Early Predictors of Fistula Formation Following Head and Neck Reconstruction.

BACKGROUND: Salivary fistula formation is a common and serious complication following head and neck reconstruction. Because it can cause delayed wound healing and infection and carotid artery rupture in severe cases, hence, early detection and treatment are crucial. This study was designed to identify early predictors of postoperative fistula formation. METHODS: We conducted a retrospective analysis of patients who underwent head and neck reconstruction between 2015 and 2022. Body temperature, serum white blood cell (WBC) count, and serum C-reactive protein (CRP) levels were assessed until postoperative day (POD) 14 and compared between patients with and without fistula. RESULTS: In this study, 200 patients were included. No significant differences in body temperature and WBC count were observed between the two groups during the entire study period. CRP levels after POD2 were higher in the fistula group than in the without fistula group. From the receiver operating characteristic curves comparing the two groups, the best cutoff level for CRP was 6.27 mg/dL from POD7 to POD8, with 77.1% sensitivity, 69.8% specificity, and 90.1% negative predictive value. CONCLUSION: CRP is a valuable predictor of fistula formation following head and neck reconstruction. The course of CRP levels in patients with fistulas remains consistently elevated compared to patients without fistulas, and it is particularly useful for the exclusion diagnosis of fistula.

Watching Food Videos Leads to Postparotidectomy Salivary Fistula.

Salivary fistula is a common postparotidectomy complication, and eating sour or spicy food ranks among the leading causes. Here we report a rare postparotidectomy salivary fistula case, a 31-year-old female patient who affirmed that she did not eat any irritating foods but admitted that she had been watching food videos for up to 4 hours every day since she left hospital. This case offers a cautionary tale about postparotidectomy precautions.

[Injection of incobotulinum toxin A for the prevention of postoperative salivary fistula and sialocele]. / Primenenie botulotoksina tipa A v profilaktike posleoperatsionnykh slyunnykh svishchei i sialotsele.

The aim of the clinical study was to improve prevention of postoperative sialocele and fistulas of parotid glands. MATERIALS AND METHODS: The study included 100 patients with tumors of parotid glands treated by superficial parotidecthomy. Fifty patients received incobotulinum toxin A preoperatively, while control group consisted of 50 patients without preoperative injections. RESULTS: Salivary fistulas formed in 17% of cases in control group. Discharging of saliva through the postoperative wound for 6 days after surgical treatment were noticed in the control group in 30% of cases. There were no complications such as forming of salivary fistula and sialocele and no saliva flow from the postoperative wound on the 4th day after surgical treatment in the main group. Conclusion. The use of botulinum toxin type A proved an efficient and effective way for prevention of postoperative salivary fistulas and sialocele.

Management of postreconstructive head and neck salivary fistulae: A review of current practices.

BACKGROUND: Salivary fistulas are common complications after reconstructive head and neck surgery with significant morbidity. Yet, there are no established guidelines for their management. METHOD: A comprehensive search of PubMed was performed from 01/01/2000 to 06/31/2019 to evaluate all treatment options in postreconstructive head and neck fistulas. RESULTS: Nineteen articles with 132 patients were included. Thirty-nine of 132(30%) patients were treated with conventional wound care. All fistulas closed after 51.6±54.0 days with no refistulations. Thirty-eight of 132(29%) patients were treated with negative pressure wound therapy (NPWT). Thirty-eight of 40(95%) fistula closed after 14.7±12.0 days with no refistulations. The reduced healing time was statistically significant as compared to patients on conventional wound care (p < 0.001). Fifty-three of 132(40%) patients received surgical management. Forty-four of 53(83%) patients had complete fistula closure without postoperative complications. A pedicled flap was used in 60% of cases (n = 32). CONCLUSION: Most salivary fistulas close with conservative management. NPWT potentially shortens fistula healing time while it achieves similar closure rates as conventional wound care. In the absence of contraindications, NPWT should be trialed on all salivary fistulas. Surgical management should be reserved for large, chronic, high-risk fistulas or those not responding to a trial of conservative treatment. Secondary reconstruction should be kept as simple as possible.

