European Journal of Cardiovascular Medicine

Only 3% of all head and neck tumors are found in the salivary glands, hence they are rarely encountered in surgical practice. The parotid gland is the most common site for salivary gland neoplasms (70%-80% of all cases)¹. Cancers of the parotid gland occur rather often. Nearly eighty percent of parotid tumors are noncancerous neoplasms ². Between the ages of 40 and 60, pleomorphic adenomas, which are the most common type of benign tumor-emerge³.

Lateral to the facial nerve lies the parotid gland's tiny deep lobe, whereas the larger superficial lobe contains most of the glandular parenchyma. Most benign parotid tumors (80%) are found in the superficial lobe. Cancer is more likely to develop in deep lobe neoplasms. Pain, facial paralysis, fast development, blurry borders, and skin penetration are all red flags that might indicate cancer.

In most cases, ultrasonography is the first line of defense in diagnosing parotid tumors, but it cannot be relied upon to identify whether or not surgical removal is necessary. A fine needle aspiration (FNA) might be utilized as a supplemental diagnostic test when a non-typical presentation of pleomorphic adenoma is suspected. FNA is used to distinguish between benign and malignant tumors, however, it may not always provide a conclusive histopathological diagnosis.

Because of the gland's proximity to the facial nerve, several surgical methods provide unique technical challenges and problems. Since 90% of parotid tumors are situated in the glandular superficial lobe and do not damage the facial nerve, a superficial parotidectomy with facial nerve preservation is the most commonly prescribed surgical treatment⁴

Since the optimal technique for such tumors is a superficial parotidectomy, it is advised that public awareness of the importance of early referral for parotid mass be raised. When conducted by a skilled surgeon who specializes in parotid surgery, the risk of complications is low.

This is a prospective observational study conducted from 2021 January to 2023 January at Siddhartha Medical College, Vijayawada over 30 patients attending the surgical OPD. Patients who are immunocompromised, on chemotherapy, less than 15 years have been excluded from the study. The study abides by the guidelines laid by the declaration of Helsinki. Data were entered into excel sheets and statistical analysis was done using Microsoft Excel 2019.

The age incidence of the patients in the study group ranged from 14-76 years. The malignant tumors occurred between the age group of 17-60 years. Most patients in this series were in the 4th decade of life (33.33%). The mean age was 37.6 years for benign tumors and 43 years for malignant tumors. In this series, 18 (60%) patients were female and 12 (40%) were male. Male: female ratio is 2:3. Both benign and malignant tumors were found to be common in females. The incidence of the tumors is shown in the table no.1.

70% of the parotid tumors occurred in the right parotid gland. Out of 30 patients, 5 patients presented with pain (16.67%) in swelling, out of which 4 were benign and 1 was malignant. Pain occurred in 20% of the patients with malignant tumors and 16% of the patients with benign tumors. Deep lope enlargement was seen in 4 patients in this series and the tumor was fixed to a masseter/mandible in one patient. No patient had facial nerve paralysis at presentation. All patients presented with swelling in the parotid regions of which most cases (86.6%) presented within 5 years after noticing the swelling. All 30 cases were subjected to FNAC and reported as parotid tumors. After surgical excision or biopsy, all specimens were studied histopathologically and the table below (Table no.2) shows a correlation between FNAC reporting and histopathological diagnosis.

Superficial parotidectomy was performed in 25 patients (83.33%), and conservative total parotidectomy in 5 patients (16.67%). In this study, radical parotidectomy and RND were not done in any of the patients. Radiotherapy was given to 5 patients, with malignant tumors of the parotid gland. Out of these 5 patients, 4 had mucoepidermoid carcinoma and one had adenoid cystic carcinoma. One patient who received radiotherapy developed xerostomia, which was treated conservatively. No patient with benign disease of the parotid was given radiotherapy. No patients were given chemotherapy in this series. Postoperatively 8 patients developed facial nerve weakness. Out of 8 patients, in 4 patients facial nerve weakness improved over 3-6 months. Permanent facial nerve weakness occurred in 6 patients (20%). 2 patients underwent lateral tarsoraphy to prevent eye complications. Wound infection occurred in 2(6.67%) patients. No postoperative death was encountered in this study. During the study period, none of the operated patients came back with recurrent diseases.

Rare tumors in the salivary glands pique the curiosity of surgeons and pathologists. Their levels of malignancy differ. Adenolymphomas, the least malignant type of lymphoma, are at the lowest end of the spectrum, followed by mixed tumors, which are also categorized as benign but have the potential for infiltration, implantation, and carcinomatous transformation, making them better categorized as tumors of low-grade malignancy.

