Management of Salivary Cutaneous Fistulas Following Non-Oncologic Head and Neck Surgery: A Systematic Review

Introduction: Optimal treatment of salivary cutaneous fistulas (SCFs) following otolaryngologic surgery has long been debated, especially in patients with benign operative indications. Our aim was to critically evaluate available evidence and answer what SCF management options exist, how their outcomes compare, and whether a management algorithm can be constructed.

Methods: A systematic review was performed using Cochrane Library, Embase, PubMed, and Web of Science as source databases. Inclusion criteria encompassed all published studies from database inception through January 2024 involving patients who were treated for SCF following non-oncologic head and neck surgery. Non-English and review publications were excluded. The primary outcome was successful SCF closure with other surgical complications as secondary outcomes. Treatment modality and duration served as independent variables. Descriptive statistics and chi-square testing quantitatively compared therapeutic options.

Results: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols, 834 records were initially identified, and 26 studies met inclusion criteria. Newcastle-Ottawa Quality Assessment and Cochrane Risk of Bias tools revealed low risk of bias among included works. Altogether 3,193 patients were represented, including 124 SCFs with patients being 65% male and 54 years old on average. Treatment categories consisted of conservative (observation, pressure dressings), pharmacotherapeutic (glycopyrrolate, scopolamine), procedural (botulinum toxin injection, radiation, sclerotherapy), and surgical management (fistulectomy, flap reconstruction). Although outcomes were dependent on treatment modality (𝛘2 = 11.60, p < 0.05), all therapies performed well (81%-100% success rate, < 1% complication rate) when utilized correctly.

Conclusions: Given their comparable success rates, non-surgical treatments for postoperative SCFs should be progressively trialed for six months, understanding that they may be less suitable for patients who require other time-sensitive therapy.