Tumores parotídeos: correlación entre estudios de imagen, punción aspiración con aguja fina y los hallazgos histopatológicos / [Parotid tumors: correlation between imaging studies, fine needle aspiration and histopathological findings]

Introducción y objetivo: Nuestro objetivo es establecer la rentabilidad del diagnóstico citológico mediante punción aspiración con aguja fina (PAAF) y la utilidad del estudio de imagen preoperatoria en el manejo de masas parotídeas. Método: Se realizó un estudio retrospectivo de una muestra de 142 pacientes con tumoración parotídea intervenidos por el Servicio de Otorrinolaringología del HUPR en los últimos 10 años, con diagnóstico preoperatorio radiológico (ecografía, TC, RNM) y citológico, mediante PAAF. Los resultados de ambas pruebas se han clasificado como positivos o negativos para malignidad y se compararon con el diagnóstico anatomopatológico. Resultados: La edad media fue de 56 años, el 61,3% eran hombres. La PAAF presentó una sensibilidad para detectar malignidad del 75% y una especificidad del 100%; con valores predictivos positivo y negativo (VPN) de 100 y 97%, respectivamente. La sensibilidad del estudio radiológico fue de 25%, y la especificidad del 99%. El valor predictivo positivo para malignidad fue de 80%, y el valor predictivo negativo, de 89%. Conclusiones: La PAAF es una prueba sencilla, pero de utilidad limitada para la orientación diagnóstica debido a su baja sensibilidad y elevados falsos negativos; sin embargo, su alta especificidad y elevado VPN hacen de la misma una prueba con mayor precisión frente a un resultado benigno o negativo. El estudio radiológico previo es útil en el diagnóstico de extensión y características tumorales, aunque se ve limitado por sí solo en el diagnóstico diferencial de malignidad. La RM se ha convertido en la modalidad de imagen de elección. (AU)

Introduction and objective: Our aim is to establish the profitability of cytological diagnosis by fine needle aspiration (FNA) and the usefulness of preoperative imaging in the management of parotid masses. Method: A retrospective study of a sample of 142 patients with parotid tumors operated on by the HUPR Otorhinolaryngology Service in the last 10 years, with preoperative radiological (ultrasound, CT, MRI) and cytological diagnosis, by FNA, was carried out. The results of both tests have been classified as positive or negative for malignancy and were compared with the pathological diagnosis. Results: The average age was 56, 61.3% were men. FNA had a sensitivity to detect malignancy of 75% and a specificity of 100%; with positive and negative predictive values (NPV) of 100 and 97%, respectively. The sensitivity of the radiological study was 25%, and the specificity 99%. The positive predictive value for malignancy was 80%, and the negative predictive value was 89%. Conclusions: FNA is a simple test, but of limited utility for diagnostic orientation due to its low sensitivity and high false negatives; however, its high specificity and high NPV make it a more accurate test against a benign or negative result. The previous radiological study is useful in the diagnosis of tumor extension and characteristics, although it is limited by itself in the differential diagnosis of malignancy. MRI has become the imaging modality of choice. (AU)

Linfoma MALT de glándula parótida. Revisión sistemática / MALT lymphoma of the parotid gland. Systematic review

Introducción y objetivo: Los linfomas de la glándula parótida son una entidad infrecuente. El objetivo de este estudio es realizar una revisión sistemática retrospectiva de la literatura sobre casos clínicos de linfomas MALT parotídeos. Se revisa su epidemiología y clínica más habitual, los métodos diagnósticos y tratamiento empleados y su pronóstico. Método: Revisión bibliográfica sistemática. Resultados: Se seleccionaron 28 estudios originales de casos o series, de los cuales 10 incluyeron más de 25 pacientes. Todos mostraron mayor incidencia en mujeres, en consonancia con su asociación con la presencia de enfermedades autoinmunes, específicamente con el síndrome de Sjögren. Los estudios evidenciaron la dificultad en el diagnóstico diferencial de otras patologías parotídeas. El tratamiento varió entre estudios, sin mostrar ninguno de ellos un claro beneficio respecto de los demás. Discusión: Se trata de un tipo de LNH relacionado principalmente con inflamación autoinmune crónica en el caso de aparición en glándulas salivales. Se presenta como una tumoración asintomática e inespecífica de crecimiento lento. Se diagnostica por su histología y se estudia su extensión mediante TC o RM en la mayoría de los casos. El tratamiento se realiza mediante parotidectomía asociada a quimioterapia y/o radioterapia. La tasa de supervivencia es >80% a los 5 años. Conclusiones: Los linfomas MALT de glándulas salivales son poco habituales y ocasionalmente se diagnostican de manera inadecuada debido a su comportamiento benigno, que mimetiza a tumores más familiares del área parotídea. Su sospecha y distinción son esenciales y no debe olvidarse en el diagnóstico diferencial de masas parotídeas. (AU)

Introduction and objective: The parotid gland lymphomas are encountered unfrequently. The objective of this study is do a retrospective systematic review of the literature on parotid MALT lymphomas, to evaluate its epidemiology, clinical presentation, diagnostic methods, treatment, and prognosis. Method: Systematic review. Results: 28 original studies have been included (case report and case series), 10 of which included more than 25 cases. Studies showed a higher prevalence in women, according to its relationship with autoimmune diseases, Sjögren disease specifically. The studies outlined the difficulty on the differential diagnosis with other parotid diseases. Treatment varied between studies, with no specific benefit for any of them. Discussion: This lymphoma is a type of NHL related to chronic autoimmune inflammation in case of salivary glands localization. It presents as an asymptomatic and non-specific, slow growing mass. It is diagnosed by CT or MRI in the majority of cases. The treatment includes the association of parotidectomy and/or chemotherapy and/or radiotherapy. The 5-year survival rate is >80%. Conclusions: MALT salivary lymphomas are a rare entity that can be easily misdiagnosed by other common benign mases. We must suspect and don't forget this entity from the differential diagnosis diagram. (AU)

Linfoma MALT de glándula parótida. Descripción de un caso / MALT linfoma of the parotid gland. Case report

