Case and Research Letters
Parotid Fistula After Skin Biopsy: Treatment With Botulinum Toxin
Fístula parotídea tras biopsia cutánea: tratamiento con toxina botulínica
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A) Material fusiforme grisáceo inmerso en un estroma hialino compatible con ácido poliláctico que infiltra tejido glandular parotídeo. B) Material basófilo laminado polimorfo compatible con ácido hialurónico. C) Microesferas negro-grisáceas compatibles con hidroxiapatita cálcica. D) Material espumoso basófilo no identificado.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B. Bancalari, B. Llombart, C. Requena, J.B. Vendrell" "autores" => array:4 [ 0 => array:2 [ "nombre" => "B." "apellidos" => "Bancalari" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Llombart" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Requena" ] 3 => array:2 [ "nombre" => "J.B." 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Lobato-Berezo, M.T. Fernández Figueras, J.A. Moreno Romero, R.M. Pujol" "autores" => array:4 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Lobato-Berezo" ] 1 => array:2 [ "nombre" => "M.T." "apellidos" => "Fernández Figueras" ] 2 => array:2 [ "nombre" => "J.A." "apellidos" => "Moreno Romero" ] 3 => array:2 [ "nombre" => "R.M." "apellidos" => "Pujol" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001731018304952" "doi" => "10.1016/j.ad.2018.02.038" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731018304952?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157821901930232X?idApp=UINPBA000044" "url" => "/15782190/0000011000000008/v1_201910050935/S157821901930232X/v1_201910050935/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S1578219019302501" "issn" => "15782190" "doi" => "10.1016/j.adengl.2018.03.022" "estado" => "S300" "fechaPublicacion" => "2019-10-01" "aid" => "2145" "copyright" => "Elsevier España, S.L.U. and AEDV" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Actas Dermosifiliogr. 2019;110:691-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Herpes Zoster Duplex and Multiplex: The Exception That Confirms the Rule" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "691" "paginaFinal" => "693" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La excepción que confirma la regla: herpes zoster duplex y multiplex" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1411 "Ancho" => 1500 "Tamanyo" => 258414 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case 3. Herpes zoster multiplex presenting with clusters of vesicles in a zosteriform distribution affecting the L5 dermatome on the left leg (A and B, tibial crest and plantar arch) as well as D6 (C) on the left side and S2 (D) on the right side.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Rodríguez-Lomba, A. Sánchez-Herrero, R. Suárez-Fernández, A. Pulido-Pérez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Rodríguez-Lomba" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Sánchez-Herrero" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Suárez-Fernández" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Pulido-Pérez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S000173101930016X" "doi" => "10.1016/j.ad.2018.03.030" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S000173101930016X?idApp=UINPBA000044" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219019302501?idApp=UINPBA000044" "url" => "/15782190/0000011000000008/v1_201910050935/S1578219019302501/v1_201910050935/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case and Research Letters</span>" "titulo" => "Parotid Fistula After Skin Biopsy: Treatment With Botulinum Toxin" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">To the Editor:</span>" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "693" "paginaFinal" => "695" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "B. Bancalari, B. Llombart, C. Requena, J.B. Vendrell" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Bancalari" "email" => array:1 [ 0 => "bernardobancalari@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "B." "apellidos" => "Llombart" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Requena" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.B." "apellidos" => "Vendrell" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Instituto Valenciano de Oncología, Valencia, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Instituto Valenciano de Oncología, Valencia, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fístula parotídea tras biopsia cutánea: tratamiento con toxina botulínica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1703 "Ancho" => 1505 "Tamanyo" => 390691 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Indurated subcutaneous plaque of 2.