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Warthins tumor 'shell out' with facial nerve monitoring

return toParotidectomy with Facial Nerve Dissection

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Modified Operative Note:

The patient was brought back to the operating room where induction checklist was performed confirming the left side as the operative side. The patient was intubated by Anesthesia and endotracheal tube was taped to the right oral commissure. The bed was then rotated 180 degrees away from Anesthesia. No neuromuscular relaxants were used. A NIMS nerve monitoring system was placed for facial nerve monitoring and the patient was sterilely prepped and draped. A timeout was performed.

Incision was planned as a doubly modified Blair incision along the left face and planned incision was injected with epinephrine in a 1:100,000 parts concentration. Incision was then performed down along the planned incision and using scalpel, hemostats, blunt dissection was performed down to the level of the sternocleidomastoid muscle, identifying and preserving the greater auricular nerve. This was traced superiorly until the nerve passed over the palpable mass. Posterior branches were preserved to the auricle, but 2 anterior branches needed to be sacrificed in order to access the mass.


Dissection was carried down through parotid onto the tumor with care to test each divided tissue layer with the Parsons-McCabe nerve stimulator to prevent injury to any branches of the facial nerve. Stimulation identified anteriorly prompted redirection of dissection to the posterior aspect of the palpable tumor mass were no stimulation occurred. The mass was exposed with an intact capsule in the mass of the superficial parotid tail.


This capsule of the mass was preserved with careful dissection facilitated with judicious use of the the Shaw scalpel and McCabe forceps. The mass was shelled out with minor bleeding controlled with bipolar cautery (no unipolar cautery used). Once the mass was excised, it was sent for permanent pathology.

The wound bed was irrigated and evaluated with sustained positive ventilation pressure requested of anesthesia with hemostasis achieved. Of note, the facial nerve was stimulated in the wound bed with a Parsons-McCabe nerve stimulator at a setting of 10 milliamps in all branches, signifying no injury.


At this time, a quarter-inch Penrose drain was placed in the incision and the deep layer was closed with 3-0 Vicryl. A drain stitch was placed in through the Penrose and the skin was closed using 5-0 nylon suture. A burn net was placed and the patient was turned back towards Anesthesia in good condition for extubation.


Of note, in the PACU, the patient's facial nerve was intact bilaterally.

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