Introducción y objetivo: El linfoma tipo MALT es un tipo de LNH relacionado principalmente con inflamación autoinmune crónica en el caso de aparición sobre glándulas salivales. Los linfomas de la glándula parótida son una entidad infrecuente. Presentamos un paciente con linfoma tipo MALT de parótida, describiendo sus métodos diagnósticos y de tratamiento más empleados. Descripción: Mujer de 69 años con tumoración asintomática en cola de parótida y visión de estructuras nodulares en imagen de TC y RM con citología por PAAF negativa. Se realiza parotidectomía total hallando el diagnóstico de linfoma MALT de la zona marginal. Se completa tratamiento mediante esquema R-CHOP durante 4 meses, sin signos de recidiva al año. Conclusiones: Los linfomas de glándulas salivales son poco habituales y ocasionalmente sufren un retraso diagnóstico debido a su comportamiento benigno que mimetiza a tumores más familiares del área parotídea. Su sospecha y distinción son esenciales y no deben olvidarse en nuestro diagnóstico diferencial de masas parotídeas. (AU)

Introduction and objective: The parotid gland lymphomas are encountered unfrequently. We present a case report from a MALT lymphoma of the parotid gland, describing its most employed diagnostic and treatment strategies. Description: 69 year old woman with an asymptomatic tumor in the parotid gland tail, showing a nodular image in CT y MRI and with a negative citology by FAAB. We perform a total parotidectomy discovering a marginal zone MALT lymphoma. We complement the treatment with r-chop chemotherapy regimen during 4 months without recurrence signs after 1 year follow up. Conclusions: The salivary gland lymphomas are a rare entity that can be easily misdiagnosed by other common benign mases. We must suspect and don't forget this entity from our differential diagnosis diagram. (AU)

Reporte de caso: poliquistosis parotídea (Adenosis poliquística esclerosante asociada a Enfermedad poliquística disgenética)

Introducción: La adenosis/adenoma poliquistico esclerosante (SPA) es aceptada como una nueva entidad neoplásica benigna muy poco frecuente de las glándulas salivales que compromete por lo general la glándula parótida. La enfermedad poliquística disgenética es otra entidad poco común con histología similar a la SPA y que también afecta a la gládula parótida con mayor frecuencia. Reporte de caso: Se presenta el caso de una mujer 28 de años con aumento de volumen de la glándula parótida derecha de aproximadamente 3 años de evolución cuyo análisis histopatológico sugirió el diagnostico de Adenosis/adenoma Poliquístico Esclerosante asociado a Enfermedad Poliquística Disgenética de la glándula parótida derecha. La paciente recibió tratamiento quirúrgico de parotidectomía total con preservación del nervio facial. Al momento con remisión de la enfermedad.

Introduction: Polycystic sclerosing adenosis / adenoma (SPA) is accepted as a very rare new benign neoplastic entity of the salivary glands that generally involves the parotid gland. Dysgenetic polycystic disease is another rare entity with histology similar to SPA and that also affects the parotid gland more frequently. Case report: The case of a 28-year-old woman with increased volume of the right parotid gland of approximately 3 years of evolution is presented, whose histopathological analysis suggested the diagnosis of Polycystic Sclerosing Adenosis / adenoma associated with Polycystic Dysgenetic Disease of the right parotid gland. The patient received surgical treatment of total parotidectomy with preservation of the facial nerve. At the moment with remission of the disease.

Carcinoma de células acinares de parótida: reporte de un caso y revisión de literatura / Acinic cell carcinoma of parotid: A case report and review of literature

Resumen Los tumores malignos de glándulas salivales (TMGS) constituyen un grupo infrecuente de cánceres de una gran variedad histológica. Dentro de las neoplasias de estirpe epitelial encontramos al carcinoma de células acinares (CCA), que representa entre un 6%-10% de todos los TMGS. No posee patrones clínicos ni radiológicos específicos, pero comparte características comunes con otros TMGS que serán discutidas a lo largo del reporte. Cabe destacar que en términos generales es un cáncer de bajo grado y poco recidivante, por lo que un tratamiento oportuno y un seguimiento estricto mejoran el pronóstico para este tipo de pacientes. Su diagnóstico se establece con evidencia histopatológica que confirme la presencia de diferenciación epitelial de tipo acinar. El tratamiento consiste en la exéresis tumoral con márgenes libres por parotidectomía suprafacial o total, asociado a vaciamiento cervical si se detecta compromiso nodal. Adicionalmente, se debe sugerir terapia adyuvante ante la presencia de un factor de mal pronóstico. Se presenta un caso y se realiza revisión de literatura.

Abstract Malignant salivary gland tumors (TMGS) constitute an infrequent group of cancers of a wide histological variety. Within the epithelial lineage neoplasms, we find acinar cell carcinoma that represent between 6%-10% of all TMGS. It does not have specific clinical or radiological patterns, but it shares common characteristics with other TMGS that will be discussed throughout the report. It should be noted that in general terms it is a low-grade cancer with low recurrence rates, so timely treatment and strict follow-up improve the prognosis for this type of patient. Its diagnosis is established with histopathological evidence that confirms the presence of acinar-type epithelial differentiation. Treatment consists of tumor excision with free margins by suprafacial or total parotidectomy, associated with cervical lymph node dissection if nodal locoregional metastasis is detected. Additionally, adjuvant therapy should be suggested in the presence of a poor prognostic factor. A case is presented and a literature review is carried out.

Masa parotídea de rápido crecimiento, representando un dilema diagnóstico / Rapidly growing parotid gland mass, posing a diagnostic dilemma

La toxoplasmosis es una infección parasitaria con distribución mundial, cuyo huésped definitivo son los felinos. Se presenta con un cuadro clínico sintomático difuso solo en el 20 % de los pacientes inmunocompetentes. Además del malestar general, fiebre y adinamia, el hallazgo más importante lo constituye la presencia de adenopatías a nivel cervical. Describimos un caso poco común de un paciente masculino con masa parotídea izquierda de crecimiento rápido, en quien se practicó parotidectomía, a fin de descartar la enfermedad linfoproliferativa. Se comprobó compromiso por Toxoplasma gondii luego de múltiples análisis.

