Facial Resection Research Articles

Impact of facial nerve resection in parotid cancer abutting the facial nerve without preoperative paralysis: A multicentric propensity score-based analysis

ObjectivesThe management of the facial nerve (FN) is a major issue in parotid cancer, especially when there is no preoperative facial palsy and FN invasion is discovered intraoperatively. The aim of this study was to assess the impact of FN resection in patients with parotid cancer abutting the FN, without pretreatment facial palsy, using a propensity score matching. Materials and methodsData from all patients treated between 2009 and 2020 for a primary parotid cancer abutting or invading the FN but without pretreatment facial palsy were extracted from the national multicentric REFCOR database. Three different definitions of tumors abutting the FN were used for sensitivity analyses, in a retrospective setting. Propensity score matching was used to assess the impact of FN resection on disease-free survival (DFS), overall survival (OS) and locoregional recurrence-free survival (LRRFS). ResultsA total of 163 patients with parotid cancer abutting or invading the FN without pretreatment facial palsy were included. Among them, 99 patients (61 %) underwent FN resection. After overlap weighting and multiple imputation, no benefit of FN resection over preservation was found in terms of OS (HR = 1.21, p = 0.6), DFS (HR = 0.88, p = 0.5) and LRRFS (HR = 0.99, p = 1).Sensitivity analyses revealed similar results, and no significant efficacy was found in the subgroup analyses. ConclusionIn this retrospective study with propensity score analysis, FN resection did not improve survival outcomes in patients without preoperative facial palsy treated surgically for a primary parotid cancer abutting the FN. In line with recent guidelines, the results of this study suggest that FN preservation should be considered whenever possible in this specific group of patients.

How to perform prespecified subgroup analyses when using propensity score methods in the case of imbalanced subgroups

BackgroundLooking for treatment-by-subset interaction on a right-censored outcome based on observational data using propensity-score (PS) modeling is of interest. However, there are still issues regarding its implementation, notably when the subsets are very imbalanced in terms of prognostic features and treatment prevalence.MethodsWe conducted a simulation study to compare two main PS estimation strategies, performed either once on the whole sample (“across subset”) or in each subset separately (“within subsets”). Several PS models and estimands are also investigated. We then illustrated those approaches on the motivating example, namely, evaluating the benefits of facial nerve resection in patients with parotid cancer in contact with the nerve, according to pretreatment facial palsy.ResultsOur simulation study demonstrated that both strategies provide close results in terms of bias and variance of the estimated treatment effect, with a slight advantage for the “across subsets” strategy in very small samples, provided that interaction terms between the subset variable and other covariates influencing the choice of treatment are incorporated. PS matching without replacement resulted in biased estimates and should be avoided in the case of very imbalanced subsets.ConclusionsWhen assessing heterogeneity in the treatment effect in small samples, the “across subsets” strategy of PS estimation is preferred. Then, either a PS matching with replacement or a weighting method must be used to estimate the average treatment effect in the treated or in the overlap population. In contrast, PS matching without replacement should be avoided in this setting.

Masseteric Nerve Transfer for Facial Paralysis Secondary to Parotid Malignancy: A Retrospective Case Series.

Background: The objective outcomes of masseteric nerve transfer in the setting of parotid malignancy are unclear. Objective: To measure objective facial reanimation outcomes of masseteric nerve transfer in patients with parotid malignancy who underwent parotidectomy with facial nerve resection. Materials and Methods: Retrospective review of patients who underwent masseteric nerve transfer for facial paralysis secondary to parotid malignancy was carried out at a tertiary referral hospital from August 2017 to November 2021. Objective facial reanimation outcomes were analyzed using Emotrics. Minimal follow-up of 6 months was required for inclusion. Results: Eight patients (five males) with a median age of 75.5 years (range 53-91) met inclusion criteria. Fifty percent had metastatic squamous cell carcinoma, and 50% had primary parotid malignancy. Five patients underwent concomitant cancer resection with facial nerve reconstruction. Seven patients received postoperative adjuvant radiotherapy. After reinnervation, patients had improved oral commissure excursion (from 1.51 mm ±1.27 to 3.77 mm ±1.81; p < 0.01) and facial symmetry during smile. Conclusion: In this study, masseteric nerve transfer enhanced oral commissure excursion and facial symmetry during smile in patients with parotid malignancy and facial nerve resection.

