Dr. Bhavik Miyani, Resident Doctor in Department of Oral & Maxillofacial Surgery, NPDCH, SPU, Visnagar.

1. JOURNAL CLUB #13
 PRESENTED BY:
 DR. BHAVIK MIYANI,
 3rdYEAR PG, OMFS.
 GUIDED BY:
 DEPARTMENT OF OMFS,
 NPDCH, SPU,VISNAGAR.
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3. CRITICS OF TITLE
 Title is not appropriate.
 Type of study is not mentioned in title.
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4. CONTENTS
1. About the Journal
2. About theAuthor
3. Abstract
4. Introduction
5. Material and Methods
6. Results
7. Discussion
8. Related Articles
9. Conclusion
10. References
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5. ABOUT THE JOURNAL
• British Journal of Oral &
Maxillofacial Surgery.
• Peer reviewed journal.
• Open access PubMed Indexed
Journal.
• Impact factor- 1.352.
• Published By- Elsevier Inc.
• Volume 51.
• Year of Publication- Apr- 2013.
• Page No.- 786 to 788.
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6. ABOUT THE AUTHORS
1. Wei-liang Chen
2. Li-ping Zhang
3. Zhi-quan Huang
4. Bin Zhou
Department of Oral and Maxillofacial Surgery, Sun
Yat-sen Memorial Hospital, SunYat-sen University,
Guangzhou 510120, China.
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7. CRITICS OF AUTHOR DETAILS
 Qualification details of authors are not
mentioned.
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8. ABSTRACT
 We evaluated the curative effect of fibrin glue combined with OK-
432 (streptococcal pyrogenic exotoxin A, PicibanilTM) and
bleomycin on 9 patients with sialoceles after parotidectomy. The
primary lesions included pleomorphic adenomas in 6 cases and
Warthin’s tumours in 3 cases. After a sialocele had been diagnosed
each patient had repeated aspirations and pressure dressings for 3–
4 weeks, but these treatments failed. The patients were then
treated with percutaneous sclerotherapy with the injection of fibrin
glue 8–10 ml combined with OK-432 5 mg and bleomycin 15 mg. All
the sialoceles disappeared completely after a single procedure in 2–
3 weeks. The patients have been followed up for more than 6
months with no evidence of recurrent sialocele or injury to the facial
nerve related to sclerotherapy. This simple, safe technique can be
successfully used to treat sialoceles after parotidectomy.
 Keywords: Sialocele; Parotidectomy; Fibrin glue; OK-432;
Bleomycin 8

9. CRITICS OF ABSTRACT
 Type of study and aim of study is not
mentioned in abstract.
 Abstract is not well structured.
 Keywords are mentioned in abstract.
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10. INTRODUCTION
 A sialocele or salivary pseudocyst after
parotidectomy is an acquired lesion that arises from
the extravasation of saliva into glandular or
periglandular tissues secondary to disruption of the
parotid duct or parenchyma.
 Operations in the parotid region and facial trauma are
the most common causes.
 A sialocele is an asymptomatic, soft, mobile swelling
in the parotid region.
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11.  Herbert and Morton reported that in 102
consecutive parotid operations, 20 patients
developed sialoceles.
 Ogita et al. first reported intralesional injection of
OK-432 into a lymphangioma in 1987, and they
have previously reported the successful
treatment of patients with massive vascular
malformations or massive macrocystic lymphatic
malformations of the head and neck with fibrin
glue combined with OK-432 and bleomycin.
 Here they present their experience of treating
sialoceles after parotidectomy with fibrin glue
combined with OK-432 and bleomycin. 11