Toxoplasmosis is a parasitic infection with worldwide distribution, whose definitive host is felines. It is only symptomatic in less than 20% of immunocompetent patients. Symptoms may vary from general malaise, fever, weakness and the presence of cervical lymphadenopathy. A description of an uncommon presentation of this disease in a male patient with progressively growing left-sided parotid mass, in whom a parotidectomy was performed to rule out lymphoproliferative disease. Infection by Toxoplasma gondii was diagnosed after a series of exams

Caracterización de pacientes con neoplasias de glándulas salivales mayores tratadas quirúrgicamente en un hospital universitario cubano / Characterization of patients with major salivary gland neoplasms treated surgically in a Cuban university hospital

Introducción: Las neoplasias de las glándulas salivales representan el grupo más heterogéneo y complejo de los procesos tumorales de la cabeza y el cuello. Objetivo: Caracterizar a los pacientes con neoplasias de glándulas salivales mayores que recibieron tratamiento quirúrgico en un hospital universitario cubano. Métodos: Se realizó un estudio observacional, descriptivo y transversal en pacientes diagnosticados histológicamente con neoplasias de glándulas salivales mayores. Las variables evaluadas fueron: edad, sexo, tipo de neoplasia, sitio primario, diagnóstico histológico y técnicas quirúrgicas. Resultados: Se estudiaron 55 pacientes con neoplasias, de las cuales 45 (81,82 por ciento) fueron benignas, con mayor frecuencia en los hombres (n = 28; 62,22 por ciento). La edad media de presentación de las neoplasias fue 55,11 ± 16,04 años, y el grupo de edad más afectado fue el de 40-59 años (n = 26; 47,27 por ciento). La parótida fue la glándula más afectada (n = 48), fundamentalmente por adenomas pleomorfos (n = 28; 58,33 por ciento). La parotidectomía subtotal fue la cirugía mayormente realizada (n = 38; 79,17 por ciento). Conclusiones: Las neoplasias parotídeas benignas presentadas en pacientes adultos del sexo masculino fueron las más frecuentes(AU)

Introduction: Salivary gland neoplasms are the most heterogeneous and complex group of head and neck tumoral processes. Objective: Characterize patients with major salivary gland neoplasms undergoing surgical treatment in a Cuban university hospital. Methods: A cross-sectional observational descriptive study was conducted of patients histologically diagnosed with major salivary gland neoplasms. The variables evaluated were age, sex, type of neoplasm, primary site, histological diagnosis and surgical techniques. Results: A total 55 neoplasms were studied, of which 45 (81.82 percent) were benign, with a higher frequency in men (n = 28; 62.22 percent). Mean age at neoplasm presentation was 55.11 ± 16.04 years, and the most affected age group was 40-59 years (n = 26; 47.27 percent). The parotid was the most frequently affected gland (n = 48), mainly by pleomorphic adenomas (n = 28; 58.33 percent). Subtotal parotidectomy was the most common surgical procedure (n = 38; 79.17 percent). Conclusions: Benign parotid gland neoplasms presenting in male adult patients were the most frequent type(AU)

Tratamento cirúrgico de sialólito no ducto da parótida: relato de caso / Surgical treatment of sialolite in the duct of the parotid: case report / Tratamiento quirúrgico de sialolito en el conducto del parótido: reporte de caso

Introdução: Os sialólitos são lesões mineralizadas nas glândulas salivares que causam obstrução total ou parcial do ducto, acometendo comumente a glândula submandibular. Sua abordagem varia de pouco invasiva à cirúrgicas, a depender do número, localização e dimensões dos cálculos. Objetivo: Esse estudo teve como objetivo relatar um caso clínico raro de sialólito no ducto da glândula parótida tratado através da remoção cirúrgica. Relato De Caso: Paciente compareceu ao ambulatório com história de dor e edema em face com 2 meses de evolução, referindo piora da sintomatologia após alimentação. Ao exame físico apresentou edema endurecido em região pré-auricular esquerda e ausência de drenagem no ducto da parótida ipsilateral. Foi realizado uma radiografia de tecidos moles com filme periapical, que revelou imagem radiopaca circunscrita sugestiva de um sialólito no ducto da glândula parótida esquerda. Assim, foi realizada excisão cirúrgica do cálculo seguida do reestabelecimento da patência ductal através da instalação de cateter venoso. Paciente evoluiu bem e segue em acompanhamento sem recidiva dos sinais e sintomas. Considerações Finais: O presente estudo revela que o diagnóstico precoce da sialolitíase e a escolha do plano de tratamento adequado estão associados a um bom prognóstico, e o reestabelecimento da patência ductal, quando danificado, é imprescindível para o sucesso do tratamento(AU)

Introduction: Sialoliths are mineralized lesions in the salivary glands that cause total or partial obstruction of the duct, commonly affecting the submandibular gland. It ranges from less invasive to surgical approach, depending on the number, location and dimension of the calculi. Objective: This study aimed to report a rare clinical case of a sialolith in the parotid gland's duct treated by surgical removal. Case Report: The patient attended the outpatient clinic with a history of pain and edema in the face with 2 months of evolution, reporting worsening symptoms after feeding. On physical examination, he had hardened edema in the left preauricular region and no drainage in the ipsilateral parotid duct. Soft tissue radiography with a periapical film was performed, which revealed a circumscribed radiopaque image suggestive of a sialolith in the left parotid gland's duct. Thus, the calculus's surgical excision was performed, followed by the reestablishment of the ductal patency through the installation of a venous catheter. The patient evolved well and is being followed up without recurrence of signs and symptoms. Final Considerations: The present study reveals that the early diagnosis of sialolithiasis and the choice of the appropriate treatment plan are associated with a good prognosis, and the reestablishment of ductal patency, when damaged, is essential for the success of the treatment(AU)

Introducción: Os sialolitos son lesiones mineralizadas en las glándulas salivales que causan obstrucción total o parcial del conducto, afectando comúnmente a la glándula submandibular. Su abordaje varía desde poco invasivo hasta quirúrgico, dependiendo del número, ubicación y dimensiones de los cálculos. Objetivo: Este estudio tuvo como objetivo reportar un caso clínico raro de sialolito en el conducto de la glándula parótida tratado mediante extirpación quirúrgica. Reporte de Caso: Paciente acudió a consulta externa con antecedente de dolor y edema en el rostro de 2 meses de evolución, refiriendo empeoramiento de la sintomatología tras la alimentación. A la exploración física presentaba edema endurecido en región preauricular izquierda y ausencia de drenaje en conducto parotídeo ipsilateral. Se realizó una radiografía de partes blandas con placa periapical, que reveló una imagen radiopaca circunscrita sugestiva de un sialolito en el conducto de la glándula parótida izquierda. Así, se realizó la escisión quirúrgica del cálculo seguida del restablecimiento de la permeabilidad ductal mediante la instalación de un catéter venoso. El paciente evolucionó bien y se le está dando seguimiento sin recurrencia de signos y síntomas. Consideraciones Finales: El presente estudio revela que el diagnóstico precoz de la sialolitiasis y la elección del plan de tratamiento adecuado se asocian a un buen pronóstico, y el restablecimiento de la permeabilidad ductal, en caso de daño, es fundamental para el éxito del tratamiento(AU)