Extracranial Facial Nerve Schwannoma-Histological Surprise or Therapeutic Planning?

Schwannomas (neurilemomas) are benign, slow-growing, encapsulated, white, yellow, or pink tumors originating in Schwann cells in the sheaths of cranial nerves or myelinated peripheral nerves. Facial nerve schwannomas (FNS) can form anywhere along the course of the nerve, from the pontocerebellar angle to the terminal branches of the facial nerve. In this article, we propose a review of the specialized literature regarding the diagnostic and therapeutic management of schwannomas of the extracranial segment of the facial nerve, also presenting our experience in this type of rare neurogenic tumor. The clinical exam reveals pretragial swelling or retromandibular swelling, the extrinsic compression of the lateral oropharyngeal wall like a parapharyngeal tumor. The function of the facial nerve is generally preserved due to the eccentric growth of the tumor pushing on the nerve fibers, and the incidence of peripheral facial paralysis in FNSs is described in 20-27% of cases. Magnetic Resonance Imaging (MRI) examination is the gold standard and describes a mass with iso signal to muscle on T1 and hyper signal to muscle on T2 and a characteristic "darts sign." The most practical differential diagnoses are pleomorphic adenoma of the parotid gland and glossopharyngeal schwannoma. The surgical approach to FNSs requires an experienced surgeon, and radical ablation by extracapsular dissection with preservation of the facial nerve is the gold standard for the cure. The patient's informed consent is important regarding the diagnosis of schwannoma and the possibility of facial nerve resection with reconstruction. Frozen section intraoperative examination is necessary to rule out malignancy or when sectioning of the facial nerve fibers is necessary. Alternative therapeutic strategies are imaging monitoring or stereotactic radiosurgery. The main factors which are considered during the management are the extension of the tumor, the presence or not of facial palsy, the experience of the surgeon, and the patient's options.

Intrapulmonary Metastasis from Adenoid Cystic Carcinoma of the External Auditory Canal: A Case Report.

External auditory canal adenoid cystic carcinoma (EAC) is rare and is associated with nonspecific clinical manifestations such as early ear pain. We report a patient with advanced lung metastases from adenoid cystic carcinoma (ACC) of the EAC, which is difficult to diagnose. Under general anesthesia, lengthened right temporal bone resection, parotidectomy, facial nerve resection, cervical lymph node dissection (I-III), partial mandibular resection, tumor resection in the inferior temporal fossa and lateral femoral flap repair were performed, followed by regular radiotherapy and chemotherapy. During 2years of postsurgical follow-up, there was no recurrence. The combination of early detection, resection, postoperative radiotherapy, and chemotherapy can result in a good therapeutic effect.

Parotid Metastasis in a Case of Papillary Thyroid Carcinoma: Case Report and Review of Literature.

Papillary thyroid carcinoma (PTC) is the most common differentiated thyroid neoplasm. Common sites of regional and distant metastasis includes lymph nodes, lungs and bone. 51year old female patient who was a known case of PTC with a history of multiple surgeries, radioactive iodine therapy (RAI) and oral chemotherapy presented with a painful right parotid mass. PET scan demonstrated FDG avid lesions in the right parotid gland, cervical lymph nodes and other distant sites. Cytology report showed features of metastatic PTC. Patient underwent extended total parotidectomy with facial nerve resection, skin and masseter muscle resection and extended radical neck dissection. Final histopathology (HPE) report showed metastatic papillary carcinoma thyroid. Patient is currently on oral chemotherapy and on regular follow up. PTC rarely metastasizes to parotid gland and such cases have to be treated with surgery alone or with a combination of surgery and RAI based on tumour burden.

