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Surgical presentation and outcome of parotid gland tumours. J Coll Physicians Surg Pak. 2013 Sep;23(9):625-8. doi: 09.2013/JCPSP.625628. [PubMed] PMID:24034185

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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
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  INTRODUCTION Parotid gland is one of the commonest seats of pathologic disorders in the head and neck region. It isthe most common site of salivary gland tumoursaccounting 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 byadenoid cystic carcinoma. 1-3 Parotid gland surgery has slowly evolved over the lastfew centuries. In the 16 th century,it was limited to thetreatment of ranula and salivary gland calculi. In the 19 th century,enucleation was performed for parotid glandtumours which was attended by 25% recurrence rate. Inthe 20 th century,the concept of more extensive surgeryto reduce the high rate of recurrence came andsuperficial parotidectomy was popularized as theminimum required procedure. Today,the widely acceptedprocedures for benign parotid gland tumours aresuperficial parotidectomy and extra capsular resectionwhile for malignant disorders, the options range fromtotal to extended parotidectomy. 4-7 The present study was conducted with the aim to assessthe clinical presentation and outcome of various parotidgland disorders that necessitated parotidectomy at atertiary 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 underwentparotidectomy from January 2003 to December 2010. Alladult patients of either gender who presented withparotid gland disease and underwent parotidectomywere included. Patients with diseases such as parotidabscess who did not undergo parotidectomy wereexcluded. Initial diagnosis was made by history, physicalexamination and ancillary investigations.The relevant data were obtained through the HospitalManagement Information System (HMIS) and patientcharts. The department of pathology was consulted toreview the histopathology and fine needle aspiration Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23(9): 625-628  625 ORIGINALARTICLE Surgical Presentation and Outcome of Parotid Gland Tumours Syed Aslam Shah 1 , Umbreen Riaz 3 , Muhammad Zubair 4 and Muhammad Saaiq 2 A BSTRACT Objective: To assess the clinical presentation and outcome of surgical management of various parotid gland disordersrequiring 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 parotidectomywereincluded. Data were obtained through the Hospital Management Information System (HMIS) and patient charts. Thesociodemographic profile of the patient, presenting features among patients, benign versus malignant nature of thedisease, FNAC reports, type of surgical procedure instituted, complications encountered and histology reports of thesurgical specimens were all recorded on a proforma. The data were subjected to statistical analysis with SPSSversion 15. Results: Out of 126 patients, 62 (49%) were males and 64 (51%) females with mean age of 41 ±12.6 years. All hadpresented 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 in19% (n=24) and extended total parotidectomy was performed in 2cases (with mucoepidermoid carcinoma). The mostcommon post-operative complication was greater auricular nerve paresis (n=19; 15%) followed by facial nerve transientparesis(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 havebenign pathology. Superficial parotidectomy is the most commonly offered surgical procedure. Parotid surgeries are safelyperformed 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 Centre 2  , 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.  cytology records. The type of surgery performeddepended on the pre-operativediagnosis based onFNAC and radiological scans as well as the clinicalpresentation of the tumour. All the patients werehospitalized.The operative procedure was tailored according to typeand extent of the disorder. Superficial parotidectomywas performed for all benign tumours confined to thesuperficial lobe. Total parotidectomy was performed for malignant tumours as well as benign tumours involvingthe deep lobe. Extended total parotidectomy wasperformed for locally advanced malignant tumours.For the identification of facial nerve, the V-shapedsulcus found between the mastoid and the bony externalauditory meatus was sought. The tympanomastoidfissure and the tragus pointer were also employed for the nerve identification. The nerve was confirmed once itwas seen to divide into two main branches. All brancheswere subsequently traced and superficial parotidectomywas completed. No nerve conductor was used inperforming these procedures. Vacuum drains wereplaced in the wound for 24hours post-operatively. Allsurgeries were performed by the consultant while someof the surgeries required the expertise from plasticsurgery to cover the large defects not amenable todirect closure.The sociodemographic profile of the patient, presentingfeatures among patients, benign versus malignantnature of the disease, FNAC reports, type of surgicalprocedure instituted, complications encountered andhistology reports of the surgical specimens were allrecorded on a proforma.The data were analysed through Statistical Package for Social Sciences (SPSS)version 15. The numerical datasuch as age were expressed as mean±standarddeviation while categorical data such as gender distribution, histological diagnosis, surgical proceduresand complications observed were expressed asfrequencies and percentages. 