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TREATMENT CONSIDERATIONS IN SALIVARY

GLAND SURGERY
MICHAEL FRIEDMAN, MD, ELLIOT ABEMAYOR, MD, PhD,
EUGENE N. M Y E R S , MD, RONALD H. SPIRO, MD

We asked the three experts n a m e d in shows residual tumor extending p e r f o r m a lateral temporal bone re-
the byline of this article to provide to the surface (Fig 1). section and radical p a r o t i d e c t o m y
treatment recommendations in five encompassing the superficial lobe,
cases of parotid tumor. I believe their deep lobe, and the facial n e r v e itself.
varying perspectives provide inter- Interpositional cable grafts are then
Questions
esting insight into the "state of the
inserted between the remaining trunk
art" in approaches to parotid sur- Should the patient undergo sur-
gery. Michael Friedman, MD, Editor of the facial nerve and the peripheral
gery, radiation, or both? If surgery, branches previously tagged. The best
should the procedure include skin source for the cable grafts are the
CASE 1 resection? How should the skin be sensory nerves f o u n d at the inferior
resurfaced? Should nerve resec-
A 49-year-old man presents with a portion of the neck or, a second
tion, with or without a nerve graft,
slowly enlarging left parotid tu- choice, the sural nerve. A gold weight
be done? If radiation, should neu-
mor. The seventh nerve is intact. w o u l d be placed to protect the eye
tron radiation be used?
Preoperative CT shows a mass in since, until, and if, function returns,
the superficial lobe extending to the eye is at risk for injury. A modi-
Dr Abemayor: This patient poses a fied neck dissection is p e r f o r m e d
the deep lobe and involving the difficult dilemma. The postoperative
skin. There is no cervical adenopa- both for treatment and staging. I
facial paralysis is likely due to iatro-
thy. would also remove the skin overly-
genic injury. In addition, this patient ing the tumor and excise it in continu-
No fine-needle aspiration is per- has been inadequately treated with
formed. The patient undergoes to- ity with the parotidectomy. Closure
gross t u m o r still present. The issues of this defect is best accomplished
tal parotidectomy without neck dis- with this patient are the following:
section. The seventh nerve is not with a pectoral-cervical-facial rota-
(1) what is the best way to achieve tion flap.
identified during surgery. Patho- optimal locoregional control of dis-
logical examination shows poorly I would r e c o m m e n d postoperative
ease?; and (2) h o w can we rehabili- radiation because this is a poorly
differentiated mucoepidermoid tate this patient at the same time?
carcinoma. differentiated lesion with a violated
The best h o p e for tumor control or t u m o r bed. The locoregional control
After surgery, the patient experi- cure is removal of gross disease fol-
ences complete ipsilateral facial rate w o u l d be increased with exter-
lowed by radiation treatment. This
paralysis. A repeated CT scan per- nal b e a m r a d i o t h e r a p y using co-
patient needs a radical parotidec-
formed 1 month after surgery balt-60 with an electric b e a m boost to
tomy, lateral temporal bone resec- about 60 Gy. Because this is a p o o r l y
tion, and a right modified neck dis-
differentiated lesion, any a d d e d ad-
section. His facial paralysis is of 1
From the Department of Otolaryngology and v a n t a g e of using n e u t r o n b e a m
month's duration, so electrical stimu- therapy is doubtful.
Bronchoesophagology, Rush Medical College,
Rush-Presbyterian-St. Luke's Medical Center, lation of the peripheral branches is
Chicago, IL; the Division of Head and Neck not possible. Therefore, I w o u l d be-
Surgery, UCLA School of Medicine, LA; the gin with an anatomic dissection of REFERENCE
Department of Otolaryngology, University of the peripheral branches of the facial
Pittsburgh School of Medicine Eye and Ear 1. TranL, Sadeghi A, Hanson DG, et al: Major
nerve tagging the eye, buccal, and salivary gland tumors: Treatment results
Institute; and the Head and Neck Service,
Memorial Sloan-Kettering Cancer Center, NY. marginal branches. After this, I w o u l d and prognostic factors. Laryngoscope 96:
Address reprint requests to Michael Fried- perform a mastoidectomy and iden- 1139-1144, 1986
man, MD, Department of Otolaryngology and tify the facial nerve in its descending
Bronchoesophagology, Rush-Presbyterian-St. portion and trace it to its exit at the Dr Myers: There are several flaws in
Luke's Medical Center, 1653 W Congress stylomastoid foramen. Frozen-sec- the initial m a n a g e m e n t of this pa-
Pkwy, Chicago, IL 60612.
Copyright © 1996 by W.B. Saunders Com- tion control of the facial nerve for the tient. The most outstanding is that
pany presence of t u m o r is performed. Fol- there was no diagnosis m a d e before
1043-1810/96/0704-0014505.00/0 lowing negative margins, I w o u l d surgery. If a t u m o r involves the deep

OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 7, NO 4 (DEC), 1996: PP 377-383 377
FIGURE 1.

lobe and skin, one would have to Cervical-pectoral rotation flap be identified with certainty,
suspect the presence of a malignant (this would give the best color then the nerve graft should
tumor. The dissection was clearly match and restore some be placed into the frontalis
inadequate because 1 month after bulk). muscle of the orbicularis oculi
surgery, residual tumor is noted. An Rectus abdominis free flap muscle and the orbicularis
error in judgment/technique resulted with split-thickness skin graft oris muscle.
would provide bulk for con- A fascia lata sling would pro-
in injury to the facial nerve. Whether
touring, but would be a poor vide for a straight commis-
this nerve has been resected or been sure in the event that nerve
color match.
injured in some other procedure is un- grafting was not performed,
Facial nerve. The facial nerve
clear. should be resected with the but is a poor second choice in
In my opinion, this patient should main specimen. A mastoidec- my opinion. A gold weight
undergo radical surgery and postop- tomy should be performed in should be placed in the up-
erative adjunctive radiation therapy. order to identify the descend- per eyelid to provide ad-
Several issues should be addressed. ing portion of the facial nerve. equate eye closure whether
Frozen-section should be per- or not the nerve can be recon-
• Adequacy of resection. This sur- formed on the proximal resec- structed.
gery must include the residual tu- The patient should receive postop-
tion margin of the nerve.
mor and the overlying skin, the mas- erative adjunctive radiation therapy
Once adequate tumor clear-
seter muscle, the periosteum of the in order to neutralize the effect of
mandible, the anterior cartilaginous ance of the nerve has been
achieved, a sural nerve graft cervical lymph node metastasis, fa-
external auditory meatus, the ante- cial nerve involvement and soft tis-
rior aspect of the superior portion of or a graft taken from C4 (cer-
vical plexus) should be used sue extension, all of which are "ag-
the sternocleidomastoid muscle, and gressive" pathological findings.
the posterior belly of the digastric as a free graft. An effort
should be made to identify Neutron radiation has been shown
muscle. to be useful in salivary gland tumors;
• A modified radical neck dissection the peripheral branches of the
facial nerve, although 1 however, there are only a few centers
type 1 should be performed. The inci-
month after surgery, this may in this country in which this therapy
dence of cervical lymph node metas-
be very difficult to do be- is available and, although this treat-
tasis in patients with high-grade mu-
cause the nerves may not ment has been found to be effica-
coepidermoid carcinoma is higher
function even with electrical cious, it may not be practical.
than in any other malignant tumor of
salivary gland origin. stimulation. If the branches
• Several types of reconstruction must can be identified, then the Dr Spiro: In the absence of specific
be performed. The choices in order of nerve graft should be anasto- information, I assume that this pa-
my own preference would be the mosed with the peripheral tient had undergone a total parotidec-
following: branches. If no branches can tomy with unintentional facial nerve

