Br. J. Surg. 1992, Vol. 79, November, 1159-1 161
Parotidectomy for parotid tumours: 19-year experience from the Netherlands A total of 150 patients t t w e treated.for parotid tumours over a period 19 1var.s. In 94 per cent supeqkiul or total parotidectomy was performed. Histological diagnosis of the resected specimen revealed pleoniorphic adenoma in 92 patients ( 6 1 per cent), Whartin’s tumour in 30 ( 2 0 per cent), various benign neoplasms in I 1 ( 7 per cent) and malignant tumour in 17 (I1per cent). After a mean .follow-up q f 7.7 ~ w w s ,no recurrence of a benign turnour lras seen. Malignant tumours recurred in .five patients. Permanent partial facial paralysis rcas seen in 4 per cent of’patients ufter surgery,for benign lesions. Frey ’s syndrome WCIS observed in 43 per cent o f patients, and tc‘as not prevented by resection of the auriculotemporal nerve. of
J. M. H. Debets and J. D. K . Munting Department of General Surgery, de Wever Hospital, PO Box 4446, 6401 CX Heerlen. The Netherlands Correspondence to: Dr J . M. H. Debets
Tumours of the parotid gland are uncommon, the estimated incidence‘,2 ranging between 1 and 3 per 100000 per year. Uncertainty exists over the optimal treatment of such tumours, some favouring conservative surgery followed by radiotherapy, others preferring parotidectomy as the treatment of choice3s4. Although parotidectomy is currently the generally recommended therapeutic option for all parotid tumours, a recent review of clinical practice in the UK revealed that local excision of such tumours is still commonly performed’. Parotidectomy has been the treatment of choice for parotid tumours in this institution, and this report gives details of this experience over the past 19 years.
Records of all those undergoing surgery for a parotid mass at this hospital during the period 1972-1990 were reviewed. Missing and follow-up data were obtained by questioning the patients by telephone or questionnaire. I n 150 patients undergoing operation for a parotid mass, 142 procedures were performed by one surgeon (J.D.K.M.). Follow-up data were obtained from 116 patients with a mean follow-up of 7.7 (range 1.0-18.6) years. Recent data were not obtained from 34 patients: 15 had died and 19 could not be contacted.
Results Figure 1 shows the final diagnosis after histological examination of the resected parotid mass for all 150 patients. The histological diagnosis of malignant tumours according to the World Health Organization International Classification’ is shown in Table 1 . The median age of patients with a pleomorphic adenoma was 43 (range 14-77) years; the median age of those with Whartin’s tumour was 61 (range 39-76) years. This tumour occurred predominantly in men, the ma1e:female ratio being 6.5: 1. Symptoms Preoperative symptoms leading to parotid surgery were a growing mass and pain. Growth of the mass was found equally in patients with a pleomorphic adenoma (57 per cent), Whartin’s tumour (52 per cent) or a malignant tumour ( 5 3 per cent). Pain was a major symptom in patients with a malignancy ( 3 5 per cent), but occurred less frequently in those with a pleomorphic adenoma (8 per cent) o r Whartin’s tumour (17 per cent). Paralysis of the facial nerve before surgery occurred in one patient with an undifferentiated carcinoma. The median duration of swelling before surgery was 24 months for pleomorphic adenoma, 12 months for Whartin’s tumour and 5 months for malignant tumour.
0 1992 Butterworth-Heinemann
L l
PIeornor p hic
adenorna (n=92)
Figure 1 Histological diagnosis ofparotid tumours. Values are numbers of patients
Patients and methods
0007-1323/92/111159-03
Malignant tumour
Other turnours
Ltd
Diagnosis
No. of patients
Adenocarcinoma Adenoid cystic carcinoma Undifferentiated carcinoma Squamous cell carcinoma Carcinoma in pleomorphic adenoma Acinic cell carcinoma Mucoepidermoid carcinoma Malignant lymphoma
Table 2
Results ofpreoperrrtiw
e.yutnitici/ioti
Result Examination
No. of patients*
Positive
Negative
Sialography Scintigraphy Computed tomography Aspiration cytology
89 32 48 35
59 28 44 26
30 4 4 9
(66) (88) (92) (74)
(34) (12) (8)
(26)
Values in parentheses are percentages. *Number in whom the results of examination could be traced
Diagnosis Table 2 shows the results of preoperative examination. Aspiration cytology correctly predicted the diagnosis in 17 of 21 patients (81 per cent) with a pleomorphic adenoma.
