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Parotid Tumors: An overview of the classification, presentation and management of tumors of the parotid. Introduction.

The salivary glands in humans are a group exocrine glands. They are divided into major glands (consisting of paired parotid, submandibular, and sublingual glands) and up to 1000 minor glands located in the oral mucosa, floor of mouth, palate, uvula, pharynx and larynx.. Salivary glands are responsible for secreting saliva with lubricating, immunologic and digestive functions. The largest of the salivary glands is the parotid gland and can be involved into a variety of disease processes that can be classified into cystic, obstructive, inflammatory and neoplastic. This paper will focus on the clinical presentation and management of parotid tumors. Anatomy(GRAY’s anatomy) . The parotid glands are the largest of the salivary glands located in the preauricular region along the posterior mandibular surface . They extend superiorly up to the zygomatic arch and inferiorly via the parotid tail to the lower border of the mandible. The parotid tail abutshthe anteromedialimargin of the sternocleidomastoid and extends posteriorly towards the mastoid process. The gland is further subdivided by the facial nerve into a superficial lobe, overlying the masseter muscle and the deep lobe extending deep between the mastoid process and the posterior ramus of the mandible. These ‘lobes’ are not anatomically discrete but are of significance in surgical interventions of the parotid (discussed later). In approximately 21 % of humans (book), an accessory parotid gland is located anterior to the main parotid gland and is connected to it by its own duct. The parotid duct exits from the anterior edge of the parotid halfway between the zygomatic arch and the angle of the mouth to run along the masseter muscle and course deeply through the buccal fat and the buccinator muscle to open into the oral cavity near the second upper molar tooth. Several important neurovascular structures pass through or just deep to the parotid glands including: 1) Facial nerve (CN VII): exits skull through stylomastoid foramen and enters the parotid gland, where it divides into the lower cervicofacial (supplying muscles of mouth and neck) and upper temporofacial branches (supplying forehead and eye muscles). The two trunks undergo further branching and anastomosis to terminate as the temporal, zygomatic, buccal, marginal, and cervical branches. The coarse of the facial nerve through the parotid gland and its subsequent terminal branching will be of significance in surgical interventions of the parotid gland. The plane through which the facial nerve courses divides the parotid into a superficial and a deep lobe 2) Vascular: The external carotid artery and retromandibular vein pass through the deep lobe of the parotid gland. These structures are also at risk of compromise in surgical intervention of the parotid gland.

}}. approximately 70-80% arise in the parotid gland {{13 Speight. Drake .}} (Improving outcomes in head and neck cancers. 2nd edition. NICE (2004)) in the western world and account for 3% to 5% of head and neck cancers {{13 Speight.Adapted from: Gray’s Anatomy for Students. PM 2002. PM 2002.000 {{13 Speight. C‐M 1971. PM 2002. Of all salivary gland tumours. Tumours Salivary gland tumors are a group of neoplasms that can pose significant diagnostic and management challenges due to their diverse morpohological and clinical presentation. of which 80% are benign {{12 Eneroth. Tumours of the salivary glands are relatively rare with a yearly incidence of 1-3 cases per 100. .}}.}}.