378 DIFFICULT DECISIONS


injury or transection. Experienced plete surgery and p h o t o n irradia- m o v e d as a functional neck dissec-
surgeons m a y undertake a subtotal tion. tion. The involved cheek skin w o u l d
p a r o t i d e c t o m y in a clinically obvious be excised with resurfacing of the
setting without a preoperative needle defect using a chest-cervical-cheek
CASE 2 rotation flap.
aspiration biopsy (FNAB), but a his-
tological diagnosis is essential (ei- A 58-year-old woman presents with Due to this patient's relative youth,
ther preoperative FNAB or intraop- a parotid tumor. Twenty years ago I w o u l d not use adjunctive radiation
erative frozen section) w h e n the the mass was biopsied through therapy for lesions that are still surgi-
findings suggest that the patient m a y the skin, and subtotal tumor resec- cally resectable. For multiple recur-
require a more extensive procedure tion was performed. The pathologi- rent lesions, I believe a radical paroti-
with greater risk to the facial nerve. cal report at that time was consis- dectomy with either pedicle or free
The highly aggressive course in this tent with pleomorphic adenoma. flap muscle reconstruction is war-
case (ie, obvious recurrence within 1 The patient now presents with a ranted.
month) is unusual even for poorly 1-year history of multicentric recur-
differentiated mucoepidermoid carci- rences. The tumor is fixed to the
noma. It indicates that gross residual skin at several sites. A level II neck REFERENCE
t u m o r remained after inadequate ini- node is palpable. A fine-needle as-
1. Conley JJ (ed): Problems with operation of
tial surgery, a most u n h a p p y prob- piration specimen is positive for the parotid gland and facial nerve. Oto-
lem which is likely to defeat all pleomorphic adenoma. laryngol Head Neck Surg 99:480-488, 1988
subsequent efforts at salvage.
If the recurrence is d e e m e d resect- Dr Myers: The initial flaw in the
Questions
able, this patient's best chance for m a n a g e m e n t of this patient was inad-
salvage w o u l d seem to be additional What procedure is appropriate? equate resection of the tumor. Pa-
surgery followed b y postoperative Skin resection? If so, how should tients w h o have been inadequately
radiation therapy (RT). The decision the skin be resurfaced? Should resected for pleomorphic a d e n o m a
w h e t h e r to sacrifice overlying skin the deep lobe be addressed? are at risk for recurrence of the pleo-
must be based on clinical evidence of Should postoperative radiation be morphic adenoma or for develop-
dermal invasion. My preference for used? ment of carcinoma expleomorphic
resurfacing is a large cervical rota- adenoma. The time sequence of 20
t i o n / a d v a n c e m e n t flap, the incision Dr Abemayor: This patient suffers years after the initial surgery is pos-
for which is carried as far inferiorly from a recurrent pleomorphic ad- sible in both instances. The fixation
on the anterior chest wall as neces- enoma due to tumor spillage and of the t u m o r to the skin and a pal-
inadequate excision. Such tumors are pable level II l y m p h node make one
sary to allow the flap to reach the
best considered as low-grade poten- more suspicious about carcinoma ex-
skin defect. Isolation of proximal and
tially aggressive neoplasms; even p l e o m o r p h i c a d e n o m a . The fine-
distal facial nerve branches 1 m o n t h
with further excisions, the patient is needle aspiration specimen positive
after a "total" parotidectomy is likely
at risk for local recurrences with for pleomorphic a d e n o m a is not a
to be a frustrating exercise with very
subsequent danger to facial function. guarantee that carcinoma ex-pleo-
limited prospect for good functional
I would begin by reviewing the morphic a d e n o m a is not present.
restoration by nerve grafting. I think
prior operative note if possible. Was I w o u l d r e c o m m e n d open biopsy
it w o u l d be more reasonable to ig-
the t u m o r r e m o v e d b y enucleation of these nodules in order to establish
nore the facial nerve during the sec- or lateral lobectomy? This is impor- a diagnosis. In m y experience, recur-
ond procedure, and insert a gold tant to k n o w because, in turn, it can rent pleomorphic a d e n o m a can usu-
weight implant at the same sitting. tell us if the main trunk of the facial ally be adequately treated by total
Additional procedures for dynamic nerve was dissected out or not. In parotidectomy with facial nerve dis-
s u p p o r t can be considered later if any event, extirpation of this tumor section. There is no mention about
locoregional control is achieved. requires removal of all remaining the condition of this patient's facial
Recognizing that resectability can parotid tissue and surrounding skin nerve, so for the sake of discussion, I
be hard to assess, it w o u l d be wise to which is seeded with t u m o r cells. assume that it is normal. If this is
have the b r a c h y t h e r a p y team stand- Under loupe magnification and us- purely pleomorphic adenoma, I
ing by. If gross t u m o r still remains ing facial nerve monitoring, I w o u l d w o u l d excise the skin overlying sev-
after the re-resection, we have f o u n d see if the main trunk of the nerve can eral sites where the t u m o r is fixed to
that an implant placed in the area of be easily identified proximally. If not, the skin and close these primarily.
concern, in conjunction with b e a m I w o u l d find the peripheral branches Removal of the t u m o r mass should
RT, can enhance t u m o r control. (eye, buccal, marginal mandibular) provide e n o u g h additional skin in a
W h e n it is not clear that residual or and trace them back to the main 58-year-old w o m a n to close these
recurrent salivary gland carcinoma trunk, removing any remaining su- areas primarily.
can be completely resected, consider- perficial parotid tissue and residual During the time that the parotid is
ation should be given to neutron tumor. Once the nerve is identified, exposed, the level IF l y m p h node
irradiation. Published data suggest the deep lobe tissue can also be should be removed. This area is ex-
that local control m a y be better than removed. The level II n o d e and any posed during most parotid surgery,
that which can be achieved by incom- other palpable nodes w o u l d be re- and by retracting the posterior belly

