Metastasizing pleomorphic adenoma of the parotid gland: A common tumour with a very unusual presentation / Metástasis de adenoma pleomorfo de la glándula parótida: un tumor frecuente con una presentación muy poco habitual

Metastasizing pleomorphic adenoma is recognized as a subtype of pleomorphic adenoma in WHO classification 5th edition of salivary glands. The controversy pertaining to the entity is the benign features of the disease even at a metastatic site. We present a rare case of left recurrent pre-auricular swelling in a young male reported as metastasizing pleomorphic adenoma. A nineteen-year-old male presented with left preauricular swelling seven years ago which was diagnosed as pleomorphic adenoma and underwent complete excision of tumour. The tumour recurred twice – two and five years after the surgery. At the second recurrence, the level II neck dissection showed multiple encapsulated deposits of pleomorphic adenoma having similar morphology in the cervical soft tissue with no features of high-grade transformation. (AU)

La metástasis de adenoma pleomorfo está reconocida como un subtipo de adenoma pleomorfo según la clasificación de tumores de las glándulas salivales de la Organización Mundial de la Salud (OMS), 5ª edición. La controversia sobre la entidad se refiere a las características benignas de la enfermedad, incluso en lugares de metástasis. Presentamos un raro caso, en un varón de 19 años, de inflamación preauricular izquierda recurrente que se comunica como una metástasis de adenoma pleomorfo. El paciente presentó inflamación preauricular izquierda hace siete años, que se diagnosticó como adenoma pleomorfo, y se sometió a una resección completa del tumor, el cual presentó dos recidivas, dos y cinco años después de la cirugía. En la segunda recidiva, la resección a nivel II del cuello mostró múltiples depósitos encapsulados de adenoma pleomorfo de morfología similar en el tejido blando cervical, sin características de transformación de alto grado. (AU)

Milan system for reporting salivary gland cytology in diagnosis and surgery of parotid gland lesions.

INTRODUCTION: A cytology report is always a challenge for both head and neck surgeons and cytopathologists to diagnose and manage parotid gland (PG) diseases, because of the various similar features between the lesions. OBJECTIVES: The present study was conducted to assess our practice using the Milan System for Reporting Salivary Cytopathology (MSRSGC) and to evaluate the risk of malignancy (ROM) in different categories. PATIENTS AND METHODS: The patients with parotid gland lesions were diagnosed by clinical examination, ultrasound, and FNAC under ultrasound guidance at our hospital from 1 May 2019 to 30 April 2021. The FNAC results were divided into six categories according to the Milan system. We calculated the ROM for each category of the Milan system based on histopathological follow-up. RESULTS: This study included 204 patients. There were 115 men (56 %) aged 46-60 years. Pathology results were 33 cases for malignant and 182 cases for benign. The rate of malignancy for each category according to the MSRSGC were 23.1 % (non-neoplastic), 20 % (atypical), 50 % (neoplastic), 1 % (benign), 10.3 % (salivary neoplasm of uncertain neoplastic potential), 84.6 % (suspicious for malignancy), and 100 % (malignant) categories. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of FNAC with application of Milan system were respectively 90.9 %, 98.2 %, 90.9 %, 98.9 % and 97 %. CONCLUSION: When the Milan system was applied, FNAC had a high efficacy, suggesting that MSRSGC can improve the communication between the cytopathologist and the surgeon. This system can allow the surgeon to decide the extent of the surgery.

Traumatic Injuries of the Parotid Gland and Duct.

This review will focus on the key steps in the recognition of parotid gland and duct injuries focusing on the important steps needed at the initial assessment. Management planning is presented in the way that trauma surgeons interact with patients, highlighting the important parts of the informed consent conversation followed by the key information that must be communicated to the anesthesia and operating room teams, which ensures proper monitoring and equipment needs are in place. Short-term and long-term outcomes for patients with persistent sequelae of the trauma and their management are reviewed.

Sialendoscopy-assisted combined approach for parotid sialolithotomy: Our long-term experience.

OBJECTIVES: To assess the long-term outcome of sialendoscopy-assisted combined approach for parotid sialolithotomy with gland preservation. PATIENTS AND METHODS: A retrospective study of patients treated with a combined sialendoscopic and open approach was conducted between 2011 and 2020. Demographic data of patients such as operative technique, stone size, stone location, complications, and symptom relief were collected. Patients were followed up via clinical examination and questionnaires. RESULTS: Seventy-four patients were included and underwent endoscopy-assisted combined operations for the removal of 98 parotid stones. Of the 98 stones, 92(94%) stones were completely removed and 6(6%) were partially removed. At a mean follow-up of 47.1 ± 35 months, 65 of 74 patients (88%) achieved long-term success. Patients with stone incomplete removal were significantly more often to develop the recurrence of obstructive symptoms (p = 0.000) There were no cases of facial nerve injury or fistula formation. Gland function was preserved in 73 of 74 patients (99%). CONCLUSIONS: The combined approach for parotid stones is a safe and gland-preserving alternative to parotidectomy. The techniques described here show high success rates and good long-term results, and they avoided the need for gland resection in >95% of cases.

