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Haemangiomas of the parotid gland in children
J. max-fac. Surg. 5 (1977) 238-941 © Georg Thierne VerJag, Stuttgart
Haemangiomas of the Parotid Gland in Children Luis TRESSERRA, Juan MARTINEz-MoRA, Jos~ BOIx-OcHoA
Cllnica lnfantil de le Seguridad Social (Head: Prof. A. Ballabriga), U,niversidad Autdnoma de Barcelona, Spain Summary The authors present the case histories of 40 intraparotid haemangiomas, in 11 of which they achieved healing after radical surgical treatment (parotidectomy). Since 1971, the authors have adopted a conservative approach (not surgical), seeing that most of the cases involute spontaneously up to complete healing. None of the 29 cases treated conservatively has undergone exacerbations of the process, after the age of 6-9 months. No emergency surgical operations were required. Key-Words: Intraparotid haemangioma. Introduction The haemangioma is a vascular tumour with high incidence in early infancy. Nevertheless, it is found only relatively rarely in the parotid gland, and there are few cases reported in the medical literature (Wol[e 1962, Curtone 1967, Goldman and Perzik 1968). From the histological point of view, it is generally a benign tumour, but in certain cases, owing to its invasive character, it can behave locally like a malignant one. In general, apart from the first five months of life, in which it grows with particular speed, it has a tendency to regression after a period of stability.
Material From 1966 to 1976, we have observed 53 vascular tumours of the parotid gland, of which 47 are haemangiomas, 40 are intraglandular and 7 extraglandular and of these, 6 were related to intraparotid lymphangiomas. The ratio is 5.7 intraglandular haemangiomas to 1 extraglandular. 600/0 present cutaneous manifestations (29). The sex incidence is 13 males to 34 females (1:2.6). 22 occurred on the right side and 23 on the left; 2 were bilateral. In 17 cases, histological specimens were obtained. In 12, a benign haemangioma-endothelioma of the solid type was diagnosed, and in 5, a capillary haemangioma.
Treatment and Results A. Surgical From 1966 to 1971, our approach to vascular tumours of the parotid area, was surgical. Thus, during this period, we performed: a) 11 total parotidectomies preserving the seventh nerve (intraparotid haemangiomas); b) 6 total excisions of the parotid zone haemangiomas (extraglandular).
Fig. 1 Clinical appearance of the intraparotid haemangioma with cutaneous involvement. Fig. 2 Sialogram of the parotid haemangioma of case of Fig. 1. Fig. 1
Fig. 2
Haemangiomas of the Parotid Gland in Children
239
Fig. 3a+ b Haemangioma with involvement of skin. a) 7-month-Cd girl with rightsided parotid haemangioma. b) The same girl when 3-yearsold. Notice the spontaneous involution of the tumour mass and only the persistence of the cutaneous involvement, from which signs of involution can be seen. Fig. 3 a
Fig. 3 b
Fig. 4 a
Fig. 4 b
Fig. 4a+ b Expectant approach. a) 11-months-old girl with leftsided parotid haemangioma. b) The s.ame girl when she was 6-years-old. Notice the complete disappearance of the tumour through spontaneous resolution.
In the 17 cases where total excision of the tumour had been performed, either by simple removal or combined with the removal of the affected gland, the cure has been complete. A n y postoperative facial palsy fully disappeared in the 15-30 days after the operation, and in no case did a permanent facial palsy result. B. Conservative From 1971, our approach has been fully conservative. From that date, we have had the opportunity to study another 29 cases (26 intraparotid and 1 extraparotid). In all of them we have adopted an expectant conservative approach in order to investigate their natural history. In order to follow their development, we measured the diameters of the tumours, the consistency, took control photographs and made a yearly radiographic study in order to determine the angioradiographic changes.
Up to the present time, the results are as follows: Complete healing: 4 eases at 5 years: 3 at 2 years: 1 Gradual involution: 15 cases at 2 years: 6 at 3 years: 4 at 4 years: 2 at 5 years: 3 Remained stationary: 8 cases at 2 years: 2 at 1 year: 6 Not followed up: 2 cases None of the cases treated conservatively has undergone exacerbations of the process after the age of 6-9 months, and we have not been obliged to perform any emergency surgical operation.
