consider salivary gland sx

8/6/2019 Consider Salivary Gland Sx

1/7

T R E A T M E N T C O N S I D E R A T I O N S IN S A L I V A R YG L A N D S U R G E R YM I C H A E L F R I E D M A N , M D , E L L I O T A B E M A Y O R , M D , P h D ,E U G E N E N . M Y E R S , M D , R O N A L D H . S P I R O , M D

W e a s k e d t h e t h r e e e x p e r t s n a m e d i nt h e b y l i n e o f t h i s a r t i c l e t o p r o v i d et r e a tm e n t r e c o m m e n d a t i o n s i n f iv ec a s e s o f p a r o t i d t u m o r . I b e l i e v e t h e i rv a r y i n g p e r s p e c t i v e s p r o v i d e i n t e r -e s t i n g i n s i g h t i n t o t h e " s t a t e o f t h ea r t " in a p p r o a c h e s t o p a r o t i d s u r -g e r y . Michael Friedman, MD, Editor

C A S E 1A 4 9 - y e a r -o l d m a n p r e s e n t s w i th as l o w l y e n l a r g i n g l e f t p a r o t i d t u -m o r . T h e s e v e n t h n e r v e i s i n t a c t .P r e o p e r a t i v e C T s h o w s a m a s s i nt h e s u p e r f i c i a l l o b e e x t e n d i n g t ot h e d e e p l o b e a n d i n v o l v i n g t h es k i n . T h e r e i s n o c e r v i c a l a d e n o p a -t h y .

N o f i n e - n e e d l e a s p i r a t i o n i s p e r -f o r m e d . T h e p a t ie n t u n d e r g o e s t o -t a l p a r o t i d e c t o m y w i t h o u t n e c k d i s -s e c t i o n . T h e s e v e n t h n e r v e i s n o ti d e n t i f i e d d u r i n g s u r g e r y . P a t h o -l o g i c a l e x a m i n a t i o n s h o w s p o o r l yd i f f e r e n t i a t e d m u c o e p i d e r m o i dc a r c i n o m a .

A f t e r s u r g e r y , t h e p a t i e n t e x p e r i -e n c e s c o m p l e t e i p s i l a t e r a l f a c i a lp a r a l y s i s . A r e p e a t e d C T s c a n p e r -f o r m e d 1 m o n t h a f t er s u r g e r y

From the Dep artment of Otolaryngolog y andBronchoesoph agology, Rush Medical College,Rush-Presbyterian-St. Luke's Medical Center,Chicago, IL; the Div is ion of Hea d and NeckSurgery, UC LA Schoo l of Medic ine, LA; theDepartment of Otolaryngology, University ofPit tsburgh Schoo l of M edic ine Eye and EarInsti tute; and the He ad and N eck Serv ice,Mem orial Sloan-Ke ttering Cance r Center, NY.Address reprint requests to Michael Fried-man, MD, Department of Otolaryngology andBronchoesop hagology, Rush-Presbyterian-St.Luke's Med ical Center , 1653 W CongressPkwy, Chicago, IL 60612.Copyright 1996 by W.B. Saunders Com-pany1043-1810/96/0704-0014505.00/0

s h o w s r e s i d u a l t u m o r e x t e n d i n gt o t h e s u r f a c e ( F i g 1 ) .

Q u e s t i o n sS h o u l d t h e p a t i e n t u n d e r g o s u r -g e r y , r a d i a t io n , o r b o t h ? I f s u r g e r y ,s h o u l d t h e p r o c e d u r e i n c l u d e s k inr e s e c t i o n ? H o w s h o u l d t h e s k i n b er e s u r f a c e d ? S h o u l d n e r v e r e s e c -t i o n , w i t h o r w i t h o u t a n e r v e g r a f t ,b e d o n e ? I f r a d i a t i o n , s h o u l d n e u -t r o n r a d i a t i o n b e u s e d ?D r A b e m a y o r : T h i s p a t i e n t p o s e s ad i ff ic u l t d i l e m m a . T h e p o s t o p e r a t i v ef a c ia l p a r a l y s i s i s li k e l y d u e t o i a t r o -g e n i c i n j u ry . I n a d d i t i o n , t h i s p a t i e n th a s b e e n i n a d e q u a t e l y t r e a t e d w i t hg r o s s t u m o r s t i l l p r e s e n t . T h e i s s u e sw i t h t h i s p a t i e n t a r e t h e f o l l o w i n g :( 1 ) w h a t i s t h e b e s t w a y t o a c h i e v eo p t i m a l l o c o r e g i o n a l c o n t r o l o f d is -e a s e ? ; a n d ( 2 ) h o w c a n w e r e h a b i l i -t a t e t h is p a t i e n t a t t h e s a m e t i m e ?

T h e b e s t h o p e f o r tu m o r c o n t r o l o rc u r e i s r e m o v a l o f g r o s s d i s e a s e f o l -l o w e d b y r a d i a t i o n t r e a t m e n t . T h i sp a t i e n t n e e d s a r a d i c a l p a r o t i d e c -t o m y , l a t e r a l t e m p o r a l b o n e r e s e c -t io n , a n d a r i g h t m o d i f i e d n e c k d i s-s e c t i o n . H i s f a c i a l p a r a l y s i s i s o f 1m o n t h ' s d u r a t i o n , s o e l ec t ri c al s ti m u -l a t io n o f t h e p e r i p h e r a l b r a n c h e s isn o t p o s s i b le . T h e r e f o r e , I w o u l d b e -g i n w i t h a n a n a t o m i c d i s s e c t io n o ft h e p e r i p h e r a l b r a n c h e s o f th e f a c ia ln e r v e t a g g i n g t h e e y e , b u c c a l , a n dm a r g i n a l b r a n c h e s . A f t e r th i s , I w o u l dp e r f o r m a m a s t o i d e c t o m y a n d i d e n -t i f y t h e f a c i a l n e r v e i n i t s d e s c e n d i n gp o r t i o n a n d t r a c e i t t o i t s e x i t a t t h es t y l o m a s t o i d f o r a m e n . F r o z e n - s e c -t i o n c o n t r o l o f t h e f a c i a l n e r v e f o r t h ep r e s e n c e o f t u m o r i s p e r f o r m e d . F o l -l o w i n g n e g a t i v e m a r g i n s , I w o u l d

