Abstract
A 70-year-old woman presented with a 2- to 3-decade history of an untreated facial/neck mass. She stated that the neck mass had grown steadily over the years, but she denied facial pain, paresis, or paralysis. Examination of the neck revealed a 25-cm right parotid mass with multiple lobes that was engorged and warm to the touch (figure 1). Facial anatomy and symmetry were distorted because of the lesion's mass effect. Palpation of the neck revealed no lymphadenopathy.
Photo Shows the Preoperative Appearance of the Superficial Parotid Tumor.
Magnetic resonance imaging demonstrated a well-circumscribed and encapsulated mass extending from the level of the right temporal region inferiorly to the right supraclavicular region, and protruding in a pedunculated fashion. A leftward shift was seen of the hypopharynx, larynx, proximal trachea, and thyroid gland.
Intraoperatively, a massive 7 to 10 lb., multilobular lesion was seen originating from the superficial lobe of the parotid gland; the lesion was excised (figure 2). Care was taken to preserve the branches of the facial nerve, and blood supply to the lesion was effectively ligated. Pathologic examination of the mass specimen was consistent with a pleomorphic adenoma without differentiation or progression to carcinoma ex-pleomorphic adenoma. The patient experienced no intraoperative or postoperative complications, with no residual facial nerve deficit.
This Photo Shows the Massive Excised Tumor.
Pleomorphic adenoma is the most common benign tumor of the salivary glands, most typically arising from the parotid gland.1–4 Because of the obvious facial deformity that occurs when parotid tumors are left untreated, it is uncommon for patients to allow such massive growth. Lack of information and fear of surgery are thought to play a role.1,2 In cases of massive superficial pleomorphic adenomas, special treatment considerations exist that are not seen with a standard parotidectomy.
Intraoperative blood loss will be considerable in such a large tumor, making preservation of hemodynamic stability challenging. Typical parotidectomy procedures usually involve minimal blood loss during surgery. Larger lesions, which establish a significant blood supply over the course of decades, can pose a significant change to the circulating blood volume once resected. Normal fluid replacement and subsequent hemodilution of the effective circulating blood volume support the need to have blood on reserve should the situation arise. A preoperative electrocardiogram, a stress echocardiogram, and a complete blood count should be considered as preliminary assessment of a patient's ability to tolerate this increased cardiovascular demand. Perioperative management is largely based on these volume losses and the subsequent physiologic changes.
Metabolic shock should also be considered when a procedure is significantly reducing the body's mass. Our patient's lesion represented approximately 10% of her body mass. Appropriate fluid replacement should be considered to preclude the occurrence of physiologic instabilities.
Preservation of the facial nerve and its branches requires special consideration when dealing with a large parotid mass. The traditional approach of anterograde dissection of the facial nerve proves ineffective in patients with large lesions that effectively obstruct the field of view and origin of the nerve trunk. A retrograde approach toward the nerve trunk should be considered in these circumstances.
Special consideration of blood loss, mass reduction, and nerve preservation contributed to a good outcome and quality of life for our patient.