Discussion The diagnosis of a parotid haemangioma is usually easy. It appears as a soft tumour in the
240
L. Tresserra et al.: Haemangiomas of the Parotid Gland in Children Fig. 5 a-d Spontaneous and gradual resolution of an intraparotid haemangioma which had originally ulcerated.
a) Initial condition. b) 5 months later. Fig. 5 a
Fig. 5 b
c) Another year later. d) 3 years after picture of initial condition. Fig. 5 c
Fig. 5 d
parotid region which is found towards the rear of the lobe of the ear. It grows rapidly and progressively in size, in many cases spreading right over the gland. It may come to occupy the whole of the cheek, the lips, the eyelids, the temples, and may even invade the external auditory canal. Diagnosis is easily made where the skin is affected (red or reddish-blue) or is transparent (bluish). Sialography and arteriography can help confirm the diagnosis. Sialography is useful for observing the growth of the tumour showing it in the same state at different periods (Tresserra 1969, Martinez-Mora et al. 1972, Martinez-Mora 1976). Surgery on the parotid gland in children is diffic u r and dangerous (Bruce 1975) because of possible lesions of the facial nerves. Despite this, in the series of parotidectomies which we have performed, we have never encountered a definitive case of facial paralysis. Some authorities (Rosenthal and Teasley 1971) continue to treat them surgically. After an initial period in which we treated parotid haemangioma surgically and with good results (Martinez-Mora et al. 1971), we decided to test the methods of authors who advocated the
conservative approach and who adapt the same position. The importance of keeping a check on the overall growth of the vascular tumour, or any significant improvement in it, encouraged us to persist with this conservative approach, except in cases of huge tumours which spread right over the gland and give rise to symptoms of compression. Thus we believe we are in a position to express an objective opinion as we have used both therapies - the surgical and the conservative. At the present time we incline to the latter.
Conclusions From this study, we can draw the following conclusion: Expectant conservative treatment in parotid haemangiomas will lead in most cases, if not to full healing, at least to a state of regression that will obviate the need for radical surgical treatment. The exceptions to this series are those haemangiomas that appear later in childhood or even in the adult, and which very rarely undergo spontaneous resolution, and these will require surgical treatment.
P. Egyedi: Utilization of the Buccal Fat Pad A further exception to conservative treatment may be those h a e m a n g i o m a s that extending beyond the limits of the p a r o t i d gland, could
241
produce peritracheal and p e r i - o e s o p h a g e a l cornpressive symptoms, in which case surgical treatmerit is indicated.
References Bruce, H.: Haemangiomas of the parotid gland in children. Plast. reconstr. Surg. 56 (1975) 1 Cutrone, F.: Contributo allo studio dei tumori angiomatosi della parotide. Arch. Ital. Laring. 75 (1967) Goldman, R. C., S. L. Perzih: Hemangioma of the parotid in Children. Arch Otolaryng. 90 (1969) 605 Martinez-Mora, ]., ]. Boix-Ochoa, L. Tresserra: Vascular tumours of the parotid region in children. Surg. Gynec. Obstet. 133 (1971) 973
Martinez-Mora, ]., J. Boix-Ochoa, L. Tresserra, ]. M. Casasa: La sialographie chez le nouveau-n4 et le nourrisson. Ann. Chir. Infant. 13 (1972) 1 Martinez-Mora, J.: ParotidograUa en el nifio: patrones
norrnales y patoldgicos. Tesis Doctoral. Universidad Auton6ma de Barcelona, Mayo 1976 Rosenthal, S. A., ]. L. Teasiey: Hemangioma of the parotid gland in children. Wisconsin M. J. 70 (1971)
202 Tresserra, L.: Sialografla parotidea en la infancia. Bol. Soe. Catalana Ped. 30 (1969) 141
Wolfe, ].: Congenital hemangioma of the parotid gland. Plast. reconstr. Surg. 29 (1962) 692 Luis Tresserra, M.D., D.M.D., Llusands 10 Barcelona-6 Spain
J. max.-fac. Surg. 5 (1977) 241-244 © Georg Th/eme Verlag, Stuttgart
Utilization of the Buccal Fat Pad for Closure of Oro-Antral and/or Oro-Nasal Communications Peter •GYEDI
Department of Maxillo-Facial Surgery (Head: P. Egyedi, M.D., D.M.D.), University of Utrecht, The Netherlands
Summary Defects in the posterior alveolus and hard palate up to a diameter of 4 cm can sometimes be closed by covering them with the buceal fat pad and grafting the latter with a split thickness skin graft. In addition local flaps may be necessary. 4 cases have been treated so far with complete success.