ulceration. a third of patient have local or distant metastasis at presentation.B. bleeding and facial nerve involvement.Classification: The World Health Organization (WHO) classification of salivary gland tumours provides a useful general scheme of categorizing salivary neoplasia according to their morphological and behavioral characteristics (Appendix 1).}}: Most common malignancy accounting for 30% of parotid maliganacies {{15 Laforga. In fact. up to 40 epithelial tumours {{13 Speight.}} Adenocarcinoma (MEDSCAPE malignant tumours): Relatively rare but aggressive patortid malignancy. {{18 Szanto. Masashi 1998. In fact. this article will focus on parotid tumours that are more frequently encountered in clinical practice. High potential for local lymph node and distant metastasis.J. 5 year survival ranges from 19-75% depending on grade and stage at presentation. Masashi 1998.}}  Adenoid cystic carcinoma: Highly aggressive malignancy with a high recurrence rate and prolonged clinical course and tendency to infiltrate and spread along perineural planes. It makes up 7. Parotid gland tumours can be broadly classified as follows 1) Malignant epithelial tumours Malignant tumors can be further classified according to their clinical behavior and prognosis into high grade or low-intermediate grade High Grade: Mucoepidermoid {{17 Boahene. 5 year survival is only 5 % if lymph node metastasis. 1999. pain. Is further sub classified into Grade I. Philip A 1984. Clinically associated with rapid growth.5% of malignant epithelial tumours of the parotid. II.}} have been indicated in salivary glands with some subtypes only being rarely reported in as little as few cases in the literature. Derek Kofi O 2004. {{16 Suzuki. . Can be further subdivided into:  High grade malignancy: High mitotic frequency with focal necrosis. PM 2002. III with respective 15 year survival rates of 39%. 26% and 5%. Thus.}}. Distant metastasis is common and carries a worse prognosis.}} Low grade malignancy: well differentiated cystic tumour with low metastatic potential. 5 year survival is 75% to 95% without nodal metastasis. {{16 Suzuki.

Robert L 2005.L. Characterized by low distant metastatic potential but can invade perineural planes. 5 years survival is 82%. Lymphoma: A non-epithelial malignant tumour that accounts for approximately 16% of parotid malignancies.gov). 4) Haematolymphoid. Usually asymptomatic and presents most often in the 6th and 7th decades in men and women. Primary lymphomas can also present in the parotid glands. hence the term ‘pleomorphic’. such as Sjogren’s syndrome.Low grade: Acinic cell carcinoma: Third most common parotid malignancy. the parotid gland is enlarged with a . Usually presents as bilateral or multicentric solid lesions with associated pain in more than 33% of patients. 2)Benign epithelial tumours: Pleomorphic adenoma: The most common of all parotid tumors accounting for 80% of benign parotid tumours.N..}}.}}. Presents as a slow growing circumbscribed surrounded by an incomplete capsule. Increased incidence in patients with a background of chronic autoimmune disease. {{22 Harris. David L 1992. Jean E 1991. Clinically. respectively {{21 Hatch. Can progress to its malignanct counterpart (carcinoma ex-pleomorphic adenoma) in 2-10 % of long-standing adenomas (MEDSCAPE BENIGN PAROTID TUMOURS) Warthin’s tumor: Second most common benign tumour accounting for 5 % of benign parotid tumours. fixation and gross invasion. {{19 Lewis.}} 3)Soft tissue tumours: Haemangiomas: Most common childhood salivary tumour {{23 Callender. Compromise of the capsule during surgical intervention can leave behind neoplastic tissue that form the bases of high recurrence rates of this tumour. More common in men than women with a ratio approaching 2:1. Its characterized by various histological characteristics. Cyrus A 1992. (MEDSCAPE MALIGNANT TUMOURS)(CANCER. leading to marginal zone lymphomas of MALT (nonHodgkin’s) and display an indolent coarse.}}. 1999. Prognosis predictors include features of pain.}}. They are bilateral in 12 % of cases and are associated with an 8-fold increased incidence in smokers compared to nonsmokers {{20 Kotwall.