p e r f o r m a l a te r a l t e m p o r a l b o n e r e -s e c ti o n a n d r a d ic a l p a r o t i d e c t o m ye n c o m p a s s i n g t h e s u p e r f i c i a l l o b e ,d e e p l o b e , a n d t h e f a c i a l n e r v e i t s e lf .I n t e r p o s i t i o n a l c a b l e g r a f t s a r e t h e ni n s e r t e d b e t w e e n t h e r e m a i n i n g t r u n ko f t h e f a c ia l n e r v e a n d t h e p e r i p h e r a lb r a n c h e s p r e v i o u s l y t a g g ed . T h e b e s ts o u r c e f o r t h e c a b l e g r a f t s a r e t h es e n s o r y n e r v e s f o u n d a t t h e i n f e ri o rp o r t i o n o f th e n e c k o r, a s e c o n dc h o i ce , th e s u r a l n e r v e . A g o l d w e i g h tw o u l d b e p l a c e d t o p r o t e c t t h e e y es i n c e , u n ti l , a n d i f, f u n c t i o n r e t u r n s ,t h e e y e i s a t r i s k f o r i n j u r y . A m o d i -f ie d n e c k d i s s e c t i o n is p e r f o r m e db o t h f o r t re a t m e n t a n d s t a g in g . Iw o u l d a l so r e m o v e t h e s k i n o v e r l y -i n g t h e t u m o r a n d e x c i s e i t i n c o n t i n u -i t y w i t h t h e p a r o t i d e c t o m y . C l o s u r eo f t h i s d e f e c t i s b e s t a c c o m p l i s h e dw i t h a p e c t o r a l - c e r v i c a l - f a c i a l r o t a -t i o n f l a p .

I w o u l d r e c o m m e n d p o s t o p e r a t i v er a d i a t i o n b e c a u s e t h i s i s a p o o r l yd i f f e r e n t ia t e d l e s i o n w i t h a v i o l a t e dt u m o r b e d . T h e l o c o r e g i o n a l c o n t r o lr a t e w o u l d b e i n c r e a s e d w i t h e x t e r -n a l b e a m r a d i o t h e r a p y u s i n g c o -b a l t- 6 0 w i t h a n e l e c tr i c b e a m b o o s t t oa b o u t 6 0 G y . B e c a u s e t h i s i s a p o o r l yd i f f e r e n t ia t e d le s io n , a n y a d d e d a d -v a n t a g e o f u s i n g n e u t r o n b e a mt h e r a p y i s d o u b t f u l .

R E F E R E N C E1. Tra n L, Sadegh i A, Hanson DG, et al: Majorsal ivary g land tumors: T reatment resultsand prognostic factors. Laryngoscope 96:1139-1144, 1986

D r M y e r s : T h e r e a re s e v e r a l f l a w s int h e in i ti a l m a n a g e m e n t o f th i s p a -t ie n t. T h e m o s t o u t s t a n d i n g is th a tt h e re w a s n o d i a g n o s i s m a d e b e f o r es u r g e ry . I f a t u m o r i n v o l v e s t h e d e e p

OPERATIVE TECHNIQU ES IN OTOLARYNG OLOGY --HEAD AND NEC K SURGERY, VOL 7, NO 4 (DEC), 1996: PP 377-383 377


2/7

lobe and skin, one would have tosuspect the presence of a malignanttumor. The dissection was clearlyinadequate because 1 month aftersurgery, residual tumo r is noted. Anerror in judgment/technique resultedin injury to the facial nerve. Whetherthis nerve has been resected or beeninjured in some other procedure is un-clear.In my opinion, this patient shouldunderg o radical surgery and postop-erative adjunctive radiati on therapy.Several issues should be addressed.

Adeq uacy of resection. This sur-gery must include the residual tu-mor a nd the overlying skin, the mas-seter muscle, the periosteum of themandible, the anterior cartilaginousexternal auditory meatus, the ante-rior aspect of the superior portion ofthe sternocle idomastoid muscle, andthe posterior belly of the digastricmuscle. A modified radical neck dissectiontype 1 should be performed. The inci-dence of cervical lymph node metas-tasis in patients with high-grade mu-coepidermoid carcinoma is higherthan in any other malignant tumor ofsalivary gland origin. Several types of reconstruction mustbe performed. The choices in order ofmy own preference would be thefollowing:

FIGURE 1.

Cervical-pectoral rotation flap(this woul d give the best colormatch and restore somebulk).Rectus abdominis free flapwith split-thickness skin graftwould provide bulk for con-touring, but would be a poorcolor match.Facial nerve. The facial nerveshould be resected with themain specimen. A mastoidec-tomy should be performed inorder to ide ntify the descend-ing portion of the facial nerve.Frozen-section should be per-formed on the proximal resec-tion margin of the nerve.Once adequate tumor clear-ance of the nerve has beenachieved, a sural nerve graftor a graft taken from C4 (cer-vical plexus) should be usedas a free graft. An effortshould be made to identifythe peripheral branches of thefacial nerve, although 1mont h after surgery, this maybe very difficult to do be-cause the nerves may notfunction even wi th electricalstimulation. If the branchescan be identified, then thenerve graft should be anasto-mosed with the peripheralbranches. If no branches can

be identified with certainty,then the nerve graft shouldbe placed into the frontalismuscle of the orbicularis oculimuscle and the orbicularisoris muscle.A fascia lata sling would pro-vide for a straight commis-sure in the event that nervegrafting was not performed,but is a poor second choice inmy opinion. A gold weightshould be placed in the up-per eyelid to provide ad-equate eye closure whetheror not the ne rve can be recon-structed.The patient should receive postop-erative adjunctive radiation therapyin order to neutralize the effect ofcervical lymph node metastasis, fa-cial nerve involvemen t and soft tis-sue extension, all of which are "ag-gressive" pathological findings.Neutron radiation has been shownto be useful in salivary gland tumors;however, there are only a few centersin this country in which this therapyis available and, although this treat-ment has been found to be effica-cious, it may not be practical.

