POSTOPERATIVE
DIAGNOSIS: Right parotid mass.
PROCEDURE:
Right superficial and deep lobe parotidectomy with complete facial nerve
dissection, continuous facial nerve monitoring, and layered wound closure.
ANESTHESIA:
General.
COMPLICATIONS: No
complications.
ESTIMATED
BLOOD LOSS: 10 mL
DESCRIPTION OF THE PROCEDURE: The patient was taken to the
operating room and placed supine on the operating room table. General anesthesia was induced via an
endotracheal tube to facilitate facial nerve monitoring. No paralysis was used throughout the
case. The head of bed was turned to 90
degrees and a shoulder roll was placed under the patient. The modified Blair incision was marked with a
marking pen and was injected with 1% lidocaine with 1:100,000 epinephrine. The patient was then prepped and draped in
the standard fashion. The incision was
made with a #15 blade down to the preparotid fascia. An anterior flap was elevated in the plane
just above the preparotid fascia.
Elevation continued anteriorly all the way until the anterior border of
the parotid and inferiorly down to the inferior border of the parotid. Posteriorly, elevation was performed until
the anterior border of the sternocleidomastoid muscle was clearly skeletonized
all the way toward the mastoid tip. The soft
tissue was then carefully dissected bluntly off the external auditory canal
until the tragal pointer could be identified.
Anterior to the anterior border of the sternocleidomastoid muscle, the
digastric was identified and was followed up towards its insertion in
the mastoid bone. Using the tragal
pointer and the digastric muscle as our landmarks, dissection was bluntly
performed in the area of the sternomastoid foramen. All fibers were carefully stimulated with the
nerve stimulator to make sure that they were not the facial nerve. This was performed into the facial nerve itself. Main trunk was identified. Stimulation confirmed firing of all branch
and again this was in fact the nerve, with the nerve identified, it was
carefully dissected anteriorly along all of its branches in the following
fashion. The nerve was bluntly dissected
over the nerve itself. The soft tissue
over the nerve was elevated keeping the nerve carefully in mind. It was cauterized with a bipolar and then
transected with a #12 blade. This was
performed along the inferior branches of the main trunk including both the
branch to the marginal mandibular as well as to the orbicularis. Both of these branches were noted to be
inferior to the level of the parotid mass itself. Attention was then turned to the mid portion
of the nerve extending to the buccal area.
This was noted to transverse the mass itself and actually head in and
through the parotid mass which was consistent with a lymphangioma. Dissection was carefully performed through
the lymphangioma following the nerve until its anterior most aspect where it
exited the parotid gland and started to insert towards the muscles. Attention was then turned towards the
superior branches, towards the forehead, and eye. These branches were noted to be stilling
having the parotid parenchyma, but above the lymphangioma mass itself. Once these were followed superiorly, the
parotid tissue medially superficial to it was divided and superficial lobe of
the parotid was sent off to pathology on block as a specimen. The wound was then copiously irrigated and
hemostasis was confirmed. There was
noted to be marked lymphangiomatous tissue in the midportion of the gland just
under the upper branch of the facial nerve.
That portion of the nerve was carefully dissected off the parotid
lymphangioma deep to it and the vein retractor was placed underneath the
nerve. The nerve was retracted very
gently inferiorly allowing access to the deep lobe lymphangioma
mass. The lymphangioma could be
palpated and was noted to be sitting right against the ramus of the
mandible. Rather than resecting the mass
completely and risk of further injury to the surrounding structures, the
lateral surface of the deep part of the lymphangioma was carefully divided with
bipolar electrocautery keeping the facial nerve branches in view at all times and
ensuring they were not injured. The
lymphangioma was thereby unroofed in its deep lobe leaving just a single layer
of lymphangioma wall along the medial most aspect of the parapharyngeal space
to scar down on its own. The wound was then again copiously irrigated. Hemostasis was confirmed. A TLS suction drain was passed through the
stab incision posterior to the wound and laid in the inferior aspect of the
parotid bed cavity. The deep tissues
were closed using interrupted 4-0 chromic suture and the skin was closed using
5-0 fast-absorbing suture followed by a layer of Mastisol and
Steri-Strips. Suction dressing, had
suction applied, and a dry compression dressing was applied. The patient was reversed from the anesthesia
where the face was noted to move postoperatively and was taken back to recovery
room in stable condition. I do note that
before the wound was closed but after it was irrigated, the facial nerve
monitor was again used to stimulate the facial nerve about its trunk and all
the branches stimulated.
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