}}. with a smoking history present in about 96% of patients {{30 Yu.ruberry consistency. thus avoiding unnecessary parotid surgery as primary treatment is chemotherapy and/or radiation. however. HER2/neu) have also been implicated and targeting them could advance treatments of parotid tumors {{29 Milano. renal. (MEDSCAPE salivary gland neoplasm). (CELLULAR CLASSIFICATION OF SALIVARY TUMOURS) Etiology and Risk factors: Etiology: The etiology of primary parotid tumors remains unknown. This is reflected in various studies where it has been observed that long-term cancer survivors who received radiotherapy to the head and neck where at an increased risk of developing neoplasia with an average latency of 15-20 years. (MEDSCAPE SALIVARY TUMOURS). Amalia 2007. however. TP53.}}.  Haematogenous metastasis  Lymphatic metastasis. Smoking and alcohol. Several genes (WHO 2005-end of paper) (EGFR. Approximately 16% of malignancies of the parotid can be attributed to secondary metastasis from distant malignancies along the following three routes:  Direct invasion by cancers lying adjacent to parotid. c-Kit. GY 1998. well known risk factors for various head and neck cancers.. do not appear to play a role in development of neoplasm. Risk factors: Radiation exposure has been associated with both benign and malignant parotid tumors. smoking has been shown to be related to the development of Warthin’s tumor. This theory describes tumors as arising from one of two undifferentiated stem cells: excretory or intercalated duct reserve cells. Approximately 80% of secondary parotid tumours arise from primary tumors of the head and neck. while pleomorphic adenomas. adenoid cystic carcinomas. lung. . (MEDSCAPE MALIGNANT PAROTID TUMOUR) 5)Secondary tumours. adenocarcinomas and acinic cell carcinomas originate from intercalated duct stem cells. the remaining 20% arise from infraclavicular sites including skin. a bicellular theory (MEDSCAPE SALIVARY TUMOURS)of origin has been proposed to account for the various histological subtypes . breast and gastrointestinal. Excretory stem cells account for mucoepidermoid. regional lymph nodes may also be palpated and biopsied to confirm diagnosis.

PM 2002. It should be appreciated that only 12-15% of patients with malignant lesions present with facial dysfunction {{27 O'Brien. Cervical node metastasis can be detected in about 20% of patients with malignancy at time of presentation. and pain. Benign tumours. Approximately 80% of all salivary tumours arise in the parotid glands {{13 Speight. thus.Epidemiology Salivary gland neoplasms have an incidence of 1-2/100. while malignant tumors typically present after the 7th decade. (PATIENT UK REFERENCE 5).}}Facial paralysis in the presence of a parotid mass indicates perineural invasion and is highly suggestive of malignancy and may indicate nodal metastasis at time of presentation in up to 80% of patients. Benign tumours typically present after 5th decade. facial weakness. The most common presentation (80%) is a painless. duration. infectious. This should be followed by a thorough general history to rule out infectious. pain is not a good indicator in differentiating the bengin from malignant {{31 Lee. with approximately 470 new yearly diagnosis (Improving outcomes in head and neck cancers. Physical examination of the parotid should aim to assess the clinical features of the mass including its degree of firmness (a rock hard mass signifies malignancy). oropharyngeal and nasopharyngeal cavity as well as inspection for skin lesions to rule out sites of primary tumors. asymptomatic mass in the posterior check.6% of benign presentations and 6. A patient presenting with a parotid mass needs to be fully examinated and investigated as a variety of pathological causes including neoplastic. NICE (2004)). autoimmune. growth rate. it should be accompanied by a thorough head and neck assessment of the local lymph nodes for signs of metastasis.5% of malignanies. Ear pain may suggest extension of the tumor into the ear canal. inflammatory or autoimmune causes. (salivary gland neoplasms MEDSCAPE) CLINICAL PRESENTATION In England and Wales. this is followed by less common presentations including pain(12%) and facial dysfunction(7%) ({{26 Byrne. up to 25% of parotid masses could be attributed to non-neoplastic (MEDSCAPE) causes and these have to ruled out before proceeding with unnecessary surgical interventions. and blood or pus from the parotid duct also . fixation to adjacent structures. Therefore.}}.}} . Pain is present in 5. skin fixation. Other aspects of the history to enquire about include prior squamous cell carcinoma. 17% with locally advanced. In fact.}} . however. are more common in women. apart from warthin’s tumor. size or symptom change with meals. Maria N 1988. YYP 2008. ulceration.000 in England and Wales. Dysphagia or foreign-body sensation in the oropharynx may indicate a tumor of the deep lobe. an examination of the oral . and inflammatory (TABLE). 7% with lymph node spread and 28% with metastatis. Patients with parotid malignancy present in about 13% of cases with early disease. malignant melanoma or previous parotid lesion excision to rule out possible metastatic or recurrent tumor lesions. Clinical examination of a parotid mass is simple in itself. it is important to approach a consulatation with an initial focused history of the mass and its onset. but malignant tumors have equal incidence in both sexes. Christopher J 2001.