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3 cm in diameter in the parotid region. B, Parotid fistula with secretion of saliva from the defect 7 days after skin biopsy. C, Parotid fistula 3 weeks after treatment, before beginning botulinum toxin treatment. Botulinum toxin was injected subcutaneously at the 6 indicated sites around the defect. D, Final outcome after botulinum toxin treatment.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Of the various causes of salivary gland fistula, the most common include accidental trauma and postoperative complications. Salivary gland fistula is characterized by marked discomfort due to drainage of saliva through the fistula, a phenomenon that usually intensifies with chewing. Proteolytic enzymes present in saliva can impair healing, leading to a chronic condition that can be difficult to resolve.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 76-year-old woman presented with asymptomatic, multinodular, indurated subcutaneous plaques of 2.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3 cm in diameter in both parotid regions that had appeared several months earlier (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). Injection of a filling material 12 years before was the only medical history of interest. The patient reported no symptoms prior to appearance of the plaques, which became evident following significant weight loss. Suspecting foreign body granuloma, a skin biopsy was obtained using a 4<span class="elsevierStyleMonospace">-</span>mm punch. The biopsy showed infiltration of the parotid with 4 different filling materials: hyaluronic acid, polylactic acid, calcium hydroxyapatite, and a fourth unidentified material (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">One week later the patient presented with secretion of saliva from the biopsy site, a phenomenon that clearly intensified with chewing. A reinforcing suture was placed in the wound and a compression bandage applied. No improvement in the patient's clinical signs was observed. Subsequent wound margin debridement and closure of the defect with interrupted sutures at the otorhinolaryngology department failed to achieve symptom control (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><p id="par0020" class="elsevierStylePara elsevierViewall">One week later the patient was seen for enlargement of the fistula. The margins were macerated and irritated, and the amount of saliva secreted had increased. We decided to locally administer botulinum toxin-A (Botox, Allergan Inc., Irvine, CA, USA); 100 U was diluted in 2 mL of physiological saline and 24 U of the solution was injected subcutaneously at 6 sites around the defect (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). While a clear decrease in the size of the defect was observed 2 weeks later the patient's symptoms persisted, and she received a second round of subcutaneous botulinum toxin-A injections (24 U). Four weeks later total closure of the fistula was achieved, with no treatment-related complications observed (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Parotid fistula most commonly occurs as a complication of parotid surgery, with incidences as high as 14% reported in some series. Fistulas can be classified according to duration: early fistulas last less than 6 weeks, while permanent fistulas last longer.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> This distinction is important. While both forms pose therapeutic challenges, the former tend to respond to conservative treatment with a compression bandage, whereas permanent fistulas tend to respond poorly and often require surgical intervention.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Injection of botulinum toxin-A is one form of treatment that has shown good results in recent years.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,5</span></a> The toxin temporarily blocks the release of parasympathetic cholinergic neurotransmitters, thereby reducing secretion by the salivary gland and facilitating closure of the fistula. Although the effect is temporary, this approach is minimally invasive, is associated with few complications, and is well tolerated.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Doses of botulinum toxin usually range from 10 U to 40 U, administered 2 to 4 weeks apart.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> A reduction in saliva secretion is observed after a few days. However, it is important to remind the patient that the maximum effect may not be observed for several weeks. While our patient underwent 2 rounds of botulinum toxin injections, it is highly likely that fistula closure could have been achieved with a single round of treatment.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Sialorrhea is treated with doses of 22.5 U per salivary gland, usually administered following ultrasound-guided blockade of the main endings of the facial nerve.