A 52-year-old man presents with a 3-month history of a painless, slow-growing swelling in the right parotid region. On examination, a firm, mobile mass of approximately 2 cm is palpated anterior to the sternocleidomastoid muscle. There is no facial nerve involvement. Fine-needle aspiration cytology (FNAC) shows epithelial cells with myoepithelial components suggestive of pleomorphic adenoma. What is the most appropriate next step in management?

Explanation

## Clinical Context A 52-year-old man presents with a 2 cm painless, slow-growing, firm, mobile mass in the right parotid region with no facial nerve involvement. FNAC confirms pleomorphic adenoma. The question asks for the **most appropriate next step in management**. ## Why Superficial Parotidectomy with Facial Nerve Preservation? **Key Point:** For a cytologically confirmed pleomorphic adenoma of the parotid gland, the standard of care is **superficial parotidectomy with facial nerve preservation** — this is both the diagnostic and therapeutic procedure of choice (Scott-Brown's Otorhinolaryngology; Cummings Otolaryngology). Pleomorphic adenoma: - Does **not** regress spontaneously - Carries a 0.5–2% risk of malignant transformation (carcinoma ex pleomorphic adenoma) that increases with time - Has a pseudocapsule prone to rupture, making enucleation alone inadequate - Requires surgical excision with a cuff of normal parotid tissue to prevent recurrence **High-Yield:** In clinical practice and exam settings, when FNAC has already confirmed a benign parotid tumor in the superficial lobe with no facial nerve involvement, **proceeding directly to superficial parotidectomy** is the accepted next step. Preoperative MRI is **not universally mandated** before parotidectomy for a straightforward superficial lobe pleomorphic adenoma; experienced surgeons routinely identify the facial nerve intraoperatively using anatomical landmarks (tragal pointer, posterior belly of digastric, tympanomastoid suture). ## Why Not the Other Options? | Option | Why Incorrect | |--------|---------------| | MRI before surgery | MRI is useful for deep lobe tumors, recurrent disease, or suspected malignancy — not routinely required for a 2 cm superficial lobe benign tumor confirmed on FNAC; it delays definitive treatment without changing management | | Observation with serial imaging | Inappropriate; pleomorphic adenomas do not regress and carry malignant transformation risk; surgery is indicated once diagnosis is confirmed | | Repeat FNAC | FNAC has already provided adequate diagnostic information; repeating it delays treatment and adds no clinical value; also carries a small risk of tumor seeding | **Clinical Pearl:** The facial nerve is identified and preserved during superficial parotidectomy using standard anatomical landmarks — MRI does not replace surgical skill in nerve identification for routine cases (Cummings Otolaryngology, 7th ed.). **Mnemonic:** **SAFE Surgery** = **S**uperficial parotidectomy, **A**natomical nerve identification, **F**acial nerve preservation, **E**xcision with cuff of normal tissue.