Minor Parotidectomy Complications: A Systematic Review.

OBJECTIVES: To report descriptive statistics for minor parotidectomy complications. METHODS: A systematic review was performed, selecting 235 studies for analysis. The incidence of complications was tabulated, and descriptive statistics calculated. Outlier studies, 1 standard deviation above the mean, were reexamined to determine potential causal factors for each complication. All studies were examined for statistically significant differences for any potential causal factor. RESULTS: The pooled incidence of minor complications reported were hematoma 2.9% (95% confidence interval [CI]: 2.4-3.5), wound infection 2.3% (95% CI: 1.8-2.9), sialocele 4.5% (95% CI: 3.5-5.7), salivary fistula 3.1% (95% CI: 2.6-3.7), flap necrosis 1.7% (95% CI: 1.1-2.5), scar issues 3.6% (95% CI: 2.4-5.4), numbness 33.9% (95% CI: 25.6-43.4), and deformity 11.8 (95% CI: 6.9-19.5). Implants result in more wound complications, such as hematoma, sialocele, or salivary fistula. Sialocele and salivary fistula appear more frequently after less extensive parotid surgery, whereas hematoma, wound infections, flap necrosis, and aesthetic considerations are worse with more extensive resections. CONCLUSIONS: Minor parotidectomy complications are more frequent than generally assumed and related to certain factors that should be investigated. Laryngoscope, 131:571-579, 2021.

Drain fluid amylase as a predictor of postoperative salivary fistula in cases with benign parotid tumours.

BACKGROUND: Late diagnosis of a salivary fistula increases the risk of wound infection and scarring. The purpose of the present study was to identify a quantitative predictor of postoperative salivary fistula for cases treated with surgery. METHODS: Demographic, intraoperative and postoperative parameters for 57 cases that received surgery for benign parotid tumours were recorded from June 2017 to June 2018, of which 18 cases developed salivary fistulas. These data were analysed using univariate and binary logistic regression analyses as well as receiver operating curve analysis. RESULTS: Drain fluid amylase concentration was positively correlated with salivary fistula development (p <  0.001), with an odds ratio of 1.14 for a 1 KU/L increase in concentration and an optimal receiver operating curve cut-off value of 51,100 U/L for predicting salivary fistula development. Cases wherein the parotid-masseteric fascia remained intact were associated with a lower risk of salivary fistula development (p = 0.006). CONCLUSION: Drain fluid amylase concentration may be a valuable predictor of postoperative salivary fistula in cases with benign parotid tumours.

A Functional Approach to Posttraumatic Salivary Fistula Treatment: The Use of Botulinum Toxin.

This manuscript highlights key aspects regarding the practical use of botulinum toxin for the conservative nonsurgical treatment of a rarely encountered, but significant posttraumatic complication-the parotid salivary fistula. It adds information to the scarce existing literature on the subject. The authors outline the main differences between postoperative and trauma-related parotid injury regarding salivary fistula treatment. A total of 6 patients with trauma-related salivary fistulas have been treated by Abobotulinum toxin A injections over the course of 5 years. The technique is detailed, describing the doses used in the presence of parenchyma and duct injuries, the location and number of injection points in relation to the wound pattern. The results were favorable, leading to the healing of the salivary fistulas in all patients, with 1 injection session, without additional conservative treatment. In our experience, the use of botulinum toxin is of great benefit for treating salivary fistulas in a traumatic context.

Management and Follow-up Results of Salivary Fistulas Treated With Botulinum Toxin.

