Parotid gland tumours series

1. INTRODUCTION
Parotid gland is one of the commonest seats of
pathologic disorders in the head and neck region. It is
the most common site of salivary gland tumours
accounting for 80% of the total. The annual incidence of
parotid gland tumours is 1 in 100,000.1,2 In 80% cases,
it is pleomorphic adenoma while Warthin's tumour
accounts for 10%. Among the malignancies, muco-
epidermoid carcinoma is the most common followed by
adenoid cystic carcinoma.1-3
Parotid gland surgery has slowly evolved over the last
few centuries. In the 16th century, it was limited to the
treatment of ranula and salivary gland calculi. In the 19th
century, enucleation was performed for parotid gland
tumours which was attended by 25% recurrence rate. In
the 20th century, the concept of more extensive surgery
to reduce the high rate of recurrence came and
superficial parotidectomy was popularized as the
minimum required procedure. Today, the widely accepted
procedures for benign parotid gland tumours are
superficial parotidectomy and extra capsular resection
while for malignant disorders, the options range from
total to extended parotidectomy.4-7
The present study was conducted with the aim to assess
the clinical presentation and outcome of various parotid
gland disorders that necessitated parotidectomy at a
tertiary care general surgical setting.
METHODOLOGY
This surgical audit was carried out at the Department of
Surgery, Pakistan Institute of Medical Sciences (PIMS),
Islamabad and included patients who underwent
parotidectomy from January 2003 to December 2010. All
adult patients of either gender who presented with
parotid gland disease and underwent parotidectomy
were included. Patients with diseases such as parotid
abscess who did not undergo parotidectomy were
excluded. Initial diagnosis was made by history, physical
examination and ancillary investigations.
The relevant data were obtained through the Hospital
Management Information System (HMIS) and patient
charts. The department of pathology was consulted to
review the histopathology and fine needle aspiration
Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (9): 625-628 625
ORIGINAL ARTICLE
Surgical Presentation and Outcome of Parotid Gland Tumours
Syed Aslam Shah1, Umbreen Riaz3, Muhammad Zubair4 and Muhammad Saaiq2
ABSTRACT
Objective: To assess the clinical presentation and outcome of surgical management of various parotid gland disorders
requiring parotidectomy.
Study Design: Case series.
Place and Duration of Study: Department of General Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad,
from January 2003 to December 2010.
Methodology: Patients presenting in surgical OPD with parotid gland disorders requiring parotidectomy were
included. Data were obtained through the Hospital Management Information System (HMIS) and patient charts. The
sociodemographic profile of the patient, presenting features among patients, benign versus malignant nature of the
disease, FNAC reports, type of surgical procedure instituted, complications encountered and histology reports of the
surgical specimens were all recorded on a proforma. The data were subjected to statistical analysis with SPSS
version 15.
Results: Out of 126 patients, 62 (49%) were males and 64 (51%) females with mean age of 41 ± 12.6 years. All had
presented with a lump usually painless. One hundred and fourteen (90.47%) patients had benign pathology while 9.52%
(n = 12) had malignanciy. Superficial parotidectomy was carried out in 79.36% (n = 100) patients, total parotidectomy in
19% (n = 24) and extended total parotidectomy was performed in 2 cases (with mucoepidermoid carcinoma). The most
common post-operative complication was greater auricular nerve paresis (n = 19; 15%) followed by facial nerve transient
paresis (n = 10; 8%). There was no in-hospital mortality.
Conclusion: Parotid gland lumps commonly affect relatively young individuals of either gender. Most of the patients have
benign pathology. Superficial parotidectomy is the most commonly offered surgical procedure. Parotid surgeries are safely
performed in general surgery units with low morbidity and no mortality.
Key Words: Parotid gland. Superficial parotidectomy. Facial nerve palsy. Pleomorphic adenoma. Mucoepidermoid carcinoma.
1 Department of General Surgery / Burn Care Centre2, Pakistan
Institute of Medical Sciences (PIMS), Islamabad.
3 Under Divisional Medical Officer, Pakistan Railways,
Rawalpindi.
