A 40-year-old Indonesian female with history of recurrent left parotid tumour for 8 years presented to us for 2nd opinion. She underwent surgery 8 years ago which was complicated with permanent facial nerve palsy. She was told the diagnosis was a benign tumour. However, in the past 1 year, the painless left parotid swelling started increasing rapidly in size especially in the past 5 months.

Examination revealed a large left parotid tumour extending to zygomatic arch, mastoid tip and supraclavicular fossae with overlying skin nodular appearance (Pictures A and B) with left facial nerve palsy grade V (House-Brackmann grading). Relevant blood parameters were within normal range of values. A contrast enhanced computerised tomography (CT) scan revealed enhancing left superficial and deep lobe parotid mass with parapharyngeal extension (Picture C).

She underwent Left Total Parotidectomy with Local Regional Flap Cover and recovered with no complications (Picture D). Her facial nerve remained status quo and she is planned for reanimation surgery at a later date. Histo-Pathological Examination (HPE) revealed Adenoid Cystic Carcinoma with perineural invasion (Picture E). She was referred to the Oncologist for Radiotherapy assessment.
We wish to highlight the challenging scenario in managing a parotid malignancy of this magnitude in presentation.