CHAPTER III

DISCUSSION

A. History

Thorough history and physical examination is important in the workup

of parotid masses. The major goal in the evaluation is to determine or exclude

the diagnosis of malignancy. History often is the most useful tool in

distinguishing inflammatory from neoplastic masses.

1. Benign Parotid Tumor

Characteristics of inflammatory conditions are sudden onset, pain,

and systemic infection. The most common presentation is that of an

asymptomatic mass (81%) noted incidentally while washing or shaving

the face. Pain (12%) or facial nerve paralysis (7%) is less frequent. Facial

nerve paralysis is more commonly due to malignancy in the presence of a

parotid mass, but most facial nerve paralysis is due to Bell palsy. Parotid

masses occur most commonly in the lower pole, or tail, and in the

superficial lobe of the gland. (Byrne and Spector, 1988)

49
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2. Malignant Parotid Tumor

Evaluation of a patient with a suspected parotid gland malignancy

must begin with a thorough medical history and physical examination.

The most common presentation is a painless, asymptomatic mass; >80%

of patients present because of a mass in the posterior cheek region.

Approximately 30% of patients describe pain associated with the mass,

though most parotid malignancies are painless. Pain most likely indicates

perineural invasion, which greatly increases the likelihood of malignancy

in a patient with a parotid mass. (Snyderman and Johnson, 1987)

Of patients with malignant parotid tumors, 7-20% present with facial

nerve weakness or paralysis, which almost never accompanies benign

lesions and indicates a poor prognosis. Approximately 80% of patients

with facial nerve paralysis have nodal metastasis at the time of diagnosis.

These patients have an average survival of 2.7 years and a 10-year

survival of 14-26%. Other important aspects of the history include length

of time the mass has been present and history of prior cutaneous lesion or

parotid lesion excision. Slow-growing masses of long-standing duration

tend to be benign. A history of prior squamous cell carcinoma, malignant

melanoma, or malignant fibrous histiocytoma suggests intraglandular

metastasis or metastasis to parotid lymph nodes. Prior parotid tumor most

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likely indicates a recurrence because of inadequate initial resection.

(Snyderman and Johnson, 1987)

Trismus often indicates advanced disease with extension into the

masticatory muscles or, less commonly, invasion of the

temporomandibular joint. Dysphagia or a sensation of a foreign body in

the oropharynx indicates a tumor of the deep lobe of the gland. A report of

ear pain may indicate extension of the tumor into the auditory canal. The

presence of numbness in the distribution of the second or third divisions of

the trigeminal nerve often indicates neural invasion (Snyderman and

Johnson, 1987).

B. Physical Examination

1. Benign Parotid Tumor

Physical examination most often reveals a mobile nontender mass

that is firm and solitary. Evaluate the possibility of a deep tumor by

intraoral examination, with attention directed to the tonsillar fossa and soft

palate. Inspect the Stensen duct for the character of the salivary flow

(clarity, consistency, purulence) and notation of redness, bulging, and

irritation of the ductal orifice as part of the physical examination. Evaluate

the skin, oral cavity, oropharynx, and neck for possible primary lesions or

nodal disease. (Byrne and Spector, 1988)

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2. Malignant Parotid Tumor

Physical examination of the head and neck must be thorough and

complete. The entire head and neck must be examined for cutaneous

lesions, which may represent malignancies that could metastasize to the

parotid gland or parotid nodes.

a. Palpation of the mass should determine the degree of firmness.

Even benign tumors are usually firm, but a rock-hard mass

generally denotes malignancy.

b. Skin fixation, skin ulceration, or fixation to adjacent structures

also indicates malignancy. The external auditory canal must be

visualized for tumor extension.

c. All regional nodes must be carefully palpated to detect nodal

metastasis. Examination of the oral cavity and oropharynx also

may yield further evidence of metastasis or malignant nature of

the lesion.

d. Blood or pus from the Stenson duct is a sign of malignancy but

is infrequently encountered. More often, one may see bulging of

the lateral pharyngeal wall or soft palate, indicating tumor in the

deep lobe of the gland.

e. Bimanual palpation with one finger against the lateral

pharyngeal wall and the other against the external neck may

confirm extent into the tonsillar fossa and soft palate.

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C. Additional Examination

1. Benign Parotid Tumor

a. Laboratory studies

Hematologic and serologic tests are of little importance in the

workup of salivary gland tumors.

b. Radiologic studies

Radiologic studies are involved minimally in the workup of an

asymptomatic mass.

1) Plain radiography findings can help the clinician exclude calculi.