Primary Lymphoepithelial Carcinoma of Parotid Gland: Inadequate Preoperative Assessment Resulting in Extensive Surgery

Parotid lymphoepithelial carcinoma is extremely rare, and makes up only 0.4% of cases among the anaplastic variant of salivary gland carcinoma. We present a 63-year-old man who had progressive enlarging right neck swelling for one year. He sought treatment in another centre and underwent superficial parotidectomy, following an ultrasound assessment of the mass that was suggestive of a benign parotid tumour. There was no fine needle aspiration cytology or other radiological imaging performed prior to the surgery. However, the surgeon encountered difficulty intraoperatively and abandoned the surgery. The incisional biopsy of the tumour was reported as lymphoepithelial carcinoma. He then presented to us with the progression of the residual parotid malignant tumour. CT and MRI showed a locally aggressive parotid tumour that had infiltrated the subcutaneous tissue, external auditory canal, facial nerve, and multiple ipsilateral metastatic cervical lymph nodes. Subsequently, the patient underwent total parotidectomy with facial nerve resection, lateral temporal bone resection and ipsilateral modified radical neck dissection. The surgical site defect was reconstructed with anterolateral thigh myocutaneous free flap. Concurrent static facial reanimation with fascia lata sling was performed. The patient received adjuvant chemoradiation following the surgery. The extent of the local infiltration by the tumour and the resulting surgery could have been reduced if the tumour had been properly assessed and excised at the initial stage. A complete preoperative assessment of a parotid mass is essential to avoid misdiagnosis, unexpected intraoperative finding and delay in definitive treatment.

694P Prognostic impact of facial nerve resection in patients treated for a primary parotid cancer abutting the facial nerve without preoperative paralysis: A multicentric study of the REFCOR group with propensity score matching analysis

Primary cancers of the parotid gland are associated to a preoperative facial paralysis in 15-30% of cases: in this situation, most authors agree to resect the facial nerve (FN) along with the tumor. In patients without preoperative facial palsy, the surgical management of tumors abutting the FN remains more controversial. The aim of this study was to assess the prognostic impact of FN resection in such patients. This was a retrospective study based on a multicentric national database (REFCOR). All patients treated surgically for a primary cancer of the parotid gland abutting the FN without preoperative facial paralysis were included. The 5-year overall survival (OS) and disease-free survival (DFS) of the patients treated with or without FN resection were assessed and compared using a propensity score (PS) matching based on known confounders to address selection bias. Different PS models and PS methods were used to check the robustness of the results. Missing data were addressed using multiple imputation with chained equations. A total of 207 patients treated for a tumor abutting the FN without preoperative FN paralysis were included in the analysis, of whom 93 (45%) had a FN resection. The 5-year OS were 59% and 79.5% in patients treated with or without FN resection, respectively. The 5-year DFS were 40.3% and 56.4% in patients treated with or without FN resection, respectively. After PS matching based on 59 patients in each group, there was no difference between groups in terms of OS (HR=1.39, p=0.4) or DFS (HR=1.22, p=0.5). Similar results were found whichever the sensitivity analysis. In this retrospective study, FN resection was not associated with better survival outcomes in patients treated for a parotid cancer abutting the FN without preoperative facial paralysis, even after a PS matching that corrected potential confounding-by-indication bias.

Does Total Parotidectomy Improve Survival Over Partial Parotidectomy in Early-Stage Adenoid Cystic Carcinoma of the Parotid Gland?

The decision to perform a partial or total parotidectomy in localized high-grade parotid cancer is often a matter of debate in the absence of a deep lobe disease. The purpose of this study was to compare survival between patients submitted to partial and total parotidectomy for early-stage parotid adenoid cystic carcinoma (ACC). This was a retrospective cohort study using data from the Surveillance, Epidemiology, and End Results database from 2004 through 2017. Patients with pT1/2 N0 M0 parotid ACC were included. The primary study predictor was surgical treatment with either total or partial parotidectomy. Other covariates included age, gender, race, T stage, and need for facial nerve resection. Outcomes were disease-specific (DSS) and overall survival (OS). Kaplan-Meier survival probabilities were calculated. Simple and multiple regression models were constructed to identify prognostic varaibles. A total of 300 patients were included in the final sample. Of these 300, 55.7% of tumors were T2, and 59.3% of patients were treated with a total parotidectomy. In the univariate time-to-event analyses, neither total parotidectomy nor facial nerve preservation reduced the risks of disease-specific or overall death. In the multivariate model, after controlling for covariates, only older age (DSS hazard ratio [HR]=2.59; P<.01, OS HR=2.72; P<.01) and T2 stage (DSS HR=2.44; P=.02, OS HR=2.02; P<.01) independently influenced survival. For localized parotid ACC, total parotidectomy did not improve survival compared to partial parotidectomy. It might be acceptable to maintain clinically uninvolved parotid gland when circumstances so permit.