Dr Spiro: In the absence of specificinformation, I assume that this pa-tient had undergone a total parotidec-tomy wit h uni ntentional facial nerve

3 7 8 DIFFICULT DECISIONS


3/7

i n j u r y o r t r a n s e c t i o n . E x p e r i e n c e ds u r g e o n s m a y u n d e r t a k e a s u b t o t a lp a r o t i d e c t o m y i n a c l in i ca l ly o b v i o u ss e t t in g w i t h o u t a p r e o p e r a t i v e n e e d l ea s p i r a t i o n b i o p s y ( F N A B ) , b u t a h i s -t o l o g i c a l d i a g n o s i s i s e s s e n t i a l ( e i -t h e r p r e o p e r a t i v e F N A B o r i n t r a o p -e r a t i v e f r o z e n s e c t io n ) w h e n t h ef i n d i n gs s u g g e s t t h a t t h e p a t i e n t m a yr e q u i r e a m o r e e x t e n s i v e p r o c e d u r ew i t h g r e a t e r r i s k t o t h e f a c ia l n e r v e .T h e h i g h l y a g g r e s s i v e c o u r s e i n t h i sc a s e ( ie , o b v i o u s r e c u r r e n c e w i t h i n 1m o n t h ) i s u n u s u a l e v e n f o r p o o r l yd i f f e re n t i a te d m u c o e p i d e r m o i d c a rc i-n o m a . I t i n d i c a t e s t h a t g r o s s r e s i d u a lt u m o r r e m a i n e d a f t e r i n a d e q u a t e i ni -t i a l s u r g e r y , a m o s t u n h a p p y p r o b -l e m w h i c h i s l i k e l y t o d e f e a t a l ls u b s e q u e n t e f f o r ts a t s a l v a g e .

I f t h e r e c u r r e n c e i s d e e m e d r e s ec t -a b l e , t h i s p a t i e n t ' s b e s t c h a n c e f o rs a l v a g e w o u l d s e e m t o b e a d d i t i o n a ls u r g e r y f o l l o w e d b y p o s t o p e r a t i v er a d i a t i o n t h e r a p y ( R T ) . T h e d e c i s i o nw h e t h e r t o s a c r i f i c e o v e r l y i n g s k i nm u s t b e b a s e d o n cl inical e v i d e n c e o fd e r m a l i n v a s i o n. M y p r e f e r e n c e f orr e s u r f a c i n g i s a l a r g e c e r v i c a l r o t a -t i o n / a d v a n c e m e n t f la p , t h e i n c is i o nf o r w h i c h i s c a r r i e d a s f a r i n f e r i o r l yo n t h e a n t e r i o r c h e s t w a l l a s n e c e s -s a r y t o a l l o w t h e f l a p t o r e a c h t h es k i n d e f e c t . I s o la t i o n o f p r o x i m a l a n dd i s t a l fa c i a l n e r v e b r a n c h e s 1 m o n t ha f t e r a " t o t a l " p a r o t i d e c t o m y i s li k e l yt o b e a f r u s t r a t i n g e x e r c i s e w i t h v e r yl i m i t e d p r o s p e c t f o r g o o d f u n c t i o n a lr e s t o r a t i o n b y n e r v e g r a f t i n g . I t h i n ki t w o u l d b e m o r e r e a s o n a b l e t o ig -n o r e t h e f a c i a l n e r v e d u r i n g t h e s e c-o n d p r o c e d u r e , a n d i n s e r t a g o l dw e i g h t i m p l a n t a t t h e s a m e s i t t i n g .A d d i t i o n a l p r o c e d u r e s f o r d y n a m i cs u p p o r t c a n b e c o n s i d e r e d l a t e r i fl o c o r e g i o n a l c o n t r o l is a c h i e v e d .

R e c o g n i z i n g t h a t r e s e c t a b i l i t y c a nb e h a r d t o as s e s s, i t w o u l d b e w i s e t oh a v e t h e b r a c h y t h e r a p y t e a m s t a nd -i n g b y . If g r o s s t u m o r s t il l r e m a i n sa f t e r t h e r e - r e s e c t io n , w e h a v e f o u n dt h a t a n i m p l a n t p l a c e d i n t h e a r e a o fc o n c e r n , i n c o n j u n c t io n w i t h b e a mR T, c a n e n h a n c e t u m o r c o n t r o l .

W h e n i t i s n o t c l e a r t h a t r e s i d u a l o rr e c u r r e n t s a l i v a r y g l a n d c a r c i n o m ac a n b e c o m p l e t e l y r e s e c te d , c o n s i d e r -a t i o n s h o u l d b e g i v e n t o n e u t r o ni r r a d i a t i o n . P u b l i s h e d d a t a s u g g e s tt h a t l o c a l c o n t r o l m a y b e b e t t e r t h a nt h a t w h i c h c a n b e a c h i e v e d b y i n c o m -

p l e t e s u r g e r y a n d p h o t o n i r r a d i a -t i o n .

C A S E 2A 5 8 - y e a r -o l d w o m a n p r e s e n t s w i tha p a r o t i d t u m o r . T w e n t y y e a r s a g ot h e m a s s w a s b i o p s i e d t h r o u g ht h e s k i n , a n d s u b t o t a l t u m o r r e s e c -t io n w a s p e r f o r m e d . T h e p a t h o l o g i -c a l r e p o r t a t t h a t ti m e w a s c o n s i s -t e n t w i th p l e o m o r p h i c a d e n o m a .

T h e p a t i e n t n o w p r e s e n t s w i t h a1 - y e a r h i s t o r y o f m u l t i c e n t r i c r e c u r -r e n c e s . T h e t u m o r i s f i x e d t o t h es k i n a t s e v e r a l s i t e s . A le v e l I I n e c kn o d e i s p a l p a b l e . A fi n e - n e e d l e a s -p i r a ti o n s p e c i m e n i s p o s i t i v e fo rp l e o m o r p h i c a d e n o m a .

Q u e s t i o n sW h a t p r o c e d u r e i s a p p r o p r ia t e ?S k i n r e s e c t i o n ? I f s o , h o w s h o u l dt h e s k i n b e r e s u r fa c e d ? S h o u l dt h e d e e p l o b e b e a d d r e s s e d ?S h o u l d p o s t o p e r a t i v e r a d i a t i o n b eu s e d ?D r A b e m a y o r : T h i s p a t i e n t s u f f e r sf r o m a r e c u r r e n t p l e o m o r p h i c a d -e n o m a d u e t o t u m o r s p i ll a g e a n di n a d e q u a t e e x c is i on . S u c h t u m o r s a r eb e s t c o n s i d e r e d a s l o w - g r a d e p o t e n -t i a l l y a g g r e s s i v e n e o p l a s m s ; e v e nw i t h f u r t h e r e x c i s i o n s , t h e p a t i e n t i sa t r i s k f o r l o c a l r e c u r r e n c e s w i t hs u b s e q u e n t d a n g e r t o fa c i a l f u n c t i o n .

