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Parotid gland tuberculosis is still a rare entity and has mostly been diagnosed after parotidectomy. We present five cases which were diagnosed on fine needle aspiration cytology (FNAC) and managed medically avoiding surgical intervention.
One hundred and eight parotidectomies performed by a single consultant were reviewed. Eighty-five patients had primary parotid disease, 23 patients had extra-parotid primaries. Pleomorphic adenoma was the most common histological diagnosis. In patients with primary parotid disease, a post-operative temporary facial nerve palsy was noted in 15 patients, with a further four developing a permanent palsy. Patients with metastatic disease to the parotid had a poor prognosis.
The demographics of parotid neoplasms in different populations have been reported by various centres. In this investigation, we reviewed retrospectively all the in-patient and out-patient charts and records of 108 patients who were diagnosed with parotid neoplasms and received parotidectomies in our department from 1 January 1993 to 15 April 2000. Patient age, gender, tumour pathology, fine-needle aspiration cytology results, and the intraparotid anatomy of the facial nerve were noted. We showed that despite the difference between our Taiwanese and previously studied patient populations, both populations had a similar distribution, diagnosis and treatment of parotid neoplasms, although the incidence of parotid tuberculosis was higher in our patient group. In addition, the facial nerve anatomy within the parotid gland had three main branching patterns in the upper and lower division.
Kaposi's sarcoma of an intraparotid lymph node is extremely rare in non-immunocompromised human immuno-1 deficiency virus (HIV)-negative patients. We report a case of a left parotid mass as an early sign of Kaposi's sarcoma-associated human herpesvirus 8 (HHV-8) infection in a 57-year-old patient. After subtotal parotidectomy and histopathological diagnosis of lymph node localization of Kaposi's sarcoma, an accurate dermatological investigation revealed a solitary small lesion in the left foot. Chemotherapy with five cycles of vincristine gave a temporary response of the cutaneous lesion. Seven months later, a few small, firm, purplish-red lesions appeared in different areas of the body, but no adjuvant treatment was accepted by the patient since the lesions occasionally disappeared or remained stable in size. At four years follow-up, there has been no recurrence in the parotid region, and the patient is alive with cutaneous disease but in good general health. The problems related to the diagnosis, the management strategy of such a rare condition and the prognosis are also discussed.
A 32-year-old male presented with a mass in the parotid gland. Superficial parotidectomy was performed. Histopathologically the tumour was found to be schwannoma (neurilemmoma) and because this is unusual, the case is presented together with the histopathological findings.
Until now, little was known about the mode of parotid involvement in external auditory canal (EAC) carcinoma. The incidence of parotid node metastasis and direct parotid invasion was examined in patients with EAC carcinoma. The study comprised 11 patients with squamous cell carcinomas (SCC) and 10 patients with adenoid cystic carcinomas (ACC). A retrospective review of the surgical specimens was undertaken with specific reference to parotid node metastasis and parotid invasion. Parotid node metastasis was noted only in two cases of advanced staged SCC, whereas none of the ACC patients showed parotid node metastasis. Direct parotid invasion occurred only in advanced staged SCC, however, it did occur in early stage ACC. Our data indicated that elective parotidectomy for control of occult parotid node metastasis is necessary only in advanced SCC carcinoma, whereas parotid management to secure adequate safety margins is mandatory for advanced SCC and all cases of ACC.
A unique case is presented of a penetrating injury of the parotid gland and complete transection of the cartilaginous portion of the external auditory canal by a tree branch. A subsequent superficial parotidectomy along with end-to-end anastomosis of the external auditory canal and appropriate antimicrobial therapy was successful. A review of the literature did not reveal any previous similar cases.
