Parotid Disease Case Discussions Valerie Jefford November 28, 2002
Case 1 44 y.o. man referred with lump anterior to R ear. Q1 What do you want to know? no pain 2 years but bigger now Smoker Q2 What to look for on physical exam?
Case 1 cont d Mobile, 2cm, not fixed, no nodes, facial nerve ok, right under the skin Q3 What next? Excision vs FNA Branches of facial nerve Q4 What is the most likely pathology? Pleomorphic Adenoma 80% parotid tumors benign, 60% P.A. 60% in women, 44 y.o. average age
Case 1 cont d Q5 What now? watchful waiting vs excision risk of malignant transformation risk of facial nerve damage comorbidities
Case 1 cont d Q6 What s the approach? incision Modified Blair enucleation vs superficial parotidectomy -pseudopods -recurrence rates 10-50% localization of facial nerve -tragal pointer (0.5 cm deep) -tympanomastoid suture (6-8mm ant/inf.) -mastoid tip (1.5cm above and 1.0cm deep) -peripheral branch -mastoidectomy
Case 1 cont d Q7 Are you going to see him again? recurrences reported 20-30 yrs later Pt. returns with flushing and sweating on side of face with eating. Q8 What s the diagnosis? Gustatory sweating (Frey s syndrome) Botox injection
Case 2 78 y.o. man with bilat. parotid masses. There a long time, not changing. On exam, mobile, soft, nontender. Q1 likely diagnosis? Warthin s 10% bilat. 10:1 male-to-female Q2 what malignant tumor can be bilat? Acinic cell carcinoma Lymphoma Q3 what do you want to do? FNA +/- superficial parotidectomy
Benign Parotid Neoplasms Pleomorphic Adenoma 65% Warthin s tumor 6-10% Oncocytoma <1% Monomorphic Adenoma
Case 3 50 y.o. woman with R parotid mass, there about 8 months, getting bigger, no pain. On exam it s hard, 3cm, fixed, facial nerve appears intact. Q1 What next? FNA mucoepidermoid carcinoma Q2 Treatment? Superficial parotidectomy, intra-op frozen section, total parotidectomy and LN dissection if high grade. Q3 When would you take the facial nerve? Involved or cannot get adequate margins Q4 Adjuvant treatment? Post-op radiation if high grade
Case 4 60 y.o. woman presents with 2cm mass L parotid, painful, no LNs palp. FNA reveals adenoid cystic carcinoma. Q1 Treatment? Total parotidectomy Intra-op dissect nerve and find pes uninvolved, but tumor involves cervical branch and marginal mandibular branch. Q2 What now? Excise branches (?nerve graft with greater auricular nerve). Grossly tumor is out.?frozen sections of perineural tissue and excise back to main trunk if needed to get clear margins. Q3 Adjuvant treatment?
Indications for Facial Nerve Resection Immediately involved with tumor Advanced to T3 stage ( >4 cm, multiple neck nodes, deep fixation, skin ulceration, dysfunction of facial nerve) Seventh nerve paralysis or recurrent malignancy
Malignant Parotid Neoplasms Mucoepidermoid Carcinoma 6-9% - low and high grade Malignant Mixed 2-5% - malignant degeneration of Pleomorphic Adenoma Adenoid Cystic Carcinoma 6% - perineural invasion Acinic Cell Carcinoma 1% - bilat. 3% of time Adenocarcinoma
Indications for Cervical Lymphadenectomy Palpable LNs Facial nerve paralysis, large tumors with deep fixation (T3) Aggressive tumors : epidermoid, malignant mixed, high-grade mucoepidermoid
Indications for Post-Op Radiotherapy Perineural involvement Large tumors (T3 or T4) Positive LNs Deep lobe tumors High grade : undiff., malignant mixed, adenoca, adenoid cystic, high-grade mucoepidermoid, epidermoid (i.e. low-grade mucoepidermoid and acinic cell do not)
Case 5 50 y.o. woman with unilateral parotid swelling, comes and goes, no pain. Q1 what else do you want to know? Dry eyes, dry mouth Phx : RA Q2 likely dx? Sjogren s syndrome (1 o vs 2 o ) Chronic d/o with immune-mediated destruction of exocrine glands 1% of population, 9:1 F:M, 40-60 y.o.
Q3 how to dx her? Case 5 Bx best, SS-A/Ro and SS-B/La autoantibodies, sialography Q4 what cancer is she at risk for? Lymphoma 5% (33-44 x gen. pop.) Q5 treatment? Supportive Steroids for severe debilitating dz
Case 6 79 y.o. man in hospital for gastroenteritis with diarrhea, not eating, dehydrated. Develops pain and swelling anterior to R ear. Tender and hot to touch. Incr. temp., incr. WBC. Q1 likely diagnosis? Sialadenitis Staph. Aureus (S.pneumoniae, E.coli, H.flu)
Case 6 Q2 treatment? Fluids, IV abx, oral hygiene, massage No improvement, seems worse. Q3 investigations? U/S, CT, sialography