2) Sialography is rarely used. When used, it helps the clinician

delineate disorders of ductal function or anatomy.

3) CT scan is almost 100% sensitive in detecting a salivary gland

mass, but it cannot help the clinician differentiate between a

benign and a malignant mass. It is most helpful in specifying the

size and anatomic extent of a tumor.

4) MRI is superior in demonstrating benign tumors of the parotid

gland because of its greater contrast than CT scan.

5) Positron emission tomography (PET) scans may be of value in

assessing malignant tumors, with attention to metastatic

adenopathy and distant metastases.

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c. Ultrasonography

A study by Rong et al identified differences between the

ultrasonographic characteristics of Warthin tumors and those of

pleomorphic adenomas, including with regard to shape, vascularity,

and the prevalence of cystic areas. The study involved 93 Warthin

tumors (61 patients) and 77 pleomorphic adenomas (70 patients), with

lobulated lesions representing 38.7% of Warthin tumors and 63.6% of

pleomorphic adenomas. Grade 2 or 3 vascularity was identified in the

majority of Warthin tumors (73.1%), while grade 0 or 1 vascularity

was present in most of the pleomorphic adenomas (77.9%); vessel

distribution also varied significantly between the two types of tumors.

In addition, cystic areas were identified in 45.2% of the Warthin

tumors but in only 20.8% of the pleomorphic adenomas. (Rong et al.,

2014)

d. Biopsy

Fine-needle aspiration may be a valuable pretreatment diagnostic

test. Its overall accuracy is greater than 96%, with a sensitivity for

benign tumors of 88-98% and a specificity of 94%. Its sensitivity for

detecting malignant tumors ranges from 58-96%, and its specificity is

71-88%. Frozen sections are 93% accurate when performed at surgery,

but their use is controversial, since diagnosis depends on the

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experience of the pathologist with regard to salivary gland tumors.

(Heller et al., 1992)

The standard biopsy approach is a superficial parotidectomy with

preservation of the facial nerve. For 80-90% of parotid neoplasms, this

procedure is both diagnostic and therapeutic. For this reason,

preoperative fine-needle aspiration biopsy is recommended, since it

can change the clinical approach in up to 35% of patients (Heller et al.,

1992). Lymph nodes can be enucleated, as can Warthin tumors, and

sialadenitis does not require surgical intervention in most cases.

(Ascani et al, 2008)

2. Malignant Parotid Tumor

a. Fine needle aspiration

Fine needle aspiration of the mass or an enlarged lymph node

may be performed to obtain a tissue diagnosis. Most surgeons

recommend excision of a parotid mass whether it is benign or

malignant unless a patient's comorbidity precludes safe surgery. As

such, many surgeons do not routinely perform cytology before

proceeding with surgery. The sensitivity of this procedure is greater

than 95% in experienced hands. However, only a positive diagnosis

should be accepted; negative results indicate the need for further

attempts at obtaining a histologic diagnosis, including repeat fine

needle aspiration. (Eneroth et al, 1967)

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The results of the fine needle aspiration provide a histologic

diagnosis and assist in preoperative planning and patient counseling. It

may not distinguish benign from malignant epithelial lesions because

malignancy of parotid epithelial cells is related to the behavior of the

tumor cells in relation to tissue planes and surrounding structures

rather than cellular architecture, which may be rather normal even in

malignancy. Therefore, nonepithelial lesions may be diagnosed with

accuracy, but epithelial lesions may require further investigation. If

fine needle aspiration is unsuccessful in obtaining a diagnosis, an

incisional biopsy should not be performed. This procedure has a high

rate of local recurrence and places the facial nerve at risk for injury

from inadequate visualization.

Some studies show large core needle biopsies, but this procedure

is less popular because of potential facial nerve injury and the

possibility of seeding the needle tract with tumor cells. If a core biopsy

is performed, the needle should be inserted so that the tract may be

excised during the definitive operation. When all attempts at obtaining

a histologic diagnosis have failed, operative exploration should

proceed after appropriate imaging studies have been obtained.

Intraoperatively, a frozen section of the specimen should be submitted

for diagnosis. The use of frozen sections has demonstrated greater than

93% accuracy in the diagnosis of parotid malignancy.

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b. Imaging Studies

Imaging studies may be helpful in staging and for surgical

planning. Sialography may help to differentiate inflammatory versus

neoplastic processes, but this test is infrequently performed and is of

limited value in the evaluation of parotid masses. It is mentioned

herein for historic interest only. Sonography may be very useful.