Parotid gland tumors, which include salivary gland tumors, account for just 3% of all tumors in the head and neck region. Seventy percent to eighty percent of tumors are benign, with pleomorphic adenoma making up the vast majority of the former⁵.

Fine-needle aspiration cytology (FNAC) is often used to diagnose lesions in the parotid gland, although its efficacy is debatable. High sensitivity (96%), specificity (98%), positive (100%), and negative (81%) predictive values were all observed for FNA in the diagnosis of benign parotid neoplasms in a comprehensive review and meta-analysis.  Both the sensitivity and specificity dropped to 79% and 96%, respectively, for cancers.⁶

More than half (53.6%) of the participants in the current research were in their thirties or forties. In the 4th and 5th decades, malignant tumors were quite widespread. In contrast to benign tumors, malignant ones were more common among the elderly. The median age for benign tumors was 37.6 years, whereas the median age for malignant tumors was 43 years. The most prevalent type of malignant tumor is mucoepidermoid carcinoma, while pleomorphic adenoma is the most common type of benign tumor. The majority of research thus far agrees on this aspect. According to  Drivas et al,⁷ study, the median age of patients with benign tumors was 48.2 years (range: 16-75 years), whereas the median age of patients with malignant tumors was 65.4 years (range: 27-90 years). In a study by the Royal College of Surgeons of England, ⁸researchers found that benign tumors peaked in the 70s and cancers in the 80s, which contradicts the findings of many previous studies.

Females were affected more than males in both benign and malignant tumors in the ratio of 3:2 in the present study. Results of the study conducted by the Royal College of Surgeons 2002, have shown Benign tumors were more common in women (M:F, 1:1.1),whereas malignant tumors were more common in men (M:F, 1.2:1). The present study have shown female predominance even for malignant tumors. According to research by Young Man Lee et al ⁹, men are more likely to develop parotid gland tumors than women.  They also discovered that benign parotid gland tumors are more common in people's fifties. Males saw a high incidence of malignant tumors in their 80s, whereas females experienced a peak incidence in their 30s and 40s, throughout a wide age range.

In this study, pleomorphic adenoma was the commonest tumor encountered constituting 70% of the parotid tumors similar to other studies. Among the benign parotid tumors, pleomorphic adenoma constituted about 84% of the benign parotid tumors. Among malignant tumors, the commonest was mucoepidermoid carcinoma constituting 80% of the malignant tumors. In a 2014 retrospective study of 154 patients by Maahs GS et al, ¹⁰found that pleomorphic adenoma was the most common benign tumor, accounting for 58%, and that mucoepidermoid carcinoma was the most common malignant tumor, accounting for 6%. Lin et al study ³ also showed pleomorphic adenoma being common at 51% and mucoepidermoid carcinoma as the most common malignant tumorat 3%.

In the present study, the most common presentation of parotid tumors is swelling in front of the ear lobule with or without pain—100% of the patients presented with swelling. Pain is seen in patients with malignant parotid tumors i.e. 16.67%.The commonest site of parotid tumors was the superficial lobe (100%).Bussu F¹¹ found that benign illness typically manifests itself clinically as a slow-growing or seemingly stable gland swelling. In 57 patients (81%), the first sign of malignancy was an asymptomatic parotid tumor; in the other 13 patients, the first sign was a facial impairment, which was accompanied by discomfort in 3 cases. Al Salamah SM and colleagues¹² performed thirty-seven parotid operations on 36 consecutive patients—all patients presented with parotid gland swelling. Parotid tumors most frequently manifest as swelling, followed by pain. Some research indicates that less common manifestations include facial paralysis and swollen lymph nodes.

The safest and the most acceptable means of diagnosis is FNAC, though complete surgical excision and histopathological examination was the final court of trial. In this series, FNAC was carried out in all cases. In this study, FNAC correctly diagnosed benign from malignant in 91.3% of the cases. The exact cytohistological correlation in the case of malignancy was 40%. The exact overall cytohistological correlation was 89.2%. In a study by Singh et al ¹³, in 58.33% of instances when histopathology specimens were available for comparison with FNAC results, cytology was shown to have a sensitivity of 76.3 and a specificity of 97.1. Overall, Thangam et al ¹⁴  found an 80% sensitivity, a 94.74% specificity, and a 91.66% diagnostic accuracy in cytohistomorphological correlation.

Parotid tumors are mostly benign and they involve the superficial lobe whereas the malignant tumors arise from the deep lobe. Pain is the most common presenting symptom. Ultrasound can detect the tumors and FNAC aids in confirming the diagnosis.