1159
Parotidectomy for tumours: J. M. H . Debets and J. D. K. Munting
Type of pxotidectomy -~
--
~
D I a g n os1s
Superficial
Totdl
Partial
Totdl
Pleomorphic adenoma Whartin's tumour Malignant tumour Other tumours
71 29
16
5 I
92
0 5 I
10 9
3
30 17
1
I1
Auriculotemporal nerve resection Performed
Frey's syndrome .
~~
Present Absent
~
_
_
_
38 48
.
Not performed .
~
~
26
25
The presence or absence of Frey's syndrome was unknown in four patients undergoing resection of the auriculotemporal nerve and in nine in whom this was not performed. z' = 0.59. I d.f.. P > 0.5 Operritiori The type of operation performed in relation to the final pathological diagnosis is shown in Tnhle 3. Thirteen patients with a malignant tumour received radiotherapy and one with an adenocarcinoma underwent radical neck dissection. In nine patients a peroperative frozen section examination of the tumour was performed, and in seven the diagnosis from this was correct.
Coniplicritior is Complications in the immediate postoperative period were a haematoma or seroma in seven patients ( 5 per cent), wound infection in three ( 2 per cent) and a temporary salivary fistula in four ( 3 per cent ). After operation, 106 patients (71 per cent) had partial or total paralysis of the facial nerve. This was temporary in 76 patients (72 per cent ), permanent in 11 ( 10 per cent ) and in 19 ( 1 8 per cent) of unknown duration. The median duration of temporary paralysis was 3 months. Permanent paralysis occurred most frequently after surgery for malignant tumours (six of 17 rersus five of 133). and in four patients the facial nerve was resected and replaced by a s u r d nerve transplant. The global palsy partially recovered in all patients. Permanent partial facial paralysis after resection of benign lesions was attributed to intraoperative damage of one or more fascicles in four of five patients. In these patients the palsy was partial, affecting primarily the mouth area. Frey's syndrome was seen in 64 patients (43 per cent). To prevent the development of this syndrome the auriculotemporal nerve was resected in 90 patients. T ~ i h l e4 shows the incidence of Frey's syndrome related to resection of the auriculotemporal nerve. Nineteen patients ( I3 per cent ) had a painful scar, sometimes accompanied by a neuroma of the greater auricular nerve. This nerve was saved in 65 per cent of patients, thereby avoiding loss of sensation in the ear lobe. Recurrence In five patients the original malignant tumour recurred; no recurrence of a benign neoplasm was reported.