Benign lesions are of lower density and have smaller caliber blood

vessels. However, determination of a cystic component may be

misleading, because cystic degeneration may occur as a result of

necrosis at the avascular center of a malignancy. (Mamlouk et al,

2015)

Computed tomography (CT) scanning and magnetic resonance

imaging (MRI) can be valuable for evaluation of parotid malignancies.

CT scanning provides better detail of the surrounding tissues, whereas

MRI demonstrates the mass in greater contrast than a CT scan. These

imaging studies may identify regional lymph node involvement or

extension of the tumor into the deep lobe or parapharyngeal space. CT

scan criteria for lymph node metastasis include any lymph node larger

than 1-1.5 cm in greatest diameter, multiple enlarged nodes, and nodes

displaying central necrosis. (Rice and Becker, 1987)

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Lymph nodes harboring metastasis also may appear round rather

than the normal kidney bean shape, and evidence of extracapsular

extension may be identified. (Rice and Becker, 1987)

A study by Mamlouk et al of pediatric patients with parotid

neoplasms indicated that on MRI scans, the presence of a hypointense

T2 signal, restricted diffusion, poorly defined borders, and focal

necrosis are suggestive of malignancy, although not specific for it. The

study involved 17 patients, including 11 with malignant tumors and

six with benign neoplasms. (Mamlouk et al, 2015)

D. Treatment

1. Benign Parotid Tumor

Superficial parotidectomy is the treatment of choice for most benign

tumors in the superficial lobe. Make every effort to preserve the facial

nerve. In order to preserve the facial nerve, it is important to try to

determine the proximity of the nerve to the capsule of the tumor prior to

surgery. Results of a retrospective review showed that malignant tumors

were likely to have a positive facial nerve margin. (Domenick and

Johnson, 2011)

Avoid enucleation (except for Warthin tumors and lymph nodes),

since it greatly increases the likelihood of recurrence (up to 80%) and

nerve damage. Deep lobe tumors demand total parotidectomy with

preservation of the facial nerve. For recurrences, postoperative

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radiotherapy may be administered, with local control rates exceeding 95%.

A study by Cristofaro et al suggested that extracapsular dissection may be

superior to superficial parotidectomy in the treatment of pleomorphic

adenoma, with extracapsular dissection leading to fewer side effects. The

study involved 198 patients with pleomorphic adenomas of the parotid

gland, including 153 patients who underwent extracapsular dissection

(mean follow-up 61.02 months) and 45 who underwent superficial

parotidectomy (mean follow-up 66.4 months). The investigators found

that although both techniques were comparably effective, superficial

parotidectomy was associated with a significantly greater rate of transient

facial nerve injury and facial paralysis than was the other procedure.

(Cristofaro et al., 2014)

Surgical incision

Parotidectomy incision should allow for adequate exposure and the

most aesthetic result. The incision begins anterior to the superior root of

the helix and descends anterior to the tragus. It then is directed behind the

lobule of the pinna and can be carried down anteriorly onto the neck as

dictated by the need for exposure. If a large soft tissue defect is created by

the excision of the parotid tumor, numerous autologous or allograft tissues

(ie, dermal grafts, fascial grafts, fat grafts, AlloDerm) or synthetic

substances may be used for filling these defects. Try to preserve a layer of

tissue (the parotid fascia or SMAS layer) if it does not compromise the
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capsule of the tumor. This preservation is important so that a layer of

tissue interposes between the cut salivary tissue and the skin. This has

been shown to reduce the incidence of Frey syndrome (gustatory

sweating).

2. Malignant Parotid Tumor

a. Operative Management

Generally, therapy for parotid malignancy is complete surgical

resection followed, when indicated, by radiation therapy. Conservative

excisions are plagued by a high rate of local recurrence. The extent of

resection is based on tumor histology, tumor size and location,

invasion of local structures, and the status of regional nodal basins.

(Johns, 1980)

Most tumors of the parotid (approximately 90%) originate in the

superficial lobe. Superficial parotid lobectomy is the minimum

operation performed in this situation. This procedure is appropriate for

malignancies confined to the superficial lobe, those that are low grade,

those less than 4 cm in greatest diameter, tumors without local

invasion, and those without evidence of regional node involvement.

(Alba et al., 2008)

Surgical resection procedure

The most important initial step is identification of the facial

nerve and its course through the substance of the parotid gland. In
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order to preserve the facial nerve, it is important to try to determine the

proximity of the nerve to the capsule of the tumor prior to surgery.

