Facial Nerve in Recurrent Benign John
Conley, MD, Albert
A.
Pleomorphic Adenoma
Clairmont, MD
\s=b\ Improvements in the treatment of benign and malignant tumors in the parotid gland have substantially reduced the
incidence of recurrence. This has come about primarily by the abandonment of the enucleation techniques and the development of the lateral lobectomy operation. The recurrence rate for benign mixed tumor in the parotid gland is variously reported in the ranges of 0.5% to 10%. Because the benign mixed tumor comprises approximately 65% of the tumors in this gland, this complication assumes an important and specific role. A review of this problem establishes the principles of management, extending from simple reexcision through total parotidectomy with preservation of the facial nerve, and radical parotidectomy with resection of the facial nerve and immediate nerve
sent
a
threat to life. The
recurrences
usually in nodular clusters in the parotid area; these are mobile and asymptomatic and slowly grow during a period of one to ten years. Neverthe¬ are
less, there is
reason for concern about these recurrences, since all subsequent operations for recurrence are more difficult to accomplish technically due to scarring, as well as the size and position of the tumor. Of equal concern is the rare possibility of an
unrecognized malignant neoplasm,
such as adenoid cystic carcinoma, mucoepidermoid carcinoma, adenocar¬ cinoma, or malignant mixed tumor. As shown in Fig 1, benign pleo¬ morphic adenoma of the parotid gland may recur under the following circum¬ stances: (1) If, during the surgery, there is gross violation or rupture of the tumor "capsule," this causes seed¬ ing of tumor into the wound. (2) If, during the surgery, the technique of "enucleation" is used, small lobulations or projections of tumor through
grafting. (Arch Otolaryngol 105:247-251, 1979)
Localpleomorphic
of a benign adenoma of the
recurrence
parotid gland does not ordinarily preAccepted
for publication Feb 4, 1978. From the Department of Otolaryngology, Columbia-Presbyterian Medical Center, the Head and Neck Service, St Vincent's Hospital, and the Pack Medical Foundation, New York. Dr Clairmont is now in private practice in Atlanta. Reprint requests to Department of Otolaryngology, Columbia-Presbyterian Medical Center, New York, NY 10032 (Dr Conley).
Fig 1 .—Morphologic
characteristics of
pleomorphic adenoma (mixed tumor).
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Fig 2.—Single focus (arrows) of recurrent pleomorphic adenoma after "enucleation" technique. Total parotidectomy with pres¬ ervation of facial
nerve was
done.
Fig 3.—Partial regional weakness of right side of face after resection of total parotid gland and two tertiary divisions of facial
4.—Patient with extensive parotid resection with preservation of major por¬ tion of facial nerve.
Fig
nerve.
of the "capsule" are and left within the wound. (3) The very rare possibili¬ ty of true multicentric foci of benign mixed tumor does exist. The original technique of "enuclea¬ tion" of pleomorphic adenomas of the parotid gland was based on the assumption that all these tumors were encased in a firm capsule (Fig 2). Recurrence rates, after the enuclea¬ tion technique, of 30% to 50% prompted a closer gross and micro¬ scopic anatomic study. These tumors were found to have a "pseudocapsule," which may be deficient in certain areas with penetration of tumor lobulations into the surrounding parotid tissue. These tumor projections could be unwittingly detached during enu¬
deficient
areas
unwittingly detached
even during a microscopic capsular dissection. Krolls and Boyers' review of 75 cases of benign mixed tumor of the parotid gland from the Armed Forces Institute of Pathology (AFIP) files1 disclosed 36 patients who had one to
cleation,
five
recurrences
(48%). There
were
21
patients with only one recurrence, nine patients with two recurrences, four patients with three recurrences, three patients with four recurrences, and two patients with five recur¬
One of their cases did not manifest a recurrence until 21 years after the first benign mixed tumor rences.
