Case Study: Young Patient Undergoes 10-Hour Palate Reconstruction to Remove Tennis Ball-Sized Mass

Otolaryngologists discuss a complex case

Presentation and diagnosis

A 22-year-old male with an unusually large mass of his soft palate was referred to the Department of Otolaryngology–Head and Neck Surgery at Cleveland Clinic. The mass, nearly the size of a tennis ball, had begun compromising his sleep, voice, breathing, and swallowing. Previously diagnosed as a mucocele, it had been known to the patient for over 10 years, growing slowly over time.

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

Recent changes in the tumor’s progression invoked concern about the potential for malignant transformation. Further workup characterized the tumor as a pleomorphic adenoma (PA), a benign salivary gland neoplasm, most often found in the parotid gland. PAs are characterized by a high rate of recurrence if not completely resected.

Due to the patient’s youth and symptomatic presentation, the surgeons recommended a complete resection and radial forearm free flap reconstruction. The complex, 10-hour procedure was led by Joseph Scharpf, MD and Dane Genther, MD, both staff in Cleveland Clinic’s Head & Neck Institute.

Resection and reconstruction

Dr. Scharpf, a head and neck surgical oncologist, who led the resection, notes that marginal removal on the tumor was challenging because of its outsized shape. “We had limited space to manipulate some of the critical anatomy, while also preserving the critical blood vessels and nerves in this complex region.”

Once the tumor was excised and margins tested negative, Dr. Scharpf and his team established vessels in the neck in preparation for the microvascular free flap reconstruction, the second part of the procedure led by Dr. Genther, a facial plastic and microvascular reconstructive surgeon.

Dr. Genther harvested tissue from the patient’s forearm to rebuild the palate, then grafted skin from the patient’s thigh to cover the forearm defect. The decision to utilize a forearm flap was straightforward. “It’s a thin and pliable tissue with a long vascular pedicle. A bulkier flap can impede speech and swallowing, making this the best choice for a soft palate reconstruction,” remarks Dr. Genther. The flap was inset to reconstruct the defect through a trans-oral approach.

Cleveland Clinic’s Head & Neck Institute has six microvascular surgeons and offers training in free flap reconstruction through the head and neck surgical oncology and reconstructive surgery fellowship.

<p>Figure 1. Soft palate tumor in situ</p>

Figure 1. Soft palate tumor in situ

<p>Figure 2. Soft palate tumor excised</p>

Figure 2. Soft palate tumor excised

<p>Figure 3. Soft palate tumor excised, alternative view</p>

Figure 3. Soft palate tumor excised, alternative view

<p>Figure 4. Soft palate defect</p>

Figure 4. Soft palate defect

<p>Figure 5. Soft palate defect with retraction</p>

Figure 5. Soft palate defect with retraction

<p>Figure 6. Soft palate reconstructed with radial forearm free flap</p>

Advertisement

Figure 6. Soft palate reconstructed with radial forearm free flap

Slide 1/6

Outcomes

The patient was discharged after five days of postoperative care, which is typical for this type of procedure. Soon after the surgery, the patient’s sleep apnea and hypernasal speech resolved. At his four-month follow-up appointment, he reported a significantly improved quality of life with no remaining symptoms. Given the severity of the patient’s presentation and the complexity of the surgery, the patient will remain in close follow up for the next several years.

Key takeaways

While this case was unusual given the age of the patient and the size of the tumor, Cleveland Clinic’s team of head and neck surgeons routinely treat a high volume of complex reconstructive cases. Additionally, the otolaryngologist-head and neck surgeons stress the importance of knowledge of and adherence to clinical and surgical guidelines of neoplasms such as PAs. Finally, a collaborative approach among surgeons and care teams is vital for a seamless implementation of surgical and post-surgical care to optimize patient outcomes.

Advertisement

Related Articles

Pediatric uvular cyst
Case Study: Treating and Managing a Pediatric Uvular Cyst

Prompt surgery was necessary when symptoms drastically increased

Patient scan
Cleveland Clinic Team Achieves Success in Complicated Surgery

Collaborative and multidisciplinary approach necessary for treatment

vestibular testing
Case Study: The Importance of the Vestibular Test Battery Evaluation

When a patient failed to improve, the value of a comprehensive vestibular test was apparent

Gingival fibroma
Mass Under the Lip

Case highlights the importance of oral hygiene in hospital and outpatient settings

Before and after images of patient with trivector trasoral trasfacial OTTT.
Cleveland Clinic Facial Reanimation Surgeons Perform Tri-Vector Reanimation in Pediatric Patient

A team of surgeons helped give a 9-year-old patient with congenital facial paralysis the ability to smile

19-ENT-4148-TongueMass&#8211;650&#215;450
Case Study: An Unusual Tongue Mass Raises Questions

Head and neck surgeons discuss the perplexing case

19-ENT-4000-tracheostomyChild_650x450
New Endoscopic Suturing Technique Trialed in 2 Patients Requiring Pediatric Airway Repair

Posterior endoscopic graft suturing may reduce costs and risks associated with postoperative intubation or tracheostomy placement in children

Ad