Results of a retrospective review showed that malignant tumors were

likely to have a positive facial nerve margin (Domenick and Johnson,

2011). Virtually all surgeons avoid using paralytic agents, and, to

assist finding the nerve, many surgeons use a nerve stimulator.

Increasingly, surgeons are using intraoperative continuous facial nerve

monitoring any time a parotidectomy is performed. This is not usually

necessary in the primary setting, but recurrent resections may be very

difficult and probably should be performed using this device.

1) Ideally, the dissection of the facial nerve should be performed

without disturbing or violating the tumor. The facial nerve may be

found exiting the stylomastoid foramen by reflecting the parotid

gland anteriorly and the sternocleidomastoid muscle posteriorly.

Landmarks include the digastric ridge and the tympanomastoid

suture. Knowledge of the relationships among these structures

allows more efficient and reproducible identification of the nerve.

2) The cartilaginous external auditory canal lies approximately 5 mm

superior to the facial nerve in this region. The facial nerve is also

anterior to the posterior belly of the digastric muscle and external

to the styloid process.

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3) A second technique for locating the facial nerve is to identify a

distal branch of the nerve and to dissect retrograde toward the main

trunk. This technique may be more difficult depending on the ease

of identifying the branching pattern. To perform this maneuver, the

buccal branch may be found just superior to the parotid duct, or the

marginal mandibular branch may be found crossing over

(superficial to) the facial vessels. These may then be traced back to

the origins of the main facial nerve trunks.

4) A final way of identifying the nerve in particularly difficult

situations is to drill the mastoid and to locate the nerve within the

temporal bone. It may then be followed through the stylomastoid

foramen antegrade towards the parotid.

5) Once these have been identified, the superficial lobe of the parotid

gland may be removed en bloc and sent to the pathology

laboratory. If the immediate intraoperative pathologic examination

reveals that the tumor is actually high-grade or >4 cm in greatest

diameter, or lymph node metastasis is identified within the

specimen, a complete total parotidectomy should be performed.

6) If the facial nerve or its branches are adherent to or directly

involved by the tumor, they must be sacrificed. However, a

pathologic diagnosis of malignancy must be confirmed

intraoperatively prior to sacrificing facial nerve branches.

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7) All involved local structures should be resected in continuity with

the tumor. This may include skin, masseter, mandible, temporalis,

zygomatic arch, or temporal bone.

8) Tumors of the deep lobe are treated by total parotidectomy.

Identification of the facial nerves and branches is the first and most

crucial step.

9) Total parotidectomy is then performed en bloc, and the fate of the

facial nerve and surrounding local structures must be decided

similar to superficial lobe tumors. The specimen should be sent to

the pathology laboratory for immediate examination.

10) Neck dissection should be performed when malignancy is detected

in the lymph nodes pre- or intraoperatively.

11) Other indications for functional neck dissection include tumors >4

cm in greatest diameter, tumors that are high-grade, tumors that

have invaded local structures, recurrent tumors when no neck

dissection was performed initially, and deep lobe tumors.

12) These recommendations are based on the higher likelihood of

occult, clinically undetectable nodal disease present at the time of

operation in patients whose tumors display the above

characteristics.
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Reconstruction

Following resection of the tumor specimen, most wounds can be

closed primarily. However, the presence of extension of the tumor to

the overlying skin or surrounding structures may require

reconstructive procedures. The overall goal following tumor excision

is to restore function and achieve the best possible aesthetic result.

Options for wound closure in the presence of a skin or soft tissue

deficit include skin grafting, cervicofacial flap, trapezius flap,

pectoralis flap, deltopectoral flap, and microvascular free flap.

Sacrifice of the facial nerve or one of its branches also must be

managed appropriately. If inadvertently severed during the operation,

the facial nerve should be immediately repaired under the operating

microscope. If intentionally resected with the tumor specimen, several

options for reconstruction are available to the surgeon.

1) The ipsilateral or contralateral great auricular nerve may be used as

an interposition graft, although this sacrifices sensation to the area

normally supplied by this nerve.

2) Another option is to anastomose the facial nerve to the ipsilateral

hypoglossal nerve. This anastomosis may be performed end-to-

side to avoid interfering with normal hypoglossal nerve function.

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3) During the period of waiting for facial nerve recovery, maintain

corneal protection if the innervation to the orbicularis oculi has

been interrupted.

4) Measures include taping the eye closed at night over ophthalmic

ointment and frequent use of wetting drops during the day. Some

authors recommend a moisture chamber.

If facial nerve recovery is not achieved, certain measures may be

taken to improve form and function.