detection of deep tissue/marrow infiltration. bimanual lateral pharyngeal wall palpation is valuable in assessing for parapharyngeal wall extension of a deep lobe tumour. high resolution ultrasound is a cheap and safe imaging tool providing A useful tool in the assessment of suspected parotid tumors is the high-resolution ultrasound (US). {{4 Lee. depending on level of expertise {{4 Lee. Thus.4% . The positive predictive value and negative predictive value of malignancy in FNAC is 84. The reported sensitivity of MRI and CT is 88% and 100% respectively. a recent study concluded that the combination of US and FNAC is highly sensitive and specific for detecting benign superficial lobe tumors and that no other additional information would be gained from MR or CT imaging. {{4 Lee. however. facial nerve invasion as well as demonstrating tumor margins {{4 Lee. The facial nerve should be carefully assessed for any indication of dysfunction or weakness signifying paraneural infiltration and malignancy. For superficial parotid lesions. CT scan provides better visualization of the surrounding tissues whereas MRI will enable visualization of mass in greater contrast. Various imaging modalities can be employed in the investigation of parotid tumors. Investigations: In addition to obtaining a thorough history and examination. intra versusllextra-glandular location. epithelial or nonepithelial in origin and metastatic or primary.}} However. and nodal or distant metastasis. (END OF PAGE REFERECNE) . (Medscape salivary tumours).” The disadvantages of MRI is the relatively higher cost. {{32 Brennan. MRI can help differentiate benign from malignant masses: benign and low grade tumors appear white on T2 weighted images whereas high grade malignancies tend to have low intensity on T1 and T2 images. and the specificity is 77% and 42% respectively. the effectiveness of FNAC is highly diependant on cytologist expertise with a reported sensitivity and specificity ranging from 88%-93% and 75%-99%. (patient uk ).}} Ultra sound or CT guided final needle aspiration cytology is valuable tool in determining a histological diagnosis and grading of malignancy thus assisting in pretreatment planning and patient counseling. Ultrasound. YYP 2008. is not useful in detecting deep lobe pathologies and depends on specialist expertise (___). YYP 2008. MRI and CT imaging.}}. MR and CT imaging are optimal in assessing tumour extent and regional lymph node metastasis. Mehmet 2003.indicate malignancy.}}. YYP 2008. MR and CT imaging are the modalities of choice when suspecting a parotid malignancy or a deep lobe tumor. In particular. Moreover.6% and 96.}}.}}. MRI is better at soft tissue differentiation. These include ultrasound. In fact. long scan times and claustrophobic environment and poorer bony structure evaluation when compared to CT (pogril book) {{33 Koyuncu. local extension9and invasion. imaging can be utilized by the clinician to differentiate benign versus malignant lesions. FNA is useful in establishing wether a lesion is neoplastic or inflammatory. US can characterize the tissue and assess for cervical node involvement (___) without the risk of radiation exposure and can be combined with fine needle aspiration cytology (FNAC). respectively. PA 2011. respectively (SALIVARY NEOPLASN MEDSCAPE). YYP 2008.

