23 Recurrent Malignancy of the Parotid Gland

John P. Leonetti

The surgical management of primary malignant parotid tumors can range from a superficial parotidectomy to advanced lateral skull base resection for transcranial disease.1 The ability to obtain locoregional control of malignant parotid neoplasms is related to the tumor-nodes-metastasis (TNM) stage, histologic grade, facial nerve involvement, and intraoperatively defined tumor extension of local neurovascular, muscular, and bony structures.² Despite meticulous preoperative planning, afggressive tumor ablation, and postoperative radiotherapy, the risk of local or regional malignant parotid tumor recurrence can be as high as 50%.³ The purpose of this chapter is to outline diagnostic and treatment options for patients with locally recurrent malignancies of the parotid gland.

Diagnosis

Follow-up Surveillance

Early detection of parotid gland tumor recurrence may affect the overall outcome in many patients. A clinical evaluation is performed on all patients with malignant disease every 3 months for 2 years and every 6 months for 3 years. A chest x-ray is obtained annually, along with a contrast-enhanced magnetic resonance imaging (MRI) scan of the parotid and neck regions.

Clinical Evaluation

A complete head and neck examination is performed, including bimanual parotid palpation, cranial nerve assessment, and microscopic otoscopy. Referred otalgia may be due to tumor invasion of the auriculotemporal branch of the trigeminal nerve, the tympanic branch of the glossopharyngeal verve, or the auricular branch of the vagus nerve.⁴ A new-onset voice change or swallowing difficulty may signify lower cranial nerve tumor invasion of the jugular foramen.⁵ Hearing loss may be due to tumor occlusion of the eustachian tube with resultant middle ear effusion or external auditory canal tumor involvement. Diploplia and headache suggest skull base erosion and abducens neuropathy due to petrous apex and carotid canal tumor extension.⁶

The most common presentation of locally recurrent parotid malignancy is the presence of a mass in the operated bed or a diffuse fullness between the angle of the mandible and the mastoid tip.⁷ Facial paresis or paralysis in a patient with a history of parotid malignancy must be assumed to be caused by tumor recurrence with or without a clinically apparent mass.⁸

Generalized fatigue, lethargy, weight loss, or peripheral bone pain are potential symptoms of metastatic disease.

Radiographic Assessment

MRI is ideal for evaluating soft tissue, intracranial, and perineural tumor recurrence.⁹ Contrast-enhanced computed tomography (CT) is helpful in the identification of temporal bone, cervical spine, petrous apex, or clival bone erosion.¹⁰ Cerebral angiography and venography are used in patients with suspected jugular foramen tumor invasion.¹¹ Collateral venous return must be demonstrated if recurrent tumor resection requires jugular bulb obliteration or ligation. Failure to identify inadequate collateral venous return could result in life-threatening venous infarction.

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