|Year : 2023 | Volume
| Issue : 1 | Page : 1-5
Clinical presentation and management of parotid gland tumors – A retrospective study in Northwestern Nigeria
Mujtaba Bala1, Ramat Oyebunmi Braimah1, Abdulrazaq Olanrewaju Taiwo2, Sufiyanu Yabo Umar3, Mukhtar Modibbo Ahmad2
1 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
3 Department of ENT, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Submission||13-Jan-2023|
|Date of Decision||08-Feb-2023|
|Date of Acceptance||09-Feb-2023|
|Date of Web Publication||18-Mar-2023|
Dr. Mujtaba Bala
Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, PMB 2370, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Parotid gland tumors are the most common major salivary gland tumors occurring in humans. Aim: This study aimed to evaluate the pattern of clinical presentation and management of parotid gland tumors in Northwestern Nigeria. Materials and Methods: In this retrospective study sociodemographics, nature of the lesion, fine-needle aspiration cytology result, surgical procedure, and complications of patients with parotid gland tumors were recorded and analyzed using SPSS version 25. Results: There were 31 (45.6%) males and 37 (54.4%) females in the age range of 17–72 years with a mean ± standard deviation of 49.03 ± 15.61 years. Benign tumors constitute the majority 50 (73.5%), with pleomorphic adenoma being the most common 46 (67.6%), whereas malignant tumors were 18 (26.5%), with adenoid cystic carcinoma being the most common 6 (8.8%). Superficial parotidectomy was the highest surgical procedure performed in 42 (70.6%) patients. Selective neck dissection was done in 5 (27.8%) cases and soft tissue reconstruction with deltopectoral flaps in 3 (16.7%) of the malignant cases. Transient facial nerve paralysis was seen in 14 (29.2%) and 8 (47.1%) of patients who had superficial and total parotidectomies, respectively. Permanent facial nerve paralysis was seen in all 5 (27.8%) patients who had radical parotidectomy. Conclusion: Pleomorphic adenoma was the most common parotid gland tumor, and superficial parotidectomy was the major surgical procedure performed. Facial nerve paralysis is an inevitable complication but can be minimized with meticulous surgical maneuver.
Keywords: Parotid gland tumors, parotidectomy, pleomorphic adenoma
|How to cite this article:|
Bala M, Braimah RO, Taiwo AO, Umar SY, Ahmad MM. Clinical presentation and management of parotid gland tumors – A retrospective study in Northwestern Nigeria. SRM J Res Dent Sci 2023;14:1-5
|How to cite this URL:|
Bala M, Braimah RO, Taiwo AO, Umar SY, Ahmad MM. Clinical presentation and management of parotid gland tumors – A retrospective study in Northwestern Nigeria. SRM J Res Dent Sci [serial online] 2023 [cited 2023 Mar 20];14:1-5. Available from: https://www.srmjrds.in/text.asp?2023/14/1/1/371998
| Introduction|| |
Salivary glands are anatomically classified into major and minor salivary glands. The major salivary glands constitute the three paired glands, namely parotid, submandibular, and sublingual. The parotid gland is the largest of the major category. The parotid is located in the parotid space and can be affected by a variety of pathological processes, especially tumors., Both benign and malignant tumors can arise from the parotid gland, but benign tumors are more common compared to their malignant counterparts. Benign tumors include pleomorphic adenoma, Warthin's tumor, basal cell adenoma, canalicular adenoma, and myoepithelioma, with pleomorphic adenoma as the most common, whereas the malignant tumors include but are not limited to adenoid cystic carcinoma, mucoepidermoid carcinoma, and carcinoma ex pleomorphic adenoma. The etiology of these tumors is unknown; however, factors such as radiation, tobacco, alcohol consumption, viral diseases, and occupational exposures have been implicated.
The treatment of parotid gland tumors depends on the nature of the tumor, the time of presentation, the extent of the tumor, and also the experience of the surgeons. Surgery in case of benign and surgery with or without chemoradiation in case of malignant remain the main treatment modalities in our environment. This study aimed to present our experience on the pattern of clinical presentation and management of parotid gland tumors from Usmanu Danfodiyo University Teaching Hospital, Sokoto, and Noma Children's Hospital, Sokoto.
| Materials and Methods|| |
This was a retrospective study.