Action of heparin and acetylcholine modulators on the neurotoxicity of the toad Rhinella schneideri (Anura: Bufonidae) in Brazil / Acción de la heparina y moduladores de acetilcolina en la neurotoxicidad del sapo Rhinella schneideri (Anura: Bufonidae) en Brasil

Abstract Introduction: Rhinella schneideri is a toad widely distributed in South America and its poison is characterized by inducing cardiotoxicity and neurotoxicity. Objective: In this work, we investigated pharmacological strategies to attenuate the peripheral neurotoxicity induced by R. schneideri poison in avian neuromuscular preparation. Methods: The experiments were carried out using isolated chick biventer cervicis preparation subjected to field stimulation for muscle twitches recordings or exposed to acetylcholine and potassium chloride for contracture responses. Results: Poison (10 μg/ml) produced complete neuromuscular blockade in chick biventer cervicis preparation within approximately 70 min incubation (times for 50 and 90 % blockade: 15 ± 3 min and 40 ± 2 min, respectively; P < 0.05, N= 5); contracture responses to exogenous acetylcholine and KCl were unaffected by poison indicating no specificity with postsynaptic receptors or myotoxicity, respectively. Poison (10 μg/ml)-induced neuromuscular blockade was not prevented by heparin (5 and 150 IU/ml) under pre- or post-treatment conditions. Incubation at low temperature (23-25 °C) abolished the neuromuscular blockade; after raising the temperature to 37 °C, the complete neuromuscular blockade was slightly slower than that seen in preparations directly incubated at 37 °C (times for 50 and 90 % blockade: 23 ± 2 min and 60 ± 2.5 min, respectively; P < 0.05, N= 4). Neostigmine (3.3 μM) did not reverse the neuromuscular blockade in BC preparation whereas 3,4-diaminopyridine (91.6 μM) produced a partial and sustained reversal of the twitch responses (29 ± 7.8 % of maximal reversal reached in approximately 40 min incubation; P < 0.05, N= 4). Conclusions: R. schneideri poison induces potent peripheral neurotoxicity in vitro which can be partially reversible by 3,4-diaminopyridine.

Resumen Introducción: Rhinella schneideri está ampliamente distribuida en Suramérica y su veneno es caracterizado por inducir cardiotoxicidad y neurotoxicidad. Objetivo: En este trabajo, investigamos estrategias farmacológicas para atenuar la neurotoxicidad periférica inducida por el veneno de R. schneideri en preparaciones neuromusculares de aves. Métodos: Los experimentos fueron realizados usando preparaciones de biventer cervicis de pollos sometidas a estimulación de campo para el registro de las contracciones musculares o expuestas a la acetilcolina y al cloruro de potasio para la respuesta contractural. Resultados: El veneno (10 µg/ml) provocó un bloqueo neuromuscular completo en las preparaciones después de aproximadamente 70 min de incubación (tiempos para 50 y 90 % de bloqueo: 15 ± 3 min y 40 ± 2 min, respectivamente; P < 0.05, N = 5); las contracturas en respuesta a la acetilcolina y el KCl exógenos no fueron afectadas por el veneno, indicando que no hay una interacción especifica con receptores postsinápticos o miotoxicidad respectivamente. El bloqueo neuromuscular causado por el veneno (10 µg/ml) no fue prevenido por la heparina (5 y 150 UI/ml) bajo condiciones pre y post-tratamiento. La incubación a bajas temperaturas (23-25 ºC) abolió el bloqueo neuromuscular; después de aumentar la temperatura a 37 ºC, el bloqueo neuromuscular total fue levemente más lento que el visto en preparaciones directamente incubadas a 37 ºC (tiempos para 50 y 90 % de bloqueo: 23 ± 2 min y 60 ± 2.5 min, respectivamente; P < 0.05, N= 4). Neostigmina (3.3 µM) no revirtió el bloqueo neuromuscular, mientras que 3.4-diaminopiridina (91.6 µM) produjo una reversión parcial y sostenida de las respuestas neuromusculares (29 ± 7.8 % de la reversión máxima alcanzada en aproximadamente 40 min de incubación; P < 0.05, N = 4). Conclusiones: El veneno de R. schneideri indujo neurotoxicidad periférica potente in vitro, el cual puede ser revertido por 3.4-diaminopiridina.

Monitorización intraoperatoria del nervio facial durante la cirugía de la glándula parótida en servicios de otorrinolaringología - cirugía de cabeza y cuello / Intraoperative monitoring of the facial nerve during parotid gland surgery in Otolaryngology services - Head and Neck Surgery

Introducción: La lesión del nervio facial continúa siendo la complicación más grave de la cirugía de la glándula parótida. Debido a la creciente evidencia sobre las ventajas del uso de la monitorización intraoperatoria del nervio facial, se distribuyó una encuesta entre los miembros de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello con el objetivo de determinar los patrones de uso en nuestro medio.Material y métodosSe distribuyó un cuestionario que incluía 12 preguntas separadas en 3 secciones en formato e-mail a través del correo oficial de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. La primera sección de preguntas evaluaba las características demográficas, la segunda sección estaba relacionada con el patrón de uso de los sistemas de monitorización intraoperatoria del nervio facial y la tercera sección se refería a los litigios relacionados con la parálisis facial.ResultadosSe enviaron un total 1.544 cuestionarios anónimos. Recibimos un total de 255 encuestas, para una tasa de respuesta global del 16,5%. De estos, 233 (91,3%) realizaban cirugía de glándula parótida y 94% usaban monitorización intraoperatoria del nervio facial. Un 94% de los encuestado usaba la monitorización intraoperatoria del nervio facial si realizaba menos de 10 parotidectomías por año y un 93,8% si realizaban más de 10 parotidectomías por año (OR, 1,02; IC del 95%, 0,68-1,45; p=0,991).ConclusiónNuestros datos demuestran que la mayoría de los otorrinolaringólogos y cirujanos de cabeza y cuello en España están empleando la monitorización del nervio facial durante la cirugía de la glándula parótida. Casi todos coinciden en que esto busca mejorar las medidas de seguridad quirúrgica y consideran que la monitorización del nervio facial es útil para prevenir lesiones inadvertidas. (AU)