FRIEDMAN ET AL 379
of the digastric superiorly, the mass erature, particularly from the United for the possibility of postoperative
can be exposed and removed. If the Kingdom, on the routine treatment facial nerve dysfunction. In addition
initial biopsy revealed tumor in a of pleomorphic adenoma, particu- to the likelihood of direct nerve
lymph node, then one must conclude larly recurrent, by radiation therapy. trauma during what often proves to
that this is malignant even though If this is a malignant tumor, then be a more tedious dissection because
open biopsy of the primary tumor postoperative radiation therapy of scarring, sacrifice of a nerve branch
may have been diagnosed as pleo- should be used as has been shown with cable grafting may occasionally
morphic adenoma on frozen section. over many years that locoregional be required when nerve and tumor
If the tumor is adherent to the recurrence is improved even though are so intimately related that separa-
branches of the facial nerve, the indi- the cure rate is not necessarily im- tion of the two will leave residual
vidual branches should be resected proved. tumor.
and cable grafts should be applied. Dermal involvement from multifo-
By extensive dissection posteriorly, Dr Spiro: The obvious explanation cal tumor recurrence poses a prob-
the great auricular nerve, if it can be for the multifocal recurrence in this lem that is best resolved by excision
found, may be used. If not, then the patient would seem to be seeding of the overlying skin. Depending on
fourth cervical nerve can be used, from the inappropriate "subtotal tu- the circumstance, resurfacing can be
which is very helpful because it has mor resection" performed 20 years accomplished by split grafting, a cer-
multiple branches. previously. The presence of a pal- vical/facial rotation advancement
If upon biopsy of the tumor mass, pable level II lymph node, however, flap (as mentioned previously) or
it is proven to be a carcinoma ex- is troublesome despite the FNAB free, revascularized tissue. Even with
pleomorphic adenoma, then the pa- report of pleomorphic adenoma. It confidence in a benign diagnosis, it
tient's best interest would be best would be wise to aspirate the neck would be wise to excise the enlarged
served by a complete resection of the node. If this yielded tissue similar to level II lymph node. If there is any
entire parotid gland, the masseter that obtained from one of the parotid question of malignant evolution of a
muscle, the periosteum of the man- masses, the true diagnosis may actu- benign pleomorphic adenoma, a lim-
dible, the facial nerve, and the overly- ally prove to be malignant mixed ited lymphadenectomy (levels I, II,
ing skin. If the facial nerve must be tumor. III) should be added to the parotidec-
sacrificed, then replacement with su- Assuming the benign diagnosis is tomy.
ral nerve or cervical plexus nerve correct, an adequate subtotal paroti- Recent experience suggests that
grafting may be performed. In the dectomy with facial nerve sparing adjunctive beam radiation therapy
event that the mass is malignant, should be possible when the previ- may offer enhanced locoregional con-
then a modified radical neck dissec- ous procedure has not exposed the trol in patients with recurrent pleo-
tion should be performed. nerve. There is no need for total morphic adenoma. Indications are
I don't believe in the use of radia- parotidectomy unless the deep lobe far from clear, but the best results are
tion therapy for the treatment of is obviously involved. The patient obtained when it is given after a
benign tumors, although there is lit- needs to be especially well prepared good debulking procedure that re-

FIGURE 2.