Pneumoparotid: Practical impact of Surgeon performed Ultrasound in an effective Diagnostic Approach.

OBJECTIVES: Pneumoparotid is characterized by air inclusions in the parotid duct system. Use of ultrasound has proved valuable for evaluating air inclusions in various parts of the body; the diagnostics of this condition has not been systematically analyzed, however. The aim of this study was to evaluate the value of ultrasound in the detection of air inclusions along the parotid duct system and its closer characterization. METHODS: Retrospective analysis was carried out of patients diagnosed with pneumoparotid between 2005 and 2020 in a salivary gland center. Ultrasound was performed in all cases, and features of air inclusions were described. Reference standard was the clinical demonstration of foamy saliva after gland massage and/or sialendoscopic evidence of intraductal air inclusions. RESULTS: Twenty-one patients were identified (48.8 ± 3.8 years). Two were associated with wind instruments; seven were iatrogenic, following treatment for duct stenosis; one after radiotherapy; four with known bruxism and seven were idiopathic and without associated conditions. On ultrasound examination, pneumoparotid was characterized by three phenomena: flattened, mobile hyperechoic reflexes, dirty shadows with reverberation or "sunbeam effect," and shifting shadows during gland massage. CONCLUSIONS: Ultrasound was useful for characterizing pneumoparotid in a fast and practical way and could serve as imaging tool of first choice.

Comparison of two transcutaneous approaches for the removal of impacted parotid stones.

The aim of this study was to comparatively evaluate the indications and treatment outcomes of two transcutaneous approaches for the removal of impacted parotid stones. Sixty-eight consecutive patients with impacted parotid stones underwent endoscopy-assisted lithotomy via a direct mini-incision or a peri-auricular flap. Clinical safety and outcomes were evaluated. Complete stone extraction was achieved in all patients. In the mini-incision group (52 patients), the stones were in the middle third of the main duct in 31 patients, at the hilum in 16, and in the intraglandular duct in five. In the flap group (16 patients), they were in the middle third of the main duct in one patient, at the hilum in seven, and in the intraglandular duct in eight. Salivary fistula occurred in five mini-incision group patients (9.6%) and four flap group patients (25%). The clinical outcome in the mini-incision group (47 patients, median 25 months of follow-up) was good in 28 patients, fair in 13, and poor in six (12.8%). The clinical outcome in the flap group (16 patients, median 84 months of follow-up) was good in nine patients, fair in five, and poor in two (12.5%). The direct mini-incision approach was found to be safe and effective for impacted stones in the middle third, hilum, and proximal third of the main duct, while the peri-auricular approach would be best reserved for deeper intraglandular stones.

Newly Discovered Parotid Lesion: What Next?

When a parotid lesion is discovered incidentally, it can be challenging for the radiologist to provide specific recommendations for the next steps. This article describes how the radiologist can play an active role in managing incidentally discovered parotid lesions. First, we explore the significance of parotid lesions. Next, the pertinent anatomy of the parotid space is presented to develop an appropriate differential diagnosis. Lastly, we discuss critical clinical and imaging characteristics the radiologist can use to provide specific recommendations.

Iodoform Gauze Packing is an Alternative Therapy for Postoperative Parotid Fistula.

Surgery-related salivary fistula is the result of intraoperative or postoperative parotid gland damage and extravasation of fluid secreted by acinar into the interstitial space. Most are treated conservatively. Local injection of botulinum toxin is an effective method, but it is relatively expensive and not available in some hospitals. In clinical practice, the authors observed that packing iodoform gauze from the fistula toward the parotid gland can quickly stop postoperative salivary fistula in several patients. This method is simple and easy to implement, and the effect is quick. The disappearance of the salivary fistula was observed on the next day after packing the iodoform gauze. Iodoform gauze packing is an alternative therapy for postoperative parotid fistula. It can be used in areas where botulinum toxin is not available.

Management of a salivary fistula following removal of mandibular distractors in a neonate.

There are multiple management options for treatment of iatrogenic salivary fistulas including reduced oral intake, pressure dressings, total parotidectomy, tympanic neurectomy, surgical repair, radiation therapy, and pharmacotherapy. However, the optimal management of salivary fistulas is unclear due to uncertain efficacy and adverse outcomes. We present a case of a neonate that developed a submandibular fistula following removal of mandibular distractors and was ultimately successfully managed using intralesional botulinum toxin injection. The purpose of this communication is to summarize the management of this complication in the context of the current literature.