2x2 table was employedto calculate sensitivity and specificity of FNAC for malignant lesions. RESULTS Out of 126 patients, 51% (n=64) were femaleswhile49% (n=62) were males. The age ranged from 10– 65years. Amajority of the patients (63%) were in the thirdand fourth decades of life. The mean age was 41±12.6years. The mean age in casesof malignant tumourswas43±9.2 years.Swelling or lump in the parotid region constituted themost frequent presenting feature, found among all thepatients. 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 while9.52% (n=12) had malignancies. The deep lobe wasinvolved in 2.38%(n=3) while in 8% (n=10) theswelling was recurrent. Table Ishows the histologicaldiagnosis among the patients found on histopathology of the surgical resection specimen.The most common surgical procedure instituted wassuperficial parotidectomy, performed in 79.36% (n=100)patients. Total parotidectomy was performed in 19%(n=24) cases. Extended total parotidectomy with useof different flaps was performed in 1.58% (n=2) of mucoepidermoid carcinoma. The present share of postoperative complicationsincluded greater auricular nerve paresis in 15% (n=19)cases, facial nerve paresis in 8% (n=10), facial nervepalsy 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 dueto its involvement by the tumour.The value of FNAC as a diagnostic tool was alsoassessed and was found to have 98.24% specificity and83.33% sensitivity. The overall diagnostic accuracy was96.82% (Table II). DISCUSSION This series focused on parotid gland disorders which isthe commonest site for diseases among the salivaryglands. It is involved by a variety of different benignand malignant conditions for which a wide range of surgical procedures areavailable. 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). DiagnosisNumber of patients (percentage)Pleomorphic adenoma101 (80.15%)Mucoepidermoid carcinoma6 (4.76%)Warthin’s tumour4 (3.17%)Oxiphilic adenoma2 (1.58%) Adenoid cystic carcinoma2 (1.58%) Acinic cell tumour2 (1.58%)Carcinoma ex-pleomorphic adenoma2 (1.58%)Chronic sialadenitis3 (2.38%)Chronic granulomatous sialadenitis1 (0.79%)Paraganglioma1 (0.79%)Myoepithelioma1 (0.79%)Sialadenectasia1 (0.79%) Table II: 2 x 2 table to calculate diagnostic accuracy of FNAC for diagnosingmalignancy in parotid gland (n = 126). FNACPositive forNegative forTotalmalignancymalignancyHistopathologyPositive for malignancy10212Negative for malignancy2 112114Total12114126 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%  isone the largest reported local series on parotid glanddisorders from Pakistan. 11,12 In this study,the mean age for parotid gland disorderswas 41 yearsconfirmingto several published studies. 10-13 However, several studies from the West have reportedthese disorders to be more common in relativelyadvanced age groups. 1,2 In this study, there was a slight female predominance.Several published studies have reported similar morefrequent involvement of females than males. 10-12 Dorairajan from India reported male predominance. 13 In this study, pleomorphic adenoma constituted thecommonest pathology affecting the parotid gland. Mostof the published literature has reported pleomorphicadenoma to be the commonest pathology afflicting theparotid 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 reported24% malignancies in their parotid gland disorders. 10 Takahama et al  . have reported even higher frequency of malignancies at 40%. 1 In this series the commonestmalignant tumour was mucoepidermoid carcinomafollowed by adenoid cystic carcinoma. These findingsconform to what is reported by most of the publishedliterature. 16-19 In this study, FNAC was found to be very useful for diagnosing malignancies of the parotid gland. It wasfound to have 98.24% specificity and 83.33% sensitivity.It is economical and easy to perform in parotidswellings. Thesefindings conform to what is reported by Awan et al  . and Hartimath et al  . who have reportedsimilar diagnostic accuracy of FNAC in parotid glandtumours. 20,21 Dissemination of tumour cells with FNAC isa theoretical risk and is not supported by any publisheddata.In this study, facial nerve transient paresis occurred in8% cases while 4.76% cases had facial nerve palsy.These finding conforms to most of the reported studieshowever,some studies have reported as high frequencyas 39% of these complications. 