0:00

This was a case of a patient presented with chronic sitis and

0:05

had a large mass here involving the left paric gland.

0:08

It was predominantly involving in the superficial lobe of the paric gland.

0:12

And we can tell that because here's the, uh, MIB vein.

0:15

So the facial nerve is gonna be, um, just lateral to the vein.

0:21

So this lesion was high signal on T two,

0:25

and this was the contrast enhanced study.

0:27

It looked like it enhanced a little bit with contrast. And let's see,

0:31

let's compare that with our, uh, non-contrast study.

0:35

There's a non-contrast study, so you can see that

0:39

here's the fat suppressed images, and so it looks,

0:41

you can see that it is enhancing with contrast.

0:44

So this was a polymorphic adenoma. Um,

0:48

the imaging findings in a way are, are, can be suggestive,

0:52

but they're not necessarily pathognomonic.

0:54

So even when you see something like this, you always have to, uh,

0:58

confirm it with the biopsy. Um, polymorphic as you know, are benign lesions,

1:03

but they can de differentiate into, uh,

1:06

polymorphic adenoma X carcinoma.

1:08

So that's one of the reasons that they're taken out because that risk for

1:12

malignant degeneration.

1:14

So I can stop there and see if you have any questions on this one.

1:19

So for the biopsy,

1:21

do you mean by f fine needle aspiration or the core biopsy?

1:26

Um, really depends on the person. You know, I actually like to do cores, but,

1:31

um, some people like to do fine needle aspiration.

1:34

I think it's something like this in your throat is only about a centimeter or

1:37

so. I think you'd, it'd be pretty safe to just do a core biopsy.

1:41

But like I said,

1:41

it really depends on the kind of the experience and the confidence level of the

1:46

person doing the biopsy.

1:49

So for the core biopsy manual, what is your, the, the,

1:51

the size of the needle that you, you will be using?

1:55

Um, probably for the core it would probably be, I haven't done 'em in a while.

2:00

I would, I would say mm-hmm.

2:02

It would be the smallest caliber that allows me to do a core.

2:07

Okay. So I'm not gonna say it's 18 or 22 or whatever,

2:09

but I don't know what the latest technologies on core biopsies.

2:12

But if there is a needle that has a small throw that can do a core,

2:18

um, I would do with the, with the least, um,

2:20

the smallest caliber that allows a core mm-hmm.

2:24

For the retro manin vein. Mm-hmm. And how, how,

2:29

when do,

2:29

when do we suggest that there is a possibility of the fas nerve

2:34

involvement? Does it mean the lesion parting the retro man vein?

2:39

Yes. Yes. Because this

2:40

One is way, way, way, way out from the retro mantl vein. Right.

2:45

Is not touching at all. So if it parting it,

2:49

so I will raise the suspicion or, uh, how, how, how,

2:54

how do you comment on that?

2:56

No, I think

2:56

That's, which is mm-hmm.

2:58

Yeah, no, I think it's good. I mean, if the mass extends deep to the MIB vein,

3:02

then you would say it's definitely, um, suspicious for

3:05

Okay. Deep

3:06

Lobe involvement. But you're right,

3:07

if it actually goes out and it butts the mib vein, you can see,

3:11

you could suggest that the inferior portion of this is close to the,

3:14

to main trunk of the facial nerve.

3:17

Okay. So for the diplo or the gram mm-hmm.

3:21

If it's anything lesion extend medial to the electro man vein,

3:26

we will suggest there's a, a Diplo extension. Yeah.

3:30

Mm-hmm. Am

3:30

I right?

3:30

Yeah. Okay. That is, that's correct. Yeah. Okay. So, uh, Dr. Han, you,

3:35

you're all set with this case.

3:37

Uh, okay. So for this case,

3:40

a bit like not difficult because you say it would be very bright on T two.

3:44

Yeah. And it's not pathognomonic.

3:46

Let me show you this one PowerPoint.

3:49

This is a talk that I just updated.

3:52

So the reason why I wanted to show this was,

3:57

so here's the main trunk of the facial nerve here. So this is the main trunk,

4:02

and this, these are the five branches. So this is the temporalis branch.

4:06

Zygomatic branch, probably the buccal branches here,

4:11

marginal mandibular branch, and then deep cervical branch. So,

4:15

and the MIB vein is gonna be just deep to it. So I think this was a nice,

4:20

I think, illustration here of the, um, retro vein.

4:24

So here's the retro vein here.

4:26

And so the facial nerve is gonna be just lateral to it.

4:29

It's a nice illustration. Huh. Nice anatomic illustration. Mm-hmm.