Giant Intraparotid hemangioma presenting with facial nerve palsy in an adult: a rare case report of surgical excision and sural nerve graft reconstruction

Imagine your body as a bustling city, where roads (blood vessels) and communication cables (nerves) run through every neighborhood. Usually, these roads are well-paved and the cables are neatly organized. But sometimes, a construction crew gets a little too enthusiastic and builds a tangled, growing mess of pipes right in the middle of a busy district. In the world of medicine, this is called a vascular anomaly. Most of the time, these messy construction projects happen in babies and then, like a temporary tent, they pack up and disappear as the child grows up. But sometimes, a very rare and stubborn version of this mess decides to stay put and keep growing in teenagers or adults. When this happens in the parotid gland—the big salivary factory sitting right in front of your ear—it's a tricky situation. This gland is surrounded by the "main highway" of the neck (major arteries and veins) and the "fiber optic cable" that controls your face (the facial nerve). If a tumor grows there, it doesn't just sit there; it can wrap around these vital structures like ivy on a house, potentially shutting down the power to your face and making it hard to chew or swallow. Doctors have to be incredibly careful because poking these tumors with a needle is like trying to take a sample of a water balloon with a pin; it usually just causes a flood of blood without giving a clear answer.

This paper tells the story of a 19-year-old guy who walked into the hospital with a massive, growing lump on the left side of his face. It wasn't just a bump; it was a giant, 15-centimeter (roughly 6-inch) monster of a tumor that had taken over his parotid gland. The scary part? It had grown so big and deep that it was squeezing the internal carotid artery and the jugular vein, and it had already paralyzed his facial nerve, leaving half his face unable to move. The doctors couldn't just cut it out easily because the tumor was hugging the blood vessels and the nerve so tightly that they couldn't tell where the tumor ended and the healthy tissue began. They had to perform a radical surgery to remove the entire mass, which meant they had to sacrifice the damaged facial nerve because it was too entangled to save. But they didn't stop there. To fix the "broken cable," they performed a delicate reconstruction using a piece of nerve harvested from the patient's leg (the sural nerve) to bridge the gap and try to restore movement to his face. The surgery was a success: the giant tumor was gone, the blood vessels were saved, and the patient was on the road to recovery.

Here is the breakdown of what happened, why it was so tricky, and what the doctors learned, told through the lens of this unique case.

The Mystery of the Growing Lump

Our patient was a 19-year-old male who had been dealing with a slowly growing mass on the left side of his face for eight months. It wasn't just a cosmetic issue; it was causing him pain, making it hard to open his mouth (a condition called trismus), and messing up his ability to chew. When the doctors first looked at him, they saw a large swelling on the left side of his face and neck.

To figure out what was going on, they used high-tech cameras inside the body. A CT scan (which uses X-rays to take 3D pictures) showed a huge, messy mass measuring 88 x 117 x 108 millimeters. It was invading three different "rooms" in the head: the masticator space (where chewing muscles live), the parapharyngeal space (a deep area behind the throat), and the parotid space. The most alarming thing the scan showed was that this mass had wrapped itself around the internal carotid artery and the jugular vein, the two major blood vessels in the neck.

They then used an MRI (which uses magnets to see soft tissues in great detail) to get a better look. The MRI confirmed the tumor was a "multilobulated" (many-lobed) beast, measuring 112 x 90 x 97 millimeters. It had completely destroyed the normal shape of the parotid gland and was squeezing the blood vessels from all sides. Because the tumor was so aggressive and had already caused facial nerve paralysis, the doctors knew they couldn't just watch and wait. They had to operate.

The Surgery: A High-Stakes Dance

The surgery was a massive undertaking. The team made a special cut (a modified Blair incision) to get access to the deep neck area. Usually, surgeons use landmarks like the tip of the ear or the jawbone to find the facial nerve, but this tumor was so big it had hidden all those clues.

Inside, they found a bilobed (two-lobed) tumor about 15 x 10 centimeters in size. It had grown from the top part of the parotid gland deep into the back part. The tumor had compressed and infiltrated the main trunk of the facial nerve so badly that it was impossible to save the nerve in its original form. The nerve was essentially crushed and tangled up with the tumor.

The surgeons had to perform a "radical parotidectomy," which means removing the entire gland and the tumor. They carefully peeled the tumor away from the internal carotid artery and jugular vein, saving the blood flow to the brain. They also removed a cluster of lymph nodes (small filters in the neck) to make sure the cancer hadn't spread, though the lab later confirmed those nodes were just reacting to the inflammation and were not cancerous.

The tumor weighed 233 grams (about half a pound) and, under the microscope, was identified as a mixed venous and cavernous hemangioma. This is a type of benign (non-cancerous) tumor made of blood vessels. It was not a cancer, but it behaved like one because it was so invasive.

Fixing the Broken Wire

Because the facial nerve was destroyed by the tumor, the patient was left with facial paralysis. To fix this, the doctors planned a second stage of surgery four months later. They needed to reconnect the "power line" to the face.

They harvested a 30-centimeter piece of the sural nerve from the patient's leg. This nerve is often used for repairs because it's long and taking it doesn't cause too much trouble for the leg. The surgeons then performed a tricky maneuver called a petrosectomy (removing a small part of the bone near the ear) to reach the remaining healthy part of the facial nerve deep inside the skull. They sewed the three segments of the leg nerve to the different branches of the facial nerve (frontal, zygomatic, and cervicofacial) to create a bridge. This graft acts like a scaffold, allowing the nerve fibers to grow across the gap and hopefully restore movement to the face.

Why This Case Matters

This story highlights a few important things for the medical world:

1. Adults vs. Babies: Most people know that "hemangiomas" (blood vessel tumors) are common in babies and usually go away on their own. But in adults, these tumors are extremely rare and don't go away. They can be much more aggressive and invasive, as seen in this 19-year-old.
2. The "No Needle" Rule: The paper emphasizes that you should never stick a needle into a suspected vascular tumor in the parotid gland to take a sample. It's like poking a water balloon; it can cause massive bleeding and make the surgery much harder. Instead, doctors must rely on MRI and CT scans to plan the operation.
3. The Danger of "Turkey Wattle": In some vascular tumors, if you push on your neck or hold your breath, the lump gets bigger (a sign called the "turkey-wattle sign"). However, in adults with parotid tumors, this sign is often missing because the tissue is too tight to expand visibly. This can lead to misdiagnosis, making doctors think it's a simple cyst or a different type of tumor.
4. The Importance of Complete Removal: If you don't get the whole tumor out, it can grow back. The paper suggests that leftover tissue can create a low-oxygen environment that triggers the tumor to grow back even faster. So, complete removal is key.
5. Reanimation is Possible: Even when the facial nerve is destroyed, it is possible to restore function using nerve grafts. It takes time and patience, but it offers a way to bring back facial symmetry and movement.

The Bottom Line

This paper reports on a very rare case of a giant, non-cancerous blood vessel tumor in a young adult's parotid gland that was so aggressive it paralyzed the face and wrapped around major neck arteries. The doctors successfully removed the entire tumor, saved the blood vessels, and then used a nerve from the leg to try to rebuild the facial nerve. The patient is currently recovering and undergoing rehabilitation.

The key takeaway is that while these tumors are rare in adults, they can be dangerous and mimic cancer. They require a very careful, coordinated team of surgeons to remove them completely without causing massive bleeding, and they often need complex reconstruction to fix the damage left behind. It's a reminder that even in the most tangled, messy situations, a careful plan and a skilled team can restore function and health.