A young boy presented with a 4-week history of an enlarging right facial mass, which had not responded to a course of azithromycin prescribed by his pediatrician. He had a history of asthma, chronic otitis media with effusion, and obstructive sleep apnea and had undergone 3 sets of tympanostomy tubes and an adenotonsillectomy. He had no history of fevers or other constitutional symptoms. Physical examination demonstrated a 3-cm firm and tender right parotid mass. Clear saliva could be expressed from the Stensen duct. A computed tomographic (CT) scan was performed, showing a discrete 2 × 2-cm necrotic mass in the right parotid gland (Figure, A). A fine-needle aspirate (FNA) yielded a cellular sample with spindloid features, suggesting a neoplasm of uncertain subtype. A broad differential diagnosis was raised, including both benign and malignant salivary neoplasms. Per recommendation of the head and neck multidisciplinary tumor board, the patient underwent total parotidectomy and neck dissection because the mass was grossly infiltrative of the parotid, and several enlarged level IB and II lymph nodes were observed at the time of surgery. The mass was shaved off the marginal mandibular branch of the facial nerve because it was adherent to it. Permanent histopathologic images showed normal parotid gland architecture effaced by confluent granulomata with Langhans-type giant cells and central necrosis (Figure, B). Additional studies, including flow cytometry and tissue cultures, were obtained.
Joshua P. Weiss, Peter A. Drew, Peter T. Dziegielewski. Aggressive-Appearing Pediatric Parotid Mass. JAMA Otolaryngol Head Neck Surg. Published online October 26, 2017. doi:10.1001/jamaoto.2017.1925