Mass in the Buccal Space

History of Present Illness

• The typical history encountered in patients with a mass in the buccal space is that of a slowly growing, painless mass in the cheek ( Fig. 90.2 ).

  

• If the mass is more deeply seated, it tends to lie more medial and the patient may be able to feel the intraoral mass with the tongue ( Fig. 90.3 ).

  

• When the mass is located in the oral cavity, patients are often seen initially by their dentist or an oral maxillofacial surgeon.

• Constitutional symptoms suggest infection, an inflammatory condition, or lymphoid neoplasm.

Past Medical History

• History of previous salivary gland or other neoplasms

• Recent dental work or cervicofacial infections

• Recent injection of facial fillers for cosmetic purposes

• Serious comorbidities

• Social History

  • Use of alcohol and tobacco

• Medications

  • Many medications may increase the likelihood of sialolithiasis.

  • Use of anticoagulants

A complete examination of the head and neck is warranted, as with all masses in the head and neck.

Particular attention should be given to examination of the skin for primary cutaneous malignancies and palpation for cervical metastases.

Inspection and bimanual examination usually reveals a mobile mass within the substance of the cheek that can be seen in the oral cavity (see Fig. 90.3 ).

Although facial nerve deficits are uncommon given the rich distal cross-innervation, attention to the facial nerve function is mandatory.

Basic determination of the patency of Stensen duct can be achieved by visualizing the duct orifice while milking or massaging the parotid gland from posterior to anterior.

Kurabayashi et al. evaluated the computed tomography (CT) features of masses in the buccal space in 53 patients (33 benign tumors, 11 malignancies, 9 non-neoplastic lesions) and concluded that CT was useful in demonstrating the presence and location of masses in the buccal space. CT can sometimes assist in the differential diagnosis but the value of CT in differentiating benign from malignant lesions in the buccal space is limited.

Tumors of the buccal space were found adjacent to the outer surface of the buccinator muscle in contrast to epidermoid cysts and tumors of the accessory lobe of the parotid gland, which were completely separate from it.

Tumors of the accessory lobe of the parotid gland, epidermoid cysts, lipomas, and lymphoma could be differentiated from other lesions.

Hemangiomas were characterized by multiple masses and the presence of phleboliths.

Kurabayashi et al. also studied 30 patients with benign and malignant lesions in the buccal space with magnetic resonance imaging (MRI). MRI was useful in demonstrating the extent of lesions in the buccal space, but similar to CT its diagnostic value in predicting malignancy was very limited ( Fig. 90.4 ). This was especially true for malignant tumors of minor salivary gland origin, which were typically seen as well-defined masses without infiltration into surrounding structures on MRI.

Ultrasound may be helpful in characterizing the lesion (size, echogenicity, flow, calcifications) or in assisting fine-needle aspiration biopsy.

Fine-needle aspiration biopsy is most helpful in determining the need for surgery rather than providing a definitive diagnosis.

Definitive diagnosis of a mass in the buccal space is made by excision of the mass and histopathologic evaluation.

Incisional biopsy is never appropriate, as the risks of facial nerve injury and tumor spillage are increased and postbiopsy changes may make the definitive surgery more complex.

The differential diagnosis of a mass in the buccal space includes lesions originating from each of the tissue components in the space. Table 90.1 lists the lesions that have been found in the buccal space.

Excisional biopsy is indicated in patients whose preoperative examination suggests a neoplastic condition.

Undesired cosmetic appearance of the mass

Patients who are not healthy enough to tolerate or benefit from excision of the mass

Several surgical approaches to the buccal space have been described.

The approach used most commonly is a direct transmucosal intraoral incision with dissection and removal of the mass. This approach is appealing, because the bulging of the mass into the intraoral area lends itself to easy excision and eliminates a skin incision with its inevitable scar (see Fig. 90.3 ).

Despite this apparent advantage, the intraoral approach may not provide adequate exposure. While removing these masses through the external approach, we have observed that the buccal branches of the facial nerve are always closely associated with or actually incorporated into the capsule on the lateral aspect of the mass, which cannot be well visualized through the intraoral approach ( Fig. 90.5 ). Stensen duct is also closely associated with these tumors. Without proper exposure, these vital structures are at risk for injury, which could produce facial paralysis and sialocele.

The direct transcutaneous approach is appealing because of the advantage of requiring less time and dissection and no need to raise skin flaps, thereby avoiding the possibility of flap necrosis. We do not recommend this approach because of the highly visible scar and the risk to branches of the facial nerve and Stensen duct. This approach also makes it difficult to use local tissue to fill in the depressed area left after removal of the mass.

An extended parotid-submandibular incision ( Fig. 90.6 ) for removal of a mass in the buccal space is used in our department because it provides excellent exposure and minimizes the risk of complications such as injury to Stensen duct or the facial nerve during excision of these tumors. This technique also provides an excellent cosmetic result.

The rhytidectomy approach that Madorsky and Allison described can be used for removal of a mass in the buccal space and offers a superior cosmetic result.