Introduction: Facial nerve injury remains the most severe complication of parotid gland surgery. Due to the increasing evidence about the advantage of the use of intraoperative facial nerve monitoring, a survey was distributed among members of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery with the objective of determining patterns of its use.Material and methodsA questionnaire which included 12 separate questions in 3 sections was distributed via email through the official email of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery. The first section of questions was in relation to demographic characteristics, the second section was related to the pattern of monitoring use and the third section referred to litigation related to facial palsy.Results1544 anonymous questionnaires were emailed. 255 surveys were returned, giving an overall response rate of 16.5%. From these, 233 (91.3%) respondents perform parotid gland surgery. Two-hundred nineteen (94%) respondents use intraoperative facial nerve monitoring. Of the respondents,94% used intraoperative facial nerve monitoring if in their current practice they performed fewer than 10 parotidectomies per year and 93.8% if they performed more than 10 (OR, 1.02; 95% CI, 0.68-1.45; p=.991). With regard to lawsuits, just 3 (1.2%) of the respondents had a history of a parotid gland surgery–associated lawsuit and in just one case the facial nerve monitor was not used.ConclusionOur data demonstrate that most otolaryngologists in Spain use intraoperative facial nerve monitoring during parotid gland surgery. Almost all of them use it to improve patient safety and consider that facial nerve monitoring should be helpful preventing inadvertent injury. (AU)

Intraoperative monitoring of the facial nerve during parotid gland surgery in Otolaryngology services - Head and Neck Surgery. / Monitorización intraoperatoria del nervio facial durante la cirugía de la glándula parótida en servicios de otorrinolaringología - cirugía de cabeza y cuello.

INTRODUCTION: Facial nerve injury remains the most severe complication of parotid gland surgery. Due to the increasing evidence about the advantage of the use of intraoperative facial nerve monitoring, a survey was distributed among members of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery with the objective of determining patterns of its use. MATERIAL AND METHODS: A questionnaire which included 12 separate questions in 3 sections was distributed via email through the official email of the Spanish Society of Otorhinolaryngology-Head and Neck Surgery. The first section of questions was in relation to demographic characteristics, the second section was related to the pattern of monitoring use and the third section referred to litigation related to facial palsy. RESULTS: 1544 anonymous questionnaires were emailed. 255 surveys were returned, giving an overall response rate of 16.5%. From these, 233 (91.3%) respondents perform parotid gland surgery. Two-hundred nineteen (94%) respondents use intraoperative facial nerve monitoring. Of the respondents,94% used intraoperative facial nerve monitoring if in their current practice they performed fewer than 10 parotidectomies per year and 93.8% if they performed more than 10 (OR, 1.02; 95% CI, 0.68-1.45; p=.991). With regard to lawsuits, just 3 (1.2%) of the respondents had a history of a parotid gland surgery-associated lawsuit and in just one case the facial nerve monitor was not used. CONCLUSION: Our data demonstrate that most otolaryngologists in Spain use intraoperative facial nerve monitoring during parotid gland surgery. Almost all of them use it to improve patient safety and consider that facial nerve monitoring should be helpful preventing inadvertent injury.

Análisis clínico y terapéutico ante la patología obstructiva crónica de las glándulas salivales / Clinical and therapeutic analysis to the chronic obstructive pathology of the salivary glands

Introducción: gran parte de la población sufre procesos relacionados con las glándulas salivales, que, con los avances técnicos, se tiende cada vez más a tratar de una manera mínimamente invasiva. Objetivos: remarcar las indicaciones y las diferencias entre los abordajes comunes y los mínimamente invasivos, guiados por el sialoendoscopio. Además, describir la presentación clínica y el estudio de dichos pacientes. Diseño: realizamos un estudio descriptivo, observacional, longitudinal y retrospectivo sobre un grupo de 67 pacientes diagnosticados con patología obstructiva crónica no tumoral de las glándulas. Material y métodos: revisamos los datos referentes a la edad, sexo, hábitos tóxicos, enfermedades sistémicas o autoinmunes asociadas, radioterapia o tratamiento con yodo radiactivo (I131), síntomas asociados y resultados del examen físico y radiológico efectuados, así como el tratamiento efectuado. En mayo de 2019 incorporamos la técnica de sialoendoscopia al manejo de esta patología. Resultados: desde la incorporación de la sialoendoscopia, los casos de patología litiásica a nivel del tercio distal del conducto de Wharton se abordaron mediante exéresis de la litiasis sobre el suelo de la boca con ayuda del sialoendoscopio. Realizamos una sialoendoscopia diagnóstico-terapéutica en pacientes con clínica obstructiva crónica no litiásica. Discusión: el abordaje mínimamente invasivo permite una recuperación más temprana con una adecuada función glandular tras la cirugía. No solo es útil en la patología litiásica, sino que también presenta buenos resultados en patología autoinmune. Conclusión: las técnicas mínimamente invasivas han hecho que el manejo haya cambiado, limitando la realización de resecciones glandulares.

Introduction: A large part of the population suffers from processes related to the salivary glands, which with new advances in technology tends to be treated in a minimally invasive way. Goals: To highlight the indications and differences between common and minimally invasive approaches, guided by the sialoendoscope. In addition, to describe the clinical presentation and the study of these patients. Design: We carried out a descriptive, observational, longitudinal and retrospective study on a group of 67 patients diagnosed with non-tumorous chronic obstructive pathology of the glands. Material and methods: We review the data regarding age, sex, toxic habits, associated systemic or autoimmune diseases, radiotherapy or treatment with I131 (radioactive iodine), associated symptoms and results of the physical and radiological examination carried out. As well as the given treatment. In May 2019 we incorporated the sialoendoscopy to the management of this pathology. Results: Since the incorporation of sialoendoscopy, cases of lithiasic pathology at the distal 1/3 of Wharton's duct were approached by excision of the stone on the floor of the mouth using sialoendoscopy. We perform diagnostic-therapeutic sialoendoscopy in patients with non-lithiasic chronic obstructive symptoms. Discussion: The minimally invasive approach allows an earlier recovery with adequate glandular function after surgery. It is not only useful in lithiasic pathology, but it also has good results in autoimmune pathology. Conclusion: Minimally invasive techniques have changed management, limiting the neck open surgeries.