1) A gold weight (0.8-1.2 g) may be inserted in the upper eyelid to

assist with closure. Dynamic slings of temporalis muscle to the

upper and lower lids and corner of the mouth or masseter sling to

the mouth have proven very successful in the reconstruction of

these patients. Static slings also have been used and include fascia

lata, tendon, and Mitek anchors.

2) Following parotidectomy, some patients develop gustatory

sweating or Frey syndrome. This denotes an aberrant connection

of regenerating parasympathetic salivary fibers to the sweat

glands in the overlying skin flap. Treatment of this condition has

included irradiation, atropinelike creams, division of the

auriculotemporal nerve (sensory), division of the

glossopharyngeal nerve (parasympathetic), insertion of synthetic

materials (AlloDerm), fascial grafts, or vascularized tissue flaps

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between the parotid bed and overlying skin flap. Intracutaneous

injections of botulinum toxin A is also an attractive option which

has showed some promise. (Luna et al., 2007)

Finally, neurovascular free tissue transfer has been described for

facial reanimation for treatment of established facial paralysis

following ablative parotid surgery. (Takushima et al., 2004)

1) Vascularized nerve grafts, such as sural nerve graft, have been

described to reestablish facial nerve continuity.

2) Functional free muscle transfer with gracilis, pectoralis minor, or

latissimus dorsi muscles are further options for reconstruction. The

ipsilateral facial nerve stump may be used as the recipient nerve.

3) Alternatively, cross facial nerve grafting can be performed. This is

typically performed as a 2-stage surgery, with anastomosis to a

nerve graft as the first stage and free tissue transfer as the second

stage.

Adjunctive Therapy

Because of the many histologic subtypes of parotid

malignancies, a general statement regarding the usefulness of

adjunctive therapy cannot be made. If resectable, surgery is the

primary modality of treatment for most malignant tumors of the

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parotid gland. General indications for postsurgical radiation therapy

include tumors >4 cm in greatest diameter, tumors of high grade,

tumor invasion of local structures, lymphatic invasion, neural

invasion, vascular invasion, tumor present very close to a nerve that

was spared, tumors originating in or extending to the deep lobe,

recurrent tumors following re-resection, positive margins on final

pathology, and regional lymph node involvement. Postoperative

radiation is, thus, usually indicated for all parotid malignancies with

the exception of small low-grade tumors with no evidence of local

invasion or nodal/distant spread. Radiation therapy is considered the

cornerstone of adjunctive therapy.

No chemotherapy has been proven effective as single modality

therapy. For certain histologic subtypes, some clinicians recommend

combined modality chemotherapy and radiation. Presently,

immunotherapy is in the clinical trial phase. A recent study

demonstrated that epidermal growth factor receptor (EGFR) is

expressed strongly in the cell membranes of parotid mucoepidermoid

carcinomas and of the lymph node metastases. EGFR-targeting agents

have potential to be used for therapy. (Shang, 2008)

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E. Prognosis

1. Benign Parotid Tumor

With the appropriate treatment of benign SGTs (ie, complete

excision, superficial parotidectomy), the outcome is excellent and the

recurrence rate is very low.

2. Malignant Parotid Tumor

The major determinants of survival are histology and clinical stage.

Poor prognostic factors include high grade, neural involvement, locally

advanced disease, advanced age, associated pain, regional lymph node

metastases, distant metastasis, and accumulation of p53 or c-erbB2

oncoproteins. (Frankenthaler et al., 1991 ; O'Brien et al., 1986 ;

Schwentner et al., 2006 ; Ghosh-Laskar et al., 2011)

Although statements regarding survival are difficult to make because

of the large variety of histologic types, 20% of all patients will develop

distant metastases (Schwentner et al., 2006). The presence of distant

metastases heralds a poor prognosis, with a median survival of 4.3-7.3

months. Overall 5-year survival for all stages and histologic types is

approximately 62%. The overall 5-year survival for recurrent disease is

approximately 37%. Because of the risk of recurrence, all patients who

have had a histologically proven malignant salivary gland tumor should

have lifelong follow-up.

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A study by Kim et al of 126 patients treated for primary parotid

cancer found the following disease-specific survival rates for the various

tumor stages (mean follow-up period 29.7 months) : (Kim et al., 2012)

a. Stage I (97%)

b. Stage II (81%)

c. Stage III (56%)

d. Stage IV (15%)

Patients in the study underwent superficial, total, or radical

parotidectomy, with 57 also undergoing postoperative radiotherapy.

Fifteen patients (12%) experienced disease recurrence. (Kim et al., 2012)