I w o u l d b e g i n b y r e v i e w i n g t h ep r i o r o p e r a t i v e n o t e i f p o s s i b l e . W a st he t u m o r r e m o v e d b y e n u c l e a ti o no r l a t e r a l l o b e c t o m y ? T h i s i s i m p o r -t a n t t o k n o w b e c a u s e , i n t u r n , i t c a nt e ll u s i f t h e m a i n t r u n k o f t h e f a c ia ln e r v e w a s d i s s e c t e d o u t o r n o t. I na n y e v e n t , e x t i r p a t io n o f t h is t u m o rr e q u i r e s r e m o v a l o f a l l r e m a i n i n gp a r o t i d t is s u e a n d s u r r o u n d i n g s k i nw h i c h i s s e e d e d w i t h t u m o r c e l l s .U n d e r l o u p e m a g n i f i c a t i o n a n d u s -i n g f a c ia l n e r v e m o n i t o r i n g , I w o u l ds e e if t h e m a i n t r u n k o f t h e n e r v e c a nb e e a s i l y i d e n t i f i e d p r o x i m a l l y . I f n o t,I w o u l d f i n d t h e p e r i p h e r a l b r a n c h e s( e y e, b u c c a l, m a r g i n a l m a n d i b u l a r )a n d t r a c e t h e m b a c k t o t h e m a i nt r u n k , r e m o v i n g a n y r e m a i n i n g s u -p e r f i c ia l p a r o t i d t i s s u e a n d r e s i d u a lt u m o r . O n c e t h e n e r v e i s i d e n t i f i e d ,t h e d e e p l o b e t i s s u e c a n a l s o b er e m o v e d . T h e l ev e l I I n o d e a n d a n yo t h e r p a l p a b l e n o d e s w o u l d b e r e -

m o v e d a s a f u n c t i o n a l n e c k d i s s e c -t io n . T h e i n v o l v e d c h e e k s k i n w o u l db e e x c i s e d w i t h r e s u r f a c i n g o f t h ed e f e c t u s i n g a c h e s t - c e r v i c a l - c h e e kr o t a t i o n f l ap .

D u e t o t h is p a t i e n t ' s r e l a t i v e y o u t h ,I w o u l d n o t u s e a d j u n c t i v e r a d i a t i o nt h e r a p y f o r l e s i o n s t h a t a r e s t il l s u rg i -c a l l y r e s e c t a b l e . F o r m u l t i p l e r e c u r -r e n t l e s i o n s , I b e l i e v e a r a d i c a l p a r o t i -d e c t o m y w i t h e i t h e r p e d i c le o r f r e ef l a p m u s c l e r e c o n s t r u c t i o n i s w a r -r a n t e d .

R E F E R E N C E1. Conley JJ (ed): Problems with operation ofthe parotid gland an d fa cial nerve. Oto-laryngo l Head Nec k Surg 99:480-488, 1988D r M y e r s : T h e i n it i a l f l a w i n t h em a n a g e m e n t o f th i s p a t i e n t w a s i n a d -e q u a t e r e s e c t i o n o f t he t u m o r . P a -t i e n t s w h o h a v e b e e n i n a d e q u a t e l yr e s ec t e d f or p l e o m o r p h i c a d e n o m aa r e a t r i s k f o r r e c u r r e n c e o f t h e p l e o -m o r p h i c a d e n o m a o r fo r d e v e l o p -m e n t o f c a r c in o m a e x p l e o m o r p h i ca d e n o m a . T h e t im e s e q u e n c e o f 2 0y e a r s a f t e r t h e i n i t i a l s u r g e r y i s p o s -s i b l e i n b o t h i n s t a n c e s . T h e f i x a t i o no f t h e t u m o r t o t h e s k i n a n d a p a l -p a b l e l e ve l II l y m p h n o d e m a k e o n em o r e s u s p i c i o u s a b o u t c a r c i n o m a e x -p l e o m o r p h i c a d e n o m a . T h e fi ne -n e e d l e a s p i r a t io n s p e c i m e n p o s i t iv ef o r p l e o m o r p h i c a d e n o m a is n o t ag u a r a n t e e t h a t c a r c i n o m a e x - p l e o -m o r p h i c a d e n o m a i s n o t pr e s e n t .

I w o u l d r e c o m m e n d o p e n b i o p s yo f t h e s e n o d u l e s i n o r d e r t o e s t a b l i s ha d ia g n o s i s . I n m y e x p e r i e n c e , r e c u r -r e n t p l e o m o r p h i c a d e n o m a c a n u s u-a l ly b e a d e q u a t e l y t r e a t e d b y t o t a lp a r o t i d e c t o m y w i t h f a c ia l n e r v e d i s-s e c t i o n . T h e r e i s n o m e n t i o n a b o u tt h e c o n d i t i o n o f th i s p a t i e n t ' s f a c i a ln e r v e , s o f o r t h e s a k e o f d is c u s s i o n , Ia s s u m e t h a t i t is n o r m a l . I f t h i s i sp u r e l y p l e o m o r p h i c a d e n o m a , Iw o u l d e x c is e th e s k i n o v e r l y i n g s e v -e r a l si t es w h e r e t h e t u m o r i s f i x e d t ot h e s k i n a n d c l o s e t h e s e p r i m a r i l y .R e m o v a l o f th e t u m o r m a s s s h o u l dp r o v i d e e n o u g h a d d i t i o n a l s k i n i n a5 8 - y e a r- o l d w o m a n t o cl o se t h e s ea r e a s p r i m a r i l y .

D u r i n g t h e t im e t h a t t h e p a r o t i d i se x p o s e d , t h e l e v e l IF l y m p h n o d es h o u l d b e r e m o v e d . T h i s a r e a i s e x -p o s e d d u r i n g m o s t p a r o t i d s u rg e r y ,a n d b y r e t r a c t i n g t h e p o s t e r i o r b e l l y

F R IE D M A N E T A L 3 7 9


4/7

of the digastric superiorly, the masscan be exposed and removed. If theinitial biopsy revealed tumor in alym ph node, then one must concludethat this is malignant even thoughopen biopsy of the primary tumormay have been diagnosed as pleo-morphic a denoma on frozen section.

