report

Although the use of rigid fixation techniques has become widespread for the treatment of mandible fractures, indications still remain for the utilization of biphasic external pin fixation in patients who suffer cranio-maxillofacial trauma. The treatment of continuity defects of the mandible secondary to avulsive injuries or ablative surgery is a primary indication for the utilization of biphasic external pin fixation. The placement of biphasic external pins requires an understanding of the surgical anatomy surrounding the mandible. In this article, the authors discuss the indications for, contraindications for, and complications associated with the use of biphasic external pin fixation, describe the procedure, and present a case report of a patient with parotid salivary fistula secondary to the placement of external pin fixation.

Pleomorphic adenoma

Pleomorphic adenoma is the most common neoplasm of the salivary glands. Though a benign lesion, proper recognition and management of this process is needed to avoid increasing enlargement of the mass, facial nerve impairment, risk of malignant degeneration, and recurrence after surgical resection. The epidemiology, diagnosis, and treatment options for this neoplasm are discussed.

Surgical complications with open treatment of mandibular condylar process fractures

PURPOSE

This study assessed the surgical complications after open treatment for fractures of the mandibular condylar process.

PATIENTS AND METHODS

A total of 178 patients with unilateral fractures of the mandibular condylar process, 85 treated closed and 93 treated open, were included in this study. A tabulation of surgical findings and intraoperative and postoperative complications was prospectively performed. Standardized animating facial photographs were obtained at several postsurgical intervals and were examined and scored by a prosthodontist and an orthodontist for signs of facial nerve palsy and the quality of the surgical scar. Standard statistical methods were used to assess differences between open and closed treatment groups.

RESULTS

There were very few intraoperative or postoperative complications. At the 6-week point, 17.2% of patients treated open had some weakness of their facial nerve. This had resolved by 6 months. The scars were judged either wide or hypertrophic in 7.5% of cases.

CONCLUSIONS

Based on this study, surgical complications of open treatment of condylar process fractures that lead to permanent dysfunction or deformity are uncommon.

A device for applying postsurgical pressure to the lateral face

OBJECTIVE

The purpose of this study was to improve the effect of pressure applied on the lateral face after operations, particularly after parotid surgery for prevention of complications, especially the formation of salivary fistula.

STUDY DESIGN

A pressure instrument (face pad) was designed to fit all types of facial morphology. The blood flow velocity of the superficial temporal artery was measured by means of a Doppler detector in 30 healthy volunteers under 2 different conditions, with and without the face pad. Values for 2 parameters, peak velocity and average peak velocity, were determined for the purpose of selecting an appropriate pressure. Each of 47 patients who had undergone regional parotidectomy received pressure with the face pad for 3 days; the results were compared with those in a control group of 44 patients who had undergone similar operations but received traditional packing dressings.

RESULTS

The peak velocities of the superficial temporal artery with and without the face pad were not significantly different (t = 1.541, P = .132) when a pressure value of 4 to 5 N was applied. However, the average peak velocity of the superficial temporal artery increased significantly (t = 3.678, P = .001) with the face pad. The 47 patients with the face pad had no postoperative parotid fistula; in contrast, salivary fistula developed in 5 of the 44 control cases, for an overall fistula rate of 11.36%. A significant difference existed between the 2 groups (P = .023).

CONCLUSIONS

The face pad worked quantitatively and was stable and comfortable. A pressure of 4 to 5 N on the lateral face did not influence the blood flow of the superficial temporal artery. The higher peak velocity was correlated with regional stenosis of the temporal vein caused by pressure. Evidently, the face pad can reduce postoperative complications after parotidectomy; moreover, it makes pressure dressing easy and shortens the in-hospital days of the patient as well.

A comparison of one hundred and fifty consecutive parotidectomies for tumours and inflammatory disease

The demographic profile and complications are compared and contrasted for 150 consecutive parotidectomies. All patients were under the care of one surgeon (JDL) over a twenty-year period (1977-1997). The case records and contemporaneous database were analysed retrospectively. 111 (74%) procedures were performed for tumours and 39 (26%) for inflammatory disease. The incidence of unexpected permanent facial nerve palsy was 1.8% in the tumour group and zero in the inflammatory group. The overall unexpected palsy rate was 1.3%. Transient paralysis was more common in the inflammatory group than the tumour group (61.5% compared with 33.3%, P<0.02) and was more likely to be panfacial (48.7% compared with 17.1%, P<0.0002). The overall incidence of Frey's syndrome was less than 20% and both salivary fistulae and sialocoeles were infrequent.

Use of a parotid fascia flap to prevent postoperative fistula

OBJECTIVE

The purpose of this study was to investigate the usefulness of a fascia flap technique designed to improve the post-operative results of regional excision in cases of benign tumor in the superficial lobe of the parotid gland and to reduce formation of postoperative fistula.