Key-Words: Buccal fat pad; Oro-naso-antral communications; Maxillary defect,
Introduction A considerable v a r i e t y of o r o - n a s o - a n t r a l communications have to be dealt with by the m a x i l l o facial surgeon. It is generally desirable to close these defects and a great n u m b e r of surgical methods to cope with them has been described. Indications and methods of course depend on size, site and cause of the defect. F r o m the thera-
peutic p o i n t of view one could roughly divide the defects into the following 3 categories: A. Those with a m a x i m u m diameter up to 1 cm (fistulas, small sized defects). B. Those with a m a x i m u m d i a m e t e r between 1 and 4 cm (medium sized defects). C. Those with a m a x i m u m diameter of more than 4 cm (large defects). W h e r e a s in category C it m a y prove necessary to obtain closure b y m a k i n g use of pedicle flaps, it is as a rule possible to close the defects as ment i o n e d under A and B with local tissue, if necessary in combination with a free skin graft. This p a p e r deals with u n i l a t e r a l defects of category B in the posterior area of the h a r d p a l a t e a n d / o r alveolus (tuberosity) eventually extending into the a n t e r i o r p a r t of the soft palate. It was found that m o b i l i z a t i o n and shifting of the buccal
Haemangiomas of the Parotid Gland in Children Luis TRESSERRA, Juan MARTINEz-MoRA, Jos~ BOIx-OcHoA
Cllnica lnfantil de le Seguridad Social (Head: Prof. A. Ballabriga), U,niversidad Autdnoma de Barcelona, Spain Summary The authors present the case histories of 40 intraparotid haemangiomas, in 11 of which they achieved healing after radical surgical treatment (parotidectomy). Since 1971, the authors have adopted a conservative approach (not surgical), seeing that most of the cases involute spontaneously up to complete healing. None of the 29 cases treated conservatively has undergone exacerbations of the process, after the age of 6-9 months. No emergency surgical operations were required. Key-Words: Intraparotid haemangioma. Introduction The haemangioma is a vascular tumour with high incidence in early infancy. Nevertheless, it is found only relatively rarely in the parotid gland, and there are few cases reported in the medical literature (Wol[e 1962, Curtone 1967, Goldman and Perzik 1968). From the histological point of view, it is generally a benign tumour, but in certain cases, owing to its invasive character, it can behave locally like a malignant one. In general, apart from the first five months of life, in which it grows with particular speed, it has a tendency to regression after a period of stability.
Material From 1966 to 1976, we have observed 53 vascular tumours of the parotid gland, of which 47 are haemangiomas, 40 are intraglandular and 7 extraglandular and of these, 6 were related to intraparotid lymphangiomas. The ratio is 5.7 intraglandular haemangiomas to 1 extraglandular. 600/0 present cutaneous manifestations (29). The sex incidence is 13 males to 34 females (1:2.6). 22 occurred on the right side and 23 on the left; 2 were bilateral. In 17 cases, histological specimens were obtained. In 12, a benign haemangioma-endothelioma of the solid type was diagnosed, and in 5, a capillary haemangioma.
