UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

64 Barangay Dona Imelda, Aurora Boulevard Quezon City 1113

DEPARTMENT OF SURGERY
SURGERY II: A.Y. 2021-2022
Preceptor: Dr. Alejandro Dizon

Submitted by: Rock Eldrick Galzote Group: B3

Section: 2023B

PAPER CASE
CHIEF COMPLAINT
36 yo Filipino female, Roman Catholic from Bulacan, came in complaining of left
preauricular mass of 2 years duration

HISTORY OF PRESENT ILLNESS

2 years PTA: palpated a firm non-tender, non-movable 1cm mass at the left pre-
auricular area, no associated pain or erythema. No consult and medications taken.

1 year PTA: gradual increase in size and sought consult at a local clinic and was
prescribed with unrecalled antibiotics

Interim: patient had her third pregnancy and noted the size to suddenly increase from
1cm to 4cm in a span of two months.

4 days PTA: patient consulted at our institution due to the progressive enlargement of
the pre-auricular mass.

CASE DISCUSSION
PERTINENT SUBJECTIVE PERTINENT OBJECTIVE
• 4 cm well-defined, non-movable, non- • The patient was prescribed antibiotics
tender hard mass on left pre-auricular but did not prove to be effective as
area. treatment.
• No associated pain or erythema. • No lymphadenopathies
• Started as a slow growing mass, then • No sign of facial nerve damage.
the growth was accelerated by • Final histopathology report:
pregnancy. (1cm to 4cm in two months) Mucoepidermoid carcinoma, low grade,
• aggregate size of 4cm in greatest
dimension. Negative for tumor
metastasis in four submitted lymph
nodes.

PRIMARY IMPRESSION

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Pleomorphic Adenoma

Pleomorphic adenoma is the most common salivary tumor, constituting up to two-thirds

of all salivary gland neoplasms. The tumors most frequently originate in the superficial
lobe but may also occur in the deep lobe in some cases. PA also has a female
predilection between 30-50 years of age. Additionally, low grade tumors behave more
like a benign tumor.

DIFFERENTIAL DIAGNOSES
RULE IN RULE OUT
Mucoepidermoid Most common primary
carcinoma malignancy of the salivary
glands

Although it accounts for

less than 10% of all tumors
of the salivary gland, it
constitutes approximately
30% of all malignant tumors
of the salivary glands

More frequent in females

and occurs in the parotid
gland

Pleomorphic adenoma
It presents as painless
swelling, with or without
facial nerve involvement
Commonly found in the Tumors are slow-growing
parotid gland and cause no symptoms

Damage to facial nerve can It is usually mobile with

occur palpation

Most of these tumors occur

in the superficial lobe of the
parotid gland

Majority of these tumors

measure 2-6cm in size
Adenoid cystic Appears to be low grade They present as slow-
carcinoma microscopically growing, ulcerated masses,
with an associated chronic
Malignant tumor arising dull pain
from exocrine glands such

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 as major and minor salivary
glands

Warthin’s tumor Second most common Male to female ratio of 7:1

benign parotid tumor
Lesion presents itself as a
slow-growing, soft,
painless mass

Linked to smoking and

exposure to radiation

Common symptoms
include ear ringing, ear
pain, and hearing loss in
some cases.

DIAGNOSTICS

Ultrasound – provides information about the site, size, and nature of any suspected
cancerous glands. Usually combined with FNAB to help guide hands and distinguish a
malignant from a benign disease. Although the gland’s proximity to the bone can
become a challenge for the physician which is why the…

MRI and CT scan - are the preferred imaging modalities for scanning a parotid tumor.
It is useful in the assessment and delineation of anatomical structures, extension into
the deep lobe, and relation to the facial nerve. Compared to CT, MRI has a superior
soft tissue discrimination and therefore is favored by many to use as an imaging
modality for the parotid gland. Tumors that are not demonstrated on CT can often be
easily identified on MRI, which has the added benefit or no ionizing radiation.

FNAB – this is the most preferred diagnostic tool for head and neck masses. However,
when one is suspecting a parotid gland tumor, FNAB is often only used if there is high
suspicion on the mass being malignant. It is valuable in preoperative planning and
counselling of the patient. This test may be useful in diagnosing metastatic carcinoma,
especially with submandibular gland masses, and to help distinguish surgically
treatable from nonsurgical pathologic conditions, such as lymphoma. FNAB may also
be useful in the evaluation of salivary gland masses in patients who are poor surgical
candidates.

MANAGEMENT

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Complete superficial parotidectomy – this has remained as the gold standard of
parotid surgery in removing a tumor in the superficial lobe. Based on the MRI results,
the tumor is in the superficial lobe that is why it is appropriate to this type of surgical
procedure. This technique entails complete dissection of the lateral, superficial lobe of
the parotid gland with identification and dissection of all branches of the nerve. It also
allows complete tumor resection while reducing the risk of recurrence. However, post-
operative complications might occur such as Frey’s syndrome and first bite syndrome.

Post-treatment surveillance – because of the possibility of recurrence and distant

metastasis, patients with a history of salivary gland cancer must be monitored
throughout their lifetime. During the follow-up care, the doctor can give patients
personalized information about the risk of recurrence.

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ALGORITHM

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Ishida, E., Ogawa, T., Rokugo, M., Ishikawa, T., Wakamori, S., Ohkoshi, A., ... & Katori, Y. (2020).
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Jain, S., Hasan, S., Vyas, N., Shah, N., & Dalal, S. (2015). Pleomorphic adenoma of the parotid gland:
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Low, G. M. (2020). Neck Dissection. Brendan C. Stack, Jr., Mauricio A. Moreno Thieme Publishers, New
York.

Prabhu, V., Johnston, J., Ingrams, D., & Passant, C. (2011). Mucoepidermoid carcinoma—Unknown
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Saha, S., Pal, S., Sengupta, M., Chowdhury, K., Saha, V. P., & Mondal, L. (2014). Identification of facial
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Smith, R. V. (2020). Parotidectomy. Retrieved from

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https://www.uptodate.com/contents/parotidectomy?search=mucoepidermoid%20carcinoma%2
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lay_rank=1#H1858237327