STUDY DESIGN

During surgery in each of 32 patients with benign tumor in the superficial lobe of the parotid gland, a fascia flap was raised from beneath the ear lobe, placed in its original position, and firmly sutured after regional resection of the tumor. The results were compared with those in a control group of 30 patients, whose operations were the same as those of the experimental group except for the fact that the fascia overlying the tumor was excised with the tumor in the controls.

RESULTS

The wounds of the 32 patients repaired with the fascia flap healed well without any complication. Among the 30 patients in the control group, fistula occurred in 4 patients (13.3%). The difference was significant when the 2 groups were compared (chi2 test: P = .049 , P < .05).

CONCLUSIONS

Use of a parotid fascia flap in partial parotidectomy for benign tumors in the superficial lobe holds promise for the prevention of postoperative fistula formation.

Unusual elimination of a salivary calculus. A case report

Salivary calculi are frequently formed in the submandibular duct. The most common sites are where the duct turns round the distal edge of the mylohyoid, where the duct crosses the lingual nerve, and just distal to the duct orifice. Untreated calculi can cause obstruction and glandular atrophy, and then may exfoliate through the floor of the mouth. An unusual case of cutaneous exfoliation of a salivary gland stone is presented. The importance of early diagnosis and treatment of sialolithiasis are discussed.

Management of external penetrating injuries into the hypopharyngeal-cervical esophageal funnel

OBJECTIVE

To compare outcomes related to observation versus exploration for the hypopharynx and the cervical esophagus as the site of proven external penetrating injuries.

METHODS

The records of 70 patients (47 with hypopharyngeal and 23 with cervical esophageal wounds) were retrospectively reviewed.

RESULTS

No patient, observed or explored, who sustained a penetration into the hypopharynx above the level of the tips of the arytenoid cartilages of the larynx developed a complication. However, 22% of the patients with a hypopharyngeal injury below this level and 39% of patients with a cervical esophageal injury developed either a deep neck infection that required drainage or a postsurgical salivary fistula.

CONCLUSIONS

Overall, the consequences of an external penetrating injury become more serious in the descending levels of the funnel formed by the hypopharynx and cervical esophagus. Injuries located in the upper portion of the hypopharynx can be routinely managed without surgical intervention. Neck exploration and adequate drainage of the deep neck spaces are, however, mandatory for all penetrating injuries into the cervical esophagus and most injuries into the lower portion of the hypopharynx.

Palatal trauma: an unusual cause of a parotid sinus

A case is described of a 3-year-old boy who presented with a seemingly trivial injury to his soft palate, who went on to develop a parotid sinus as a result of a retained foreign body. This is a rare clinical problem and it highlights the difficulty in the clinical assessment of a palatal injury--especially in children. The child had the foreign body removed successfully 5 months after the initial injury and made an uneventful recovery.

Complicated course of local mycobacterial infection in an immunocompetent girl

A complicated course of cervical Mycobacterium avium adenitis in a healthy 3-year-old girl is described. A retropharyngeal and a parotic abscess developed resulting in a salivary fistula. Surgery was not judged possible but chemotherapy was given for 6 months during which the infection healed. It is not clear whether the regression was spontaneous or caused by the therapy.

Suction drain management of salivary fistulas

Salivary fistulas remain an unpleasant complication of upper aerodigestive tract surgery. To avoid a disastrous outcome such as carotid rupture, clinicians "medialize" (i.e., incise the skin flap in the anterior aspect of the neck and insert a Penrose drain) to divert fistula fluid from the carotid sheath and then perform laborious wound care. Meanwhile, patients endure the unpleasant odor, discomfort due to the wound dressing, occasional secondary surgical procedures, a lengthened hospital stay, and increased financial costs. In an effort to mitigate these problems, suction drains that had been placed at the time of the original surgical procedure were used as an alternative management technique. Out of a population of 118 reviewable patients who underwent standard or extended variations of supraglottic laryngectomy, partial laryngopharyngectomy, near-total laryngectomy, or total laryngectomy between 1988 and 1992, 16 patients appropriate for inclusion in this study developed postsurgical fistulas. Eight of these patients were treated with traditional medialization procedures, and the other 8 patients were treated with suction drainage. Comparison of the two groups revealed no significant difference with respect to complications or time to fistula closure. The advantages of simplified postsurgical care, less patient discomfort, reduced time demands on the clinician, and cost containment were noted for the group treated with suction drainage.

Prospective study using skin staplers in head and neck surgery

BACKGROUND

A prospective trial was undertaken to investigate the advantages and disadvantages of stapled skin closure versus conventional nylon sutures in head and neck surgery.

PATIENTS AND METHODS

The study included 20 consecutive patients who underwent extensive surgery in which their skin was closed with staples. Another group of 20 matched patients receiving a noncontinuous nylon suture closure was followed in parallel.