12. CRITICS OF INTRODUCTION
• It describes aim of the study.
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13. MATERIAL AND METHODS
 Total no. of patients- 09
M:F
• Male- 06
• Female- 03
Pathology
• Pleomorphic
adenoma- 06
• Warthin’s
tumor- 03
Parotidectomy
• Partial
• Superficial
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14.  Asymptomatic soft, mobile swellings
developed in surgical region.
 At 9-12 post-op day.
 Mean size- 5x5 cm.
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15. INVESTIGATIONS
Computed
Tomography
scan
Fine Needle
Aspiration
Raised
Amylase
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16. MANAGEMENT
Aspiration was done with 18 gauge
Fibrin glue (8-10ml) + OK-432(5mg)
+ Bleomycin (15mg)
Fibrin glue was injected about 1/3rd
– 1/4th of the volume of the cavity
Single procedure
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17. 17
PRE-OPERATIVE POST-OPERATIVE
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18. CRITICS OF MATERIAL & METHOD
 Sample size is sufficient for final outcome.
 Treatment method is mentioned in detail.
 Complications are not mentioned in study.
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19. RESULTS
 All sialoceles disappeared completely in 2-3
weeks.
 Follow-up period- 6 months.
 No signs of
 Recurrence
 Facial nerve involvement
 Hepatic involvement
 Renal involvement
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21. CRITICS OF RESULT
 Results in text match with the table.
 Testing Methodology is not mentioned.
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22. DISCUSSION
 Parotidectomy:
a) Superficial
b) Partial
c)Total
 Superficial Parotidectomy:
Removing all of the gland superficial to the facial nerve.
 Partial Parotidectomy:
Removing only the portion of the gland surrounding a tumor or
mass.
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23.  The sialocele is a subcutaneous cavity
containing saliva, usually resulting from
trauma to the parotid gland parenchyma,
laceration of the parotid duct or ductal
stenosis with subsequent dilation.
 Extravasation of saliva into the
surrounding tissues occurs following injury
thus creating the sialocele.
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24. DIAGNOSIS
 Diagnosis of sialocele is usually straightforward and can be made by history
and clinical assessment of patient.
 Often history of trauma or surgical wound before the onset of the swelling
will be present as was seen in the present case.
 An aspirated fluid medium is analyzed for salivary amylase (exceeding
10,000 U/L).
 Simple way to confirm the presence of ductal injury is to cannulate the duct
from its distal oral opening with a pediatric intravenous catheter after
dilating it with a lacrimal probe and inject saline or methylene blue.
 If the liquid appears in the wound, it is safe to conclude that a ductal injury
exists and needs to be repaired.
Youngs RP, Walsh-Waring GP.Trauma to the parotid region. J Laryngol Otol 1987;101(5):475–479 24

25. SCLEROTHERAPY
 Sclerotherapy refers to the introduction of a
foreign substance into the lumen of a vessel,
aiming to create venous wall damage leading to
occlusion of the vessel.
 The mechanism of action for sclerosing
solutions is that of producing endothelial
damage (endosclerosis) that causes
endofibrosis.
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26. Detergent
• Sodium
morrhuate
• Ethanolamine
oleate
Hypertonic
solution
• Sodium salicylate
40%
• Sodium chloride
10% sodium
salicylate 30%
• Invert sugar 75%
• Saccharose 5%
• Phenol 1%
• Dextrose 66%
• Sodium chloride
20%
• Sodium salicylate
30%
• Glycerin.
Chemical
• Poly iodinated
iodine
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27. OK-432
 OK-432 is a promising new sclerosing agent consisting of
lyophilized low-virulence groupA strep. pyogenes
incubated with penicillin.
 OK-432 evokes inflammation and filtration of
inflammatory cells into the cystic spaces.
 Extensive production of cytokine, including interleukin-6
and tumor necrotic factor.
 Increase the endothelial permeability.
 Shrinkage of the cystic spaces. 2718-04-2020

28.  Twenty-one patients with plunging ranula were treated with intralesional
injection of OK-432.
 7 patients with plunging ranulas showed total shrinkage and resolution
 4 patients showed near-total shrinkage (>90%)
 4 patients revealed marked shrinkage (>70%)
 3 patients showed partial shrinkage (<70%)
 Only 3 patients showed recurrence after total shrinkage 1 month after
injection.
 No serious side effects except one who had severe odynophagia
 OK-432 sclerotherapy is a safe and potentially curative procedure that may
be used as a primary treatment for plunging ranula before considering
surgery.
Rho MH, Kim DW, Kwon JS, Lee SW, SungYS, SongYK, Kim MG, Kim SG. OK-432 sclerotherapy of
plunging ranula in 21 patients: it can be a substitute for surgery. American Journal of
Neuroradiology. 2006 May 1;27(5):1090-5. 28

29. BLEOMYCIN
 Bleomycin is anti-tumour agent, discovered by
Umezawa in 1966.
 Sclerosing effect due to its direct action on the
endothelial cells producing non-specific
inflammatory reaction.
 Adverse effects- pulmonary fibrosis, anaphylaxis and
hyperpigmentation.
 The pulmonary manifestation of bleomycin toxicity
is dose dependent.
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30. Case 1
• b/l parotid swelling
• Right- 8cm
• Left- 10 cm
• CD4- 490/cu.mm
• Aspiration done
• Bleomycin -3ml on
each side
• Procedure was
repeated after 2
weeks
• Total – 18ml
• NO recurrence after
1 yr follow up
Case 2
• b/l parotid swelling
• Right- 11 cm
• Left- 07 cm
• CD4- 550/cu.mm
• Aspiration done
• Bleomycin -3ml on
each side
• Procedure was
repeated after 2
weeks
• Total – 24 ml
• NO recurrence after
15 months follow up
Case 3
• b/l parotid swelling
• Right- 08 cm
• Left- 05 cm
• CD4- 410/cu.mm
• Aspiration done
• Bleomycin -3ml on
each side
• Procedure was
repeated after 2
weeks
• Total – 27 ml
• NO recurrence after
14 months follow up
Monama GM,Tshifularo MI. Intralesional bleomycin injections in the treatment of
benign lymphoepithelial cysts of the parotid gland in HIV‐positive patients.The
Laryngoscope. 2010 Feb;120(2):243-6. 30