If the tumor is adherent to thebranches of the facial nerve, the indi-vidual branches should be resectedand cable grafts should be applied.By extensive dissection posteriorly,the great auricular nerve, if it can befound, may be used. If not, then thefourth cervical nerve can be used,which is very hel pful because it hasmultiple branches.

If upon biops y of the tumor mass,it is proven to be a carcinoma ex-pleomorphic adenoma, then the pa-tient's best interest would be bestserved by a complete resection of theentire parotid gland, the massetermuscle, the periosteum of the man-dible, the facial nerve, and the overly-ing skin. If the facial nerve must besacrificed, then replacement wit h su-ral nerve or cervical plexus nervegrafting may be performed. In theevent that the mass is malignant,then a modified radical neck dissec-tion should be performed.I don't believe in the use of radia-tion therapy for the treatment ofbenign tumors, although there is lit-

erature, particularly from the UnitedKingdom, on the routine treatmentof pleomorphic adenoma, particu-larly recurrent, by radiation therapy.

If this is a malignant tumor, thenpostoperative radiation therapyshould be used as has been shownover many years that locoregionalrecurrence is improved even tho ughthe cure rate is not necessarily im-proved.Dr Spiro: The obvious explanationfor the multifocal recurrence in thispatient would seem to be seedingfrom the inappropriate "subtotal tu-mor resection" performed 20 yearspreviously. The presence of a pal-pable level II lymp h node, however,is troublesome despite the FNABreport of pleomorphic adenoma. Itwould be wise to aspirate the necknode. If this yielded tissue similar tothat obtained from one of the parotidmasses, the true diagnosis may actu-ally prove to be malignant mixedtumor.Assuming the benign diagnosis iscorrect, an ade quate subtotal paroti-dectomy with facial nerve sparingshould be possible when the previ-ous procedure has not exposed thenerve. There is no need for totalparotidectomy unless the deep lobeis obviously involved. The patientneeds to be especially well prepared

for the possibility of postoperativefacial nerve dysf unction. In additionto the likelihood of direct nervetrauma during what often proves tobe a more te dious dissection becauseof scarring, sacrifice of a nerve branchwith cable grafting ma y occasionallybe required when nerve and tumorare so intimate ly related that separa-tion of the two will leave residualtumor.

Dermal invol vement from multifo-cal tumor recurrence poses a prob-lem that is best resolved by excisionof the overlying skin. Depending onthe circumstance, resurfacing can beaccomplished by split graf ting, a cer-vical/facial rotation advancementflap (as mentioned previously) orfree, revascularized tissue. Even withconfidence in a benign diagnosis, itwoul d be wise to excise the enlargedlevel II lymph node. If there is anyquestion of malignan t evolution of abenign pleomorphic ade noma, a lim-ited lymphadenectomy (levels I, II,III) shou ld be added to the parotidec-tomy.Recent experience suggests thatadjunctive beam radiation therapymay offer enhanced locoregional con-trol in patients with recurrent pleo-morphic adenoma. Indications arefar from clear, but the best results areobtained when it is given after agood debulking procedure that re-

FI GURE 2 .



5/7

FIGURE 3.

m o v e s a l l g r o s s t u m o r . I n o w t e n d t ouse the RT soone r , r a the r t han l a t e r .E v e n i f a g o o d c l e a n o u t i s a c c o m -p l i s h e d , t h i s p a r t i c u l a r p a t i e n t r e -m a i n s a t h i g h r i s k f or a n o t h e r r e c u r -r e n c e , a t w h i c h t i m e a d d i t i o n a l ,n e r v e - s p a r i n g s u r g e r y i s q u i t e u n -likely.

C A S E 3A 48-year-old woman has under-gone r ight-sided parot idectomytwice for mixed tumor. She has apositive neck node, and results offine-needle aspiration are positivefor p leomorphic adenoma. CTscans are shown in Figs 2 and 3.

Q u e s t i o n sWhat procedu re is appropriate?Should an external surgical ap-proach be used, with or withoutcutting the mandible? A transoralapproach? Or a combined externaland transoral approach? Shouldpostoperat ive radiat ion be admin-istered?D r A b e m a y o r : T hi s p a ti e n t h a s ar e c u r r e n t p a r a p h a r y n g e a l t u m o r .M o s t c a n b e r e m o v e d t h r o u g h t h en e c k ; h o w e v e r , I a l s o p r e p a r e t h e

p a t i e n t f o r a p o s s i b l e m a n d i b u -l o t o m y . T h i s t u m o r i s b e s t a p -p r o a c h e d t h r o u g h a t r a n s c e r v i c a l -t r a n s p a r o t i d r o u t e . I n t h i s f a s h i o n ,t h e g r e a t v e s s e l s a n d t h e l o w e rb r a n c h e s o f t h e f a ci a l n e r v e a r e i d e n -t i f i e d a n d p r o t e c t e d , i p r e f e r t h e a p -p r o a c h p o p u l a r i z e d b y S t el l e t a l 1a n d c l e a r l y d e s c r i b e d b y O l s e n . 2 I ne s s e n c e , t h i s a p p r o a c h i d e n t i f i e s a tl e a s t th e l o w e r b r a n c h e s o f t h e f a ci aln e r v e o u t t o t h e s u b m a n d i b u l a rg l a n d . O n c e t h e s t e r n o c l e i d o m a s t o i dm u s c l e i s r e t r a c t e d l a t e r a l ly a n d c r a-n i a l ne rves X-XII a re i den t i f i ed , t hec a r o t i d a r t e r y a n d j u g u l a r v e i n a r el a t e ra l ly r e t r ac t ed . Rout ing sac r i f i ceo f t h e e x t e r n a l c a r o t i d a r t e r y i s n o ta l w a y s n e e d e d b u t c a n b e d o n e f o ra d d e d e x p o s u r e . T h e a n g l e o f t h em a n d i b l e i s r e t r a c t e d a n t e r i o r l y a n d ,i f f u r t h e r e x p o s u r e i s n e e d e d , t h es u b m a n d i b u l a r g l a n d is r e m o v e d .W i t h r e t r a c t i o n o f t h e m a n d i b l e , t h es t y l o m a n d i b u l a r l i g a m e n t i s v i s u a l -i z e d a n d d i v i d e d , r e s u l t i n g i n a l a r g e ro p e n i n g i n t o t h e p a r a p h a r y n g e a ls p ac e . F o r e v e n m o r e m e d i a l a n ds u p e r i o r e x p o s u r e , m a n d i b u l o t o m ya t t h e a n g l e i s a d d e d . I n s u c h c a s e s , If i r s t p u t t h e p a t i e n t i n m a x i l l o m a n -d i b u l a r f i x a t io n u s i n g c o r t i ca l b o n es c r e w s a t t h e n a s a l p y r i f o r m a p e r -t u r e a n d l o w e r m a n d i b l e . B e f o r e t h e