Aggressive tumors with invasion to the perineural plane and/or surrounding structures require a radical parotidectomy with . a recent study has shown partial superficial paridoctomy to be as effective as superficial paridoctomy in resection of localized benign neoplasia. In the case of suspected tumor recurrence. However. and close proximity of the tumor to the facial nerve [3.}}. the degree of resection is determined by the histological subtype.}}. {{34 O'Brien. capsule rupture. positive margins are common after resection of this tumor.76. Treatment Treatment of parotid tumor depends on whether it is benign or malignant. The parotid gland is divided into a superficial and deep lobe by the facial nerve. However. BENIGN TUMOURS Superficial paridoctomy with facial nerve preservation is recommended for benign tumors restricted to the superficial lobe. a tendency of the tumor to form perforating pseudopodia.77].75].}}. an ultrasound guided core biopsy can be performed but this carries a risk of facial nerve damage and should be kept as a last resort (malignant parotid tumor Medscape). In benign tumors occurring in the deep lobe. Malignant tumours For malignant lesions. Moreover. this is followed by postoperative radiotherapy when necessary.8invasiveness andirelationship to facial nerve. an MRI combined with FNAC will confirm the recurrence. malignant tumors require a total parotidectomy with every effort made to preserve the facial nerve. total paridectomy is indicated with effort to preserve the facial nerve {{35 Roh. Positive margins. this phenomenon may be due to the increased possibility of capsule rupture and tumour spillage in enucleation resulting in seeding of tumor cells into parotid tissue. after simple enucleation. size. recurrence rates are reduced to less than five percent [74. Superficial parotidectomy is the treatment of choice for pleomorphic adenomas arising in the parotid gland. in a series conducted at Christie’s Hospital in Manchester. Jong‐Lyel 2008. Typically. The recurrence rate after simple enucleation is 20 to 45 percent. Christopher J 2003. location and size of tumour. The chief treatment is adequate surgical resection with the objective of preserving the facial nerve. M 1996. a more extensive procedure (total parotidectomy) does not reduce the risk of recurrence further and is associated with higher rates of facial nerve dysfunction and other complications [74. pleomorphic adenomas are associated with a recurrence rate of 20%-45% versus <5% in superficial parotidectomy. Tumors confined to the superficial lobe can be effectively excised using superficial parotidectomy. with superficial parotidectomy. and tumor spillage have been implicated as a potential causes for high recurrence rates.If the aspirate is unable to determine a diagnosis.74. For most pleomorphic adenomas. It has been noted that. these occur because of an incomplete tumor capsule.78]. extracapsular dissection of pleomorphic adenomas was as effective as superficial paridectomy with similar recurrence rates of 2% but with significantly reduced morbidity {{36 McGurk. and these should be avoided when possible. its location. (BOOK).

Remco 2007. adjuvant radiotherapy is associated with better outcomes {{37 Mendenhall. perineural. for this reason.}} Complications: Temporary facial nerve paralysis could be expected in up to 46% of patients with less than 4% progressing to permenant dysfunction {{40 Mehle. a long-lasting. vascular.}}. {{37 Mendenhall. but data is inconclusive as to its effectiveness in reducing postoperative facial nerve dysfunction. Various methods can be utilized to predict the prognosis of parotid tumours. positive resection margins in most high-grade and some low-grade tumors (instead of re-exploration).excision of involved strcutures. William M 2005. high-grade or advanced stage. (BOOK). Another possible complication occurring in upto 10% of patients is Gustatory sweating. Resection of the facial nerve should ideally be reconstructed in the same operation using a nerve graft to aid in its functional recovery {{38 Kimata.}}. Prognosis. and this may be not be possible with large masses. or lymphatic invasion. This may cure up to 20% of patients with advanced disease {{37 Mendenhall. recurrent following resection and lymph node metastasis. 53%.}}. Thus. . effective treatment is the use of botulism toxin injection. The use of intraoperative facial nerve monitoring may be of good aid. Yoshihiro 2005. and extracapsular spread. William M 2005. Mark E 1993. The five year survival rates for stages 1-4 are 85%. Jason D 2006. These are discussed below: 1) Staging of parotid tumours can aid in predicting average survival times. the extent of invasion or location of the tumor may be such that surgical resection would result in significant functional or cosmetic dysfunction. adjuvant RT is suggested after surgical resection for patients who have T2 or greater high-grade tumors. 66%. radiotherapy is indicated in all malignancies excluding small low-grade malignancies with no evidence of local invasion or metastasis. Radiotherapy Isolated radiotherapy is the treatment of choice for lymphoma and is reserved for medically inoperable or unresectable tumors. and 32% in their respective orders.}}. deep lobe rumors. skin or neural infiltration.}}. Resection should be along a tumor free margin. a positive surgical margin. locally advanced T3 and T4 tumors or positive regional lymph nodes. {{39 Meier. William M 2005.}} Consequently. This is characterized by sweating and flushing of the facial skin overlying the parotid gland during mastication and is thought to be due to regeneration of “parasympathetic fibers resulting in abnormaloinnervation of sweat glands and subcutaneous vessels {{41 de Bree. Adjuvant radiation therapy Surgery in combination with radiotherapy is indicated in tumors with high risk features such as tumors with a large diameter (>4cm).