31. FIBRINGLUE
 Supplied in a pre-filled, dual-chambered syringe, comprises a protein
solution containing fibrinogen and synthetic aprotinin (a fibrinolysis
inhibitor), and a solution containing thrombin.
 Pre-warmed and reconstituted liquids are mixed, a fibrin gel-like clot
forms almost immediately.
 The synthetic aprotinin in the solution delays the degradation of the
clot by endogenous plasmin, and allows a watertight seal to remain in
place, typically for 10 -14 days.
 The fibrin clot is not degraded by salivary amylase, and it forms a
strong bond with the surrounding tissue.
Brennan PA, KiwanukaT, AldridgeT, Colbert S.The use ofTisseal™ fibrin glue in the
management of chronic oro-cutaneous fistula in the radiotherapy treated neck–a
technical note. British Journal of Oral and Maxillofacial Surgery. 2016 Sep 1;54(7):828-9.31

32. Conservativemanagement
 According to review article by Christians H et al the management of
parotid sialocele first line of treatment should be conservative
approach.
 Frequent aspirations and compression dressings ususally helps in
resolving sialocele because it involves collection of saliva beneath the
skin.
 Use of anticholinergic agents can be done to close the sialocele.
 Anticholinergic drugs induce a temporary decrease in salivary
secretion and are consequently considered useful in fistula
management, but cause distressing side-effects.
Christiansen H,Wolff HA, Knauth J, Hille A,Vorwerk H, Engelke C et al. Radiotherapy : an
option for refractory salivary fistulas. HNO. 2009 Dec;57(12):1325-8 32

33. CONSERVATIVE MANAGEMENT
 Most commonly used agent is propantheline bromide (Pro-
Banthine) and Hyoscine (Buscopan) which inhibits the action
of acetylcholine at post ganglionic nerve endings of
parasympathetic nervrous system.
 Its use should be under constant monitoring and regular
follow up because they have many undesired side effects
such as xerostomia, constipation, photophobia, tachycardia
and urinary retention.
Christiansen H,Wolff HA, Knauth J, HilleA,Vorwerk H, Engelke C et al. Radiotherapy : an
option for refractory salivary fistulas. HNO. 2009 Dec;57(12):1325-8 33

34. HYPERTONICSOLUTION
 Chandra N et all did a trial in which a regimen of hypertonic saline
injections into the parotid substance was started.
 3–4 ml of warm hypertonic saline (3%) at 60°C was injected into
the parotid substance surrounding the fistulous tract followed by
pressure dressings in that area.
 The injections were repeated every other day for a period of 5
days.
 After 5 days, the fistula closed spontaneously which was the
result of the rapid sclerosing property of warm hypertonic saline.
Chhabra N et al. Use of hypertonic saline in the management of parotid fistulae and sialocele: a
report of 2 cases; J Maxillofac Oral Surg 8(1):64–67 34

35. BOTULINUMTOXIN
 Reported a case of a 52-year-old Chinese man who had a 10-year
history of right parotid swelling.
 Following fine-needle aspiration cytology,Warthin’s tumour was
diagnosed, but after elective parotidectomy, a swelling developed
and parotid sialocele was diagnosed.
 Botulinum toxin type A was given after the sialocele had persisted
for almost 3 weeks after surgery, and after conservative
management had been tried.
 The sialocele disappeared after two doses of treatment.
ChowTL, Kwok SP. Use of botulinum toxin type A in a case of persistent parotid sialocele.
Hong Kong Med J. 2003; 9: 293-294. 35

36. BOTULINUMTOXIN
 Two doses of botulinum toxin type A (Botox; Allergan Botox Ltd,Westport,
County Mayo, Ireland), of 50 and 70 units, were administered
percutaneously in the parotid region around the sialocele 4 days apart.
 Almost immediately after the second injection, the sialocele disappeared,
even though the patient had resumed oral nutrition after the first
botulinum toxin treatment.
 The drug acts by blocking acetylcholine release, thereby inhibiting
neurotransmission at the secretomotor parasympathetic autonomic nerve
ending responsible for salivation.
 Botulinum toxin therapy was thus an effective method of treating
persistent sialocele.
ChowTL, Kwok SP. Use of botulinum toxin type A in a case of persistent parotid sialocele.
Hong Kong Med J. 2003; 9: 293-294. 36