Fig
5.—Total
parotidectomy
for recurrent
removed. Krolls and Boyers1 mentioned the case reported by McFarland2 that recurred 47 years after the initial operation. In the AFIP series, however, the majority of the lesions (80%) recurred within the first ten years. They attributed the high recurrence rate to probable inad¬ equate initial surgery. In 1951 Kirklin and colleagues' from the Mayo Clinic reported a 30% recurrence rate after enucleation (28% after 20 years, 33% after 30 years). PateyJ reported no
was
benign mixed
tumor with facial
nerve
intact.
in 133 patients; the followperiod ranged from two to 15 years. Foote and Frazell reported only six of 142 (4%) recurrent benign mixed tumors. Buxton et al" reported a 4.7% recurrence rate of 183 primary benign recurrence
up
'
mixed tumors. The rate of further was 10%. Buxton et al" noted that there were no recurrences if a total parotidectomy was per¬ formed. Houck7 reported a 4% recur¬ rence rate from 24 benign mixed tumors. Stea8 reported 44 cases of recurrence
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Fig 6.—Top left, Solid, fixed, twice recur¬ rent pleomorphic adenoma shown by dotted lines. Top center, Postoperative status of radical parotidectomy for third recurrence, and facial nerve graft for recurrent pleomorphic adenoma. Top right, Excellent return of movement on left side during two years after nerve graft. Bottom left, Patient after second radical parotidectomy for fourth recurrence and second nerve graft. Bottom right, Excel¬ lent return of second nerve graft one year later.
Fig 7.—Left, Five-times recurrent multilobulated and extensively implanted recurrent pleomorphic adenoma requiring radical ablation and facial nerve grafting technique. Right, Excellent return of movement of face in two years. Patient is free of tumor ten years postoperatively.
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benign mixed tumors of the parotid gland; these tumors were removed by the enucleation technique. There were
six recurrences (13.6%) within the first eight years. Richardson and asso¬ ciates'1 reported a 2% five-year recur¬ rence rate; of 205 patients with benign mixed tumors, a recurrence also devel¬ oped in three others-one at eight years, one at nine years, and another at ten years. In their study, there were 47 patients who had secondary treatment with a recurrent benign mixed tumor; a subsequent recurrence developed in eight (22.9%) of 35 cases that were followed from five to 22 years. Generally, it is agreed that if there is one recurrence, additional ones may be expected at a more frequent rate.1 In 1954, Frazell1" reported seven recurrences from 143 (4.8%) cases of primary benign mixed tumors of the parotid gland. He noted that in those patients whose tumors were recurrent on admission, 18 of 74 (24.3%) were recurrent again. In 1975, Sinha and Buntine11 reported that of 79 cases of primary mixed tumors, there were ten recurrences in seven patients (9%). All patients in whom recurrences had developed had under¬ gone local excision (enucleation and limited local excision). In 1973, Garas and co-workers1- reported that of 56 benign mixed tumors, removed by the enucleation technique, only two (3.5%) recurred. They concluded that, despite other reports in the literature, the enucleation technique does not yield a higher recurrence rate. Their maxi¬ mum follow-up period was two years. Work et al" have called attention to the hazard to the facial nerve in recur¬ rent mixed tumor of the parotid gland. They reported two cases of radical resection of these recurrences and successful facial nerve grafting. PROCEDURE The lateral lobectomy surgical procedure has replaced the enucleation technique for pleomorphic adenomas of the parotid gland, since the majority of these tumors are lateral to the facial nerve and not in the deep (medial) portion of the parotid gland. During the lateral lobectomy, the main trunk of the facial nerve is first identified as it exits from the stylomastoid foramen, then the main divisions of the nerve, and, finally, the branches are dissected, resect-
Fig 8.—Recurrent benign gland.
mixed tumor has been found in these
areas
beyond parotid
Fig 9.—Tumor's relation to facial nerve. For local recurrence after lateral lobectomy or "enucleation," suggested treatment is total parotidectomy, which spares facial nerve (at left). For multiple, isolated recurrent nodules after total parotidectomy, suggested treatment is "berry-picking" removal of nodules, which spares most of branches of facial nerve (at center). For multiple confluent mass of recurrent mixed tumor, suggested treatment is total parotidectomy, including muscle cuff (portions of masseter, sternoclei¬ domastoid, and posterior belly of digastric muscles), tip of mastoid bone, sacrifice of facial nerve, and immediate nerve graft (at right).