http://www. (RED BOOK). This index uses a weighted combination of parameters including age. the most important prognostic factor in determing treatment. Low grade tumours (acinic cell carcinoma and low-grade mucoepidermoid carcinomas) correlate with an 80-90% 5 year survival.}}. including rapid size change. facial nerve dysfunction can also be regarded as an independent risk factor for predicting survival rates {{24 Terhaard. Patients presenting with a parotid mass will require a full workup consisting of a thorough history. skin invasion. {{25 Vander Poorten. Vincent LM 2003. high grade tumours. adenocarcinoma and carcinoma ex-plemorphic adenoma) the 5 year survival is 20-50%. They are heterogenous in nature and vary in their anatomy . in fact. {{24 Terhaard. uncommon. (including high grade mucoepidermoid carcinoma. Chris HJ 2004. metastisis and infiltratio of the tumor can determine its biological nature and is.Carcinomas associated with normal nerve function had 69% 5 year survival compared with 37% in partial facial nerve dysfunction and 13 % with complete dysfunction.cancerresearchuk. Although studies over the years have advanced our understanding of the diverse group of tumors.org/cancer-help/type/salivary-glandcancer/treatment/statistics-outlook-salivary-gland-cancer#stage 1) Clinical features of aggression. hence the diagnosis and treatment remains challenging for the surgeon. Approximately 85 percent arise in the parotid. A significant clinical prognostic indicator in malignancy is pain. most evidence is based on reviews of clinical experience. heterogeneous group of neoplasms that vary considerably in their anatomic site of origin. and biologic behavior NTRODUCTION — Salivary gland tumors include a wide range of tumor types. histology. On the other hand.}}. The role clinical features in determining the prognostic outcome can be appreciated in the prognostic index developed by the ‘Dutch Head and Neck Cooperative Group’ for patients with parotid cancer. Moreover..2) Histological subtyping has correlation with the biological behavior and thus prognosis of parotid tumours. histology and biologic behavior. facial nerve involvement. studies report a 5 year survival rate of 35% in patients with carcinomas reporting pain versus 68 % of patient with carcinomas not reporting pain (MEDSCAPE SALIVARY GLANDS) . Chris HJ 2004. pain. examination and investigations to arrive at a definitive diagnosis. . Staging and treatment options are based upon the clinical features of tumor and its histological subype. Comprehensive randomized trials will help guide management with emphasis on providing the best quality of care and outcome for patients.}} Conclusion: Neoplasms of the parotid gland are relatively uncommon but account for approximately 85% of all salivary gland tumors and 6% of head and neck tumors. which can be either benign or malignant (table 1). perinueral growth and involved surgical margin to quantify prognosis and aid in clinical management. the remainder originate in the submandibular.

which includes stages I through IVB. compared with 40 to 45 percent of submandibular gland tumors. Benign tumours of the parotid account for 80% of parotid gland tumour {{13 Speight.}}. Some common salivary gland neoplasms are listed in the image below.gov/cancertopics/pdq/treatment/salivarygland/HealthProfessional/page3 on 26-6-2013. the diagnosis and treatment of salivary gland neoplasms remain complex and challenging problems for the head and neck surgeon. reflecting the relative frequency of parotid gland tumors compared to tumors at other sites. will be discussed here (table 2).cancer. Approximately 25 percent of parotid tumors are malignant.sublingual. which are located throughout the submucosa of the mouth and upper aerodigestive tract (figure 1) [1]. Adapted from a) PRIMARY TUMOUR (T): http://www. . Although researchers have learned much from the study of this diverse group of tumors over the years. Neoplasms that arise in the salivary glands are relatively rare. The 2005 WHO classification of salivary gland tumours has TABLE 1 The American Joint Committee on Cancer (AJCC) staging by TNM classification. and there are almost no data from randomized trials to guide treatment decisions. 70 to 90 percent of sublingual gland tumors. and minor salivary glands. PM 2002. The published literature predominately focuses on the parotid gland. The treatment of locoregional disease. Treatment is based upon retrospective reviews of clinical experience. yet they represent a wide variety of both benign and malignant histologic subtypes as seen in the image below. and 50 to 75 percent of minor salivary gland tumors.