m a n d i b u l o t o m y , I c o n t o u r a 4 - h o l ec o m p r e s s i o n p l a t e f o r l a t e r u s e i nm a n d i b u l a r f i x at i on . U n d e r d i r e c t v i -s u a l i z a t i o n a n d w i t h d i g i t a l m a n i p u -l a t i on , t he mass i s r emoved . Al l a t -t e m p t s s h o u l d b e m a d e t o p r e s e r v et h e i n t e g r i t y o f t h e t u m o r ' s c a p s u l e .I n t r a o r a l e x c i s i o n i s c o n t r a i n d i c a t e db e c a u s e o f p o s s i b l e i n f e c t i o n , t u m o rs e e d i n g , o r d a m a g e t o v i t a l v a s c u l a rs t r u c t u r e s .

T h r o u g h t h e t r a n s c e r v i c a l a p -p r o a c h , a s u p r a h y o i d n e c k d i s s e c ti o ni s p o s s i b l e t o r e m o v e a n y l y m p hn o d e s o r t u m o r - b e a d i n g t is s ue .

B e c a u s e o f t h e p a t i e n t ' s a g e , iw o u l d r e s e r v e r a d i a t i o n f o r r e c u r -r e n t l e s i o n s n o t a m e n a b l e t o f u r t h e rsurg i ca l exc i s ion .

R E F E R E N C E S1. Stell PH, M ansfield AO, Stoney PJ: Surgicalapproaches to tumors of the parapharyn-geal sp ace. Am J Oto]ary ngol 6:92-97, 19882. Olsen KD: Tum ors and surgery of theparapharyngeal space. LaryngoscopeSuppl63:104, 1994D r M y e r s : T h i s c a s e p r e s e n t s a p a -t i en t w i t h a p a r a p h a r y n g e a l s p a c ee x t e n s i o n o f a d e e p l o b e p a r o t i dt u m o r . T h e s e t u m o r s a r i s i n g f r o mt h e d e e p l o b e a r e , i n m y e x p e r i e n c e ,p l e o m o r p h i c a d e n o m a , c a r c i n o m a e x-

FRIEDMAN ET AL 381


6/7

p l e o m o r p h i c a d e n o m a , o r m a l i g n an tm i x e d t u m o r . A l t h o u g h t h e f i n e -n e e d l e a s p i r a t i o n b i o p s y r e p o r t isp o s i t i v e f o r p l e o m o r p h i c a d e n o m a ,t h e p o s s i b i l i t y o f c a r c i n o m a e x - p l eo -m o r p h i c a d e n o m a o r m a l i g n a n tm i x e d t u m o r i s n o t n e c e s sa r i l y e s t a b -l i s h e d w i t h o u t a d e q u a t e h i s t o p a t h o l -o g y .T h e d i a g n o s i s i s v e r i f i e d b y t h es c a n s h o w n i n F i g 3.

O n e w o u l d h a v e t o b e s o m e w h a tc i r c u m s p e c t a b o u t t h e p o s s i b i l i t y o fm a l i g n a n c y b e c a u s e t h e p a t i e n t i ss a i d t o h a v e a " p o s i t i v e n e c k n o d e . "B e c a u s e o f t h e m e n t i o n o f t hi s l y m p hn o d e , t h i s is a r a t h e r e n i g m a t i c s i t u a -t i on . I f t h e p a t i e n t w a s k n o w n w i t hc e r t a i n t y t o h a v e a p l e o m o r p h i c a d -e n o m a , i t s h o u l d b e r e m o v e d t h r o u g ha p a r o t i d - s u b m a n d i b u l a r a p p r o a c hi n o r d e r to p r o v i d e a d e q u a t e e x p o -s u r e . T h e s u b m a n d i b u l a r g l a n ds h o u l d b e m o b i l i z e d b y l i g at i n g a n dt r a n s e c t i n g t h e f a c i a l a r t e r y p o s t e r i -o rl y, a n d p e d i c a l i n g t h e s u b m a n d i b u -l a r g l a n d o n t h e l i n g u a l n e r v e a n dt h e W h a r t o n ' s d u c t . A t o t a l p a r o t i d e c -t o m y s h o u l d b e p e r f o r m e d , c a r e fu l lyd i s s e c t i n g a n d p r e s e r v i n g t h e f a c i a ln e r v e . T h i s w i l l a l l o w a d e q u a t e a c -c e s s t o t h e d e e p l o b e t u m o r a n d , b ya p p r o a c h i n g i t l a t e r a l l y f r o m t h e e x -p o s u r e g a i n e d b y a p a r o t i d e c t o m y a sw e l l as t h e s u b m a n d i b u l a r a p p r o a c ht o th e p a r a p h a r y n g e a l s p a c e , t h e t u -m o r c a n b e r e m o v e d , p r e s e rv i n g t h ef a c i a l n e r v e . I n m y e x p e r i e n c e , am a n d i b u l o t o m y a p p r o a c h i s n o t ne c -e s s a ry . A t r a n s o r a l a p p r o a c h , a l -t h o u g h i t h a s b e e n r e p o r t ed b y G o o d -w i n e t a l s o m e y e a r s a g o , 1 i sp o t e n t i a l l y d a n g e r o u s t o t h e f a c i a ln e r v e i n t h e r e s e c t io n o f a d e e p l o b et u m o r , e s p e c i a l l y in a p r e v i o u s l y o p -e r a t e d c a s e .I f t h i s p r o v e s t o b e a m a l i g n a n tt u m o r , t h e n p o s t o p e r a t i v e r a d i a t i o ns h o u l d b e m o s t c e r t a i n l y a d m i n i s -t e r e d .R E F E R E N C E1. Go odw in WJ, Chandle r JR: Transoral exci-sion of lateral parapharyngeal space tu-mors presenting intraorall. Laryngoscope98:266-269, 1988D r S p i r o : T h i s p a t i e n t ' s M R I s h o w sa t y p i c a l in t r a o r a l p r e s e n t a t i o n o f ad e e p l o b e o r r e t r o m a n d i b u l a r p a -r o t id t u m o r , w h i c h I w o u l d n o t e x -p e c t t o b e p a l p a b l e i n t h e n e c k . I f t h e

" p o s i t i v e n e c k n o d e " i m p l i e s a n -o t h e r , s e p a r a t e c e r v i c a l m a s s , t h e n Iw o u l d h a v e t h e sa m e c o n c er n s a b o u tt h e p o s s i b i l i t y o f m a l i g n a n t t r a n s f o r -m a t i o n t h a t I e x p r e s s e d p r e v i o u s ly .