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In our patient, botulinum toxin was injected at several sites surrounding the defect in order to decrease the secretion of saliva in the area without completely blocking salivation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The appearance of parotid fistulas as a complication after removal of skin tumors and foreign body granulomas near the parotid gland has been anecdotally described, and should be kept in mind when performing any invasive procedure in this region.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,8</span></a> In these cases, imaging techniques such as ultrasound, computerized axial tomography, and nuclear magnetic resonance imaging may be useful to attempt to identify the filling material used.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9,10</span></a> Fine-needle aspiration, with or without ultrasound guidance, can also be used to obtain biopsies from sites of risk.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We have reported this case to highlight the risks associated with skin biopsy near the parotid gland and the excellent results that can be achieved with conservative treatment with botulinum toxin in parotid fistula patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Bancalari B. Fístula parotídea tras biopsia cutánea: tratamiento con toxina botulínica. Actas Dermosifiliogr. 2019;110:693–695.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1703 "Ancho" => 1505 "Tamanyo" => 390691 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Indurated subcutaneous plaque of 2.5<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3 cm in diameter in the parotid region. B, Parotid fistula with secretion of saliva from the defect 7 days after skin biopsy. C, Parotid fistula 3 weeks after treatment, before beginning botulinum toxin treatment. Botulinum toxin was injected subcutaneously at the 6 indicated sites around the defect. D, Final outcome after botulinum toxin treatment.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1131 "Ancho" => 1505 "Tamanyo" => 551601 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Skin biopsy composed mainly of parotid glandular tissue and 4 distinct synthetic materials (hematoxylin-eosin). A, Grayish fusiform material embedded in a hyaline stroma compatible with polylactic acid infiltration of the parotid glandular tissue. B, Polymorphous laminated basophilic material compatible with hyaluronic acid. C, Blackish-gray microspheres compatible with calcium hydroxyapatite. D, Unidentified basophilic foam-like material.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The secretion, components, and properties of saliva" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G.H. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 15 | 11 | 26 |
| 2024 Octubre | 114 | 56 | 170 |
| 2024 Septiembre | 154 | 39 | 193 |
| 2024 Agosto | 177 | 76 | 253 |
| 2024 Julio | 119 | 42 | 161 |
| 2024 Junio | 150 | 43 | 193 |
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| 2024 Marzo | 134 | 25 | 159 |
| 2024 Febrero | 100 | 50 | 150 |
| 2024 Enero | 125 | 33 | 158 |
| 2023 Diciembre | 119 | 27 | 146 |
| 2023 Noviembre | 148 | 37 | 185 |
| 2023 Octubre | 120 | 43 | 163 |
| 2023 Septiembre | 109 | 24 | 133 |
| 2023 Agosto | 121 | 26 | 147 |
| 2023 Julio | 117 | 35 | 152 |
| 2023 Junio | 123 | 20 | 143 |
| 2023 Mayo | 163 | 22 | 185 |
| 2023 Abril | 118 | 24 | 142 |
| 2023 Marzo | 111 | 14 | 125 |
| 2023 Febrero | 88 | 31 | 119 |
| 2023 Enero | 76 | 29 | 105 |
| 2022 Diciembre | 99 | 37 | 136 |
| 2022 Noviembre | 72 | 31 | 103 |
| 2022 Octubre | 68 | 30 | 98 |
| 2022 Septiembre | 74 | 32 | 106 |
| 2022 Agosto | 55 | 33 | 88 |
| 2022 Julio | 57 | 47 | 104 |
| 2022 Junio | 29 | 22 | 51 |
| 2022 Mayo | 105 | 48 | 153 |
| 2022 Abril | 127 | 26 | 153 |
| 2022 Marzo | 140 | 50 | 190 |
| 2022 Febrero | 144 | 38 | 182 |
| 2022 Enero | 141 | 38 | 179 |
| 2021 Diciembre | 116 | 48 | 164 |
| 2021 Noviembre | 100 | 40 | 140 |
| 2021 Octubre | 79 | 62 | 141 |
| 2021 Septiembre | 71 | 43 | 114 |
| 2021 Agosto | 119 | 28 | 147 |
| 2021 Julio | 64 | 25 | 89 |
| 2021 Junio | 84 | 23 | 107 |
| 2021 Mayo | 99 | 34 | 133 |
| 2021 Abril | 171 | 90 | 261 |
| 2021 Marzo | 98 | 28 | 126 |
| 2021 Febrero | 51 | 30 | 81 |
| 2021 Enero | 75 | 11 | 86 |
| 2020 Diciembre | 52 | 17 | 69 |
| 2020 Noviembre | 75 | 16 | 91 |
| 2020 Octubre | 51 | 14 | 65 |
| 2020 Septiembre | 51 | 19 | 70 |
| 2020 Agosto | 33 | 22 | 55 |
| 2020 Julio | 338 | 23 | 361 |
| 2020 Junio | 20 | 27 | 47 |
| 2020 Mayo | 19 | 12 | 31 |
| 2020 Abril | 16 | 10 | 26 |
| 2020 Marzo | 19 | 9 | 28 |
| 2020 Febrero | 2 | 4 | 6 |
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