380 DIFFICULT DECISIONS


FIGURE 3.

moves all gross tumor. I n o w tend to patient for a possible m a n d i b u - mandibulotomy, I contour a 4-hole
use the RT sooner, rather than later. lotomy. This t u m o r is best ap- compression plate for later use in
Even if a good cleanout is accom- proached through a transcervical- mandibular fixation. Under direct vi-
plished, this particular patient re- transparotid route. In this fashion, sualization and with digital manipu-
mains at high risk for another recur- the great vessels and the lower lation, the mass is removed. All at-
rence, at w h i c h time additional, branches of the facial nerve are iden- tempts should be m a d e to preserve
nerve-sparing surgery is quite un- tified and protected, i prefer the ap- the integrity of the t u m o r ' s capsule.
likely. proach popularized by Stell et al 1 Intraoral excision is contraindicated
and clearly described by Olsen. 2 In because of possible infection, t u m o r
essence, this approach identifies at seeding, or d a m a g e to vital vascular
CASE 3
least the lower branches of the facial structures.
A 48-year-old woman has under- n e r v e out to the s u b m a n d i b u l a r T h r o u g h the transcervical ap-
gone right-sided parotidectomy gland. Once the sternocleidomastoid proach, a s u p r a h y o i d neck dissection
twice for mixed tumor. She has a muscle is retracted laterally and cra- is possible to remove any l y m p h
positive neck node, and results of nial nerves X-XII are identified, the nodes or tumor-beading tissue.
fine-needle aspiration are positive carotid artery and jugular vein are Because of the patient's age, i
for pleomorphic adenoma. CT laterally retracted. Routing sacrifice w o u l d reserve radiation for recur-
scans are shown in Figs 2 and 3. of the external carotid artery is not rent lesions not amenable to further
always n e e d e d but can be done for surgical excision.
a d d e d exposure. The angle of the
Questions
mandible is retracted anteriorly and, REFERENCES
What procedure is appropriate? if further exposure is needed, the
Should an external surgical ap- submandibular gland is removed. 1. Stell PH, Mansfield AO, Stoney PJ: Surgical
proach be used, with or without With retraction of the mandible, the approaches to tumors of the parapharyn-
cutting the mandible? A transoral geal space. Am J Oto]aryngol 6:92-97, 1988
stylomandibular ligament is visual- 2. Olsen KD: Tumors and surgery of the
approach? Or a combined external ized and divided, resulting in a larger parapharyngeal space. LaryngoscopeSuppl
and transoral approach? Should o p e n i n g into the p a r a p h a r y n g e a l 63:104, 1994
postoperative radiation be admin- space. For even more medial and
istered? superior exposure, m a n d i b u l o t o m y Dr Myers: This case presents a pa-
at the angle is added. In such cases, I tient with a p a r a p h a r y n g e a l space
Dr A b e m a y o r : This patient has a first put the patient in maxilloman- extension of a deep lobe parotid
r e c u r r e n t p a r a p h a r y n g e a l tumor. dibular fixation using cortical bone tumor. These tumors arising from
Most can be r e m o v e d through the screws at the nasal p y r i f o r m aper- the deep lobe are, in m y experience,
neck; however, I also prepare the ture and lower mandible. Before the pleomorphic adenoma, carcinoma ex-

