Clinical scenario: Your recent new patient is a 42-year-old female, mother of three children, who presented on referral from one of your primary care colleagues with a one-year history of an enlarging mass in the left parotid region. The patient is first seen by the third-year university otolaryngology resident who is rotating with you for three months to gain more head and neck surgery experience. The resident briefs you on the medical history and findings and introduces the patient.
Explore this issue:February 2015
The patient states that she did not seek evaluation for the mass sooner because she has been so busy with her three children in elementary, middle, and high school. The patient also works part-time as a salesperson at a clothing boutique. She denies pain, facial weakness, headaches, and tobacco and alcohol use. There are no other medical or surgical histories, and the review of systems is otherwise unremarkable. Her concerns center on the risk of malignancy and what that could mean for her family, and, if the mass is benign, how soon she can return to her family and work obligations. Her husband appears to be appropriately concerned about her condition and supportive of having the mass removed.
Examination and Recommendation
Physical examination reveals a slightly overweight female with a mass in the left pre-auricular angle of mandible region. Cranial nerve examination reveals no evidence of any weakness or dysfunction. The skin overlying the mass appears normal, although there is minimal movement of the skin over the underlying mass. The mass itself measures approximately 5 cm by 6 cm with an estimated 4-cm depth, located primarily in the anterior pre-tragal region and extending posteriorly and inferiorly toward the angle of the mandible. It feels firm and reasonably well demarcated. The patient’s neck is negative to palpation for additional masses or abnormalities. The right parotid region is likewise unremarkable.
Magnetic resonance imaging of the head and neck region reveals only the left parotid mass, involving much of the superficial parotid but also a bit of the deep lobe at its maximal depth. Fine needle aspiration cytology is suggestive of a benign mixed tumor (pleomorphic adenoma) of the parotid. No other pathology is noted on these examinations.
Based on the history, physical examination, and diagnostic studies, you make the recommendation to the patient that she consider a left parotidectomy to remove what appears to be a benign tumor. After you have answered all of her questions, and those of her husband, she feels comfortable agreeing to this procedure. She admits to being nervous about the surgery, and you try your best to reassure her with both factual information and personal empathy. You discuss in detail with her and her husband the goals, benefits, and risks for the procedure, and you give her the option of watchful waiting. You especially emphasize the known risks and possible complications of the procedure, and you explain how you would manage them if one or more should occur. After all parties are satisfied with the informed consent, the proper surgical documents are completed and signed. Barring unforeseen medical concerns by her primary care physician in the conduct of his pre-operative evaluation, the surgery date is set.
On the morning of surgery, you again discuss the goals, risks, and benefits with the patient and her husband, and try to reassure her that you will do your best to minimize the risks for a complication during the surgery.
You are an experienced parotid surgeon and feel this procedure will not be a high enough risk to utilize a facial nerve monitoring device. After a safe and uneventful anesthetic induction, you proceed with the procedure, utilizing a 2.5 power loupe for magnification. The third-year otolaryngology resident physician is serving as your first assistant.
After raising the skin flap uneventfully, you begin the dissection along the tragal “pointer” to locate the main trunk of the facial nerve. The mass appears to be quite firm and not easily mobilized anteriorly or inferiorly. Still feeling comfortable with the progress of the dissection, you allow the resident physician to dissect several millimeters of the soft tissue just anterior to the tragal pointer to gain a feel for the proper dissection technique in that region, all the while trying to keep a close watch on the surgical field.
When the resident achieves a depth consistent with your spatial awareness of proximity to the facial nerve main trunk, you take over the surgical dissection and identification of the nerve; however, you are unable to identify the facial nerve after you dissect the region in which it is expected to be located. You continue a slow, but deliberate, dissection to mobilize more of the mass superiorly and inferiorly to improve the exposure of the likely location of the facial nerve main trunk. Both the temporal and marginal mandibular branches of the facial nerve are identified and retrograde dissected; three millimeters of the main trunk before the separation of the inferior and superior divisions, but it is discontinuous with the proximal stump of the facial nerve, which you finally located beneath the tragal pointer. Realizing that the nerve has been transected, you complete the tumor dissection away from the distal branches of the nerve and reestablish the continuity of the nerve using a short segment interpositional graft from the greater auricular nerve.
A frozen section examination of the tumor is reported to you in the operating room as “likely a pleomorphic adenoma.” After the neurorrhaphy is completed, the wound is closed, and the patient is taken in stable condition to the recovery room, you turn to the resident physician and tell him that it is time to speak with the family.
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