ing the portion of the parotid gland and enclosed tumor lateral to the facial nerve elements. This unit is submitted for fro¬ zen-section analysis. It is diagnostic and therapeutic in the vast majority of cases. There are exceptions to this concept of avoiding dissection on or near the tumor capsule. First, if the tumor is located in the isthmus portion of the parotid gland, in
intimate contact with some of the terminal divisions of the facial nerve in the middle third of the face, delicate separation of the nerve from the tumor capsule is required. Second, these tumors may also occasionally occur in the superior part of the parotid gland with extension underneath the zygo¬ ma or toward the malar compound, inti¬ mately associated with the superior divi-
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sion of the facial nerve; once again, delicate separation of the nerve from the tumor capsule is required. Third, benign tumors of the deep portion of the parotid gland are not readily accessible, have very little surrounding parotid tissue, and are always in intimate contact with the facial nerve. In some instances, a branch of the facial nerve will enter directly into the neoplasm. Rather than macerate the neoplasm in an attempt to save this nerve filament, it is usually advisable to remove the nerve fila¬ ment with the tumor. Cutting a small filament in the middle third of the face usually results in no permanent deficit, due to multiple connectors from one branch to another. Cutting either the frontal or cervical division leaves a permanent paral¬ ysis of the muscles that are supplied by these terminal branches in about 85% of the cases, due to a lack of connectors in these cases.
MATERIAL In a series of 663 primary cases of benign pleomorphic adenoma at the Pack Medical Foundation, New York, two known
have been discovered. One 65 years, refused operation for an apparent recurrence that appeared seven years after the primary operation. The other patient had a solitary recurrence three years after the primary operation; this patient underwent total parotidecto¬ my and has had no evidence of disease for recurrences
patient, aged
eight years. There
were
42
cases
in the referred
secondary recurrent benign pleo¬ morphic adenoma. This group had been operated on elsewhere; these patients ei¬ ther had local resection, total parotidecto¬ my with preservation of the facial nerve, or radical parotidectomy and paraglandular dissection complemented with nerve graft¬ ing (Fig 3-5). It was imperative to check the previous histologie conditions, since three cases originally in this group were reclassified as malignant tumor: one ma¬ lignant mixed, one adenoid cystic, and one low-grade mucoepidermoid. The latter cases had had 16 operations for a so-called benign mixed tumor. Two patients in this group (4.7%) have had another local recur¬ group of
after their definitive treatment, and both of these have been identified since 1974. One patient had had two previous recurrences elsewhere during a 15-year interval for a large tumor in the deep lobe (Fig 6). He underwent radical parotidecto¬ my with immediate nerve grafting. Seven years after this technique, he appeared with another recurrence; there was exten¬ sion of the tumor toward the mesopharynx behind the mandible, and the patient again underwent radical paraglandular dissecrence
tion with immediate nerve grafting. He has been free of tumor for two years. The second patient had a recurrence two years after the previous operation. For the first recurrence, he had undergone total paroti¬ dectomy with lysis of the facial nerve and reapproximation. He had recurrence with¬ in one year and underwent radical para¬ glandular dissection and immediate facial nerve grafting (Fig 7). His tumor extended underneath the zygoma and malar com¬ pound and also into the region of the deep lobe behind the mandible. He has been free of tumor for two years. An analysis of 42 cases indicated that the time interval for recurrence was one to 11 years. Twenty-one patients had one recur¬ rence, eight had two recurrences, six had three recurrences, five had four recur¬ rences, and two had five recurrences. Fifteen patients had a clinically unicentric recurrence, and 27 had multiple foci. In 35 instances, the recurrence was mobile, in five, it was partially fixed, and in two, it was fixed. The position of the primary tumor had some bearing on the recurrence (Fig 8 shows severals areas where tumors might occur). Fifteen of these original neoplasms were located in the lateral lobe, and 16 were in the deep lobe or isthmus. In 11 instances, this information was not available. In 20 cases, the recurrence was primarily in the lateral lobe, eight were in the deep lobe or isthmus, and, in 14, it was in multiple regions. Before the definitive operation, 78% of this group had a normal facial nerve. Twenty-two percent had some mild degree of regional weakness. After the definitive procedure, 29% had a completely normal face, 57% had some regional weakness, and 14% had had radical resection of the nerve and nerve grafting. Some return of movement has developed in all patients in this latter group. The facial nerve was involved in direct proportion to the number of recurrences, the position of the recurrence in respect to the nerve, the size of the recurrence, and the amount of scar tissue.
