A 56-year-old woman consulted for a right parotid tumor of 2 years of evolution, asymptomatic, with faster growth in recent months.
As the only relevant personal history, the patient had been operated 20 years before for a dermatofibrosarcoma in the scapular region.
On examination, the tumor is 2 cm in diameter, poorly defined and located in the thickness of the right parotid tail.
There were no alterations in facial motility or palpable adenopathies in the cervical exploration.
Biopsy performed by needle aspiration (FNA), obtained material suggestive of benign cystic lesion, with slight lymphocytosis without epithelial component.
The cervicofacial computed tomography (CT) shows a tumor of irregular contours, located in the superficial lobe of the right parotid gland, with focal extension to the deep lobe.
This is a hypodense 18 × 24 × 34 mm lesion with a wall and enhancement minimally after contrast administration.
Thus, the first suspected diagnosis is benign cystic parotid tumor, without ruling out other possibilities.
1.
The patient was operated under general anesthesia, by means of an incision in the urethroidectomy and a sphincter flap.
Routine identification of the trunk of the facial nerve is performed, with great difficulty in its location, which shows its close relationship with the tumor.
After retrograde dissection of the main branches of the par (marginal, buccal, palatal and frontal), using the optical coherence, it is not possible to separate tumors from the nerve trunk.
The lesion is composed of spindle fascicles imbricated between nerve branches and cystic areas, forming a lobulated lesion well defined respect for the parotid tissue.
Cystic content was drained, with a large reduction in tumor size and two intraoperative biopsies were ordered.
The first was reported as inflammatory connective tissue and the second as low-grade fusiform tumor suggestive of colitis.
1.
After explaining the different therapeutic options to the family during surgery, it was decided not to remove the tumor completely and to wait for the definitive histopathological result.
A silicone tube is available around 3 of the distal branches of the dissected facial nerve to facilitate its further identification if a second intervention is necessary.
Suture closure was performed with vacuum drainage and bandaging according to the usual protocol.
1.
In the immediate postoperative period, the patient presented complete facial paralysis (grade VI House-Brackman scale) with good recovery at 15 months (grade I, House-Brackman).
The patient also presented symptoms of Frey's syndrome two months after surgery, and was successfully treated with botulinum toxin.
1.
The definitive pathological diagnosis was peripheral nerve palsy.
We discuss with the patient the possibility of complete removal of the tumor, with sacrifice of the facial nerve and immediate reconstruction with nerve graft, but until now the patient rejects this option.
1.
The first post-surgical control was performed with magnetic resonance imaging (MRI) 5 months after surgery, in which a nodular hypercapsular image appeared in the parotid cell, encompassed in an area of fibrosis.
The image is compatible with immature fibrosis without ruling out residuals.
Clinically, the patient had no palpable tumor in the intervened region or worsening of facial motility after a 3-year follow-up.
Annual MRI controls showed no changes compared to previous controls.