FRIEDMAN ET AL 381
pleomorphic adenoma, or malignant "positive neck node" implies an- I would also perform a fine-needle
mixed tumor. Although the fine- other, separate cervical mass, then I aspiration of the neck mass. In the
needle aspiration biopsy report is would have the same concerns about hands of an experienced cytopatholo-
positive for pleomorphic adenoma, the possibility of malignant transfor- gist, a cell button can be prepared
the possibility of carcinoma ex-pleo- mation that I expressed previously. and lymphoma ruled in or out. If
morphic adenoma or malignant I will always attempt transcervical further definition of tissue type is
mixed tumor is not necessarily estab- resection of retromandibular parotid needed, I could excise the neck mass.
lished without adequate histopathol- tumors with the patient prepared for Cystic parotid lesions in HIV-
ogy. the possibility of a paramedian man- positive patients act as inflammatory
The diagnosis is verified by the dibulotomy. The transcervical ap- masses, making identification and
scan shown in Fig 3. proach should start with exposure preservation of the facial nerve diffi-
One would have to be somewhat and identification of the facial nerve cult. Therefore, I would avoid a pa-
circumspect about the possibility of trunk and its ramus marginalis rotidectomy and concentrate on the
malignancy because the patient is branch in order to avoid injury to cervical lymph nodes.
said to have a "positive neck node." these structures. If this access proves
Because of the mention of this lymph inadequate, which is seldom the case,
REFERENCE
node, this is a rather enigmatic situa- the mandible is divided between the
tion. If the patient was known with ipsilateral cuspid and lateral incisor. 1. Finter MD, Schinella RA, Rothskin S, Per-
certainty to have a pleomorphic ad- The paralingual incision is then car- sky M: Cysticparotid lesions in patients at
enoma, it should be removed through ried up to the soft palate, which risk for the Acquired Immunodeficiency
Syndrome. Arch Otolaryngol Head Neck
a parotid-submandibular approach usually provides good external and Surg 114:1290-1294,1988
in order to provide adequate expo- transoral exposure. I believe that any
sure. The submandibular gland attempt at direct transoral removal is Dr Myers: In my opinion, this pa-
should be mobilized by ligating and ill-advised and inappropriate. tient has a lymphoepithelial lesion
transecting the facial artery posteri- Regardless of the approach, resec- that is highly correlated with HIV-
orly, and pedicaling the submandibu- tion of deep lobe tumors entails a positivity. MRI scanning is usually
lar gland on the lingual nerve and certain amount of blunt dissection. helpful in such a case. Fine-needle
the Wharton's duct. A total parotidec- Given that margins are often mini- aspiration biopsy should be per-
tomy should be performed, carefully mal, I believe that postoperative irra- formed. These lymphoepithelial cysts
dissecting and preserving the facial diation is usually indicated in any can be aspirated. Sometimes the cysts
nerve. This will allow adequate ac- patient whose lesion proves to be are painful and the patient is re-
cess to the deep lobe tumor and, by malignant. lieved of pain by repeat aspiration.
approaching it laterally from the ex- Special precautions should be taken
posure gained by a parotidectomy as by the caregiver in order to avoid
well as the submandibular approach CASE 4
auto-inoculation of the HIV. It is not
to the parapharyngeal space, the tu- A 38-year-old HIV-positive man necessary or recommended that sur-
mor can be removed, preserving the presents with a right-sided parotid gery be performed, and parotidec-
facial nerve. In my experience, a mass with cervical nodes. tomy is contraindicated unless there
mandibulotomy approach is not nec- is strong suspicion of associated ma-
essary. A transoral approach, al- lignancy. There is also a higher than
though it has been reported by Good- Questions
expected incidence of lymphoma in
win et al some years ago, 1 is What imaging studies, if any, HIV-infected patients and, if clinical
potentially dangerous to the facial should be done? Should fine- behavior or adjunctive studies indi-
nerve in the resection of a deep lobe needle aspiration be done? At sur- cate the possibility of lymphoma,
tumor, especially in a previously op- gery, is biopsy of the node alone then open biopsy to establish this
erated case. required? Should a parotidectomy diagnosis should be performed.
If this proves to be a malignant be done?
tumor, then postoperative radiation Dr Spiro- The association of parotid
should be most certainly adminis- Dr Abemayor: HIV-positive patients masses with seropositivity to HIV
tered. can develop benign lymphoepithe- is now well recognized. Usually
lial cysts of the parotid that in reality these are cystic and part of a pattern
REFERENCE are cystic, incompletely encapsu- of generalized lymphadenopathy,
lated lymph nodes. These patients which is often bilateral. FNAB of the
1. Goodwin WJ, Chandler JR: Transoral exci- parotid mass is indicated, and will
sion of lateral parapharyngeal space tu- are also prone to developing lympho-
mors presenting intraorall. Laryngoscope mas that are amenable to medical probably yield turbid, amber, or
98:266-269,1988 therapy. Therefore, a diagnosis of milky fluid and cellular architecture
these lesions is needed. I would be- similar to that observed in benign
Dr Spiro: This patient's MRI shows gin with a contrast CT. Are other lymphoepithelial lesions. Limited
a typical intraoral presentation of a lesions visible in the contralateral surgery to remove the cystic mass
deep lobe or retromandibular pa- parotid and neck? If so, this would may be appropriate in this setting,
rotid tumor, which I would not ex- strongly suggest a working diagno- particularly when pain or discomfort
pect to be palpable in the neck. If the sis of "benign" HIV cysts. are present. Other possibilities in-