4 Department of General Surgery, MIHS, Islamabad.
Correspondence: Prof. Syed Aslam Shah, House No. 352,
Street 33, Sector F-11/2, Islamabad.
E-mail: drsaslamshah@gmail.com
Received: January 09, 2012; Accepted: May 14, 2013.

2. cytology records. The type of surgery performed
depended on the pre-operative diagnosis based on
FNAC and radiological scans as well as the clinical
presentation of the tumour. All the patients were
hospitalized.
The operative procedure was tailored according to type
and extent of the disorder. Superficial parotidectomy
was performed for all benign tumours confined to the
superficial lobe. Total parotidectomy was performed for
malignant tumours as well as benign tumours involving
the deep lobe. Extended total parotidectomy was
performed for locally advanced malignant tumours.
For the identification of facial nerve, the V-shaped
sulcus found between the mastoid and the bony external
auditory meatus was sought. The tympanomastoid
fissure and the tragus pointer were also employed for
the nerve identification. The nerve was confirmed once it
was seen to divide into two main branches. All branches
were subsequently traced and superficial parotidectomy
was completed. No nerve conductor was used in
performing these procedures. Vacuum drains were
placed in the wound for 24 hours post-operatively. All
surgeries were performed by the consultant while some
of the surgeries required the expertise from plastic
surgery to cover the large defects not amenable to
direct closure.
The sociodemographic profile of the patient, presenting
features among patients, benign versus malignant
nature of the disease, FNAC reports, type of surgical
procedure instituted, complications encountered and
histology reports of the surgical specimens were all
recorded on a proforma.
The data were analysed through Statistical Package for
Social Sciences (SPSS) version 15. The numerical data
such as age were expressed as mean ± standard
deviation while categorical data such as gender
distribution, histological diagnosis, surgical procedures
and complications observed were expressed as
frequencies and percentages. 2 x 2 table was employed
to calculate sensitivity and specificity of FNAC for
malignant lesions.
RESULTS
Out of 126 patients, 51% (n = 64) were females while
49% (n = 62) were males. The age ranged from 10 – 65
years. A majority of the patients (63%) were in the third
and fourth decades of life. The mean age was 41 ± 12.6
years. The mean age in cases of malignant tumours
was 43 ± 9.2 years.
Swelling or lump in the parotid region constituted the
most frequent presenting feature, found among all the
patients. It was followed by facial nerve palsy in 3%
(n = 4) and pain in 1.58% (n = 2) of the cases. Overall,
90.47% (n = 114) cases had benign pathology while
9.52% (n = 12) had malignancies. The deep lobe was
involved in 2.38% (n = 3) while in 8% (n = 10) the
swelling was recurrent. Table I shows the histological
diagnosis among the patients found on histopathology of
the surgical resection specimen.
The most common surgical procedure instituted was
superficial parotidectomy, performed in 79.36% (n = 100)
patients. Total parotidectomy was performed in 19%
(n = 24) cases. Extended total parotidectomy with use
of different flaps was performed in 1.58% (n = 2) of
mucoepidermoid carcinoma.
The present share of postoperative complications
included greater auricular nerve paresis in 15% (n = 19)
cases, facial nerve paresis in 8% (n = 10), facial nerve
palsy in 4.76% (n = 6), Frey's syndrome in 1.58% (n = 2)
and flap tip necrosis in 0.79% (n = 1). In 3.17% (n = 4)
patients, the facial nerve was deliberately sacrificed due
to its involvement by the tumour.
The value of FNAC as a diagnostic tool was also
assessed and was found to have 98.24% specificity and
83.33% sensitivity. The overall diagnostic accuracy was
96.82% (Table II).
DISCUSSION
This series focused on parotid gland disorders which is
the commonest site for diseases among the salivary
glands. It is involved by a variety of different benign
and malignant conditions for which a wide range of
surgical procedures are available.7-10 The present study
Syed Aslam Shah, Umbreen Riaz, Muhammad Zubair and Muhammad Saaiq
626 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (9): 625-628
Table I: Histopathological diagnoses among the patients (n = 126).
