Abstract
The patient is a 41-year-old woman who presented with a 1 year history of a painful left cheek mass. She denied weight loss, fevers, chills, or difficulty tolerating a normal diet. However, she presented for removal because of persistent pain. On exam, a 1.0 × 1.0-cm mass was palpated in the left cheek, overlying the masticator muscle.
Magnetic resonance imaging (MRI) confirmed the presence of a lesion distinct from the main parotid gland. It measured 1 × 0.6 × 0.7 cm, was located in the cheek fat pad, and was associated with a possible accessory parotid gland (figure 1). A fine-needle aspiration (FNA) was ordered but was nondiagnostic (consistent with a fibrotic mass). Based on these findings and the patient's persistent pain, surgery was recommended.
MRI shows a hyperdense mass in the left cheek, overlying the masticator muscle (arrow).
Intraoperatively, the accessory parotid gland tumor was mobilized via a standard parotidectomy approach. Upon identification of the Stensen duct, it was clear that the duct would have to be segmentally resected in order to remove the tumor en bloc (figure 2). The infiltrative nature of the mass suggested malignancy, and ductal resection was deemed necessary for adequate margins. Therefore, the tumor and duct were resected and the duct was reanastomosed using a standard microvascular technique. The facial nerve was identified and preserved.
Intraoperative dissection demonstrates the Stensen duct (arrow) and surrounding tumor.
Pathology was consistent with adenoid cystic carcinoma (1.5 cm) without perineural or angiolymphatic invasion. The patient was referred to radiation oncology for further evaluation and treatment. She recovered well, with no sialocele or salivary duct obstruction or sialadenitis.
Lesions in the area of the masticator muscle may arise from any number of the soft tissues of the face, including skin, lymphatic, adnexal, neural, and salivary structures (i.e., the accessory parotid gland). 1 In this case, the location of the tumor and the patient's symptom of pain were suggestive of an accessory parotid gland malignancy.
Operative concerns in cases of accessory gland tumors differ from those of the parotid gland. Specifically, there is less concern about facial nerve injury but more concern about injury to the Stensen duct. 2 While malignancies of the accessory parotid gland are rare, when they do occur they jeopardize ductal integrity. Surgical planning mandates thoughtful attention to the possibility of ductal ligation and reanastomosis to achieve control of the tumor.3,4
In this case, ligation and reanastomosis were performed in order to remove the tumor in its entirety, with the presumption of malignancy despite a negative FNA. Reanastomosis can be a challenging undertaking but one that must be performed in cases of confirmed or suspected malignancy when ductal involvement is observed.