PMC3638544_01
Anterior (a) and lateral (b) pictures of the patient at presentation. Axial (c) and coronal (d) CT scan images of the primary tumor. Note extension of the tumor into the parapharyngeal space with occlusion of the jugular vein (black arrowhead) and skull base involvement (white arrowhead).
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She presented again to the head and neck surgery clinic one year later with significant interval growth of the mass and a partial right facial paresis (Figures 1(a) and 1(b)). A CT scan demonstrated a 11.2 x 9.4 x 10.7 cm mass centered in the right parotid effacing the jugular vein and abutting the mandible and skull base with extension along the facial nerve to the geniculate ganglion (Figures 1(c) and 1(d)).
Intraoperative photographs demonstrating the radical parotidectomy with facial nerve sacrifice (a and b). (a) The large arrowhead indicates the divided jugular vein. (b) The single arrowhead (white) again marks the divided jugular vein, the double arrowhead (white) indicates residual tumor at the jugular foramen, and the black arrowhead indicates the divided end of the accessory nerve that was grafted to a cervical rootlet. (c) Temporal bone resection with surgicel occluding the sigmoid sinus (white arrowhead) and a fascia and muscle plug occluding the eustachian tube (black arrowhead). Demonstration of the primary tumor (d) and reconstruction with a large cervicofacial advancement flap and radial forearm free flap ((e) arrow marks forearm flap skin paddle).
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fig2
She was taken to the operating room and underwent a radical parotidectomy with facial nerve sacrifice, radical neck dissection, parapharyngeal space resection, and lateral temporal bone resection (Figures 2(a), 2(b), and 2(c)). Gross tumor removal was accomplished (Figure 2(d)). The defect was reconstructed with a large cervicofacial rotation flap and a radial forearm free flap (Figure 2(e)).
Axial CT scan images of the thorax (panels (a) and (b)) demonstrating the interval development of pulmonary metastases (arrowheads).
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Follow-up imaging one year after treatment revealed no evidence of local or regional recurrence; however, there was interval development of multiple new bilateral lung nodules up to 0.9 cm highly suspicious for metastases (Figures 3(a) and 3(b)).