382 DIFFICULT DECISIONS


clude a primary Kaposi's sarcoma Dr Abemayor: A contrast CT or MRI lower division of the facial nerve. I
arising in the parotid gland, or possi- with gadolinium is helpful to inform make an effort to ligate the Stensen's
bly even an unrelated primary carci- the patient and prepare the patient duct in order to prevent postopera-
noma, either of which should be and surgeon for a possible deep lobe tive salivary fistula. The tumor can
suggested by the FNAB findings. or dumbbell parotid tumor. This is then be removed. Protecting the up-
Parotidectomy is best avoided when especially important, because the tu- per division without necessarily dis-
the process is benign and HIV-re- mor is in the parotid tail. secting it, provides an efficient and
lated, unless the patient has multiple, I would approach this tumor by effective way of dealing with these
symptomatic masses. In the presence finding the main trunk of the facial tumors.
of other, potentially lethal pathology, nerve inferior and medial to the tympa-
the extent of the indicated parotidec- nomastoid structure and then identify- Dr Spiro: The information provided
tomy will depend on the stage and ing the pes ansefinus distally. Given the strongly suggests that this patient
histology of the lesion, and neck tumor's inferior location, it is adequate has a Warthin's tumor in the tail of
dissection may also be required. to dissect the tumor off the inferior his parotid gland. At issue is the
branches of the nerve and dissect the question of preoperative evaluation
upper branches of the nerve just far and the type of operation to be per-
CASE 5 enough to transect the gland. I believe formed. Although the clinical impres-
this would provide adequate margins sion could be easily verified by FNAB
A 64-year-old man presents with a
with minimal potential morbidity. or a technetium scan, I do not see a
tumor at the tail of the parotid.
compelling indication for either pro-
Surgery discloses a 2 × 2 cm,
Dr Myers: This, in my experience, is cedure unless the surgeon has de-
relatively soft mass caudal to the
a very common problem and this cided to perform a limited local exci-
marginal mandibular branch of the
patient probably has a papillary cyst sion, rather than a parotidectomy.
facial nerve (Fig 4).
adenoma lymphomentosum (War- I believe that a case can be made
thin's tumor). Warthin's tumors com- for less than a subtotal parotid resec-
monly occur in the tail of the parotid. tion with facial nerve dissection in
Questions
In my opinion, tumors in the tail of carefully selected patients with small,
Are any imaging studies needed? the parotid, whether they are War- benign tumors in the tail of the gland.
Should a complete dissection be thin's or other benign tumors, can be An important caveat for those who
done along the distal aspects of removed without dissecting the en- would perform limited excision with-
the upper branches of the facial tire facial nerve or removing the out nerve exposure is that the ramus
nerve (because this part of the entire superficial lobe of the parotid marginalis branch is always closer
gland is more than 4 cm away from gland. I always identify the main than one might think. Although this
the tumor)? Or will it be adequate trunk of the facial nerve as it exits the can be minimized by nerve exposure
to dissect the upper branches of stylomastoid foramen, carry the dis- and partial removal of the inferior
the nerve just far enough to tran- section anteriorly until the bifurca- portion of the gland lateral to it,
sect the gland and still provide tion of the nerve is noted, and then there may be increased risk of sali-
wide margins away from the tu- dissection is continued along in or- vary drainage following partial exci-
mor? der to expose the branches of the sion.

Parot
Glandid TemporalBranch

~ ~~" ~ J ' ~~ ZygomaticBranch


Facial~ ~
~L~.~~ BuccalBranch
terMuscl
oc,e,i:
e /j~
~

~'~~
~ ~ MandibularBranch

Mandible
Tumor~-
)~CervicalBranch
,-/

FIGURE 4.

FRIEDMAN ET AL 383

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