This study was conducted at Usmanu Danfodiyo University Teaching Hospital and Noma Children Hospital, Sokoto. The Usmanu Danfodiyo University Teaching Hospital is located in the main Sokoto town in Northwestern Nigeria. The Committee of Sokoto State Ministry of Health dated December 24, 2022 (SKHREC/065/2022). All the participants provided written informed consent for their participation in the study. All procedures performed in the study were conducted in accordance with the ethical standards given in the 1964 Declaration of Helsinki, as revised in 2013.
The duration of the study was 8 years (2015 to April 2022).
Case record of patients with complete information required by the study were included. Case notes with incomplete data as well as those who were not treated were excluded from the study.
Patients' sociodemographics including age, sex, level of education, and occupation were retrieved. The chief complaints of the patients, time of presentation, clinical features, Fine-needle aspiration cytology (FNAC) result, histological report, surgical procedure performed, and treatment outcome were recorded.
The data obtained from the record were analyzed using the Statistical Package for the Social Sciences (IBM SPSS) version 25 (IBM Corp., Armonk, NY, USA). Chi-square was used to test for significance between the histological type of the tumors and the sex of the patients. P < 0.005 was taken as statistically significant.
| Results|| |
A total of 68 patients' case notes were analyzed. There were 31 (45.6%) males and 37 (54.4%) females, the age range of 17–72 years with a mean ± standard deviation of 49.03 ± 15.61 years. Most of the patients were farmers 35 (51.5%) and majority of them in their 4th decade 23 (33.8%) [Table 1]. Facial swelling was the major presenting complaint in all the patients [Figure 1], [Figure 2], [Figure 3]. Ultrasound scan was a basic investigation recorded from the majority 50 (73.5%). FNAC was used in identifying the nature of the tumor as to whether benign or malignant. Among the 50 benign tumor cases, pleomorphic adenoma was the most common 46 (92.0%), followed by Warthin's tumor 2 (4%) and oncocytoma 2 (4%), while adenoid cystic carcinoma 6 (33.3%) comprises the most common of the 18 cases of malignant tumors, followed by mucoepidermoid carcinoma 5 (27.8%), squamous cell carcinoma 5 (27.7%), and acinic cell carcinoma 2 (11.1%). Warthin's tumor and oncocytoma were the only tumors found to be more common in males in this study, and the rest were more common in females (P = 0.218) [Table 2]. When the gender distribution of these tumors was cross-tabulated, most of the tumors were more common in females but no statistically significant difference was found [Table 2]. Superficial parotidectomy was the highest surgical procedure performed in 42 (70.6%) patients followed by total parotidectomy 16 (23.5%) and radical parotidectomy 10 (14.7%). Selective neck dissection was done in 5 (27.8%) cases and soft tissue reconstruction with deltopectoral flaps in 3 (16.7%) of the malignant cases. Transient facial nerve paralysis was seen in 14 (29.2%) and 8 (47.1%) of patients who had superficial and total parotidectomies, respectively. Permanent facial nerve paralysis was seen in all 5 (27.8%) patients who had radical parotidectomy. Available data on follow-up did not show any recurrence in any of the patients in this study.
|Figure 1: Clinical photograph of a patient with large parotid tumor and the specimen histologically diagnosed as pleomorphic adenoma|
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|Figure 3: Clinical photograph of large parotid tumor histologically diagnosed as mucoepidermoid carcinoma|
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|Table 2: Distribution of the benign and malignant tumors of the parotid gland according to the histologic type|
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| Discussion|| |
Parotid gland tumors are the most common salivary gland tumors which are mostly benign. This study identified parotid gland tumors to be generally more common in females, which is in tandem with several studies in the literature worldwide.,, However, some specific diagnostic variations exist such as Warthin's tumor being common in males due to their more involvement in smoking habit. In this study also, Warthin's tumor was found to be common in male individuals.
The peak age of occurrence of these tumors has been reported to be between the sixth and seventh decades.,, However, this study recorded the predominance of parotid gland tumors in the fourth decade. Omisakin et al. reported most cases of parotid gland tumors in their study to occur in the fifth decade of life. A wide age range for the occurrence of parotid tumors has been recorded in the literature. Satko et al. and Omisakin et al. recorded an age range of 2–87 years and 12–76 years, respectively. The age range of occurrence of these tumors recorded in this study was 17–72 years. This observation in disparity in the age range of occurrence could mean that parotid gland tumor could occur at any age.
History, clinical examination, and investigation constitute the most important steps in the work-up for parotid gland lesions. Parotid gland tumors are usually painless growth that progresses slowly most, especially if benign. Ajiya et al., Diom et al., and Al Salamah et al. reported swelling as the most common presenting complaint. This current research also reported swelling as the most common presenting complaint although other features such as pain, ulceration, lymph node enlargement, rapid growth, and facial nerve palsy predominate in some instances, particularly the malignancies. The size of the presenting swelling could be so large with marked facial disfigurement because of late presentation [Figure 3].
