The parotid gland is divided into two lobes, superficial and deep, and the VII Cranial Nerve (facial nerve) passes between the two. It is the nerve that supplies the muscles of facial expression.
Patients usually present with a swelling in the region of the gland. There can be a slow-growing mass/ lump near the jaw, in front of the ear or in the neck. It can sometimes be associated with persistent pain in the area of the gland. If the tumor has grown to impinge or involve the facial nerve, it can cause muscle weakness on the same side of the face.
In addition to a thorough history and clinical examination, a contrast-enhanced CT scan/ MRI and a fine needle aspiration biopsy are the investigations usually carried out to diagnose a parotid pathology. A tissue diagnosis is essential to determine the surgical plan. If the FNA reveals a benign pathology, the mass is excised. However, if malignancy is detected, the surgery involves removal of the entire parotid gland for adequate margin and lymph nodes.
Surgery is the treatment of choice in most salivary gland tumors and needs experienced surgeons. Post-operative radiotherapy is advised in cases of advanced stage and/or high-grade disease, difficult margins or inadequate surgery Parotid surgery is highly technique sensitive due to the facial nerve as it traverses through the substance of the gland. The nerve needs to be preserved as any injury to the nerve can lead to temporary or permanent facial palsy.
In cases where the malignant tumor is invading the nerve, the patient may develop facial palsy, which can cause an inability to close the eye, drooping of the corner of mouth etc. Hence, if a patient reports with a parotid mass along with facial nerve paralysis, facial numbness, muscle weakness on one side of the face, a malignant tumor may be suspected.
If the facial nerve needs to be sacrificed in the process of complete excision of the malignant tumor, reconstruction of the nerve is possible by using a nerve graft, from the greater auricular nerve. Microsurgical repair of the damaged facial nerve is the most effective procedure for restoring motor function (voluntary movement) of the face.
Pleomorphic adenomas are the most common benign salivary gland neoplasm encountered in the parotid gland. The standard treatment for benign parotid tumors, like pleomorphic adenomas, is superficial parotidectomy wherein the superficial lobe of the parotid gland is removed with preservation of the facial nerve.
For benign tumors involving the deep lobe of the gland or for malignancies arising in the gland, a total parotidectomy is the choice of treatment.
Radical parotidectomy, with the sacrifice of the facial nerve, is performed when neoplastic involvement of the facial nerve is present. Immediate facial nerve reconstruction/ repair involves identification of the proximal and distal ends and an interposition autogenous graft. Options for graft include nerves such as the sural nerve, the great auricular nerve, and the cervical nerve branches. If this is not feasible, alternative donor nerves such as the hypoglossal nerve, masseter nerve, and the contralateral facial nerve can be utilized.
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