측두공 내 종양을 암시하는 안면마비 표정의 특성

Background : The objective of this study was to analyze the characteristics of facial expressions by their pathogenesis in subjects with chronic facial paralysis and to describe the partial defect of facial function in elucidating the etiology of facial paralysis. Materials and Methods : The etiology of chronic facial paralysis could be categorized into 3 groups: Group I, total resection without any reanimation surgery; Group II, acute facial nerve injury such as Bell’s palsy, and Group III, facial nerve resection and anastomosis. There was a total number of 104 subjects included in this study. Each subject with chronic facial paralysis and were investigated based on the severity of synkinesis, regression of muscular volume, latency and amplitude in electromyography, and facial movement by House-Brackmann grade system. Results : Subjects from the Group I had no synkinesis with profound regression of muscular volume, H-B grade 5.7 ± 0.34. Subjects from the Group II had moderate to severe synkinesis with moderate to severe regression of muscular volume, H-B grade 3.4 ± 0.96. In this group, thirteen subjects with atypical facial expression also had an incidental finding of a hidden mass in the intratemporal area. Lastly, subjects from the Group III had severe synkinesis without regression of muscular volume, H-B grade 3.7 ± 0.76. Conclusions : With careful examination of facial expression, a crucial point for elucidating the pathogenesis of facial paralysis may be provided. Severe facial palsy without muscular regression may indicate an incidental finding of a hidden mass in the intratemporal area.

Minimally invasive temporalis tendon transposition and upper lid lipofilling for immediate and secondary facial reanimation in patients treated for malignant tumors of the parotid gland

Treatment for facial nerve-invading parotid malignancies usually results in complete facial palsy. The authors present a novel technique to treat facial palsy following radical parotid surgery and retrospectively evaluate results in terms of soft tissue symmetry at rest and during smiling and eyelid closure using the eFACE system.9 patients with facial palsy following parotid malignancies resection or undergoing parotidectomy with planned facial nerve resection for tumor invasion were treated with the association of mini-invasive temporalis flap rotation and upper lid lipofilling to restore symmetry of the middle facial third at rest and during smiling and eyelid closure. The technique was employed during the same surgical session as the tumor removal or for secondary facial reanimation.Systematic eFACE evaluation demonstrated significant improvement in static nasolabial fold depth orientation and oral commissure position, palpebral fissure narrowing during eye closure, and oral commissure movement and nasolabial fold depth and orientation with smile (p respectively .008, .011, 0.008, 0.035, 0.011, 0.008, and 0.011, Wilcoxon's test). Furthermore, all patients described subjective improvement of corneal discomfort.The presented technique appears promising in treating facial palsy in oncological patients, representing a potential alternative to other more complex reconstructive techniques.

Preoperative Magnetic Resonance Image and Computerized Tomography Findings Predictive of Facial Nerve Invasion in Patients with Parotid Cancer without Preoperative Facial Weakness-A Retrospective Observational Study.

Simple SummaryFacial nerve invasion in parotid cancer affects survival outcomes as well as functional outcomes after surgery-based treatment. Normal facial muscle function before surgery does not always exclude the possibility of involvement of the facial nerve by a tumor. Especially in patients without facial palsy, accurate evaluation of invasion before surgery is necessary to plan optimal facial nerve resection and reconstruction. Various findings are obtained from preoperative radiological findings, such as CT and MRI. We evaluated the role of these radiological findings in predicting nerve invasion. Large tumor, spiculated margin, and anterolateral location may suggest a high risk of nerve involvement even in patients with normal preoperative facial function. These findings may help surgeons to avoid unexpected facial nerve invasion and to make adequate surgical plans to get optimal oncological and functional outcomes. (1) Background: Facial nerve resection with reconstruction helps achieve optimal outcomes in the treatment of facial nerve invasion (FNI) of parotid cancer. Preoperative imaging is crucial to predict facial nerve reconstruction. The radiological findings of CT or MRI may predict FNI in the parotid cancer even without facial paralysis. Methods: We retrospectively reviewed the records of 151 patients without facial nerve paralysis before surgery who had undergone tumor resection. Previously untreated parotid cancers were included. (2) Results: The median follow-up duration was 62 months (range: 24–120 months). The FNI (+) group (n = 30) showed a significantly worse 5-year overall survival compared with the FNI (−) group (75.5 vs. 93.9%; hazard ratio = 4.19; 95% confidence interval: 1.74–10.08; p = 0.001). The tumor margin, tumor size, presence in the anterolateral parotid region (area 3), retromandibular vein involvement, distance from the stylomastoid foramen to the upper tumor margin, and a high tumor grade were significant factors related to FNI in the univariate analysis. A spiculated tumor margin, the tumor size (2.2 cm), and presence in area 3 were factors predicting FNI in the logistic regression model (p = 0.020, 0.005, and 0.050, respectively; odds ratio: 4.02, 6.40, and 8.16, respectively). (3) Conclusions: The tumor size (≥2.2 cm), spiculated margin, and presence in area 3 as presented in CT and MRI may help clinicians preoperatively predict FNI in patients with parotid cancer and establish an appropriate surgical plan.