COMMENT It is obvious that recurrent benign pleomorphic adenoma is a rare occur¬ rence when lateral lobectomy is the surgical technique, and when it is associated with no spillage. The recur¬ rence rate is approximately half of 1%. Recurrences are more likely to occur in very large tumors in the isthmus or deep lobe, or tumors in intimate contact with the facial nerve where the dissection is necessarily capsular in proximation to preserve the integrity of the nerve. A single
recurrence may be handled by simple local resection in certain cases. In¬ deed, in the older age group, one may be justified in observing the recur¬ rence for an indefinite period of time, once the microscopy is firmly estab¬ lished. Unfortunately, the majority of recurrences are multiple, and this automatically predisposes to tradi¬ tional recurrences. In the long perspective, total paroti¬ dectomy with preservation of all or the major portion of the facial nerve is the operation of choice. This technique is tedious and difficult, requires mag¬ nification in most instances, and is usually a piecemeal resection. Recur¬ rent tumors that are confluent and have encased the facial nerve are best managed by total resection of the residuum of the gland, the facial nerve, and paraglandular structures (Fig 9). Approximately 14% will fall into this category. Particular atten¬ tion must be directed to occult exten¬ sions in the region of the deep lobe, mesopharynx, behind the mandible, and underneath the zygoma and malar arches. Immediate nerve graft¬ ing should be part of this technique.
References 1. Krolls SO, Boyers RC: Mixed tumors salivary glands. Cancer 30:276-281, 1972.
of
2. McFarland J: Three hundred mixed tumors of the salivary glands, of which 69 recurred. Surg Gynecol Obstet 63:457-462, 1936. 3. Kirklin JW, McDonald JR, Harrington SW, et al: Parotid tumors: Histopathology clinical behavior and end results. Surg Gynecol Obstet
92:721-733, 1951. 4. Patey DH: The treatment of mixed tumours of the parotid gland. Br J Surg 28:29-31, 1940. 5. Foote FW Jr, Frazell EL: Tumors of the major salivary glands. Cancer 6:1065-1074, 1953. 6. Buxton RW, Maxwell JH, French AJ: Surgical treatment of epithelial tumors of the parotid gland. Surg Gynecol Obstet 97:401-404, 1953. 7. Houck JW: Tumors of the salivary glands: II. A study of 48 cases, with the presentation of a classification. Surgery 6:565-570, 1939. 8. Stea G: Conservative surgical treatment of mixed tumors of the parotid gland. J Maxillofac Surg 3:135-137, 1975. 9. Richardson GS, Dickason WL, Gaisford JC, et al: Tumors of salivary glands. Plast Reconstr Surg 55:131-136, 1975. 10. Frazell EL: Clinical aspects of tumors of the major salivary glands. Cancer 7:637-659, new
1954. 11. Sinha
tumors:
BK, Buntine DW: Parotid gland
Clinicopathologic study.
Am J
Surg
129:675-679, 1975. 12. Garas J, Politis A, Besbeas S, et al: Neoplasms of the parotid gland, review of 185 operated cases. Int Surg 58:178-182, 1973. 13. Work WP, Batsakis JG, Bailey DG: Recurrent
Arch
benign mixed tumor and the facial Otolaryngol 102:15-19, 1976.
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nerve.
Conley, MD, Albert
A.
Pleomorphic Adenoma
Clairmont, MD
\s=b\ Improvements in the treatment of benign and malignant tumors in the parotid gland have substantially reduced the
incidence of recurrence. This has come about primarily by the abandonment of the enucleation techniques and the development of the lateral lobectomy operation. The recurrence rate for benign mixed tumor in the parotid gland is variously reported in the ranges of 0.5% to 10%. Because the benign mixed tumor comprises approximately 65% of the tumors in this gland, this complication assumes an important and specific role. A review of this problem establishes the principles of management, extending from simple reexcision through total parotidectomy with preservation of the facial nerve, and radical parotidectomy with resection of the facial nerve and immediate nerve
sent
a
threat to life. The
recurrences
usually in nodular clusters in the parotid area; these are mobile and asymptomatic and slowly grow during a period of one to ten years. Neverthe¬ are
less, there is
reason for concern about these recurrences, since all subsequent operations for recurrence are more difficult to accomplish technically due to scarring, as well as the size and position of the tumor. Of equal concern is the rare possibility of an
unrecognized malignant neoplasm,
such as adenoid cystic carcinoma, mucoepidermoid carcinoma, adenocar¬ cinoma, or malignant mixed tumor. As shown in Fig 1, benign pleo¬ morphic adenoma of the parotid gland may recur under the following circum¬ stances: (1) If, during the surgery, there is gross violation or rupture of the tumor "capsule," this causes seed¬ ing of tumor into the wound. (2) If, during the surgery, the technique of "enucleation" is used, small lobulations or projections of tumor through
grafting. (Arch Otolaryngol 105:247-251, 1979)
Localpleomorphic
of a benign adenoma of the
recurrence
parotid gland does not ordinarily preAccepted
for publication Feb 4, 1978. From the Department of Otolaryngology, Columbia-Presbyterian Medical Center, the Head and Neck Service, St Vincent's Hospital, and the Pack Medical Foundation, New York. Dr Clairmont is now in private practice in Atlanta. Reprint requests to Department of Otolaryngology, Columbia-Presbyterian Medical Center, New York, NY 10032 (Dr Conley).