I w i l l a l w a y s a t t e m p t t r a n sc e r v i c alr e s e c t io n o f r e t r o m a n d i b u l a r p a r o t i dt u m o r s w i t h t h e p a t i e n t p r e p a r e d f o rt h e p o s s i b il i t y o f a p a r a m e d i a n m a n -d i b u l o t o m y . T h e t r a n s c e r v i c a l a p -p r o a c h s h o u l d s t a r t w i t h e x p o s u r ea n d i d e n t i f i c a t i o n o f t h e f a c i a l n e r v et r u n k a n d i t s r a m u s m a r g i n a li sb r a n c h i n o r d e r t o a v o i d i n j u r y t ot h e s e s t r u c t u r e s . I f t h i s a c c e s s p r o v e si n a d e q u a t e , w h i c h i s s e l d o m t h e c a s e ,t h e m a n d i b l e i s d i v i d e d b e t w e e n t h ei p s i l a t e r a l c u s p i d a n d l a t e r a l i n c i s o r .T h e p a r a l i n g u a l i n c i s i o n i s t h e n c a r -r i e d u p t o t h e s o f t p a l a t e , w h i c hu s u a l l y p r o v i d e s g o o d e x t e r n a l a n dt r a n s o r a l e x p o s u r e . I b e l i e v e t h a t a n ya t t e m p t a t d i r e c t tr a n s o r al r e m o v a l i si l l - a d v i s e d a n d i n a p p r o p r i a t e .

R e g a r d l e s s o f t h e a p p r o a c h , r e s e c -t i o n o f d e e p l o b e t u m o r s e n t a il s ac e r t a in a m o u n t o f b l u n t d i s se c t io n .G i v e n t h a t m a r g i n s a r e o f t e n m i n i-m a l , I b e l i e v e t h a t p o s t o p e r a t i v e i r ra -d i a t i o n i s u s u a l l y i n d i c a t e d i n a n yp a t i e n t w h o s e l e s i o n p r o v e s t o b em a l i g n a n t .

C A S E 4A 3 8 - y e a r - o l d H I V - p o s i t iv e m a np r e s e n t s w i t h a ri g h t - s i d e d p a r o t i dm a s s w i t h c e r v i c a l n o d e s .

Q u e s t i o n sW h a t i m a g i n g s t u d i e s , i f a n y ,s h o u l d b e d o n e ? S h o u l d f in e -n e e d l e a s p i r a t i o n b e d o n e ? A t s u r -g e r y , is b i o p s y o f t h e n o d e a l o n er e q u i re d ? S h o u l d a p a r o t i d e c t o m yb e d o n e ?D r A b e m a y o r : H I V - p o s i ti v e p a t i e n t sc a n d e v e l o p b e n i g n l y m p h o e p i t h e -l i al c y s t s o f th e p a r o t i d t h a t i n r e a l i t ya r e c y s t i c , i n c o m p l e t e l y e n c a p s u -l a t e d l y m p h n o d e s . T h e s e p a t i e n t sa r e a ls o p r o n e t o d e v e l o p i n g l y m p h o -m a s t h a t a re a m e n a b l e t o m e d i c a lt h e r a p y . T h e r e f o r e , a d i a g n o s i s o ft h e s e l e s io n s is n e e d e d . I w o u l d b e -g i n w i t h a c o n t r a s t C T . A r e o t h e rl e s i o n s v i s i b l e i n t h e c o n t r a l a t e r a lp a r o t i d a n d n e c k ? I f s o , t h is w o u l ds t r o n g l y s u g g e s t a w o r k i n g d i a g n o -s is o f " b e n i g n " H I V c y s t s .

I w o u l d a l s o p e r f o r m a f i n e - n e e d lea s p i r a t i o n o f t h e n e c k m a s s . I n t h eh a n d s o f a n e x p e r i e n c e d c y t o p a t h o l o -g i s t , a c e l l b u t t o n c a n b e p r e p a r e da n d l y m p h o m a r u l e d i n o r o u t . I ff u r t h e r d e f i n i t i o n o f t i s s u e t y p e i sn e e d e d , I c o u l d e x c i se t h e n e c k m a s s .

C y s t i c p a r o t i d l e s i o n s i n H I V -p o s i t i v e p a t i e n ts a c t as i n f l a m m a t o r ym a s s e s , m a k i n g i d e n t i f i c a t i o n a n dp r e s e r v a t i o n o f t h e f a c ia l n e r v e d i f f i-c u l t . T h e r e f o r e , I w o u l d a v o i d a p a -r o t i d e c t o m y a n d c o n c e n t r a t e o n t h ec e r v ic a l l y m p h n o d e s .