However, it may not be feasible to rely on clinical features alone in making a diagnosis, but some basic investigation must be carried out to augment the clinical features in providing an adequate diagnosis.
Imaging studies such as lesional ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) were found helpful in the work-up for parotid gland tumors. Ultrasound imaging records suggest that salivary gland tumors have been found in the majority (73.5%) of the cases in this study, and this was similarly reported by others in previous studies.,, An ultrasound scan is inexpensive, rapid, and readily available, but it is incapable of characterizing large masses extending to the deep lobe of the parotid gland. No record of CT or MRI was found in any of the study case notes, likely due to financial constraints as well a lack of a functional MRI facility nearby.
Although incisional biopsy was done in some selected cases, all patients had FNAC done to distinguish the tumors into benign and malignant entities. FNAC is an important tool in the initial assessment of parotid mass. It has been widely used in the diagnosis of salivary gland tumors. It has been used as the first tissue-based technique used to establish a diagnosis before carrying out any surgical intervention. Some of its advantages include being easy to perform, quick, relatively inexpensive, and well accepted by the patients. Controversies exist in its use in the diagnosis of salivary gland tumors, but it has a key role in distinguishing benign and malignant tumors. Incisional biopsy could not be done universally due to the risk of seeding the tumor to the neighboring healthy tissue and the chance of recurrence. However, it can be done in diffuse pathologic conditions such as lymphoma, whereby all or most of the glands are involved, tumor spillage may not be irrelevant, as the patient will be treated systemically (chemotherapy and/or immunotherapy).
Histopathological examination of the excised salivary gland tissue gives the most accurate and reliable diagnosis. Pleomorphic adenoma tops the list of benign tumors in this study. This finding agrees with most of the studies in the available literatures.,,, We recorded adenoid cystic carcinoma as the most commonly diagnosed malignant tumor of the parotid gland. This is contrary to the report of Takahama Junior et al. and Wahlberg et al. in their retrospective reviews of 600 and 2465 cases, respectively, whereby mucoepidermoid carcinoma was the most common malignancy diagnosed in their studies. It may be possible that the comparatively larger sample in the two studies cited above could favor the diagnosis of mucoepidermoid carcinoma.
Most of the patients had superficial parotidectomy. It was reported to be the most common surgical procedure of the parotid gland being performed since most of the tumors involve only the superficial lobe of the parotid gland.,, Some cases of malignant tumors required additional flap surgeries to cover the defects. Surgeries of benign tumors rarely need any flap reconstruction. Some of the complications variably encountered include surgical site infection, hematoma, seroma, and facial nerve dysfunction. The degree of facial nerve involvement ranges from paresis and mild and transient facial nerve palsy to more severe and permanent facial nerve paralysis, some of which could be minimized with meticulous techniques. In this current study, transient facial nerve paralysis was seen in 29.2% and 47.1% of patients who had superficial and total parotidectomies, respectively, whereas permanent facial nerve paralysis was seen in all 27.8% of patients who had radical parotidectomy. The record of the approach to facial nerve identification has not been consistently found in this study. The available record obtained from six of the case notes showed an anterograde method of facial nerve identification used in five cases. Adeyemo et al., in Nigeria, reported the anterograde method of identification as the most commonly used technique of facial nerve identification. The higher frequency of the anterograde method could be related to the relatively larger parotid tumors in our clime possibly due to late presentation. The retrograde method may be more feasible for smaller size tumors at the tail of the parotid or in the presence of fibrosis from previous surgeries. It is also helpful when a bigger size tumor impedes the visualization of the main nerve trunk. It permits the preservation of some vital structures including the superficial musculoaponeurotic system, great auricular nerve, and Stensen's duct. A meta-analysis study published by Mashrah et al., in 2018, found no statistically significant difference in terms of transient or permanent facial nerve palsy with antegrade or retrograde identification of facial nerve used during parotidectomy. No recurrence, as well as survival rate, was observed in this study likely due to poor documentation and loss of follow-up in most of the cases recorded.
| Conclusion|| |
Pleomorphic adenoma was the most common parotid gland tumor, and superficial parotidectomy was the major surgical procedure performed. Facial nerve dysfunction is a frequent complication but can be minimized with meticulous surgical maneuvers.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]