The facial nerve in parotid malignancy

Adenoid cystic carcinoma of the parotid gland with temporal bone invasion

OBJECTIVE

To present our series of 16 patients with adenoid cystic carcinoma (ACC) of the parotid gland with temporal bone invasion.

PATIENTS

All patients treated at our institution between July 1988 and July 2004 with parotid gland ACC with temporal bone invasion.

INTERVENTIONS

Preoperative radiographic assessment with combined surgical and radiation therapy treatment.

MAIN OUTCOME MEASURES

Postoperative- or radiation-related complications and overall 2-, 5-, and 10-year survival.

RESULTS

The most common surgically related complications were new-onset cranial nerve deficits, whereas osteoradionecrosis of the bony external auditory canal was the most frequently noted complication associated with radiation therapy. The overall survival rates at 2, 5, and 10 years were 94, 75, and 60%, respectively.

CONCLUSION

Lateral cranial base access should be used in the extirpation of ACC of the parotid gland with temporal bone involvement.

Carcinoma ex benign pleomorphic adenoma of the parotid gland

BACKGROUND

Carcinoma in pleomorphic salivary adenoma is a common histologic subtype of primary parotid malignancy.

METHODS

In this study, 28 patients (predominantly male) with histologically diagnosed carcinoma in pleomorphic salivary adenoma presenting over 10 years were retrospectively reviewed.

RESULTS

Only 25 percent of patients had a previously treated pleomorphic salivary adenoma. Although the presenting features suggested malignancy in some cases, overall they were nonspecific, overlapping with the presentation of benign disease. Preoperative investigations included fine needle aspiration cytology, which was only 29-percent sensitive, and computed tomography and/or magnetic resonance imaging. There were 14 superficial and 12 total or radical parotidectomies. The facial nerve was resected en bloc with the tumor in nine cases and immediately reconstructed with good reanimation results in patients with recent-onset facial paresis. Only 44 percent of patients had a complete histologic tumor clearance, and this was the most significant determinant of survival (p < 0.01, log-rank analysis). The locoregional control rate was 66 percent at 5 years, but recurrent disease proved invariably fatal. Five-year disease-specific survival was 44 percent with a high rate of disease-specific mortality (87 percent).

CONCLUSIONS

Carcinoma in pleomorphic salivary adenoma is very difficult to diagnose preoperatively. Fine needle aspiration cytology had a disappointingly low sensitivity for this tumor, potentially misdirecting surgical management. While good locoregional disease control could be achieved with surgery and radiotherapy, carcinoma in pleomorphic salivary adenoma was shown to be aggressive with a high disease-specific rate of mortality. Given that incomplete tumor resection was the most important prognostic factor, a high index of clinical suspicion, radical ablative surgery, and immediate soft-tissue and nerve reconstruction for proven cases are advocated.

Parotid neoplasms in children: experience of diagnosis and management in a district general hospital

Parotid neoplasms are uncommon in children and the available literature is predominantly from specialized centres. This paper highlights our experience at a district general hospital, in the diagnosis and management of parotid neoplasms in children. The case records of all parotidectomies performed in a 26-year period between 1974-1999 were scrutinized and patients aged 18 years and below identified. The demographic data, histology, presentation, investigations, treatment, outcomes and complications were analysed. 545 parotidectomies were performed in 536 patients, in whom 569 neoplasms were diagnosed. Only 12 patients aged 18 and under were identified (2.2%). The relative frequency of individual tumours differed markedly from that in adults. 75% of the tumours were benign. Pleomorphic adenoma and mucoepidermoid carcinoma were the most common tumours. A painless mass was the most frequent clinical presentation and CT sialogram was the most common investigation. Parotidectomy with preservation of the facial nerve was performed in all cases, and adjuvant radiotherapy employed in the case of malignant tumours. All patients were alive and well at the time of last follow up. Transient facial nerve palsy and hypertrophic scars were the most common complications.

Malignant tumours of the parotid gland: a 12-year review

Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.