RESULTS

The complications recorded occurred in 5 patients in the stapled group and 3 in the sutured group. Analysis of cosmetic results showed 16 patients (80%) in the stapled group with good wound appearance and 17 (85%) in the sutured group. The mean closure time was 5 minutes for the stapled group and 25 minutes for the sutured group. Cost was $19.75 for conventional closure and $22.00 for mechanical suture.

CONCLUSION

The use of skin staples speeds up closure time by 80%, yields similar cosmetic results with no increase in complications, although at a slightly higher cost.

Salivary megalith with a sialo-cutaneous and a sialo-oral fistula: a case report

A rare case of a salivary megalith with a sialo-cutaneous and a sialo-oral fistula in an elderly man is presented. A brief review of the literature is made.

Closure of large orocutaneous fistulas in end-stage malignant disease

Expanding Silastic foam was used to close and dress a large orocutaneous salivary fistula secondary to a massive local recurrence of squamous cell carcinoma. The technique is simple, rapid, and effective. The patient found the dressing superior in every way to the traditional absorbent dressings previously supplied. We recommend this technique for the closure of large defects in the head and neck.

Facial sinus formation secondary to a parotid duct calculus

A case of facial sinus formation secondary to calculus obstruction of the parotid duct is reported. The aetiology and management of this condition are discussed.

Bilateral parotid duct fistula. Case report

Parotid duct fistulas (PDFs) are rare and have various causes such as gunshot wounds and human and animal bites; they may also be congenital. We have not found previous publications on bilateral PDF. Our patient, although young, also had generalized pigmentation characteristic of aging and thick, dry, wrinkled skin, as well as pyoderma. Biochemical analysis was performed on discharge from the patient's face, and histopathologic and immunologic studies were done. The fistulas were treated by intraoral fistulization. Cephalosporins were given to the patient for 5 days postoperatively to treat the pyoderma.

Barium swallow is a predictor of salivary fistula following laryngectomy

Pharyngocutaneous salivary fistula after laryngectomy is a serious complication that can lead to prolonged hospitalization and increased patient morbidity. A postoperative barium swallow provides the surgeon with information regarding the integrity of the pharyngeal suture line. In an attempt to determine whether this information can be used to predict or prevent salivary fistula, we reviewed the records of 109 patients who underwent total laryngectomy, including 51 who had a barium swallow before they began oral intake. Ten patients (20%) demonstrated a sinus tract originating from the pharyngeal suture line. A clinical salivary fistula developed in all four patients with a sinus tract 2 cm or longer, but in only one of six patients with a tract shorter than 2 cm. Other factors predictive of salivary fistula included tumor stage, previous radiation therapy, and the presence of concurrent postoperative complications. A single fistula developed in the 58 patients not studied with barium. Information provided by postlaryngectomy barium swallow appeared to predict, but not prevent salivary fistula formation.

Management of traumatic parotid sialoceles and fistulae: a prospective study

A prospective study of 13 patients with traumatic parotid fistulae or sialoceles showed that 54% resolved on conservative management within a 3 week period. Those that did not were treated by internal surgical drainage with uniform success, although care had to be taken with the catheter placement. No factors predictive of those cases requiring operative drainage other than failure of conservative management were found.

Staple closure of the hypopharynx after diverticulectomy and total laryngectomy

The use of stapling devices to close hypopharyngeal defects was first published in 1969 but the technique does not seem to have gained much popularity among head and neck surgeons. Fifty-nine hypopharyngeal defects were closed using a linear stapler between January, 1984, and April, 1989, at the Department of Otolaryngology, Head and Neck Surgery of the University Hospital of Zurich. Twenty closures were performed following resection of hypopharyngeal diverticula, 39 following wide field laryngectomy. A total of 10 salivary fistulae was observed: 2 after diverticulectomy (10%), 3 after laryngectomy in nonirradiated patients (11%), and 5 after laryngectomy in irradiated patients (45%). These fistula rates are comparable with average rates quoted in the literature. Only after laryngectomy for radiation failure was the fistula rate unusually high. No other complications were seen that could have been attributed to this type of pharyngeal closure. Closure of a hypopharyngeal defect with a stapler is easier and faster than with traditional suture methods. Provided the patient has not been previously irradiated, staple closure of the hypopharynx appears to be as reliable as closure by standard techniques and can be safely recommended.

Delayed pharyngoesophageal perforation: a complication of anterior spine surgery

Stabilization of the cervical spine is often accomplished via an anterior cervical approach. Bone grafts and/or plates and screws are used to achieve stabilization. Injuries to the pharynx and esophagus are known complications in anterior exposure of the cervical spine. These injuries are manifest in the early postoperative period. Reports of late perforations are very rare. We present four cases of delayed injury to the pharynx and esophagus that resulted in abscess or fistula. We postulate that graft displacement with resulting erosion was responsible for these serious complications. Postoperative odynophagia in patients who undergo anterior cervical fusion warrants evaluation of the bone graft location. Early surgical intervention and repair may decrease prolonged morbidity in these patients.