10,22,23 The use of nervestimulators, staining methods and other techniques havebeen explained in literature for safeguarding the nerveand these may help to reduce the frequency of suchdisabling complications.Thisstudy has some limitations. It is a single-centreobservational study. Observer bias could not beeliminated completely. Cosmetic or long-term functionalresults among the patients could not be evaluated. Theauthors recommend the conduct of a multi-centre localstudy to confirm and improve upon these results. CONCLUSION Parotid gland tumours commonly affect relatively youngindividuals of either gender. Majority of the patientspresent as a painless lump in parotid region. Most of the patients have benign pathology while a smallpercentage has malignancy. Superficial parotidectomy isthe most commonly offered surgical procedure. Parotidsurgeries are safely performed in general surgery unitswith low morbidity and no mortality. REFERENCES 1.Takahama Junior A, Almeida OP, Kowalski LP. Parotidneoplasms: analysis of 600 patients attended at a singleinstitution. Braz J Otorhinolaryngol 2009; 75 :497-501.2.Satko I, Stanko P, Longauerová I. Salivary gland tumourstreated in the stomatological clinics in Bratislava. Craniomaxillofac Surg 2000; 28 :56-61.3.Al-Khateeb TH, Ababneh KT. Salivary glands tumours in NorthJordanians: a descriptive study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103 :53-9.4.Quer M, Pujol A, López M, García J, Orús C, Sañudo JR.Parotidectomies in benign parotid tumours: "Sant Pau"surgical extension classification.  Acta Otorrinolaringol Esp 2010; 6 :1-5.5.Laccourreye H, Laccourreye O, Cauchois R, Jouffre V, MónardM, Brasnu D. Total conservative parotidectomy for primarybenign pleomorphic adenoma of the parotid gland: a 25-year experience with 229 patients. Laryngoscope 1994; 104 :1487-94.6.Johnson JT, Ferlito A, Fagan JJ, Bradley PJ, Rinaldo A. Roleof limited parotidectomy in management of pleomorphicadenoma. J Laryngol Otol 2007; 1 :1-3.7.Roh JL, Kim HS, Park CI. Randomized clinical trial comparingpartial parotidectomy versus superficial or total parotidectomy. Br J Surg 2007; 94 :1081-7.8.Guntinas-Lichius O, Gabriel B, Klussmann JP. Risk of facialnerve palsy and severe Frey's syndrome after conservationparotidectomy for benign disease:analysis of 610 patients.  Acta Oto-laryngologica 2006; 1104 -9.9.Auclair PL, Ellis GL, Gnepp DR, Wenig BN, Janey CG. Salivarygland neoplasms: general considerations. In: Ellis GL, Auclair PL, Gnepp DR, editors. Surgical pathology of salivary glands.Philadelphia: WB Saunders; 1991.p.135-64.10.Kara MI, Goze F, Ezirganli S, Polat S, Muderris S, ElagozS. Neoplasms of the salivary glands in a Turkish adultpopulation. Med Oral Pathol Oral Cir Bucal 2010; 15 :880-5.11.Musani MA, Sohail Z, Zafar A, Malik S. Morphological patternof parotid gland tumours. J Coll Physicians Surg Pak 2008; 18 :274-7.12.Malik KA. Parotid gland tumours: a six years experience. Pak J Surg 2007; 23 :133-5.13.Dorairajan N. Salivary gland tumours: a 10-year retrospectivestudy of survival in relation to size, histopathologicalexamination of the tumour, and nodal status. Int Surg 2004; 89 :140-9.14.Silas OA, Echejoh GO, Manasseh AN, Mandong BM. Patternsof malignant salivary gland tumours in Jos University TeachingHospital (JUTH), Jos: a ten-year retrospective study. Niger J Med 2009; 18 :282-5.15.Amirlak B. Malignant parotid tumours. (serial online) Dec15, Parotid gland tumoursJournal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23(9): 625-628  627  2011: (03 screens) :(Cited Nov 03,2012). Available at: URL:emedicine.medscape.com/article/1289616-overview16.Li LJ, Li Y, Wen YM, Liu H, Zhao HW. Clinical analysis of salivary gland tumour cases in west china in past 50 years. Oral Oncol 2008; 44 :187-92. 17.Subhashraj K. Salivary gland tumours: a single institutionexperience in India. Br J Oral Maxillofac Surg 2008; 46 :635-8.18.Vargas PA, Gerhaid R, Filho A, DeCastro IV VJ. Salivarygland tumours in Brazilian population: a retrospective study of 124 cases. Rev Hosp Clin Fac Med Sao Paulo 2002; 57 :271-6.19.Thakur J. Bilateral parotid tuberculosis. J Glob Infect Dis 2011; 3 :296-9.20.Awan MA, Ahmed Z. Diagnostic value of fine needle aspirationcytology in parotid tumours. J Pak Med Assoc 2004; 54 :617-20.21.Hartimath B, Kudva A, Singh Rathore A. Role of fine-needleaspiration cytology in swellings of the parotid region. Indian J Surg 2011; 73 :19-23.22.Shashinder S, Tang IP, Velayutham P, Prepageran N, Gopala KG,Kuljit S, et al  . Areview of parotid tumours and their manage-ment: a ten-year-experience. Med J Malaysia 2009; 64 :31-3.23.Redaelli de Zinis LO. Management and prognostic factorsof re-current pleomorphic adenoma of the parotid gland:personal experience and review of the literature. Eur ArchOtorhinolaryngol 2008; 265 :447-52. Syed Aslam Shah, Umbreen Riaz, Muhammad Zubair and Muhammad Saaiq 628 Journal of the College of Physicians and Surgeons Pakistan 2013, Vol. 23(9): 625-628
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