These are discussed below: . Prognosis.b) Regional Lymph Nodes (N) c) Distant Metastasis (M) d) Anatomic Staging/Prognostic groups. Various methods can be utilized to predict the prognosis of parotid tumours.

}} Initial history taking should focus on the presentation of the mass. Chris HJ 2004. Chris HJ 2004. On the other hand. (RED BOOK). This index uses a weighted combination of parameters including age. facial nerve involvement. Approach to parotid mass in clinical practice. http://www. metastisis and infiltratio of the tumor can determine its biological nature and is. the most important prognostic factor in determing treatment. and associated pain. facial nerve dysfunction can also be regarded as an independent risk factor for predicting survival rates {{24 Terhaard. high grade tumours. and 32% in their respective orders. including rapid size change.}}.org/cancer-help/type/salivary-glandcancer/treatment/statistics-outlook-salivary-gland-cancer#stage 2) Clinical features of aggression. {{24 Terhaard. Moreover. Vincent LM 2003. {{25 Vander Poorten. perinueral growth and involved surgical margin to quantify prognosis and aid in clinical management. A significant clinical prognostic indicator in malignancy is pain. The role clinical features in determining the prognostic outcome can be appreciated in the prognostic index developed by the ‘Dutch Head and Neck Cooperative Group’ for patients with parotid cancer. skin invasion. growth rate. in fact. or autoimmune etiologies. Low grade tumours (acinic cell carcinoma and low-grade mucoepidermoid carcinomas) correlate with an 80-90% 5 year survival. (including high grade mucoepidermoid carcinoma.Carcinomas associated with normal nerve function had 69% 5 year survival compared with 37% in partial facial nerve dysfunction and 13 % with complete dysfunction. changes in size or symptoms with meals. 66%.}}. facial weakness or asymmetry. 2) Histological subtyping has correlation with the biological behavior and thus prognosis of parotid tumours. infectious. A thorough general history provides insight into possible inflammatory. adenocarcinoma and carcinoma ex-plemorphic adenoma) the 5 year survival is 20-50%. The five year survival rates for stages 1-4 are 85%.. studies report a 5 year survival rate of 35% in patients with carcinomas reporting pain versus 68 % of patient with carcinomas not reporting pain (MEDSCAPE SALIVARY GLANDS) . .cancerresearchuk.1) Staging of parotid tumours can aid in predicting average survival times. pain. 53%.

3% and 85. and accuracy for malignant masses was 20%. with the remaining 25% of parotid masses falling under the non-neoplastic category which includes cystic. The sonographic characteristics of parotid masses between benign and malignant lesions had no significant differences. obstructive and inflammatory causes. Approximately 75% of parotid masses are considered neoplastic . 93. S 2012.}} Check ref id 4 for imaging. negative predictive value and accuracy of ultrasound for the diagnosis of parotid gland masses were 38. respectively. The sensitivity.2%. positive predictive value.Imaging and diagnostic tests. 29. . {{1 Wu. Treatment.2%.Masses of the parotid gland can be attributed to a variety of pathological or physiological causes.9%. 90.1%.Examination . Quality of life. (Medscape) -History . specificity.

com .uptodate. Reichart P. Eveson JW. and staging on 26-6-2013 Tumours of the Salivary Glands. diagnosis. p. In: Pathology and Genetics of Head and Neck Tumours. Lyon 2005. evaluation.Adapted from: www. Barnes L. Sidransky D. Salivary gland tumors: Epidemiology. World Health Organization. (Eds).215 .