¿Parótida crujiente? / Crackling parotid gland?

La neumoparótida consiste en la presencia de aire en la glándula parótida. Es una entidad rara que se origina secundariamente a un incremento importante de la presión intraoral. Puede ocurrir en relación con actividades cotidianas, como tocar instrumentos de viento, hinchar globos, procedimientos dentales o maniobras de Valsalva. Es una entidad rara, pero debe incluirse en el diagnóstico diferencial ante un aumento o inflamación de la glándula parótida. Para su diagnóstico son claves una anamnesis y un examen físico detallado. El manejo va a ser habitualmente conservador y el curso autolimitado, con tratamiento sintomático si es preciso (analgesia y antiinflamatorios). Se puede considerar el uso de antibióticos para evitar sobreinfecciones (neumoparotiditis). Los casos graves o recurrentes pueden precisar manejo quirúrgico mediante escisión de la glándula. (AU)

Pneumoparotid is the presence of air in the parotid gland. It is a rare condition that is secondary to a significant increase in intraoral pressure. It may develop in relation to everyday activities, such as playing wind instruments, blowing up balloons, dental procedures or Valsalva manoeuvres. It should be included in the differential diagnosis of inflammation of the parotid gland. A detailed history-taking and physical examination are the key to its diagnosis. Management is usually conservative and the disease self-limiting, with symptomatic treatment if necessary (analgesia and anti-inflammatory drugs). Antibiotics may be considered to avoid superinfection (pneumoparotitis). Severe or recurrent cases may require surgical management with excision of the gland. (AU)

Síndrome auriculotemporal tardío en el adulto: síndrome de Frey / Late auriculotemporal syndrome in adult: Frey syndrome

Objetivos: reconocimiento de una patología muy poco prevalente en Atención Primaria que cursa con sensación de humedad en la cara. Metodología: se expone un caso en el que tras la anamnesis se plantea la realización de la prueba de Minor para dilucidar tanto la zona afectada como su naturaleza. Conclusiones: ante las secreciones faciales de origen y composición desconocida, se puede sospechar patología posquirúrgica de la parótida, aun habiendo pasado mucho tiempo y que pudieran requerir o no tratamiento para su solución. También puede orientar tanto en preferencia como destino en el diagnóstico diferencial con fístulas salivales o de líquido cefalorraquídeo.(AU)

Objectives: recognition of a very rare pathology in primary care whose clinical course includes a feeling of moisture on the face. Methodology: a case is reported in which after history the Minor test was proposed to elucidate both the affected area and its nature. Conclusions: when clinicians differentiate between facial secretions of unknown origin and composition, post-surgical pathology of the parotid may be suspected, even after a long time. This may or not require treatment for its resolution. It can also provide guidance both in terms of preference and final differential diagnosis with salivary fistulas or cerebrospinal fluid.(AU)

Postparotidectomy sialocele: 6-year review of underlying factors.

BACKGROUND: Postparotidectomy sialocele is a frustrating challenge. Published rates of postparotidectomy fluid collections range from 6% to 39%. We report our experience of 398 parotidectomies performed over a 6-year period. METHODS: A retrospective chart review of parotidectomies performed over a 6-year period was completed. Drain placement, smoking status, tumor size, and postoperative utilization of scopolamine were analyzed. Binary logistical regression and odds ratio calculations were performed. RESULTS: Postparotidectomy sialocele occurred in 25% of patients. Neither suction drain placement nor usage of immediate postoperative scopolamine (in a 22-patient subset) prevented sialocele formation. Smoking status also did not correlate. Increasing resection size was linearly correlated with the risk of sialocele. CONCLUSION: Drain placement and smoking status do not correlate with sialocele prevention after parotidectomy. Sialocele formation directly correlates with the resection size. These data may guide preoperative counseling; however, additional work is necessary to identify effective prevention mechanisms for postparotidectomy sialocele.

Surgical navigation in parotid sialolith extraction.

Posterior parotid lithiasis may in some cases require a combined surgical approach associating sialendoscopy to an external intraoral or transfacial approach. This single-center retrospective study describes the surgical technique for parotid lithiasis extraction by a combined external and sialendoscopic approach with the help of CT-navigation. Five patients were included between November 2014 and July 2020. The sialolith was extracted in 100% of cases. Navigation and transillumination localizations matched consistently. No patients showed postoperative facial paresis. At 2 to 21 months' follow-up, there was no recurrence of sialolithiasis. Navigation can be a complement to transillumination, improving surgical comfort and safety, but does not replace first-line sialendoscopy. Visual control is required whenever possible after extraction. In combined procedures, it enables accurate identification of parotid sialoliths. In case of impassable stenosis, it could be a therapeutic alternative to parotidectomy.