0:00

This is a patient that actually had a scalp lesion,

0:03

but it wasn't squamous cell carcinoma, it was a just scalp lesion.

0:06

I remember this case 'cause I discussed it with the referring physician and the

0:10

issue was is that they had bilateral palpable carotid masses.

0:15

I'm gonna zoom this down a little bit and that I think they're actually best

0:19

seen on the non-contrast T one weighted images. Alright,

0:22

so when we start from the top and go to the bottom.

0:24

So you can see this mass right here. Everybody see that mass right there?

0:28

So there's one on the left side, there's another one here on the right side,

0:37

there's another one here and there's another one here.

0:41

So the challenge on this one really was, you know,

0:45

which of these are

0:48

actual neoplasms and which are basically intra producted lymph nodes.

0:52

So this was actually an example of bilateral war's tumors.

0:58

Um, in general,

0:59

when I'm sure you guys will be reading a lot of brain Mrs when you, you know,

1:03

in your, in your regular practice.

1:05

So you're gonna run into these little masses involving the product land.

1:10

You know, you see 'em incidentally.

1:12

So the rule of thumb that I use is anything that's less than 10 millimeters,

1:16

I just say it's probably an intra prodded lymph node.

1:19

But if something is greater than 10 millimeter,

1:22

then I start worried of worry about a parotid neoplasm.

1:26

So remember that war's tumors have a propensity to be, uh,

1:30

bilateral multiple and involve the tail of the parotid gland.

1:34

The reason why that's the case is that the other name for war's tumors is

1:38

cystadenoma lymphoma,

1:40

which means they're actually arising within the lymphoid tissue of the parotid

1:43

gland. So that's why they, uh,

1:46

are felt to be associated with the intra potid lymph nodes.

1:49

And that's why they tend to be multiple, um,

1:52

bilateral and involve the parotid tail.

1:54

Because the inid lymph lymph nodes are located in four different locations.

1:59

They're located anterior to the external auditory canal we call the

2:04

Prego portion. They are located, this is a good example here.

2:09

Let me minimize that, just a smidgen. In fact,

2:13

what I can do this and probably do this and this, this would probably better.

2:18

So you can see this little guy right here,

2:20

this is actually right below the capsule.

2:22

So intra lymph nodes can be subcapsular,

2:25

they can be along the course of the facial nerve.

2:28

So we identify the facial nerve by looking at the retro inhibitor vein,

2:33

and then finally they can arise in the tail of the

2:38

paric gland. So there's a, a little mass right here. So that's probably,

2:43

uh, a little parotid, a little, um, a little, uh,

2:46

W'S tumor or intra product lymph. In fact, there's another one right here.

2:50

So this was an example of W'S tumors and I think if you

2:55

said squamous cell carcinoma metastases, that would,

2:58

that would probably be fine as well too,

3:00

because they can metastasize to the parotid gland as well. But in this case,

3:04

this was an example of orphan's tumors. Any questions on this case?

3:10

Uh, sorry, but the mo can you show me where is that pre tracker region again?

3:15

Mm-hmm.

3:17

Yeah, sure. So the actual name for the, this,

3:21

I'll magnify this right here. It's a great question.

3:24

So this is the external auditory canal here.

3:28

And this little area right here is the anterior portion of the external auditory

3:32

canal. It's sometimes called the trauss.

3:34

And so this area right here, the tragus,

3:38

there's a small amount of parotid gland that's located anterior to the tragus,

3:42

which is called the pre trago portion of the parotid gland.

3:45

So it's gonna be just anterior to the tragus clinically.

3:50

This is actually referred to as a draggle pointer.

3:52

And the reason why it's called the tracheal pointer is that the tracheal

3:56

pointer, um,

3:58

actually helps the surgeons identify where the facial nerve is when it exits

4:02

the, um, stylo mastoid foramen. So, in fact,

4:06

this is a nice example here. Here's the mastoid bone here,

4:09

here's the condyle of the mandible.

4:11

See this little dot right under my cross here,

4:13

said.that.is the facial nerve where it exits the fat.

4:19

So the reason why this is important is that this little area right here,

4:23

which is the external auditory canal, it's called the tragus.

4:27

And notice how this tragus is, is,

4:29

is oriented from right to left.

4:34

And so clinically the facial nerve is usually identified one centimeter

4:39

medially and one centimeter inferiorly to that tra.

4:43

And if they do that, and that's how the clinicians,

4:45

that's how the surgeons find the facial nerve in the or.

4:51

But for me, what I do is I like to just find the nerve right as it,

4:55

it's a stylo mastoid foramen. And you can see that cross here going here,

4:58

that's the facial nerve extending into the parotid limb.

5:01

That's probably it right there. Does that make sense?

5:04

So now it may sense when the surgeon ask me where if the trigger part

5:09

because they want to identify the station during the conference.

5:14

Yeah, that's exactly right. That's now you know exactly why they're,

5:17

they're asking. Yeah. Okay.

5:19

So this is the tragus right here and the Prego portion.

5:22

The Paraic land is gonna be right here. Yeah. Good for you.

5:24

I'm glad they're asking you those questions. Excellent.