A 52-year-old man presents with a 6-month history of progressive swelling in the right parotid region. On examination, there is a firm, fixed mass measuring 3 cm in the superficial lobe of the parotid gland. The overlying skin appears normal. He denies facial nerve involvement. Fine-needle aspiration cytology (FNAC) shows pleomorphic adenoma. What is the most appropriate management?

Explanation

## Diagnosis and Management of Parotid Pleomorphic Adenoma **Key Point:** Pleomorphic adenoma (mixed tumor) is the most common benign parotid tumor, accounting for 60–80% of parotid neoplasms. FNAC confirmation of benign pathology allows conservative surgical planning. ### Surgical Approach for Superficial Lobe Pleomorphic Adenoma **High-Yield:** The standard of care for benign parotid tumors confined to the superficial lobe is **superficial parotidectomy with facial nerve preservation**. This approach: - Removes the tumor with adequate margin (lateral to the facial nerve plane) - Preserves all branches of the facial nerve - Minimizes recurrence risk (< 5% with proper technique) - Avoids unnecessary sacrifice of functional nerve ### Anatomical Basis The facial nerve divides the parotid gland into superficial and deep lobes. Tumors in the superficial lobe (lateral to the nerve) can be safely removed without nerve sacrifice. The nerve is identified using anatomical landmarks (posterior belly of digastric, tragal pointer) and electrophysiological monitoring. ### Why Superficial Parotidectomy? | Feature | Superficial Parotidectomy | Total Parotidectomy | |---------|---------------------------|---------------------| | **Indications** | Superficial lobe tumors, benign pathology | Deep lobe tumors, malignancy, recurrent disease | | **Facial nerve** | Preserved | May be sacrificed if involved | | **Morbidity** | Lower (temporary weakness 20–30%) | Higher (permanent paralysis if nerve sacrificed) | | **Recurrence** | 2–5% | 1–3% | **Clinical Pearl:** Pleomorphic adenomas have a risk of malignant transformation (< 5% over 20 years). Delayed presentation or rapid growth may warrant preoperative imaging (MRI/CT) to assess for deep lobe extension or malignant features. ### Preoperative Imaging MRI is the gold standard for: - Confirming superficial vs. deep lobe location - Assessing facial nerve involvement - Ruling out multifocal disease **Tip:** FNAC showing pleomorphic adenoma with normal facial nerve function and superficial location = superficial parotidectomy is curative and definitive.