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C
7. What will be the optimal treatment for this lesion?
A Radiation therapy
B Total parotidectomy with preservation of the facial nerve
C Total parotidectomy including resection of the facial nerve
D Superficial parotidectomy
E Enucleation
View Answer
D
P.401
Answers and Explanations
1. The answer is D (Chapter 18, IV F 2). These are common presenting systems of an acoustic neuroma. Evaluation for acoustic neuroma is indicated in all cases of unilateral hearing complaints, especially when hearing loss is documented. Magnetic resonance imaging (MRI) of the brain with internal auditory canal views and gadolinium contrast is sensitive in 98% of patients with acoustic neuroma. Complications associated with gadolinium are exceedingly rare, and this contrast should always be used in an MRI to look for a tumor. Brain stem auditory response testing may or may not be normal in cases such as this. The differential diagnosis with this presenting complaint is quite extensive, and it includes processes that result in bilateral hearing loss.
2–3. The answers are 2-D and 3-E (Chapter 19, IV C; Chapter 19, IV B 2, C 2 b). The two most common presenting symptoms of cancer of the nasopharynx are enlarged posterior cervical lymph nodes and unilateral serous otitis media. Cancer of the right ear, right tonsil, or right maxillary sinus or Hodgkin's lymphoma generally do not cause otitis media and usually occur in an older age group. Hodgkin's lymphoma will lead to serous otitis media only if Waldeyer's ring involvement has led to eustachian tube dysfunction, which is a rare occurrence.
Bilateral radiotherapy is the primary treatment for all epithelial nasopharyngeal tumors.
4–5. The answers are 4-D and 5-A (Chapter 19, II C 3, VIII D 3; Chapter 19, VIII E 4). Any carcinoma of the vocal cord that leads to fixation of the cord or of the hemilarynx is at least T3. Massive involvement of surrounding soft tissues will make the tumor stage T4. The presence of a single homolateral lymph node greater than 3 cm but less than 6 cm in diameter makes the stage of the neck node N2a. Multiple small lymph nodes on the same side of the neck as the primary tumor are classified N2b, and lymph nodes involving the opposite side of the neck change the staging to N3.
T3 tumors cannot be adequately treated with partial laryngectomy in most cases; total laryngectomy is required. Radiation therapy is used postoperatively as a planned combined treatment in most cases. Chemotherapy is used for inoperable cases or in experimental protocols.
6–7. The answers are 6-C and 7-D (Chapter 20, II A 1–4). The history given is most consistent with a benign neoplasm of the parotid gland. Benign mixed tumors are the most common benign tumors of the salivary glands. Benign salivary tumors account for 60% of all parotid tumors. Malignant tumors, such as a mucoepidermoid cancer, usually grow more rapidly and are more often associated with facial nerve paralysis. The absence of pain makes acute parotitis unlikely. Hemangiomas of the parotid gland are much rarer than benign mixed tumors.
The optimal treatment for a benign mixed tumor is removal of the tumor with a margin of normal parotid gland. This usually can be accomplished with a superficial parotidectomy. Although these tumors often appear to shell out, removal by simple enucleation results in a very high recurrence rate. Excision of the entire gland with or without the facial nerve is indicated for malignant tumors. Radiation therapy does not have a role in the management of this lesion.
Study Questions for Part VII(special subjects)
Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.
1. In which of the following situations would the best results be obtained for an emergency department thoracotomy?
A Cardiac arrest in a construction worker after falling from a scaffold eight stories high
B Cardiac arrest following a motor vehicle accident with expulsion of the individual from the car
C Cardiac arrest following a gunshot wound to the abdomen
D External cardiac massage that has failed after more than 10 minutes in a trauma patient
E Cardiac arrest following a stab wound to the chest