Clinical outcomes and management of facial nerve in patients with parotid gland cancer and pretreatment facial weakness

ObjectivesIn parotid gland cancer (PGC), it is not clear whether facial weakness always reflects tumor invasion of the facial nerve (FN) requiring nerve resection. The aims of this study were to evaluate oncological and functional outcomes in patients with PGC and pre-treatment facial weakness, and to analyze local tumor invasion of the FN. Materials and methodsThe clinical outcomes of patients (n = 45) with PGC and pretreatment facial weakness were retrospectively analyzed. Patients had undergone 1 of 4 types of treatments: complete tumor resection, FN sacrifice with or without FN reconstruction, tumor resection with FN preservation and primary non-surgical treatments. Pathologic specimens in patients with nerve resection patients (n = 26) were reviewed to identify FN invasion by the tumor. ResultsPatients with PGC and facial weakness had poor clinical outcomes (44.0%, 3Y progression-free survival), and 86.7% of tumors were high-grade. In these subjects, regional or distant metastasis was an independent prognostic factor for survival. Recovery from facial weakness was suboptimal in patients with FN graft. In cases with nerve resection, 26.9% had intra-neural tumor invasion, 42.3% had perineural invasion, and 30.8% had no neural invasion in the FN. ConclusionFacial weakness did not always indicate tumor invasion of the FN in PGC. Thus, the decision regarding FN resection can reasonably be further based on intraoperative findings. In cases with incomplete facial weakness and safe separation of the FN from the tumor, FN preservation offers the best functional outcomes, without compromising oncological outcomes.

Reoperation following the use of non-standardized procedures for malignant parotid tumors.

Non-standardized or conservative procedures are employed when parotid tumors involving the facial nerve or parotid carcinoma are misdiagnosed as benign parotid tumors prior to or during surgery. Remedial measures are usually required when the pathological diagnosis of a malignant parotid tumor is confirmed following surgery. The aim of the present study was to systematically evaluate reoperation subsequent to treatment with non-standardized procedures for malignant parotid tumors, and to explore the preoperative diagnoses, the primary procedure selection and the necessity of reoperation following non-standardized procedures in malignant parotid tumors. A total of 30 patients who met the inclusion criteria, were diagnosed with a malignant parotid tumor and underwent reoperation following the use of a non-standardized procedure were included in the present study. Surgical conditions and clinical data were analyzed. Among the patients with a malignant parotid tumor who underwent reoperation subsequent to a non-standardized procedure, the incidence of residual tumor, as confirmed by pathological examination, was 63.3% (19/30). The intact facial nerve preservation rate was 83.3% (25/30), the facial nerve branch resection rate was 6.7% (2/30), the facial partial nerve resection rate was 6.7% (2/30) and the facial nerve resection rate was 3.3% (1/30). In total, 3 patients underwent facial nerve reconstruction, 3 patients underwent a local flap repair of skin defects in the parotid region and 3 patients underwent pectoralis major muscle flap repair. The current findings indicate that the qualitative diagnosis of malignant parotid tumors prior to surgery is difficult, there is a high incidence of residual tumor following non-standardized procedures, and that reoperation in a timely manner is required in such cases.

