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Observation
March 26, 2020

Fluctuant Facial Mass

Author Affiliations
  • 1Rutgers New Jersey Medical School, Department of Otolaryngology – Head and Neck Surgery, Newark, New Jersey
JAMA Otolaryngol Head Neck Surg. Published online March 26, 2020. doi:10.1001/jamaoto.2020.0240

Facial varices are abnormally dilated and tortuous veins usually caused by weakening of the venous wall or obstruction distally from the area of the dilated vein.1 The standard treatment modality for these facial varices is surgical resection.2 Historically this was done through an open surgical approach; however, there is risk to the facial nerve using this method. Here we demonstrate the first report to our knowledge of a transoral endoscopic approach to a facial varix resection, which provides considerably less risk of injury to the facial nerve.

Report of a Case

A woman in her 60s with no significant medical history presented with a more than 10-year history of intermittent left-sided facial swelling associated at times with considerable pain. The patient reported an increase in the size of the swelling when she bent her head downward. She had a palpable soft mass in the left cheek that felt intraorally adjacent to the angle of the mandible. A computed tomographic scan with contrast revealed a facial varix in the left buccal space (Figure 1). The decision was made to take the patient to the operating room for surgical excision via a transoral endoscopic approach.

Figure 1.  Computed Tomographic Image With Contrast of the Neck
Computed Tomographic Image With Contrast of the Neck

The red box indicates the left-sided facial varix.

A 0° rigid nasal endoscope was used throughout the entire procedure. The approach was begun by making an intraoral incision over the palpable area of the varix. The assistant provided lateral traction on the buccal mucosa, and dissection using blunt instrumentation or bipolar cautery proceeded laterally through the buccinator until the buccal fat pad was reached. The facial varix and the long buccal nerve were then identified medial to the buccal fat pad (Figure 2). To prevent facial nerve injury, dissection remained medial to the facial varix and the facial artery. In this case, the long buccal nerve had to be sacrificed owing to close adherence to the varix. The varix was then isolated from the facial vein and artery, clips were applied to the tributary to the facial vein and to the proximal portion of the varix, and the varix was then removed in its entirety.

Figure 2.  Endoscopic Intraoral Approach to the Left Facial Varix
Endoscopic Intraoral Approach to the Left Facial Varix

A, Initial view of the varix immediately after incision and superficial dissection. The black arrowhead indicates the varix. B, Intraoperative view during dissection of the varix. The black arrowhead points to the long buccal nerve. The white arrowhead indicates the varix. C, Postoperative view after resection of the varix. The blue arrowhead indicates the facial vein into which the varix was draining.

Discussion

The differential diagnoses of a soft, mobile mass overlying the mandible include parotid lesions, lymphatic masses, cysts, and vascular lesions.2 In this case, the patient had the turkey wattle sign, which is changes in the size of the mass with bending of the head downward, a characteristic finding for a facial varix.2 Imaging also revealed a dilated and tortuous vascular structure, thus most likely ruling out a solid mass such as a parotid or cystic lesion.

Open surgical approaches were routinely done in the past owing to excellent exposure and ability to excise the varix in its entirety thus minimizing recurrence.2 However, there is significant risk for injury to the facial nerve owing to the close proximity to the varix of the facial vein.2

For this patient, we approached the facial vein varix through an intraoral incision and endoscopically resected and ligated the lesion. To our knowledge, this is the first report of an endoscopic resection of a facial varix. Open resection uses a face lift incision through the skin and requires meticulous dissection of the facial nerve in to fully excise the facial vein varix. Approaching the lesion through an intraoral incision provides significant benefits in terms of protecting the facial nerve, owing to avoidance of dissecting in its proximity, and cosmetically, owing to avoidance of a skin incision.

An endoscope is required for most of the procedure owing to deep dissection resulting in acute angles intraorally. This prevents discrete visualization of important structures such as the long buccal nerve, which is lateral throughout the procedure, and tributaries of the facial varix itself.

There is a sensory nerve that is encountered during this approach called the long buccal nerve, which is a distal branch of the mandibular division of the trigeminal nerve.3-5 It provides sensory input to the buccal mucous membrane, the skin of the cheek, and the second and third molars.3-5 It passes between the lateral pterygoid heads, then inferior to the temporalis tendon running along the lateral aspect of the buccinator muscle and then provides branches to the buccal mucous membrane.3-5 The nerve can be differentiated from branches of the facial nerve by how it runs in a superior-to-inferior direction and how it is medial to the buccal fat pad and the facial artery and vein. Although the nerve should be preserved whenever possible, it may also be sacrificed, as in this case, with minimal sensory deficits to the patient. Of note, the long buccal nerve can anastomose with the buccal branch of the facial nerve as well.

Conclusions

Postoperatively the patient did not have any signs of facial weakness and had minimal sensory deficits involving the left buccal mucosa, thus suggesting a surgical method for resection of these facial varices while protecting the facial nerve. The intermittent left-sided facial swelling did not return and the patient had no further recurrence of the varix.

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Article Information

Corresponding Author: Peter Ashman, MD (pea31@njms.rutgers.edu), and Boris Paskhover, MD (borpas@njms.rutgers.edu), Rutgers New Jersey Medical School, Department of Otolaryngology–Head and Neck Surgery, 90 Bergen St, Ste 8100 Newark, NJ 07103.

Published Online: March 26, 2020. doi:10.1001/jamaoto.2020.0240

Conflict of Interest Disclosures: None reported.

References
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