History: The patient is a 63-year-old white man with a painless right neck mass and a history of resection of multiple cutaneous squamous cell carcinomas of the facial region.
Findings
Figure 1: Demonstrates an intraparotid soft tissue mass with an irregular hypodense area centrally consistent with necrosis.
Figure 2: Demonstrates a second intraparotid soft tissue mass that is homogeneous.
In light of the patient's history, this constellation of findings is most consistent with intraparotid nodal metastases.
Diagnosis: Metastatic squamous cell carcinoma
Malignant neoplasms of the parotid glands generally present with a palpable, discrete, painless mass. More specific indications of malignancy include facial nerve paralysis or dysfunction, and cervical adenopathy; however, these symptoms are present in only 24% and 6% of cases, respectively.
Evaluation of parotid malignancies must include localization to the superficial or deep aspect, determination of degree of involvement of the facial nerve, and whether there has been spread of tumor through the stylomastoid foramen, to determine the extent of surgical intervention required. If the skull base has been breeched, the cartilaginous external auditory canal may require dissection and possible resection. MRI is the most effective imaging modality to fully evaluate malignant parotid tumors, and provides the best demonstration of perineural, vascular, or dural invasion.
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