Conclusion

We have followed a general plan for the routine evaluation and management of an adult patient who presents with a parotid mass, as illustrated in the algorithm depicted in Figure 64-1. For further information on this subject, the reader is referred to two recently published, concise and excellent

History (pain or rapid growth, suggest malignancy)

Physical Exam (facial paresis skin involvement suggest malignancy)

CT scan FNA biopsy

Non-Neoplastic Disease

/

Further E & M as appropriate

Parotid Neoplasm suspected

Further E & M as appropriate

Superficial Lobe Parotidectomy with permanent section histopathology ("Grand Biopsy")

Benign neoplasm

T1 or T2

low-grade malignant neoplasm

T1 or T2 highgrade or

T3, Malignant Neoplasm no extra parotid spread

T4 malignant neoplasm with extraparotid spread

No further treatment (if not a recurrent tumor)

T1 or T2 highgrade or

T3, Malignant Neoplasm no extra parotid spread

T4 malignant neoplasm with extraparotid spread

Figure 64-1 Routine pathway for evalutation and management of a parotid mass in an adult patient.

22.23

REFERENCES

Bailey—CHAPTER 64

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The Parotid Neoplasm

CHAPTER 65

Marshall Strome

Given the remarkable advances during the last decade in our understanding of tumor biology, intracellular ultrastructural aberrations, imaging, radiotherapy delivery, and the synergism of radiotherapy with chemotherapeutic agents, it is remarkable that management controversies facing otolaryngologists 30 years ago remain today for parotid neoplasia. Some issues defy ready resolution in part because prospective data of statistical import are and have been difficult to acquire. It is the rarity and multiplicity of these malignancies that makes the former so. Further, in some instances, accuracy would require a 20-year follow-up period, because of growth characteristics and long intervals before recurrences are identified.

Given the complexities of the diagnosis and management of malignant parotid tumors, differences of opinion are both understandable and inevitable. Questions legitimately disputed are the efficacy and indications for fine-needle aspiration biopsy (FNAB), imaging technology, nerve monitoring, frozen section, surgical extent, facial nerve sacrifice, the use of radiotherapy, and chemotherapy. Classic articles are reviewed in virtually all book chapters and recent articles, with some presenting raw data for reader interpretation, others suggesting a format for management. My approach is to define the issues, followed by a personal philosophy based on an extensive experience with parotid neoplasia.

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