OBJECTIVES/HYPOTHESIS: Salivary fistulas are a common minor complication of parotid surgery. botulinum toxin has repeatedly been reported to be an adequate treatment of this entity. To date, there is little scientific evidence for clinical decision making after appearance of a salivary fistula. STUDY DESIGN: Retrospective chart analysis of 16 patients who had been treated with botulinum toxin for salivary fistula. METHODS: All patients who had been treated for salivary fistula at a tertiary referral hospital from 2010 to 2016 were included. Patient files were used to obtain characteristics of patients, treatment, and follow-up. RESULTS: Sixteen patients with salivary fistula received 27 injections of botulinum toxin. Nine patients required one injection for the fistula to heal, five patients needed two injections, and one patient needed three and four injections, respectively. No patient underwent additional surgery or radiotherapy. We observed no adverse effects in any patient treated with botulinum toxin. CONCLUSIONS: In most cases of salivary fistula, injections of botulinum toxin are a valid treatment. If the initial injection is not successful, injections may be repeated once. Otherwise, revision surgery should be considered. In general, treatment with botulinum toxin should be commenced in an earlier stage and with higher dosages. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:403-408, 2019.

Transdermal scopolamine for the prevention of a salivary fistula after parotidectomy.

Our aim was to investigate whether perioperative transdermal application of scopolamine could help to prevent fistulas after parotidectomy, and to this end we retrospectively studied the records of all patients (n=645) who had benign parotid tumours treated by partial parotidectomy between 2011 and 2016. We found that scopolamine led to a significant decrease in the incidence of salivary fistulas from 54/371(15%) in the group not given it to 10/274 (4%) in the group given it (p<0.0001). The "number needed to treat" was 9.17. There was a relatively low incidence of all adverse effects after scopolamine. Our results are encouraging. Thorough consideration of the contraindications and a knowledge of the potential adverse effects are crucial for its successful implementation.

Primary treatment of early fistula of parotid duct with botulinum toxin type A injection

Abstract: Salivary duct injury can be idiopathic, iatrogenic, or post-trauma and may result in sialocele or fistula. Most injuries regress spontaneously and botulinum toxin A is one of several therapeutic possibilities. We report a case of iatrogenic injury to the parotid duct after Mohs' micographic surgery for a squamous cell carcinoma excision in the left jaw region, treated by injection of botulinum toxin type A. Although the fistula by duct injury can be self-limiting, botulinum toxin injection by promoting the inactivity of the salivary gland allows rapid healing of the fistula.

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.

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.

Primary treatment of early fistula of parotid duct with botulinum toxin type A injection.

Salivary duct injury can be idiopathic, iatrogenic, or post-trauma and may result in sialocele or fistula. Most injuries regress spontaneously and botulinum toxin A is one of several therapeutic possibilities. We report a case of iatrogenic injury to the parotid duct after Mohs' micographic surgery for a squamous cell carcinoma excision in the left jaw region, treated by injection of botulinum toxin type A. Although the fistula by duct injury can be self-limiting, botulinum toxin injection by promoting the inactivity of the salivary gland allows rapid healing of the fistula.

Factors influencing sialocele or salivary fistula formation postparotidectomy.

BACKGROUND: Does the extent of parotidectomy or other patient or tumor characteristics influence the rate of sialocele/salivary fistula formation? METHODS: All patients who underwent parotidectomy at the University of Wisconsin from 1994 to 2013 were considered. Patients who developed a sialocele/salivary fistula were identified. Extent of dissection, age, sex, body mass index (BMI), volume of specimen, and rate of malignancy were examined. RESULTS: Seventy of 771 patients (9.1%) developed a sialocele/salivary fistula. Sixty-seven fistulae (96%) developed within 1 month and all resolved by 6 months. Age, sex, pathology, and BMI were not increased in the sialocele group. Inferior and middle superficial parotidectomy had a significantly higher rate of sialocele than other extents of dissection. Volume of tissue removed was not significantly different between dissection groups. CONCLUSION: Sialocele/salivary fistula is common postparotidectomy and is more likely with inferior and middle superficial parotidectomy. © 2016 Wiley Periodicals, Inc. Head Neck 39: 387-391, 2017.