We performed Computed Tomography (CT) immediately following, or simultaneous with, conventional sialography on a group of 45 patients with parotid gland swellings over a two-year period. Tumours occurred in eight, sarcoidosis in 22, actinomycosis in two and chronic pyogenic parotitis in 13 patients. In the latter group, there were two cases of bilateral disease, for a total of 15 glands. The sialographic and the combined CT-sialographic features were retrospectively analysed. In all cases, ductal pathology was more severe in the main and proximal branches, was better demonstrated on conventional sialography and was diagnostic in 10/14 glands (71%). CT-sialography was the superior modality in the evaluation of the gland parenchyma and the adjacent structures, demonstrating diagnostic features of infection in 8/14 glands (57%). However, a combination of both modalities presented a consistent pattern of infection in all cases, distinctive from tumours and sarcoidosis. CT-directed aspiration was performed on the four glands which were equivocal on conventional sialography, and two of these underwent a simultaneous aspiration-irrigation with antibiotics. Although this report is based on a limited experience, CT-sialography with aspiration appears to be an interventional radiological alternative to the traditional diagnostic superficial parotidectomy. Ultrasonography (two cases) and nuclear scintigraphy (one case) added little useful information in chronic pyogenic parotitis.
Frey's syndrome or gustatory sweating is a common complication of parotid gland injury or surgery. Forty to 60 percent of the patients undergoing parotidectomy will develop manifestations of this syndrome but only 10-15 percent of these require treatment. To date tympanic neurectomy is the most efficacious method of treating the problem but relief is not obtained in all cases. Based on an experimental study in the dog, a new approach to the prevention of Frey's syndrome is presented. Since Frey's syndrome is due to the aberrent regeneration of parasympathetic nerve fibers of the parotid gland into the severed sympathetic nerve endings in skin overlying the gland, it is proposed that the insertion of a dermal graft barrier between the resected parotid gland and the skin will prevent Frey's syndrome. Histological sections of dermal grafts, buried for three to six months tend to confirm that this idea has some merit.
Two studies are reported in an attempt to give a broader interpretation of the management of salivary gland disorders. One study analyzes 232 patients seen over a six year period and divides the grouping into parotid, submaxillary, and accessory salivary gland disorders. The numbers and percentages of patients who underwent surgery are reported along with a pathological break-down of the various lesions encountered. Eighty-five (36%) of the 232 patients had a documented surgical procedure. Thirty-eight of the entire 232 patients had tumor involvement, for a 16% incidence of neoplasia. At the same time 244 patients had various sorts of salivary gland surgery in the four local hospitals. Of these, 210 had either a parotidectomy or submaxillary gland excision. A surgical and pathological breakdown of the 117 neoplastic lesions fairly well corresponds to most of the published series, but fails to relay the overall picture that the head and neck surgeon encounters in dealing with salivary glands.
One hundred sixty patients with Sjogren's syndrome have been evaluated and managed at Scripps Clinic. Objective diagnosis has relied heavily on rose-bengal vital staining and corneal slit lamp examination to establish the presence of KCS and lip biopsy. The role of the head and neck surgeon in evaluating the patient with "dry mouth" is discussed. Usually Sjogren's syndrome is managed nonsurgically, but problems of abscess, recurrent infection, disfigurement, and malignant transformation may result in the need for total parotidectomy with nerve preservation. Radiation for Sjogren's syndrome is rarely, if ever, indicated. The etiology of Sjogren's syndrome may be closely tied to the homogeneous genetic background of its patients and the presence of a chronic immunogenic stimulus well recognized in the secondary form but less clear in the primary.
Benign hypertrophy of the salivary glands can occur in patients with anorexia nervosa. This enlargement has been related to nutritional deficiencies and bulimia, which is a form of episodic binge eating followed by vomiting. The surgical management of a patient with bulimia and benign bilateral parotid enlargement secondary to bulimia will be discussed. Superficial parotidectomy may be a useful adjunct in managing the cosmetic and psychological aspects of patients with anorexia nervosa and bulimia complicated by massive parotid hypertrophy intractable to medical management.