Monosodium glutamate alters the function and morphology of the parotid gland in Sprague Dawley rats / Glutamato monosódico altera la función y morfología de la glándula parótida en ratas Sprague Dawley

Monosodium glutamate (MSG) is a flavor enhancer widely used in the food industry, with obesogenic properties, in addition to causing alterations in the oral cavity. The aim of the study was to observe the morphofunctional changes in the parotid gland after the administration of MSG in rats. 18 newborn male Sprague Dawley rats were used, divided into three groups (Control group; MSG1 group: 4 mg/g weight of monosodium glutamate, 5 doses, kept for 8 weeks, and MSG2 group: 4 mg/g weight of MSG, 5 doses, kept for 16 weeks). The body mass index (BMI) was calculated, and the salivary flow, pH, a-amylase activity, Na, Cl, K and Ca were analyzed by quantitative analysis. After euthanasia by ketamine/xylazine overdose, parotid volume was analyzed and stereology was performed. MSG administration caused an increase in BMI and a decrease in parotid volume as well as a reduction in salivary flow and pH and an increase in a-amylase activity, also increasing the salivary sodium and chlorine levels. Alterations in the normal stereological parameters of the gland were observed. Exposure to MSG caused morphofunctional alterations at parotid gland.

El glutamato monosódico (MSG), es un potenciador del sabor ampliamente utilizado en la industria alimentaria. Diversos estudios han propuesto la relación entre éste y el desarrollo de obesidad, además de provocar alteraciones en la cavidad oral. El objetivo del estudio fue observar los cambios morfofuncionales a nivel de la glándula parótida, posterior a la administración de MSG en ratas. Se utilizaron 18 ratas neonatas Sprague Dawley machos, divididas en tres grupos según su tiempo de exposición y dosis a MSG (Grupo Control, Grupo MSG1: 4 mg/g peso de glutamato monosódico, 5 dosis, mantenidas 8 semanas, Grupo MSG2: 4 mg/g peso de MSG, 5 dosis, mantenidas 16 semanas. Fue calculado el índice de masa corporal (BMI), además de ser analizado el flujo salival, pH, actividad de α-amilasa, y Na, Cl, K y Ca mediante análisis semicuantitativo. Luego de la eutanasia por sobredosis de ketamina/xilasina, las glándulas parótidas fueron extraídas y analizado su volumen y fueron procesadas para histología, y estudio estereológico. La administración de MSG causó aumento en BMI y disminución del volumen parotídeo, además de disminución del flujo y pH salival, así como aumento en actividad de la a-amilasa, aumentando además los niveles de sodio y cloro salival. Fueron observadas alteraciones a nivel de los parámetros estereológicos normales de la glándula. La exposición a MSG causó alteraciones morfofuncionales a nivel parotídeo, observándose una disminución del volumen de la glándula, acompañado de alteraciones en el adenómero y conductos estriados de la glándula, implicados en la producción, secreción y modificación de la saliva, la cual se vio alterada, en el flujo, pH, y en sus componentes.

Is serum bilirubin level a predictor factor in parotid gland carcinoma? / O nível sérico de bilirrubina é um fator preditivo no carcinoma da glândula parótida?

Abstract Introduction: Bilirubin levels have been associated with risk of several malignancies. The association between pretreatment serum bilirubin levels and overall survival of patients with parotid gland carcinoma is unclear. Objectives: In this study, we assessed the effect of serum bilirubin levels to overall survival in malignant parotid tumors. Methods: This study included a total of 35 patients, 15 female and 20 male. The mean age of these patients was 60.7 ± 14.5 years. All patients who were diagnosed with parotid gland carcinoma and underwent total parotidectomy between 2008 and 2018, were retrospectively assessed. The relationship between the overall survival of patients and total bilirubin, direct bilirubin, and indirect bilirubin levels was estimated. The receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off points. Results: Patients with low direct bilirubin, total bilirubin and indirect bilirubin had significantly longer overall survival than those with high levels. Cut-off values for total bilirubin, direct bilirubin and indirect bilirubin were detected as 0.545 mg/dL, 0.175 mg/dL and 0.435 mg/dL, respectively. Conclusion: In our study, we observed that increased preoperative bilirubin levels are associated with reduced survival time in the postoperative period of patients with parotid gland carcinoma.

Resumo Introdução: Os níveis de bilirrubina têm sido associados ao risco de várias lesões malignas. A associação entre os níveis séricos de bilirrubina pré-tratamento e a sobrevida global dos pacientes com carcinoma da glândula parótida ainda não é clara. Objetivos: Neste estudo, avaliamos o efeito dos níveis séricos de bilirrubina na sobrevida global em tumores malignos de parótida. Método: Este estudo avaliou 35 pacientes, 15 do sexo feminino e 20 do masculino. A média de idade foi de 60,7 ± 14,5 anos. Pacientes diagnosticados com carcinoma da glândula parótida e submetidos a parotidectomia total entre 2008 e 2018 foram avaliados retrospectivamente. A relação entre a sobrevida global dos pacientes e os níveis de bilirrubina total, bilirrubina direta e bilirrubina indireta foi estimada. A análise da curva Receiver Operating Characteristic foi realizada para determinar os pontos de corte ideais. Resultados: Pacientes com níveis mais baixos de bilirrubina direta, bilirrubina indireta e bilirrubina total tiveram sobrevida global significantemente maior do que aqueles com valores mais altos. Valores de corte para bilirrubina total, bilirrubina direta e bilirrubina indireta foram estabelecidos como 0,545 mg/dL, 0,175 mg/dL e 0,435 mg/dL, respectivamente. Conclusão: Em nosso estudo, verificamos que níveis de bilirrubina aumentados no pré-operatório estão associados à redução do tempo de sobrevida no período pós-operatório em pacientes com carcinoma da glândula parótida.