R E F E R E N C E1. F inter MD, Schinella RA, Roth skin S, Per-sky M: C ystic parotid lesions in pa tients atrisk for the Acquired ImmunodeficiencySyndrome. Arch Otolaryngol Hea d NeckSurg 114:1290-1294,1988D r M y e r s : I n m y o p i n i o n , t h i s p a -t i e n t h a s a l y m p h o e p i t h e l i a l l e s i o nt h a t i s h i g h l y c o r r e l a t e d w i t h H I V -p o s i t i v i t y . M R I s c a n n i n g i s u s u a l l yh e l p f u l i n s u c h a c a s e . F i n e - n e e d l ea s p i r a t i o n b i o p s y s h o u l d b e p e r -f o r m e d . T h e s e l y m p h o e p i t h e l i a l c y s t sc a n b e a s p i r a t e d . S o m e t i m e s t h e c y s t sa r e p a i n f u l a n d t h e p a t i e n t i s r e -l i e v e d o f p a i n b y r e p e a t a s p i ra t i on .S p e c ia l p re c a u t i o n s s h o u l d b e t a k e nb y t h e c a r e g i v e r i n o r d e r t o a v o i da u t o - i n o c u l a t i o n o f t h e H I V . I t is n o tn e c e s s a r y o r r e c o m m e n d e d t h a t s u r -g e r y b e p e r f o r m e d , a n d p a r o t i d e c -t o m y i s c o n t r a i n d i c a t e d u n l e s s t h e r ei s s tr o n g s u s p i c i o n o f a s s o c i a te d m a -l i g na n c y . T h e r e i s a l s o a h i g h e r t h a ne x p e c t e d i n c id e n c e o f l y m p h o m a i nH I V - i n f e c t e d p a t i e n t s a n d , i f c l i n ic a lb e h a v i o r o r a d j u n c t i v e s t u d i e s i n d i -c a t e t h e p o s s i b i l i t y o f l y m p h o m a ,t h e n o p e n b i o p s y t o e s t a b l i s h t h i sd i a g n o s i s s h o u l d b e p e r f o r m e d .D r S p i r o - T h e a s s o c i a t i o n o f p a r o t i dm a s s e s w i t h s e r o p o s i t i v i t y t o H I Vi s n o w w e l l r e c o g n i z e d . U s u a l l yt h e s e a r e c y s t i c a n d p a r t o f a p a t t e r no f g e n e r a l i z e d l y m p h a d e n o p a t h y ,w h i c h i s o f t e n b i la t e r a l . F N A B o f t h ep a r o t i d m a s s i s i n d i c a t e d , a n d w i l lp r o b a b l y y i e l d t u r b i d , a m b e r , orm i l k y f l u i d a n d c e l l u l a r a r c h i t e c t u r es i m i la r t o t h a t o b s e r v e d i n b e n i g nl y m p h o e p i t h e l i a l l e s i o n s . L i m i t e ds u r g e r y t o r e m o v e t h e c y s t i c m a s sm a y b e a p p r o p r i a t e i n t h i s s e t t i n g ,p a r t i c u la r l y w h e n p a i n o r d i s c o m f o r ta r e p r e s e n t . O t h e r p o s s i b i l i t i e s i n -



7/7

clude a primary Kaposi's sarcomaarising in the parotid gland, or possi-bly even an unrelat ed primary carci-noma, either of which should besuggested by the FNAB findings.Parotidect omy is best avoide d whenthe process is benign and HIV-re-lated, unless the patient has multiple,symptomati c masses. In the presenceof other, potentially lethal pathology,the extent of the indicated parotidec-tomy will depend on the stage andhistology of the lesion, and neckdissection may also be required.

C A S E 5A 6 4 - y e a r -o l d m a n p r e s e n t s w i th at u m o r a t t h e t a i l o f t h e p a r o t i d .S u r g e r y d i s c l o s e s a 2 2 c m ,r e l a t i v e l y s o f t m a s s c a u d a l t o t h em a r g i n a l m a n d i b u l a r b r a n c h o f t h ef a c i a l n e r v e ( F i g 4 ) .

Q u e s t i o n sA r e a n y i m a g i n g s t u d i e s n e e d e d ?S h o u l d a c o m p l e t e d i s s e c t i o n b ed o n e a l o n g t h e d i s t a l a s p e c t s o ft h e u p p e r b r a n c h e s o f t h e fa c i a ln e r v e ( b e c a u s e t h i s p a r t o f t h eg l a n d i s m o r e t h a n 4 c m a w a y f r o mt h e t u m o r ) ? O r w i l l i t b e a d e q u a t et o d i s s e c t t h e u p p e r b r a n c h e s o ft h e n e r v e j u s t f a r e n o u g h t o t r a n -s e c t t h e g l a n d a n d s t i l l p r o v i d ew i d e m a r g i n s a w a y f r o m t h e t u -m o r ?

Dr Abemay or: A contrast CT or MRIwith ga dolinium is helpful to informthe patient and prepare the patientand surgeon for a possible deep lobeor dumbbell parotid tumor. This isespecially important, because the tu-mor is in the parotid tail.I would approach this tumor byfinding the main trunk of the facialnerve inferior and medial to the tympa-nomastoid structure and then identify-ing the pes ansefinus distally. Given thetumor' s inferior location, it is adequateto dissect the tumor off the inferiorbranches of the nerve and dissect theupper branches of the nerve just farenough to transect the gland. I believethis would provide adequate marginswith minimal potential morbidity.Dr Myers : This, in my experience, isa very common problem and thispatient probably has a papillary cystadenoma lymphomentosum (War-thin's tumor). Warthin's tumors com-monly occur in the tail of the parotid.

In my opinion, tumors in the tail ofthe parotid, whether they are War-thin's or other benign tumors, can beremoved without dissecting the en-tire facial nerve or removing theentire superficial lobe of the parotidgland. I always identify the maintrunk of the facial nerve as it exits thestylomastoid foramen, carry the dis-section anteriorly until the bifurca-tion of the nerve is noted, and thendissection is continued along in or-der to expose the branches of the

lower division of the facial nerve. Imake an effort to ligate the Stensen'sduct in order to prevent postopera-tive salivary fistula. The tumor canthen be removed. Protecting the up-per division without necessarily dis-secting it, provides an efficient andeffective way of dealing with thesetumors.Dr Spiro: The informati on provide dstrongly suggests that this patienthas a Warthin's tumor in the tail ofhis parotid gland. At issue is thequestion of preoperative evaluationand the type of operation to be per-formed. Although the clinical impres-sion could be easily verified by FNABor a technetium scan, I do not see acompelling indication for either pro-cedure unless the surgeon has de-cided to perform a limited local exci-sion, rather t han a parotidectomy.

I believe that a case can be madefor less than a subtotal parotid resec-tion with facial nerve dissection incarefully selected patients w ith small,benign tu mors in the tail of the gland.An important caveat for those whowould perform limited excision with-out nerve exposure is that the ramusmarginalis branch is always closerthan one might think. Although thiscan be minim ized by nerve exposureand partial removal of the inferiorportion of the gland lateral to it,there may be increased risk of sali-vary drainage following partial exci-sion.

ParotidGland

Facial ~ ~e r c , e , i :uscle / j ~Tumor~-

,- /

Temporalranch~ ~~ " ~ J ' ~ ~ ZygomaticBranch~ L ~ . ~ ~ Buccalranch~ ~ ~ MandibularBranch~ ' ~ ~ Mandible

)~CervicalBranchF I G U R E 4 .

FRIEDMAN ET AL 3 8 3

consider salivary gland sx

Documents