Malignant epithelial parotid tumours: a rational treatment policy

Formal parotidectomy was undertaken in 271 patients by one surgeon over 11 years. Forty patients were treated for malignant salivary tumours (nine were recurrent). Low-grade tumours (45 per cent) were treated by surgery alone, untreated high-grade tumours (55 per cent) by surgery and radiotherapy, before or after operation, depending on clinical findings. The aims of surgery were to obtain tumour clearance, to preserve the facial nerve if possible, and to perform radical neck dissection for palpable malignant lymphadenopathy proven cytologically and for high-grade tumours when intraoperative jugulodigastric lymph node biopsy confirmed metastasis. Four patients sustained facial weakness as a result of surgery. At a median of 46 months follow-up two patients had developed local recurrence. Eleven patients with high-grade but none with low-grade tumours died from metastases. Patients with high-grade lesions with facial weakness from malignant infiltration and those with lymphatic metastasis have a significantly worse prognosis than those without. Locoregional control of parotid cancers can be achieved by formal parotidectomy and selective irradiation without routine sacrifice of the facial nerve.

Subtotal petrosectomy in the management of advanced parotid neoplasms

Circumferential growth of parotid neoplasms may involve the external auditory meatus posteriorly, the floor of the middle cranial fossa superiorly, and the neurovascular structures of the jugular foramen medially. Inadequate tumor resection in these anatomically complex regions will result in local disease recurrence at the lateral skull base. A subtotal petrosectomy approach has been combined with a standard total parotidectomy in the management of 27 patients with aggressive parotid tumors. Twenty-two patients had malignant lesions and 10 individuals had recurrent disease. The resultant conductive hearing loss is outweighed by the following advantages of this technique: (1) the ability to obtain tumor-free bony margins, (2) proximal intratemporal facial nerve identification, (3) vascular control of the jugular bulb and petrous carotid artery, and (4) the dissection and protection of cranial nerves IX through XII. Our series of 27 patients will be detailed with an emphasis on surgical technique and overall patient results.

Acinic cell carcinoma of the salivary glands. A review of 20 new cases

Twenty patients with acinic cell carcinoma of the salivary glands are presented. Seventeen tumours were located in the parotid and three in minor salivary glands, one being considered intraosseous. According to the growth patterns, they were classified as solid-acinar in 8 patients, microcystic in 5 patients, follicular in 3 patients and papillocystic in 4 patients. 9 cases were considered high grade malignant tumours and among the 11 well-differentiated, 2 suffered dedifferentiation in local recurrences. Local recurrence appeared in 9 cases. Three cases had nodal disease on admission while 5 developed this during the course of the disease. Distant metastasis appeared in 2 cases. Local recurrence and nodal disease correlated with the degree of differentiation and state of the margins in the surgical specimen. We recommend an aggressive surgical approach followed by postoperative radiotherapy for the undifferentiated tumours and extensive ones. For the limited and better differentiated, a more limited excision, such as total parotidectomy preserving the facial nerve is suggested.

An approach to malignant parotid tumours

A series of 30 patients with malignant parotid tumours selected for surgical treatment is presented. There were 18 males and 12 females, with an age range of 12-80 years. All presented with a parotid lump, one had an associated painful facial nerve palsy and one had clinically involved neck nodes. Four had previous surgery, surgical biopsy or radiotherapy. Pre-operative fine needle aspiration was performed on one patient. Postoperative radiotherapy was administered to 14 patients. Follow-up was for a mean of 5.5 years. The primary tumour was controlled by surgery alone in 15 of the 16 patients. There was one local recurrence and two patients in this group died from distant metastases. Of the group receiving postoperative radiotherapy, there was one local recurrence, one local and neck recurrence and one death from distant metastases. Mobile, discrete tumours can be treated by parotidectomy with preservation of the facial nerve and the selective use of radiotherapy. The malignant tumour with restricted mobility but no facial palsy is treated by parotidectomy, sacrificing only involved branches and postoperative radiotherapy. The clinically fixed lesions with facial palsy demand total parotidectomy in operable cases, nerve sacrifice and postoperative radiotherapy.