Linfoma no Hodgkin tipo MALT de la glándula parótida. Presentación de un caso / MALT non-Hodgkin Lymphoma of the Parotid Gland. Presentation of a Case

Resumen Los linfomas de las glándulas salivales son una entidad e incidencia rara. La localización más frecuente es la glándula parótida, seguida de las glándulas submandibular y sublingual. La mayoría de los linfomas parótidos son linfomas no Hodgkin y se consideran derivados de tejido linfoide asociado a la mucosa (MALT). De manera poco frecuente, estos casos se han notificado y con frecuencia se diagnostican de manera inadecuada, ya que su presentación es relativamente benigna, comportamiento localizado, crecimiento lento y varios años de evolución.

Abstract Lymphomas of the salivary glands are a rare entity with a rare incidence. They are more commonly found on the parotid gland, followed by the submandibular and sublingual glands. The majority of parotid lymphomas are non-Hodgkin's lymphomas and are considered to be derived from mucosal-associated lymphoid tissue (MALT). Reports of these cases are scarce and often misdiagnosed since: their manifestation is relatively benign, they have a localized behavior, a slow growth and the evolution takes several years.

Adenoma Pleomorfo de Parótida, Manejo Quirúrgico: A Propósito de un caso / Pleomorphic adenoma of the parotid gland, surgical management: a case report

INTRODUCCIÓN: El adenoma pleomorfo es el tumor benigno más común de las glándulas salivales y particularmente de la glándula parótida, la característica principal de este tumor benigno es su crecimiento lento, provocando la presencia notoria de una masa a nivel facial o cervical. Su tratamiento es quirúrgico y uno de los principales riesgos, es la posibilidad de parálisis facial posquirúrgica. Presentamos un caso, resuelto de forma quirúrgica mediante parotidectomía parcial, que conlleva la disección del nervio facial. CASO CLÍNICO: Se trató de una paciente de sexo femenino de 34 años de edad que acude para valoración por presentar masa de crecimiento lento en región parotídea derecha, negó asociación con dolor o parálisis facial. Luego de valoración tomográfica y por PAAF, se diagnosticó Adenoma Pleomorfo de parótida y se decidió parotidectomía parcial derecha. EVOLUCIÓN: Para el tratamiento quirúrgico se recurrió a la técnica descrita en la bibliografía con la variante en la incisión, se usó incisión modificada de Blair. Se logró extirpar la totalidad del tumor. Paciente en su postquirúrgico mediato, presentó parálisis facial, tratada con corticoides, fue dada de alta con una puntuación de House Brackmann CONCLUSIÓN: En concordancia con la bibliografía citada, el manejo adecuado de esta patología es netamente quirúrgico, la realización de parotidectomía en casos de tumoración de glándulas salivales es la única manera de evitar que la masa provoque lesiones a nivel de estructuras cercanas, como el nervio facial. Su correcta disección e identificación están dentro de los principales asuntos dentro del procedimiento.(au)

BACKGROUND: Pleomorphic adenoma is the most common benign tumor of the salivary glands, particularly of the parotid gland. The main characteristic of this benign tumor is its slow growth, causing the noticeable presence of facial or cervical mass. The treatment is surgery, with the main risk of postoperative facial paralysis. We present a case report, resolved surgically with a partial parotidectomy, which involves dissection of the facial nerve. CASE REPORTS: A 34 year old female patient, seeking medical attention due to a slow-growing mass in the right parotid region. Patient denied associated symptoms. After CT and Fine needle puncture, the patient was diagnosed of a pleomorphic adenoma of the parotid gland, and treated with right partial parotidectomy. EVOLUTION: The surgical technique used is described on literature, with a variant in the incision type. We used modified Blair incision. The whole tumor was removed. After surgery patient presented with facial paralysis, she was treated with corticoids. Patient was discharged with a House Brackmann 1 score. CONCLUSIONS: Accordingly with literature, the resolution of this pathology is surgical, paratidectomy is the only treatment that avoids the mass causing damage to adjacent structures, like the facial nerve. The proper identification and dissection of this nerve, is one of the main concerns of the procedure.(au)

Is serum bilirubin level a predictor factor in parotid gland carcinoma?

INTRODUCTION: Bilirubin levels have been associated with risk of several malignancies. The association between pretreatment serum bilirubin levels and overall survival of patients with parotid gland carcinoma is unclear. OBJECTIVES: In this study, we assessed the effect of serum bilirubin levels to overall survival in malignant parotid tumors. METHODS: This study included a total of 35 patients, 15 female and 20 male. The mean age of these patients was 60.7±14.5 years. All patients who were diagnosed with parotid gland carcinoma and underwent total parotidectomy between 2008 and 2018, were retrospectively assessed. The relationship between the overall survival of patients and total bilirubin, direct bilirubin, and indirect bilirubin levels was estimated. The receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off points. RESULTS: Patients with low direct bilirubin, total bilirubin and indirect bilirubin had significantly longer overall survival than those with high levels. Cut-off values for total bilirubin, direct bilirubin and indirect bilirubin were detected as 0.545mg/dL, 0.175mg/dL and 0.435mg/dL, respectively. CONCLUSION: In our study, we observed that increased preoperative bilirubin levels are associated with reduced survival time in the postoperative period of patients with parotid gland carcinoma.

Surgical treatment strategy in Warthin tumor of the parotid gland / Estratégia de tratamento cirúrgico no tumor de Warthin de glândula parótida

Abstract Introduction: Warthin tumors are the second most common benign tumors of the parotid gland. We examined the clinical features of Warthin tumors in our hospital, and analyzed the consistency within the literatures. Objective: The aim of this study is to analyze the clinical features of Warthin tumors in our 10-year experience of 118 Warthin tumors undergoing surgery at a single institute. Methods: From December 2006 to December 2016, 110 patients who underwent surgical treatment for Warthin tumors were identified based on their medical records. Results: A total of 118 parotid gland operations were performed in 110 patients. Almost 90% of Warthin tumors were found in males, and average patient age was 66.1 ± 6.1 years. The prevalence of smoking history was 89.1% (98/110). Eight patients (7.3%) had bilateral Warthin tumors. Seventy-seven lesions (65.3%) were located in the parotid tail portion, followed by 34 lesions in the superficial lobe (28.8%) and 7 lesions in the deep lobe (5.9%). Conclusion: We determined the appropriate extent of surgery depending on the fine needle aspiration cytology and tumor location by computed tomography scans. Partial facial dysfunction after the operation was detected in 12 cases, and facial nerve function recovered within 3 months. Only one patient experienced a recurrence, and was disease free after the re-operation. We suggest that our treatment algorithm, depending on the location of tumors and the result of fine needle aspiration cytology, can be useful to determine the appropriate extent of surgery for Warthin tumors.

