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Significance
Salivary gland disorders are not a major public health problem in the Western world.
Neoplasms of the salivary glands account for fewer than 3% of tumors in the US and only 6%
of head and neck neoplasms.
Salivary gland tumors in children are uncommon, but the frequency of malignant tumors is
higher in children than in adults. (For more information, see Medscape Reference article
Malignant Parotid Tumors.) All masses in children require thorough diagnostic evaluation.
Benign masses of the parotid gland in children may be due to vasoformative abnormalities,
cysts, inflammatory processes, or neoplasms. The most common intraparotid mass is the
benign lymph node, as a significant number of lymph nodes are present in the parotid. The
most common benign tumor in children is the hemangioma. Of the benign epithelial tumors,
the mixed tumor (pleomorphic adenoma) is the most common.
Anatomy
The parotid gland is the largest of the major salivary glands. It arises as an epithelial
proliferation from the lining of the oral cavity at 5 weeks postovulation. It lies in the preauricular
region deep to the skin and subcutaneous tissue. The facial nerve (cranial nerve VII) divides
the gland into the larger superficial and smaller deep component. Though these are commonly
referred to as the superficial and deep lobes, they are not true lobes.
The parotid duct (Stensen duct) courses from the anterior border of the parotid gland below the
zygoma, crosses the masseter muscle and the buccal fat pad, and turns deep to penetrate the
buccinator muscle, finally opening intraorally at a papilla opposite the second upper molar. The
duct varies in length from 4.0-7.0 cm. The parotid tail extends inferiorly into the neck as low as
the sternocleidomastoid muscle. Acinar cells of the parotid gland are primarily secretory and
produce thin, watery saliva devoid of mucous.
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Benign Parotid Tumors: Significance, Anatomy, Incidence and Etiology http://emedicine.medscape.com/article/1289560-overview
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. [1] 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.
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.
Diagnosis
Laboratory studies
Hematologic and serologic tests are of little importance in the workup of salivary gland tumors.
Radiologic studies
Ultrasonography
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Benign Parotid Tumors: Significance, Anatomy, Incidence and Etiology http://emedicine.medscape.com/article/1289560-overview
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 experience of the pathologist with regard to salivary gland
tumors.
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. [3] Lymph nodes can be enucleated, [4] as can
Warthin tumors, and sialadenitis does not require surgical intervention in most cases.
Classification
Table 1. Classification of Benign Primary Epithelial Salivary Gland Tumors (Open Table in a
new window)
Oncocytoma
Monomorphic tumors
Sebaceous tumors
Unclassified
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Benign Parotid Tumors: Significance, Anatomy, Incidence and Etiology http://emedicine.medscape.com/article/1289560-overview
Oncocytoma
Monomorphic tumors
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 radiotherapy
may be administered, with local control rates exceeding 95%.
Surgical incision
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Benign Parotid Tumors: Significance, Anatomy, Incidence and Etiology http://emedicine.medscape.com/article/1289560-overview
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 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).
Complications
Parotidectomy can be performed with little morbidity and no mortality. Most serious
complications result from damage to the facial nerve (either temporary or permanent paralysis).
Injury to the greater auricular nerve results in hypesthesia of the ear. A slight loss of fullness
and an increased prominence of the angle of the mandible may occur after superficial
parotidectomy. Uncommon sequelae include salivary fistula, seroma, hematoma, and infection.
References
1. Byrne MN, Spector JG. Parotid masses: evaluation, analysis, and current management.
Laryngoscope. 1988 Jan. 98(1):99-105. [Medline].
3. Heller KS, Dubner S, Chess Q, Attie JN. Value of fine needle aspiration biopsy of salivary
gland masses in clinical decision-making. Am J Surg. 1992 Dec. 164(6):667-70. [Medline].
6. Domenick NA, Johnson JT. Parotid tumor size predicts proximity to the facial nerve.
Laryngoscope. 2011 Nov. 121(11):2366-70. [Medline].
8. Greenfield LJ, Mulholland M, Oldhan KT. Head and neck. Surgery: Scientific Principles
and Practice. 1997. 635-51.
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Benign Parotid Tumors: Significance, Anatomy, Incidence and Etiology http://emedicine.medscape.com/article/1289560-overview
9. Johnson JT, Kohut RI, Pillsbury HC. Head and Neck Surgery-Otolaryngology. 1993.
447-83.
10. OBrien JC. Head and neck I: Tumors. Selected Readings in Plastic Surgery. 2000. 9
(9):30-42.
11. Rodriguez-Bigas MA, Sako K, Razack MS, et al. Benign parotid tumors: a 24-year
experience. J Surg Oncol. 1991 Mar. 46(3):159-61. [Medline].
12. Thawley SE, Panje WR, Batsakis JG. Comprehensive Management of Head and Neck
Tumors. 1987. 1042-138.
Media Gallery
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Tables
Oncocytoma
Monomorphic tumors
Sebaceous tumors
Unclassified
Back to List
Author
Sanford Dubner, MD Assistant Clinical Professor, Department of Surgery, Long Island Jewish
Medical Center, Hofstra University School of Medicine
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Benign Parotid Tumors: Significance, Anatomy, Incidence and Etiology http://emedicine.medscape.com/article/1289560-overview
Surgeons, American Head and Neck Society, American Society of Plastic Surgeons, New York
Head and Neck Society
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega
Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American College of
Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial
Surgeons, Texas Medical Association, Texas Society of Plastic Surgeons
Disclosure: Received none from Allergan for speaking and teaching; Received none from
LifeCell for consulting; Received grant/research funds from GID, Inc. for other.
Chief Editor
Deepak Narayan, MD, FRCS Associate Professor of Surgery (Plastic), Yale University School
of Medicine; Chief of Plastic Surgery, West Haven Veterans Affairs Medical Center
Deepak Narayan, MD, FRCS is a member of the following medical societies: American
Association for the Advancement of Science, American College of Surgeons, American Medical
Association, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons,
Plastic Surgery Research Council, Royal College of Surgeons of England, Royal College of
Surgeons of Edinburgh, Indian Medical Association
Acknowledgements
Lawrence Ketch, MD, FAAP, FACS Head, Program Director, Associate Professor, Department
of Surgery, Division of Plastic Surgery, University of Colorado Health Sciences Center; Chief,
Pediatric Plastic, The Children's Hospital of Denver
Lawrence Ketch, MD, FAAP, FACS is a member of the following medical societies: American
Academy of Pediatrics, American Association for Hand Surgery, American Association of Plastic
Surgeons, American Burn Association, American Cleft Palate/Craniofacial Association,
American College of Surgeons, American Society for Surgery of the Hand, American Society of
Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic
Surgery, andPlastic Surgery Research Council
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