37. SCALP-VEINCANULA
 A 28-year-old male patient was operated for Lefort II #.
 After 12 days the patient presented with a huge painful
swelling on right side of the face of about 5x5 cm.
 The diagnosis of salivary fluid was confirmed by elevated
salivary amylase content (40,000 units/L) of aspirated fluid.
 The incision was made on right buccal mucosa near the duct
opening.
Sulabha AN, Sangamesh NC, Warad N, Ahmad A. Sialocele: An unusual case report and
its management. Indian Journal of Dental Research. 2011 Mar 1;22(2):336.
37

38.  Scalp vein cannula was inserted into the cavity and was
secured with buccal mucosa with sutures (Vicryl 5-0),
which allowed continuous drainage of the fluid into the
oral cavity via the tube.
 The subsequent healing was uneventful and a follow up
of 1 year postoperatively revealed no recurrence of the
lesion.
Sulabha AN, Sangamesh NC, Warad N, Ahmad A. Sialocele: An unusual case report and
its management. Indian Journal of Dental Research. 2011 Mar 1;22(2):336. 38

39. CRITICS OF DISCUSSION
 The points mentioned in material &
method and results are well justified by
discussion.
 All the treatment modalities are mentioned
in the discussion.
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40. CONCLUSION
 The management of parotid sialoceles and fistulae
have been unsatisfactory in the past, and numerous
methods of treatment with varying success and
morbidity have been described.
 Persistent salivary fistula may be most troubling to the
patient.
 The treatment depends on the duration of the injury
and thus should be specifically chosen for each
situation.
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41.  Pressure dressing and use of anticholinergic drugs
should be first line of treatment in sialocele.
 Glandular and partial duct injuries have better
prognosis after conservative treatment as compared
to complete duct transaction.
 Surgical treatment should be taken in to
consideration only if leakage persists for longer
duration.
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42. REFERENCES
1. Medeiros Júnior R, Rocha Neto AM, Queiroz IV, et al. Giant sialocele
following facial trauma. Braz Dent J 2012;23:82–6.
2. Herbert HA, Morton RP. Sialocele after parotid surgery: assessing the risk
factors. Otolaryngol Head Neck Surg 2012;147:489–92.
3. Ogita S,TsutoT,Tokiwa K, et al. Intracystic injection of OK-432: a new
sclerosing therapy for cystic hygroma in children. Br J Surg 1987;74:690–1.
4. Chen WL, Huang ZQ, Zhang DM, et al. Percutaneous sclerotherapy of
massive venous malformations of the face and neck using fibrin glue
combined with OK-432 and pingyangmycin. Head Neck 2010;32:467–72.
5. ChenWL, Huang ZQ, Chai Q, et al. Percutaneous sclerotherapy of massive
macrocystic lymphatic malformations of the face and neck using fibrin glue
with OK-432 and bleomycin. Int J Oral Maxillofac Surg 2011;40:572–6.
6. Araujo MR, Centurion BS, Albuquerque DF, et al. Management of a parotid
sialocele in a young patient: case report and literature review. J Appl Oral Sci
2010;18:432–6.
7. Edkins O, van Lierop AC, Fagan JJ, et al. Peroral drainage of post-traumatic
sialocoeles: report of three cases. J Laryngol Otol 2009;123:922–4.
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43. 8. Gahir D, Clifford N,Yousefpour A, et al. A novel method of
managing persistent parotid sialocele. Br J Oral Maxillofac Surg
2011;49: 491–2.
9. Marchese Ragona R, Blotta P, Pastore A, et al. Management of
parotid sialocele with Botulinum toxin. Laryngoscope
1999;109:1344–6.
10. Vargas H, Galati LT, Parnes SM. A pilot study evaluating the
treatment of postparotidectomy sialoceles with Botulinum toxin
type A. Arch Otolaryngol Head Neck Surg 2000;126:421–4.
11. ChowTL, Kwok SP. Use of Botulinum toxin typeA in a case of
persistent parotid sialocele. Hong Kong Med J 2003;9:293–4.
12. Pantel M,Volk GF, Guntinas-Lichius O, et al. Botulinum toxin type
b for the treatment of a sialocele after parotidectomy. Head Neck
2013;35:E11–2.
13. Blitzer A, Sulica L. Botulinum toxin: basic science and clinical uses
in otolaryngology. Laryngoscope 2001;111:218–26.
14. Zwaveling S, Steenvoorde P, da Costa SA.Treatment of
postparotidectomy fistulae with fibrin glue. Acta Med (Hradec
Kralove) 2006;49: 67–9.
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