Surgical management of carcinomas at the inner canthus is based on three criteria which are listed in a descending order of importance: tumor resectability with adequate margins, preservation of vision, and acceptable cosmetic result. The lesions resected are to create trapezoid or rectangular defects which can be closed simply with primary closures or with Z- or W-plasties. In medium sized defects skin is borrowed from the glabella, upper nasal dorsum, or nasolabial sulci and used as rotational flaps. In more extensive lesions, through and through defects, or when lined flaps are required, nondelayed midline forehead pedicled or island flaps are employed. For very large defects, sliding cheek flaps, sickle forehead flaps, horizontal forehead flaps, and (in rare instances) scalping flaps where the distal segment is the temporal, hairless skin is used. Tumors which extend intracranially and are deemed resectable are removed with a combined intracranial approach. The latter may be via a transfrontal sinus resection or a combined lateral rhinotomy and frontal craniotomy resection. Regional lymph node metastasis normally requires a superficial parotidectomy, radical neck dissection (including submaxillary, angular, and mandibular nodes), and occasionally postauricular lymph node dissection. Distant metastases are contraindications for major surgical procedures.
Meibomian gland carcinomas of the eyelid are rare neoplasms, accounting for less than 1% of all eyelid tumors. They usually mimic chalazia and undergo repeated curettage before a definitive diagnosis is made. Although they are relatively slow growing tumors they behave in an aggressive manner, frequently metastasizing to regional lymph nodes. Approximately 50% of the patients who develop metastasis to lymph nodes of the neck will survive five years. We present a case of meibomian gland carcinoma with preauricular lymph node metastasis, treated with orbital exenteration, superficial parotidectomy, and radical neck dissection.
Frey's syndrome, or gustatory sweating, is most commonly seen as a sequela of superficial parotidectomy. It can also be caused by other forms of trauma, including blunt trauma, but rarely does it occur without trauma.
The authors present a case of a 33-year-old white man with a 4-month history of a rapidly enlarging, tender, painful, circumscribed facial mass located in the masseter muscle. CT scan and fine needle aspiration cytology, coupled with clinical assessment, suggested the diagnosis of proliferative myositis. Curative intraoral excisional biopsy was done, thereby avoiding a parotidectomy incision and approach to the lesion. The pathology showed proliferative myositis. A review of the literature revealed 36 cases which indicated that proliferative myositis is a relatively rare etiology of a head and neck mass. Careful clinical, radiologic, and pathologic evaluations were required to make this unusual diagnosis and avoid any unnecessary facial mutilation in its treatment.
Two hundred thirty-one sequential parotid masses seen from January 1982 to July 1986 were reviewed for their clinical presentation, diagnostic evaluation, pathologic findings, and therapeutic approach. The results were compared with the previously reported findings on parotid masses. There were 146 (63.2%) benign tumors, 50 (21.6%) malignancies, and 35 (15.2%) nonmalignant lesions. Tumors were classified according to their histopathologic diagnosis. An asymptomatic mass was the most common presentation. Radiological evaluation was mainly with computed tomography. The primary surgical procedure was parotidectomy with facial nerve preservation. A selected group of patients was referred for radiation therapy. Our study demonstrated that non-neoplastic lesions contribute a significant number of masses in the differential diagnosis of parotid tumors. Metastatic squamous cell carcinoma was the most frequently encountered malignancy. Deep lobe tumors were twice as common as previously reported.
Over the past 7 years, nine fatty tumors within the parotid gland have been managed (eight lipomas, one liposarcoma). High-resolution computed tomography examination was carried out in all cases; with correct preoperative diagnosis recorded each time. The computed tomography imaging characteristics of lipoma, liposarcoma, and the differential diagnosis from other fat density lesions, such as a fatty infiltration, appear quite specific. The liposarcoma and six of the lipomas were resected at formal parotidectomy with facial nerve preservation. Two patients with small intraglandular lipomas have elected to undergo long-term clinical and imaging observation. Our experience indicates that high-resolution, soft-tissue imaging with computed tomography and magnetic resonance imaging permits consistent preoperative fatty tumor diagnosis. This imaging input facilitates rational treatment decision-making.