Submandibular Duct Fistula Caused by a Large Sialolith: Incidental Finding in a Barium Swallow Study.

BACKGROUND: This case report details an incidental finding of a submandibular duct fistula to a patient's posterior mouth floor found on a barium swallow examination that was performed to rule out gastrological causes of substernal chest pain. The radiologist was unable to determine the cause of the filling defect at the time of the study. The patient's history revealed that a large calculus of unknown size had been passed spontaneously through the floor of the mouth, rupturing the proximal gland duct and creating the fistula. DISCUSSION: Sialolithiasis is the formation of calculi in the salivary gland and is the most common disease of the salivary glands, with the submandibular glands affected more often than others. The condition is more common in men than in women and most often affects individuals aged between 30 and 60 years. CONCLUSION: In general, the etiology of sialolithiasis is unknown. However, examining comorbidities and possible risk factors, such as tobacco use, and how they alter the saliva and the function of the salivary glands might lead to a better understanding of their cause.

[The primary use of pectoralis myofascial flap in salvage laryngectomy]. / Die primäre Verwendung des myofaszialen M. pectoralis-major-Lappens bei der Salvage-Laryngektomie.

BACKGROUND: The salvage laryngectomy (SLE) is very often the only curative option in recurrent laryngeal or hypopharyngeal carcinomas. But the SLE is associated with an increased risk of complications such as the formation of salivary fistulas. To reduce the rate of fistulas a simultaneous elevation of the myofascial pectoralis major flap (PMML) is described. The aim of this study was to compare the SLE with and without the use of the PMML for prophylaxis of salivary fistulas. PATIENTS AND METHOD: 9 patients were included, suffering from a T4a larynx or hypopharynx carcinoma recurrence after RCT in the years 2012 and 2013 and subsequently treated by a SLE. An additional elevation of PMML was indicated due to the following criteria: end of RCT less than one year ago, tumor localization outside the glottis, infiltration of thyroid cartilage and prelaryngeal muscles. After PMML elevation the flap was sewed onto a primary closed pharynx. RESULTS: 6 out of 9 patients (2/3) received an additional covering of the pharynx by the PMML during SLE. In no case a postoperative salivary fistula was seen. In the remaining 3 patients (1/3) the pharynx was primarily closed without an additional covering by the PMML. In this group of patients one postoperative salivary fistula was seen. CONCLUSION: Due to the simultaneous application of the PMML in the context of SLE the rate of postoperative salivary fistula could be effectively reduced in our own patients. The PMML is suitable due to its safe elevation technique, the missing secondary thoracal cutaneous defect, and a good modelling possibility in the recipient area.

Modified gastric pull-up reconstructions following pharyngolaryngectomy with total esophagectomy.

Reconstruction following pharyngolaryngectomy with total esophagectomy is a challenging surgery to perform. Between April 2008 and August 2012, three types of modified gastric pull-up reconstruction procedures, including a gastric tube creation combined with a free jejunal transfer (n = 7), elongated gastric tube creation with vascular anastomoses (n = 2) and pedunculated gastric tube creation with Roux-en-Y anastomosis (n = 5), were performed after pharyngolaryngectomy with total esophagectomy. To clarify feasibility of these reconstructive methods, we retrospectively analyzed the short-term outcomes. There were no graft failures. Salivary fistulae were observed in two cases after high pharyngoenteral anastomoses due to oropharyngeal extension of hypopharyngeal cancers. Overall morbidity rate was 21.4%, and no deaths occurred. Although the operation time was shortest for pedunculated gastric tube reconstructions, morbidity rates were similar among all methods. All three types of modified gastric pull-up reconstruction procedures can be performed safely. We can choose one of these methods according to the tumor status and the patient condition, understanding advantages and disadvantages of each procedure.

Submandibular hydatid cyst fistulized into the oral cavity.

UNLABELLED: 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.

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.