Neck Management

There can be no argument as to the need for nodal removal in the clinically positive neck. For the N0 neck, tumor size and/or stage, histology (squamous cell carcinoma), grading (highgrade mucoepidermoid carcinoma), and facial nerve paralysis (60 to 77%) suggest occult metastasis. For the latter group, ultrasound may identify adenopathy in the clinically N0 neck and subsequent ultrasound-guided FNAB of identified adenopathy would provide additional meaningful data. If the FNAB was positive, this would obviously lend support for lym-phadenectomy. If there is no clinical evidence preoperatively of nodal spread in these high-risk pathologies, I sample readily identifiable level I and intraparotid nodes. If frozen section is negative, no further nodal removal is performed. If positive, levels I to III are cleared, with the lowest nodes in level III submitted for frozen section. The latter algorithm would appear to decrease morbidity, while maximizing efficacy.

Having proposed the latter, to my knowledge, no data are available confirming that removal of microscopic disease confers a survival advantage in aggressive parotid neoplasms, as virtually all are managed with postoperative radiotherapy. However, the approach espoused provides prognostic information potentially identifying and clearing microscopic disease. Although unsubstantiated, it is my bias that removal of microscopic disease could confer a survival advantage with little or no associated morbidity.

Low-grade malignancies of <4 cm in size in most instances require no neck nodal sampling. Intraparotid nodes >1 cm, if identified, are submitted for frozen section at surgery, as low-grade tumors infrequently will be found to have intraparotid nodal spread requiring then and only then a total parotidectomy.

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