Diagnosis Number of patients (percentage)
Pleomorphic adenoma 101 (80.15%)
Mucoepidermoid carcinoma 6 (4.76%)
Warthin’s tumour 4 (3.17%)
Oxiphilic adenoma 2 (1.58%)
Adenoid cystic carcinoma 2 (1.58%)
Acinic cell tumour 2 (1.58%)
Carcinoma ex-pleomorphic adenoma 2 (1.58%)
Chronic sialadenitis 3 (2.38%)
Chronic granulomatous sialadenitis 1 (0.79%)
Paraganglioma 1 (0.79%)
Myoepithelioma 1 (0.79%)
Sialadenectasia 1 (0.79%)
Table II: 2 x 2 table to calculate diagnostic accuracy of FNAC for diagnosing
malignancy in parotid gland (n = 126).
FNAC
Positive for Negative for Total
malignancy malignancy
Histopathology
Positive for malignancy 10 2 12
Negative for malignancy 2 112 114
Total 12 114 126
Sensitivity = a/a+c x 100 =10/10+2 x 100=83.33%
Specificity = d/b+d x 100 =112/2+112 x 100=98.24%
Positive predictive value = a/a+b x 100= 10/10+2 x 100=83.33%
Negative predictive value = d/c+d x 100= 112/2+112 x 100=98.24%
Diagnostic accuracy=TP+TN/TP+FP+TN+FN x 100=10+112/10+2+112+2= 122/126 x100=96.82%

3. is one the largest reported local series on parotid gland
disorders from Pakistan.11,12
In this study, the mean age for parotid gland disorders
was 41 years confirming to several published studies.10-13
However, several studies from the West have reported
these disorders to be more common in relatively
advanced age groups.1,2
In this study, there was a slight female predominance.
Several published studies have reported similar more
frequent involvement of females than males.10-12
Dorairajan from India reported male predominance.13
In this study, pleomorphic adenoma constituted the
commonest pathology affecting the parotid gland. Most
of the published literature has reported pleomorphic
adenoma to be the commonest pathology afflicting the
parotid gland.10-15
In this study, the share of malignancies was about 9.52%.
Different studies have reported variable percentage of
malignancies in their patients. Kara et al. have reported
24% malignancies in their parotid gland disorders.10
Takahama et al. have reported even higher frequency of
malignancies at 40%.1 In this series the commonest
malignant tumour was mucoepidermoid carcinoma
followed by adenoid cystic carcinoma. These findings
conform to what is reported by most of the published
literature.16-19
In this study, FNAC was found to be very useful for
diagnosing malignancies of the parotid gland. It was
found to have 98.24% specificity and 83.33% sensitivity.
It is economical and easy to perform in parotid
swellings. These findings conform to what is reported by
Awan et al. and Hartimath et al. who have reported
similar diagnostic accuracy of FNAC in parotid gland
tumours.20,21 Dissemination of tumour cells with FNAC is
a theoretical risk and is not supported by any published
data.
In this study, facial nerve transient paresis occurred in
8% cases while 4.76% cases had facial nerve palsy.
These finding conforms to most of the reported studies
however, some studies have reported as high frequency
as 39% of these complications.10,22,23 The use of nerve
stimulators, staining methods and other techniques have
been explained in literature for safeguarding the nerve
and these may help to reduce the frequency of such
disabling complications.
This study has some limitations. It is a single-centre
observational study. Observer bias could not be
eliminated completely. Cosmetic or long-term functional
results among the patients could not be evaluated. The
authors recommend the conduct of a multi-centre local
study to confirm and improve upon these results.
CONCLUSION
Parotid gland tumours commonly affect relatively young
individuals of either gender. Majority of the patients
present as a painless lump in parotid region. Most of
the patients have benign pathology while a small
percentage has malignancy. Superficial parotidectomy is
the most commonly offered surgical procedure. Parotid
surgeries are safely performed in general surgery units
with low morbidity and no mortality.
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628 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23 (9): 625-628