Fig 1 .—Morphologic
characteristics of
pleomorphic adenoma (mixed tumor).
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/24/2015
Fig 2.—Single focus (arrows) of recurrent pleomorphic adenoma after "enucleation" technique. Total parotidectomy with pres¬ ervation of facial
nerve was
done.
Fig 3.—Partial regional weakness of right side of face after resection of total parotid gland and two tertiary divisions of facial
4.—Patient with extensive parotid resection with preservation of major por¬ tion of facial nerve.
Fig
nerve.
of the "capsule" are and left within the wound. (3) The very rare possibili¬ ty of true multicentric foci of benign mixed tumor does exist. The original technique of "enuclea¬ tion" of pleomorphic adenomas of the parotid gland was based on the assumption that all these tumors were encased in a firm capsule (Fig 2). Recurrence rates, after the enuclea¬ tion technique, of 30% to 50% prompted a closer gross and micro¬ scopic anatomic study. These tumors were found to have a "pseudocapsule," which may be deficient in certain areas with penetration of tumor lobulations into the surrounding parotid tissue. These tumor projections could be unwittingly detached during enu¬
deficient
areas
unwittingly detached
even during a microscopic capsular dissection. Krolls and Boyers' review of 75 cases of benign mixed tumor of the parotid gland from the Armed Forces Institute of Pathology (AFIP) files1 disclosed 36 patients who had one to
cleation,
five
recurrences
(48%). There
were
21
patients with only one recurrence, nine patients with two recurrences, four patients with three recurrences, three patients with four recurrences, and two patients with five recur¬
One of their cases did not manifest a recurrence until 21 years after the first benign mixed tumor rences.
Fig
5.—Total
parotidectomy
for recurrent
removed. Krolls and Boyers1 mentioned the case reported by McFarland2 that recurred 47 years after the initial operation. In the AFIP series, however, the majority of the lesions (80%) recurred within the first ten years. They attributed the high recurrence rate to probable inad¬ equate initial surgery. In 1951 Kirklin and colleagues' from the Mayo Clinic reported a 30% recurrence rate after enucleation (28% after 20 years, 33% after 30 years). PateyJ reported no
was
benign mixed
tumor with facial
nerve
intact.
in 133 patients; the followperiod ranged from two to 15 years. Foote and Frazell reported only six of 142 (4%) recurrent benign mixed tumors. Buxton et al" reported a 4.7% recurrence rate of 183 primary benign recurrence
up
'
mixed tumors. The rate of further was 10%. Buxton et al" noted that there were no recurrences if a total parotidectomy was per¬ formed. Houck7 reported a 4% recur¬ rence rate from 24 benign mixed tumors. Stea8 reported 44 cases of recurrence
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/24/2015
Fig 6.—Top left, Solid, fixed, twice recur¬ rent pleomorphic adenoma shown by dotted lines. Top center, Postoperative status of radical parotidectomy for third recurrence, and facial nerve graft for recurrent pleomorphic adenoma. Top right, Excellent return of movement on left side during two years after nerve graft. Bottom left, Patient after second radical parotidectomy for fourth recurrence and second nerve graft. Bottom right, Excel¬ lent return of second nerve graft one year later.
Fig 7.—Left, Five-times recurrent multilobulated and extensively implanted recurrent pleomorphic adenoma requiring radical ablation and facial nerve grafting technique. Right, Excellent return of movement of face in two years. Patient is free of tumor ten years postoperatively.