Intracranial Facial Nerve Grafting in the Setting of Skull Base Tumors: Global and Regional Facial Function Analysis and Possible Implications for Facial Reanimation Surgery.

Reconstructive surgeons may encounter patients presenting after intracranial facial nerve resection and grafting in the setting of skull base tumors, who inquire regarding progression, final facial function, and need for future operations. Study goals were to analyze global and regional facial function using established grading systems and videography, while examine variables possibly affecting outcomes. Between 1997 and 2012, 28 patients underwent intracranial nerve grafting. Fifteen were prospectively evaluated by three facial nerve physical therapists with the Facial Nerve Grading System 2.0 and the Sunnybrook Facial Grading Score for function and the Facial Disability Index for quality of life. Still photographs and videography were used to assess quality of motion and tone, while demographic and medical variables were analyzed regarding their effect on end results. Average patient age was 41.9 years (range, 22 to 66 years), and there were 10 women and five men. Average time interval between nerve grafting and evaluations was 42.9 months (range, 12 to 146 months). Both grading scores demonstrated best outcomes in the periorbita and worst outcomes in the brow. Buccinator muscle tone also improved. The average total Facial Disability Index was 67.5 percent. Although not statistically significant, the data suggest that nerve gap length affected total resting symmetry and voluntary movement, whereas preoperative palsy and age may affect total resting symmetry. Perioperative radiation therapy, tumor type, donor nerve, and coaptation technique were not found to affect outcomes. Intracranial facial nerve grafting largely provides better resting tone and facial symmetry, potentially improving end results of future intervention; however, overall voluntary facial motion is poor. Therapeutic, IV.

A surgical approach as dysmasking in patients with malignant tumors of the paranasal sinuses and skull base

A surgical approach as dysmasking implies a bitemporal skin incision followed by a single flap from upper facial soft tissues. The advantages of this technique may include a wide surgical approach to the structures of the anterior skull base, a possibility of intraoperative extension of the approach through parapalpebral and/or pre-auricular incisions, the lack of incisions in the central zone of the face, the preservation of the integrity of mimic muscles and the sensitivity of soft tissues in the central zone of the face. This paper gives experience in surgically treating 5 patients with malignant tumors of the paranasal sinuses and skull base. All the cases required a wide approach to the skull base and anterior facial skeleton. This was achieved by the use of the dysmasking approach, if need be, parapalpebral incisions or facial nerve resection followed by single-stage microsurgical neurorrhaphy were made. All operations were performed under endotracheal anesthesia. The wide surgical approach to the tumor, which permitted its removal in the maximum volume without skin incisions in the central zone of the face, as vitally indicated, could be achieved by dysmasking that yielded satisfactory postoperative cosmetic and functional results in all the cases.

Functional Outcomes of Multiple Sural Nerve Grafts for Facial Nerve Defects after Tumor-Ablative Surgery.

BackgroundFunctional restoration of the facial expression is necessary after facial nerve resection to treat head and neck tumors. This study was conducted to evaluate the functional outcomes of patients who underwent facial nerve cable grafting immediately after tumor resection.MethodsPatients who underwent cable grafting from April 2007 to August 2011 were reviewed, in which a harvested branch of the sural nerve was grafted onto each facial nerve division. Twelve patients underwent facial nerve cable grafting after radical parotidectomy, total parotidectomy, or schwannoma resection, and the functional facial expression of each patient was evaluated using the Facial Nerve Grading Scale 2.0. The results were analyzed according to patient age, follow-up duration, and the use of postoperative radiation therapy.ResultsAmong the 12 patients who were evaluated, the mean follow-up duration was 21.8 months, the mean age at the time of surgery was 42.8 years, and the mean facial expression score was 14.6 points, indicating moderate dysfunction. Facial expression scores were not influenced by age at the time of surgery, follow-up duration, or the use of postoperative radiation therapy.ConclusionsThe results of this study indicate that facial nerve cable grafting using the sural nerve can restore facial expression. Although patients were provided with appropriate treatment, the survival rate for salivary gland cancer was poor. We conclude that immediate facial nerve reconstruction is a worthwhile procedure that improves quality of life by allowing the recovery of facial expression, even in patients who are older or may require radiation therapy.

