Parotid pilomatrixoma: Diagnostic trap and management dilemma

Introduction. Pilomatrixoma is a benign cutaneous adnexal neoplasm originating from the matrix cells of the hair follicles. Usually a slow growing and painless lesion, it must be considered in differential diagnosis of a preauricular swelling. Rapidly progressive lesion with skin fixity and missed subtle cytological features may lead to a misdiagnosis of parotid neoplasm resulting in management dilemma. Aim. This report emphasizes consideration of pilomatrixoma as a differential diagnosis in a similar clinical scenario, the role of frozen section during surgery and fascia lata interposition to prevent Frey’s syndrome. A brief review of literature is presented. Description of the case. We present a similar dilemmatic case of a 19 years old male with preauricular swelling. Based on cytology and image findings, a diagnosis of parotid neoplasm with possible malignancy was made. Surgical exploration revealed primarily a subcutaneous lesion with partial attachment to superficial surface of parotid. Lesion was excised with a cuff of normal parotid tissue. Frozen section confirmed it to be a nonmalignant lesion with possibility of pilomatrixoma. Fascia lata was interposed between parotid and thin skin flap to avoid gustatory sweating. Patient is on follow up for 6 months without recurrence or any complication. Conclusion. Pilomatrixomas can be misdiagnosed in case of lesions in subcutaneous plane in parotid region. In such cases, the differential diagnosis should include tumor and non-tumor lesions of skin and parotid gland. Importance of frozen section should also be kept in mind and the pathologist should be engaged at the time of surgical excision of the tumor. Interposition of soft tissue between parotid and thin skin flap helps prevent gustatory sweating in such cases. A high index of suspicion is needed for proper diagnosis and management of these lesions.

Parotidectomy

When a patient presents with a mass at the angle of the mandible, a neoplasm within the parotid gland is a strong consideration. The parotid is the largest of the salivary glands. Terminal branches of the facial nerve are found within the gland. Their functional preservation is an important goal of parotid surgery. Risks of facial nerve injury rise in reoperative procedures and resection of cancers. Surgical principles apply in parotidectomy. In addition to facial nerve injury, a numb earlobe, contour deficit, salivary fistula, and gustatory sweating should be discussed with the patient before an operation. Most lesions can be removed after identification of the main trunk of the facial nerve, but a retrograde approach after finding a peripheral branch may be required. No randomized trials support a benefit from nerve monitoring. An intact facial nerve will usually begin to function, but months of recovery time may be needed. Permanent paralysis is rare. Salivary fistulae are usually self-limited. Many methods to ameliorate the cosmetic changes after parotidectomy have been described. None has gained ascendency. This review contains 6 figures and 61 references. Key words: facial nerve, facial paralysis, Frey syndrome, gustatory sweating, nerve monitoring, parotid gland, parotid neoplasm, parotidectomy, salivary fistula

R3 versus R4 Thoracoscopic Sympathectomy for Severe Palmar Hyperhidrosis

Background Thoracoscopic sympathectomy (TS) was the preferred surgical treatment for palmar hyperhidrosis (PH), but postoperative complications such as compensatory sweating (CS) were common. This study was projected to compare R3 versus R4 TS for treating severe PH. Methods From April 2009 and March 2015, 106 consecutive patients with severe PH underwent bilateral R3 (n = 62) or R4 (n = 44) TS at The Second Affiliated Hospital of Nanchang University. The patients were followed up to evaluate symptom resolution, postoperative complications, satisfaction level, and severity of CS. Results The 106 patients underwent 212 sympathecotomies and were cured with no severe complications or perioperative mortality. The incidence of minor side effects (such as pneumothorax, gustatory sweating, moist hands, and bradycardia) was similar in both groups. More patients had overdry hands in the R3 group than in the R4 group (6/62 vs. 0/44; p = 0.040). More CS occurred in the R3 group as compared with the R4 group (42/62 vs. 23/44; p = 0.156). The incidence of moderate-to-severe CS was higher in the R3 group than in the R4 group (14/62 vs. 4/40; p = 0.045). Most patients were satisfied with the results, except for three (5.84%) in the R3 group and one (2.27%) in the R4 group. Conclusion PH can be effectively treated by either R3 or R4 TS, with high rates of patient satisfaction. R4 sympathectomy appears to be associated with less severe CS and should be the choice of denervation level.