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benign mixed tumors of the parotid gland; these tumors were removed by the enucleation technique. There were
six recurrences (13.6%) within the first eight years. Richardson and asso¬ ciates'1 reported a 2% five-year recur¬ rence rate; of 205 patients with benign mixed tumors, a recurrence also devel¬ oped in three others-one at eight years, one at nine years, and another at ten years. In their study, there were 47 patients who had secondary treatment with a recurrent benign mixed tumor; a subsequent recurrence developed in eight (22.9%) of 35 cases that were followed from five to 22 years. Generally, it is agreed that if there is one recurrence, additional ones may be expected at a more frequent rate.1 In 1954, Frazell1" reported seven recurrences from 143 (4.8%) cases of primary benign mixed tumors of the parotid gland. He noted that in those patients whose tumors were recurrent on admission, 18 of 74 (24.3%) were recurrent again. In 1975, Sinha and Buntine11 reported that of 79 cases of primary mixed tumors, there were ten recurrences in seven patients (9%). All patients in whom recurrences had developed had under¬ gone local excision (enucleation and limited local excision). In 1973, Garas and co-workers1- reported that of 56 benign mixed tumors, removed by the enucleation technique, only two (3.5%) recurred. They concluded that, despite other reports in the literature, the enucleation technique does not yield a higher recurrence rate. Their maxi¬ mum follow-up period was two years. Work et al" have called attention to the hazard to the facial nerve in recur¬ rent mixed tumor of the parotid gland. They reported two cases of radical resection of these recurrences and successful facial nerve grafting. PROCEDURE The lateral lobectomy surgical procedure has replaced the enucleation technique for pleomorphic adenomas of the parotid gland, since the majority of these tumors are lateral to the facial nerve and not in the deep (medial) portion of the parotid gland. During the lateral lobectomy, the main trunk of the facial nerve is first identified as it exits from the stylomastoid foramen, then the main divisions of the nerve, and, finally, the branches are dissected, resect-
Fig 8.—Recurrent benign gland.
mixed tumor has been found in these
areas
beyond parotid
Fig 9.—Tumor's relation to facial nerve. For local recurrence after lateral lobectomy or "enucleation," suggested treatment is total parotidectomy, which spares facial nerve (at left). For multiple, isolated recurrent nodules after total parotidectomy, suggested treatment is "berry-picking" removal of nodules, which spares most of branches of facial nerve (at center). For multiple confluent mass of recurrent mixed tumor, suggested treatment is total parotidectomy, including muscle cuff (portions of masseter, sternoclei¬ domastoid, and posterior belly of digastric muscles), tip of mastoid bone, sacrifice of facial nerve, and immediate nerve graft (at right).
ing the portion of the parotid gland and enclosed tumor lateral to the facial nerve elements. This unit is submitted for fro¬ zen-section analysis. It is diagnostic and therapeutic in the vast majority of cases. There are exceptions to this concept of avoiding dissection on or near the tumor capsule. First, if the tumor is located in the isthmus portion of the parotid gland, in
intimate contact with some of the terminal divisions of the facial nerve in the middle third of the face, delicate separation of the nerve from the tumor capsule is required. Second, these tumors may also occasionally occur in the superior part of the parotid gland with extension underneath the zygo¬ ma or toward the malar compound, inti¬ mately associated with the superior divi-
Downloaded From: http://archotol.jamanetwork.com/ by a Penn State Milton S Hershey Med Ctr User on 05/24/2015
sion of the facial nerve; once again, delicate separation of the nerve from the tumor capsule is required. Third, benign tumors of the deep portion of the parotid gland are not readily accessible, have very little surrounding parotid tissue, and are always in intimate contact with the facial nerve. In some instances, a branch of the facial nerve will enter directly into the neoplasm. Rather than macerate the neoplasm in an attempt to save this nerve filament, it is usually advisable to remove the nerve fila¬ ment with the tumor. Cutting a small filament in the middle third of the face usually results in no permanent deficit, due to multiple connectors from one branch to another. Cutting either the frontal or cervical division leaves a permanent paral¬ ysis of the muscles that are supplied by these terminal branches in about 85% of the cases, due to a lack of connectors in these cases.