Surgical Resection of a Small Cell Carcinoma Primary Tumor of the Parotid Gland with Perineural and Skull Base Involvement

Background: One of the rarest tumors of the parotid gland is a Small Cell Carcinoma (SmCC) of neuroendocrine or ductal origin. These lesions tend to be aggressive, often invading bone and nerve and carry a grave prognosis for the patient. Presently there is no standardized treatment protocol and no consensus to tumor management. Case Report: This case report is of a 70 year-old male with a right-sided facial mass, facial pain, severe otalgia, weight loss, and right-sided facial paralysis. Subsequent imaging and Fine Needle Aspiration (FNA) revealed T4aN2bM0 SmCC of the parotid gland with facial nerve enhancement and skull base erosion. The patient underwent major extirpative surgery including radical neck dissection, total parotidectomy with facial nerve resection and cable graft, and partial temporal bone resection as the initial step in a combined modality therapy The patient has done very well post-operatively. Conclusion: This case report describes the successful, aggressive surgical management of locally and regionally advanced SmCC of the parotid gland. Although the prognosis for patients with SmCC of the parotid gland is typically grave, the absence of distant metastatic disease in the presented case provided the rationale for an aggressive surgical approach with a curative, rather than palliative, focus.

Clinicopathological and Targeted Exome Gene Features of a Patient with Metastatic Acinic Cell Carcinoma of the Parotid Gland Harboring an ARID2 Nonsense Mutation and CDKN2A/B Deletion.

We describe the presentation, treatment, clinical outcome, and targeted genome analysis of a metastatic salivary acinic cell carcinoma (AciCC). A 71-year-old male presented with a 3 cm right tail of a parotid lesion, first detected as a nodule by the patient seven months earlier. He had a right total parotidectomy with cranial nerve VII resection, right facial nerve resection and grafting, resection of the right conchal cartilage, and right modified radical neck dissection. The primary tumor revealed AciCC with two distinct areas: a well-differentiated component with glandular architecture and a dedifferentiated component with infiltrative growth pattern associated with prominent stromal response, necrosis, perineural invasion, and cellular pleomorphism. Tumor staging was pT4 N0 MX. Immunohistochemistry staining showed pankeratin (+), CD56 (−), and a Ki67 proliferation index of 15%. Upon microscopic inspection, 49 local lymph nodes resected during parotidectomy were negative for cancer cells. Targeted sequencing of the primary tumor revealed deletions of CDKN2A and CDKN2B, a nonsense mutation in ARID2, and single missense mutations of unknown significance in nine other genes. Despite postoperative localized radiation treatment, follow-up whole body PET/CT scan showed lung, soft tissue, bone, and liver metastases. The patient expired 9 months after resection of the primary tumor.

Supraclavicular Artery Island Flap for Reconstruction of Complex Parotidectomy, Lateral Skull Base, and Total Auriculectomy Defects

There are limited data on the use of the supraclavicular artery island flap (SCAIF) for parotid and lateral skull base (LSB) surgery. This flap can be an important reconstructive tool for these procedures. To describe the use of the SCAIF for parotid and LSB surgery and its success, as well as important technique modifications for successful use of the flap in this setting. Retrospective single-institution review from July 1, 2011, to September 30, 2013, of patients in a tertiary care referral center. A prospectively collected institutional database was reviewed to identify patients who received SCAIF reconstruction for parotid and/or LSB surgery. Forty-six SCAIF reconstructions were identified; 16 were performed for the indication of parotidectomy or LSB surgery. The SCAIF reconstruction for parotid and/or LSB surgery. Indication for reconstruction, flap viability, flap size, reconstruction site complication, and donor site complication. Resection was performed for advanced cutaneous malignant tumor in 10 patients, primary salivary gland malignant tumor in 4 patients, and chronic infection and mastoid cutaneous fistula in 2 patients. All defects were complex, involving multiple subsites; 5 patients underwent facial nerve resection and 4 had previous radiation therapy. No complete flap loss occurred. One partial flap loss occurred. The average flap island size was 7 × 10 cm. No major complications occurred. Two minor reconstruction site complications and 3 donor site seromas occurred. The SCAIF can be successfully and reliably used for complex defects following parotid and LSB surgery. There are 3 important technique modifications to help facilitate rotation and coverage of this region.