Tonsillar Asymmetry from a Parotid Tumor
An otherwise healthy 28-year-old woman presented with tonsillar asymmetry, which she had just recently discovered, and a small painless lump behind the left cheek that had been slowly enlarging over several months. Physical examination revealed medial displacement of the left tonsil (Panel A, arrow) and confirmed the presence of a firm, immobile mass in the left retromandibular region. There was no cervical lymphadenopathy or facial-nerve abnormality. T2-weighted magnetic resonance imaging (MRI) revealed a hyperintense tumor of the left parotid gland (Panel B, coronal view, arrows) measuring 6 cm by 4 cm by 5 cm, principally occupying the deep lobe and extending into the left parapharyngeal space, with displacement of the palatine tonsil (Panel C, axial view, arrow). The MRI findings and the results of an ultrasound-guided fine-needle aspiration biopsy were compatible with a diagnosis of pleomorphic adenoma. Treatment consisted of total parotidectomy with facial-nerve preservation; the postoperative period was uneventful. Tumors of the deep lobe of the parotid gland may produce no visible deformity of the parotid region and can reach considerable dimensions before being discovered. A key finding on physical examination is the tonsillar bulge that represents the edge of the otherwise hidden mass.