MATERIAL In a series of 663 primary cases of benign pleomorphic adenoma at the Pack Medical Foundation, New York, two known
have been discovered. One 65 years, refused operation for an apparent recurrence that appeared seven years after the primary operation. The other patient had a solitary recurrence three years after the primary operation; this patient underwent total parotidecto¬ my and has had no evidence of disease for recurrences
patient, aged
eight years. There
were
42
cases
in the referred
secondary recurrent benign pleo¬ morphic adenoma. This group had been operated on elsewhere; these patients ei¬ ther had local resection, total parotidecto¬ my with preservation of the facial nerve, or radical parotidectomy and paraglandular dissection complemented with nerve graft¬ ing (Fig 3-5). It was imperative to check the previous histologie conditions, since three cases originally in this group were reclassified as malignant tumor: one ma¬ lignant mixed, one adenoid cystic, and one low-grade mucoepidermoid. The latter cases had had 16 operations for a so-called benign mixed tumor. Two patients in this group (4.7%) have had another local recur¬ group of
after their definitive treatment, and both of these have been identified since 1974. One patient had had two previous recurrences elsewhere during a 15-year interval for a large tumor in the deep lobe (Fig 6). He underwent radical parotidecto¬ my with immediate nerve grafting. Seven years after this technique, he appeared with another recurrence; there was exten¬ sion of the tumor toward the mesopharynx behind the mandible, and the patient again underwent radical paraglandular dissecrence
tion with immediate nerve grafting. He has been free of tumor for two years. The second patient had a recurrence two years after the previous operation. For the first recurrence, he had undergone total paroti¬ dectomy with lysis of the facial nerve and reapproximation. He had recurrence with¬ in one year and underwent radical para¬ glandular dissection and immediate facial nerve grafting (Fig 7). His tumor extended underneath the zygoma and malar com¬ pound and also into the region of the deep lobe behind the mandible. He has been free of tumor for two years. An analysis of 42 cases indicated that the time interval for recurrence was one to 11 years. Twenty-one patients had one recur¬ rence, eight had two recurrences, six had three recurrences, five had four recur¬ rences, and two had five recurrences. Fifteen patients had a clinically unicentric recurrence, and 27 had multiple foci. In 35 instances, the recurrence was mobile, in five, it was partially fixed, and in two, it was fixed. The position of the primary tumor had some bearing on the recurrence (Fig 8 shows severals areas where tumors might occur). Fifteen of these original neoplasms were located in the lateral lobe, and 16 were in the deep lobe or isthmus. In 11 instances, this information was not available. In 20 cases, the recurrence was primarily in the lateral lobe, eight were in the deep lobe or isthmus, and, in 14, it was in multiple regions. Before the definitive operation, 78% of this group had a normal facial nerve. Twenty-two percent had some mild degree of regional weakness. After the definitive procedure, 29% had a completely normal face, 57% had some regional weakness, and 14% had had radical resection of the nerve and nerve grafting. Some return of movement has developed in all patients in this latter group. The facial nerve was involved in direct proportion to the number of recurrences, the position of the recurrence in respect to the nerve, the size of the recurrence, and the amount of scar tissue.
COMMENT It is obvious that recurrent benign pleomorphic adenoma is a rare occur¬ rence when lateral lobectomy is the surgical technique, and when it is associated with no spillage. The recur¬ rence rate is approximately half of 1%. Recurrences are more likely to occur in very large tumors in the isthmus or deep lobe, or tumors in intimate contact with the facial nerve where the dissection is necessarily capsular in proximation to preserve the integrity of the nerve. A single
recurrence may be handled by simple local resection in certain cases. In¬ deed, in the older age group, one may be justified in observing the recur¬ rence for an indefinite period of time, once the microscopy is firmly estab¬ lished. Unfortunately, the majority of recurrences are multiple, and this automatically predisposes to tradi¬ tional recurrences. In the long perspective, total paroti¬ dectomy with preservation of all or the major portion of the facial nerve is the operation of choice. This technique is tedious and difficult, requires mag¬ nification in most instances, and is usually a piecemeal resection. Recur¬ rent tumors that are confluent and have encased the facial nerve are best managed by total resection of the residuum of the gland, the facial nerve, and paraglandular structures (Fig 9). Approximately 14% will fall into this category. Particular atten¬ tion must be directed to occult exten¬ sions in the region of the deep lobe, mesopharynx, behind the mandible, and underneath the zygoma and malar arches. Immediate nerve graft¬ ing should be part of this technique.
References 1. Krolls SO, Boyers RC: Mixed tumors salivary glands. Cancer 30:276-281, 1972.
of
2. McFarland J: Three hundred mixed tumors of the salivary glands, of which 69 recurred. Surg Gynecol Obstet 63:457-462, 1936. 3. Kirklin JW, McDonald JR, Harrington SW, et al: Parotid tumors: Histopathology clinical behavior and end results. Surg Gynecol Obstet
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