Treatment and Results A. Surgical From 1966 to 1971, our approach to vascular tumours of the parotid area, was surgical. Thus, during this period, we performed: a) 11 total parotidectomies preserving the seventh nerve (intraparotid haemangiomas); b) 6 total excisions of the parotid zone haemangiomas (extraglandular).
Fig. 1 Clinical appearance of the intraparotid haemangioma with cutaneous involvement. Fig. 2 Sialogram of the parotid haemangioma of case of Fig. 1. Fig. 1
Fig. 2
Haemangiomas of the Parotid Gland in Children
239
Fig. 3a+ b Haemangioma with involvement of skin. a) 7-month-Cd girl with rightsided parotid haemangioma. b) The same girl when 3-yearsold. Notice the spontaneous involution of the tumour mass and only the persistence of the cutaneous involvement, from which signs of involution can be seen. Fig. 3 a
Fig. 3 b
Fig. 4 a
Fig. 4 b
Fig. 4a+ b Expectant approach. a) 11-months-old girl with leftsided parotid haemangioma. b) The s.ame girl when she was 6-years-old. Notice the complete disappearance of the tumour through spontaneous resolution.
In the 17 cases where total excision of the tumour had been performed, either by simple removal or combined with the removal of the affected gland, the cure has been complete. A n y postoperative facial palsy fully disappeared in the 15-30 days after the operation, and in no case did a permanent facial palsy result. B. Conservative From 1971, our approach has been fully conservative. From that date, we have had the opportunity to study another 29 cases (26 intraparotid and 1 extraparotid). In all of them we have adopted an expectant conservative approach in order to investigate their natural history. In order to follow their development, we measured the diameters of the tumours, the consistency, took control photographs and made a yearly radiographic study in order to determine the angioradiographic changes.
Up to the present time, the results are as follows: Complete healing: 4 eases at 5 years: 3 at 2 years: 1 Gradual involution: 15 cases at 2 years: 6 at 3 years: 4 at 4 years: 2 at 5 years: 3 Remained stationary: 8 cases at 2 years: 2 at 1 year: 6 Not followed up: 2 cases None of the cases treated conservatively has undergone exacerbations of the process after the age of 6-9 months, and we have not been obliged to perform any emergency surgical operation.
Discussion The diagnosis of a parotid haemangioma is usually easy. It appears as a soft tumour in the
240
L. Tresserra et al.: Haemangiomas of the Parotid Gland in Children Fig. 5 a-d Spontaneous and gradual resolution of an intraparotid haemangioma which had originally ulcerated.
a) Initial condition. b) 5 months later. Fig. 5 a
Fig. 5 b
c) Another year later. d) 3 years after picture of initial condition. Fig. 5 c
Fig. 5 d
parotid region which is found towards the rear of the lobe of the ear. It grows rapidly and progressively in size, in many cases spreading right over the gland. It may come to occupy the whole of the cheek, the lips, the eyelids, the temples, and may even invade the external auditory canal. Diagnosis is easily made where the skin is affected (red or reddish-blue) or is transparent (bluish). Sialography and arteriography can help confirm the diagnosis. Sialography is useful for observing the growth of the tumour showing it in the same state at different periods (Tresserra 1969, Martinez-Mora et al. 1972, Martinez-Mora 1976). Surgery on the parotid gland in children is diffic u r and dangerous (Bruce 1975) because of possible lesions of the facial nerves. Despite this, in the series of parotidectomies which we have performed, we have never encountered a definitive case of facial paralysis. Some authorities (Rosenthal and Teasley 1971) continue to treat them surgically. After an initial period in which we treated parotid haemangioma surgically and with good results (Martinez-Mora et al. 1971), we decided to test the methods of authors who advocated the
conservative approach and who adapt the same position. The importance of keeping a check on the overall growth of the vascular tumour, or any significant improvement in it, encouraged us to persist with this conservative approach, except in cases of huge tumours which spread right over the gland and give rise to symptoms of compression. Thus we believe we are in a position to express an objective opinion as we have used both therapies - the surgical and the conservative. At the present time we incline to the latter.
