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.

Role of Negative-Pressure Wound Therapy in the Management of Submandibular Fistula After Reconstruction for Osteoradionecrosis.

PURPOSE: Although negative-pressure wound therapy (NPWT) for complicated wounds has been extensively studied, it is rarely used in cases involving a submandibular fistula due to radiation-induced osteoradionecrosis of the mandible. This study aimed to investigate the efficacy of NPWT for submandibular fistulas after reconstruction for osteoradionecrosis. PATIENTS AND METHODS: Nine patients with submandibular fistulas after reconstruction for osteoradionecrosis treated with NPWT between 2011 and 2014 were included in the study. The wound healing was documented. RESULTS: The NPWT device was removed postoperatively between days 7 and 12 (mean duration, 9.6 days). The wound bed was filled with healthy granulation tissue, and successful healing by second intention was observed in all patients within 2 weeks. No complications were observed. The follow-up ranged from 4 to 27 months (mean, 18 months); the fistulas exhibited excellent healing, and no recurrence or infection was observed. CONCLUSIONS: NPWT is a safe, effective technique for managing submandibular fistulas after reconstruction for osteoradionecrosis.

[Auriculomastoid incision for parotid surgery]. / Parotis cerrahisinde aurikülomastoid insizyon.

OBJECTIVES: This study aims to analyze the treatment outcomes of benign parotid tumors operated through auriculomastoid incision (the authors defined incision as "ariculomastoid incision" in this study). PATIENTS AND METHODS: Between April 2008 and March 2012, 23 patients (15 females, 8 males; mean age 48.8 years; range 28 to 67 years) who underwent parotidectomy first at Bolu State Hospital, Ear, Nose and Throat Clinic due to benign and mobile mass lesions in superficial lobe of parotid gland were retrospectively analyzed. Approximately a 5 cm incision starting at anterior to the tragus, extending along the ear lobule and ending at the mastoid apex was performed. Facial nerve traces were identified according to the anatomical landmarks. Pathological diagnoses, complications and follow-up results were recorded. RESULTS: Pathological diagnoses were pleomorphic adenoma in 15, Warthin tumor in six, branchial cleft cyst in one, and extrapulmonary lymph node tuberculosis in one patient. The main truncus and bifurcation of the facial nerve was identified at the lower level of the incision and in the direction of mandibular angle. Facial nerve was identified by following high calibration stylomastoid artery a few millimeters inferomedialy in 16 patients. Incision was extended in three patients due to an inferior mass located. No local recurrence occurred during at a mean follow-up of 28 months (range; 6-48 months). Three patients developed transient, partial facial paralysis, which recovered completely within two months. Two patients had salivary fistulas, which recovered by compression dressing within three weeks. CONCLUSION: Auriculomastoid incision can be applied safely in the treatment of mobile, benign parotid tumors localized in the superficial lobe with a low rate of postoperative complication.

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.

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.

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.

[Successful use of botulinum toxin injection in the treatment of salivary fistula following parotidectomy]. / Parotidektomi sonrasi gelisen tükürük fistülünün botulinum toksini ile iyilesmesi.

A twenty-year-old woman underwent right superficial parotidectomy for pleomorphic adenoma. On the 10th postoperative day she presented with a salivary fistula, for which repeated aspirations with pressure dressings were applied for a month. Despite decreases in the salivary fluid volume, reaccumulation persisted. Following aspiration of the salivary fluid, 40 units of botulinum toxin was injected into the pouch. On the second day of injection, the discharge ceased and the pouch disappeared. No side effects were observed and the patient remained symptom-free during four-month follow-up.

Postparotidectomy fistula: a different treatment for an old problem.

There is little consensus on the optimal management of postparotidectomy salivary fistulas. Timely treatment is important since fistulas may result in wound dehiscence and infection. Management options include pressure dressings, total parotidectomy, tympanic neurectomy, graft interpositioning, surgical closure of the tract, radiation therapy, and pharmacotherapy. Unfortunately, many therapies require weeks to months for resolution and possess additional risks. The affected patient often suffers social embarrassment from the drainage. Through our work with neurologically impaired children with sialorrhea, we have had success with using glycopyrrolate, an anticholinergic frequently used to decrease salivary secretions. We present a case of a patient with a postparotidectomy fistula which was successfully treated with glycopyrrolate and pressure dressings. The rationale and potential use of glycopyrrolate for the treatment of a salivary fistula are the focus of this presentation.

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.

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.

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.

Post-parotidectomy fistula.

Today parotidectomy is a common, safe surgical procedure. With the increase in the number of parotidectomies being performed there have been many reviews of both the immediate and delayed operative complications. Postoperative salivary fistula, although a common occurrence, is usually glossed over or barely mentioned in most reviews. The present study reviews the parotid experience at a major teaching hospital, The Wellesley Hospital, University of Toronto, over a 10-year period. This information was used to draw general conclusions concerning the incidence, etiology and treatment of salivary fistulas as well as their prevention.

Conservative management of post-traumatic parotid fistulae and sialoceles: a prospective study.

A prospective study of 14 consecutive patients with parotid injuries treated over a 4-month period, is presented. Three patients underwent emergency duct repair and 11 patients, presenting with delayed fistulae or subcutaneous collections of saliva (sialoceles), were treated conservatively with uniform success. Glandular injury closed within an average of 5 days of treatment and ductal leaks within approximately 14 days.

The effects of tympanic neurectomy and chorda tympanectomy on experimentally induced parotid duct fistulae in rabbits.

To study the effects of parasympathetic denervation on the secretory activity of parotid fistulae, polyethylene catheters were introduced bilaterally into the parotid main excretory ducts of 10 rabbits, followed by unilateral parasympathectomy performed by segmental resection of the tympanic plexus and the chorda tympani nerve. Although salivary flow from the fistulae of the denervated parotid glands stopped up to 8 days earlier than that from the healthy (control) glands, the effect of parasympathectomy was not strong enough to recommend this operation as the method of choice for the clinical inactivation of persistent parotid fistulae.

[Therapy of benign diseases of the parotid gland by instillation of a resorbable protein solution into the duct system]. / Die Therapie benigner Erkrankungen der Ohrspeicheldrüse durch Instillation einer resorbierbaren Eiweisslösung in das Ausführungsgangsystem.

Non-neoplastic disorders of the parotid gland like chronic recurrent parotitis, asymptomatic gland enlargement or salivary fistulae present a therapeutic problem. Surgical removal of the gland is often difficult as scar tissue may be present in these benign diseases. Therefore alternative methods are suggested to eliminate parenchyma by inducing atrophy. This goal can also be attained by intraluminal duct occlusion. The principle consists of instillation of a resorbable protein solution into the duct system, a procedure similar to sialography injection. In animal experiments marked atrophy of parenchyma and complete reabsorption of the instilled substance within four weeks could be demonstrated histologically. The clinical experiences in 33 cases of major salivary gland diseases and three year follow up data are reported. The main advantages of the new method described are a simple technique, rapid onset of atrophy and preservation of facial nerve function.