Resumo Introdução: Os tumores de Warthin são os segundos tumores benignos mais comuns da glândula parótida. Avaliamos as características clínicas dos tumores de Warthin em nosso hospital e analisamos a consistência com a literatura. Objetivo: Analisar as características clínicas dos tumores de Warthin em nossa experiência de 10 anos de 118 tumores de Warthin submetidos a tratamento cirúrgico em um único instituto. Método: De dezembro de 2006 a dezembro de 2016, 110 pacientes que receberam tratamento cirúrgico para tumores de Warthin foram identificados com base em seus prontuários médicos. Resultados: Foram feitas 118 cirurgias na glândula parótida em 110 pacientes. Quase 90% dos tumores de Warthin foram encontrados em homens e a média da idade dos pacientes foi de 66,1 ± 6,1 anos. A prevalência de tabagismo foi de 89,1% (98/110). Oito pacientes (7,3%) tinham tumores de Warthin bilaterais na glândula parótida. Das lesões, 77 (65,3%) localizavam-se na porção da cauda da parótida, seguidas por 34 no lobo superficial (28,8%) e 7 no lobo profundo (5,9%). Conclusão: Determinamos a extensão apropriada da cirurgia de acordo com a punção aspirativa com agulha fina e localização do tumor por tomografia computadorizada. Disfunção facial parcial após a cirurgia foi detectada em 12 casos e a função do nervo facial foi recuperada em 3 meses. Apenas um paciente apresentou recidiva e ficou livre da doença após reoperação. Sugerimos que nosso algoritmo de tratamento, a depender da localização dos tumores e do resultado da PAAF, pode ser útil para determinar a extensão apropriada da cirurgia para os tumores de Warthin.

Epithelioid hemangioendothelioma of the parotid gland: A case report in an unusual location with a review of the literature.

Epithelioid hemangioendothelioma (EHE) is a malignant vascular tumor that usually affects the liver, lung, bone and deep soft tissues of the extremities or trunk. To our knowledge, only 3 cases in the parotid gland have been reported to date. We report a case of a 62-year-old woman who presented with a 1-year history of a slow-growing, painless mass over the left mandibular angle. Imaging studies showed a 2cm mass over the left parotid gland with peripheral calcifications. The patient underwent a superficial parotidectomy. Sections displayed neoplastic epithelioid cells with cytoplasmic vacuoles containing erythrocytes, surrounded by a myxohyaline stroma. Immunohistochemistry was positive for CD31, CD34, ERG, and factor VIII, but negative for cytokeratin AE1/AE3, CK7, EMA, SMA, and S100. The findings were those of an EHE involving the parotid gland. This case demonstrates an EHE in a rare location and emphasizes the need to consider this tumor when diagnosing uncommon soft tissue tumors of salivary glands.

Parotidectomy-related facial nerve lesions: proposal for a modified Sunnybrook Facial Grading System / Lesões do nervo facial relacionadas à parotidectomia: proposta de um sistema Sunnybrook de graduação facial modificado

ABSTRACT Facial nerve injury, affecting mainly the marginal mandibular branch, is the most frequent neurologic complication from parotidectomy. Objective To test a modified Sunnybrook Facial Grading System as a new tool to assess the facial nerve function following parotidectomy, emphasizing the marginal mandibular branch. Methods We reviewed the medical records of 73 post-parotidectomy patients (40 female, 18-84 years old, mean age 53.2 years) with facial nerve sparing, referred to the Department of Physical Therapy. All patients had parotid neoplasms or advanced skin cancer, and were followed by the principal author between 2006 and 2014. Results The muscles innervated by the marginal mandibular branch were the most frequently affected (72.6%), particularly in patients undergoing neck dissection (p = 0.023). The voluntary movement scores obtained with the modified system were significantly lower compared with the original version (p < 0.001). The best and worst scores were observed in patients with benign parotid tumors and skin cancer, respectively. Patients requiring neck dissection (p = 0.031) and resection of other structures (p = 0.021) had the lowest scores, evidenced only with the modified version. Patients with malignant tumors had significantly worse ratings, regardless of the Sunnybrook system version. The post-physiotherapy analysis involved 50 patients. The worst facial rehabilitation outcomes were related to the marginal mandibular branch function. Conclusion The modified Sunnybrook Facial Grading System improved the marginal mandibular branch assessment, preserving the evaluation of other facial nerve branches.

RESUMO A lesão do nervo facial é a principal complicação neurológica relacionada às parotidectomias e, em geral, o ramo marginal mandibular é o mais frequentemente acometido. Objetivo Testar um Sistema Sunnybrook de Graduação Facial modificado (mS-FGS) como uma nova ferramenta para avaliar a função do nervo facial após a parotidectomia, enfatizando o ramo marginal mandibular. Métodos Estudo retrospectivo, baseado em prontuários de 73 casos (40 do sexo feminino, 18-84 anos, idade média = 53,2), submetidos à parotidectomia, com preservação do nervo facial. Todos os pacientes apresentavam neoplasias parotídeas ou câncer de pele avançado, e foram tratados pela autora principal entre 2006 e 2014. Resultados Neste estudo, os músculos inervados pelo ramo marginal mandibular foram os mais acometidos (72,6% dos casos), principalmente nos pacientes que realizaram esvaziamento cervical (p = 0,023). Os Escores de Movimento Voluntário obtidos pelo sistema modificado foram inferiores aos obtidos pelo original (p < 0,001). As melhores pontuações foram observadas em pacientes com tumores benignos parotídeos e os piores resultados, naqueles com câncer de pele. Pacientes que necessitaram de esvaziamento cervical e ressecção de outras estruturas, além da parótida, apresentaram escores menores (p = 0,031 e p = 0,021), evidenciados apenas pelo sistema modificado. Os tumores malignos geraram escores significativamente menores, independentemente do instrumento empregado. A análise pós fisioterapia envolveu 50 casos. Os piores resultados, após a intervenção fisioterapêutica, também foram observados nos músculos inervados pelo ramo marginal mandibular. Conclusão A avaliação da disfunção facial pós-parotidectomia, através do Sistema Sunnybrook com a modificação proposta permitiu uma apreciação mais detalhada do ramo marginal mandibular, sem prejuízo à avaliação dos demais ramos.