Conclusions From this study, we can draw the following conclusion: Expectant conservative treatment in parotid haemangiomas will lead in most cases, if not to full healing, at least to a state of regression that will obviate the need for radical surgical treatment. The exceptions to this series are those haemangiomas that appear later in childhood or even in the adult, and which very rarely undergo spontaneous resolution, and these will require surgical treatment.
P. Egyedi: Utilization of the Buccal Fat Pad A further exception to conservative treatment may be those h a e m a n g i o m a s that extending beyond the limits of the p a r o t i d gland, could
241
produce peritracheal and p e r i - o e s o p h a g e a l cornpressive symptoms, in which case surgical treatmerit is indicated.
References Bruce, H.: Haemangiomas of the parotid gland in children. Plast. reconstr. Surg. 56 (1975) 1 Cutrone, F.: Contributo allo studio dei tumori angiomatosi della parotide. Arch. Ital. Laring. 75 (1967) Goldman, R. C., S. L. Perzih: Hemangioma of the parotid in Children. Arch Otolaryng. 90 (1969) 605 Martinez-Mora, ]., ]. Boix-Ochoa, L. Tresserra: Vascular tumours of the parotid region in children. Surg. Gynec. Obstet. 133 (1971) 973
Martinez-Mora, ]., J. Boix-Ochoa, L. Tresserra, ]. M. Casasa: La sialographie chez le nouveau-n4 et le nourrisson. Ann. Chir. Infant. 13 (1972) 1 Martinez-Mora, J.: ParotidograUa en el nifio: patrones
norrnales y patoldgicos. Tesis Doctoral. Universidad Auton6ma de Barcelona, Mayo 1976 Rosenthal, S. A., ]. L. Teasiey: Hemangioma of the parotid gland in children. Wisconsin M. J. 70 (1971)
202 Tresserra, L.: Sialografla parotidea en la infancia. Bol. Soe. Catalana Ped. 30 (1969) 141
Wolfe, ].: Congenital hemangioma of the parotid gland. Plast. reconstr. Surg. 29 (1962) 692 Luis Tresserra, M.D., D.M.D., Llusands 10 Barcelona-6 Spain
J. max.-fac. Surg. 5 (1977) 241-244 © Georg Th/eme Verlag, Stuttgart
Utilization of the Buccal Fat Pad for Closure of Oro-Antral and/or Oro-Nasal Communications Peter •GYEDI
Department of Maxillo-Facial Surgery (Head: P. Egyedi, M.D., D.M.D.), University of Utrecht, The Netherlands
Summary Defects in the posterior alveolus and hard palate up to a diameter of 4 cm can sometimes be closed by covering them with the buceal fat pad and grafting the latter with a split thickness skin graft. In addition local flaps may be necessary. 4 cases have been treated so far with complete success.
Key-Words: Buccal fat pad; Oro-naso-antral communications; Maxillary defect,
Introduction A considerable v a r i e t y of o r o - n a s o - a n t r a l communications have to be dealt with by the m a x i l l o facial surgeon. It is generally desirable to close these defects and a great n u m b e r of surgical methods to cope with them has been described. Indications and methods of course depend on size, site and cause of the defect. F r o m the thera-
peutic p o i n t of view one could roughly divide the defects into the following 3 categories: A. Those with a m a x i m u m diameter up to 1 cm (fistulas, small sized defects). B. Those with a m a x i m u m d i a m e t e r between 1 and 4 cm (medium sized defects). C. Those with a m a x i m u m diameter of more than 4 cm (large defects). W h e r e a s in category C it m a y prove necessary to obtain closure b y m a k i n g use of pedicle flaps, it is as a rule possible to close the defects as ment i o n e d under A and B with local tissue, if necessary in combination with a free skin graft. This p a p e r deals with u n i l a t e r a l defects of category B in the posterior area of the h a r d p a l a t e a n d / o r alveolus (tuberosity) eventually extending into the a n t e r i o r p a r t of the soft palate. It was found that m o b i l i z a t i o n and shifting of the buccal