Discussion The de Wever Hospital is a large regional centre serving a population of approximately 200000-250000: no patient came from outside the region. The estimated incidence of parotid tumours was 3.2-3.9 per I00000 per year, which is higher than that reported by others'.6. but in agreement with the incidence
1160
of 4 per I00000 per year reported by Lennox et d.for eastern Scotland'. The proportion of malignant tumours ( I I per cent) was lower than that reported by others8 I". Over-representation of malignant tumours in other series may derive from specialist referral. Computed tomography ( C T )proved to be the most accurate preoperative method of examination. Magnetic resonance imaging, which is reported to give more detailed anatomical information and to define the position of a parotid mass relative to the facial nerve better' ' - I 3 , may surpass CT. Sialography has been replaced by CT; scintigraphy may be useful in that Whartin's tumours take up technetium-99m pertechnetate. The sensitivity of fine-needle aspiration cytology was 74 per cent for all tumours in which it was performed and 81 per cent for pleomorphic adenoma; these results are comparable to those obtained by others'". Failure of aspiration cytology to give an accurate diagnosis was attributed to insufficient material in the biopsy specimen in six of nine patients. The sensitivity of peroperative frozen section examination was only 78 per cent, but this method is known to be associated with false-negative results in 5-25 per cent of Superficial or total parotidectomy was performed in 94 per cent of patients. All benign tumours were completely excised and, after a mean follow-up of 7.7 years, no recurrence has occurred. Excision of the lesion with sufficiently wide tumour-free margins precludes recurrence. Rates for recurrence of pleomorphic adenoma range between 3 and 8 per cent for enucleation with radiotherapy3.16,and zero and 2 per cent for parotidectomy4.'7.18.Five malignant tumours recurred despite postoperative radiotherapy; two tumours were incompletely excised and in two tumour spilling occurred. Those who advocate enucleation or limited resection of benign parotid tumours in combination with radiotherapy argue that this reduces the incidence of complications. especially facial nerve injury. Eleven patients ( 7 per cent) had an established permanent facial paralysis, six having a malignant and five a benign lesion. Permanent facial paralysis occurred in 4 per cent of patients with benign tumours, comparable to other result^*^^^'^-^^ . Permanent facial paralysis in four of five patients was attributed to deliberate sacrifice of one or more fascicles to permit radical tumour excision. In all these patients facial paralysis was partial. resulting in only minor disability. Peroperative resection of the auriculotemporal nerve did not lower the incidence of gustatory sweating: resection of the auriculotemporal nerve to prevent Frey's syndrome is not justified. Symptoms were mild in almost all patients and could be alleviated by topical application of an anticholinergic agent'".
References I.
2. 3.
Chapnik JS. The controversy of Whartin's tumour. Laryngoscope 1983; 93: 695-716. Gunn A, Parrott NR. Parotid tumours: a review of parotid tumour surgery in the Northern Regional Health Authority of the United Kingdom 1978-1982. Br J Surg 1988; 75: 1144-6. McEvedy BV. Ross W M . The treatment of mixed parotid tumours by enucleation and radiotherapy. Br J S i i y 1976: 63:
341-2. 4. 5.
6.
Stevens KL. Hobsley M. The treatment of pleomorphic adenomas by Cormal parotidectomy. Br J S m / 1982: 69: 1-3. Seifert G. Brocheriou C. Cardcsa A. Evcson J W . WHO International Classification of Tumours: tentative histological classification of salivary gland turnours. f c i r h d Rc.\ frcic.t 1990: 186: 555-81. Evans R W. Cruickshank A H , eds. Epirliclictl
Tiiriioiir.\ O /
rhc.
Scilircirj. G/o/rc/.Philadelphia: W B
7.
8.
Saunders. 1970: I I -26. Lennox B. Clarke JA, Drake F. Ewcn SWB. Incidence ofsalivary gland turnours in Scotland: accuracy of national records. B M J 1978: i: 687-9. Woods JE. Chong GC. Beahrs OH. Experience with 1360 primary parotid tumours. Ani J Stir
Parotidectomy for parotid tumours: 19-year experience from the Netherlands A total of 150 patients t t w e treated.for parotid tumours over a period 19 1var.s. In 94 per cent supeqkiul or total parotidectomy was performed. Histological diagnosis of the resected specimen revealed pleoniorphic adenoma in 92 patients ( 6 1 per cent), Whartin’s tumour in 30 ( 2 0 per cent), various benign neoplasms in I 1 ( 7 per cent) and malignant tumour in 17 (I1per cent). After a mean .follow-up q f 7.7 ~ w w s ,no recurrence of a benign turnour lras seen. Malignant tumours recurred in .five patients. Permanent partial facial paralysis rcas seen in 4 per cent of’patients ufter surgery,for benign lesions. Frey ’s syndrome WCIS observed in 43 per cent o f patients, and tc‘as not prevented by resection of the auriculotemporal nerve. of
J. M. H. Debets and J. D. K . Munting Department of General Surgery, de Wever Hospital, PO Box 4446, 6401 CX Heerlen. The Netherlands Correspondence to: Dr J . M. H. Debets
Tumours of the parotid gland are uncommon, the estimated incidence‘,2 ranging between 1 and 3 per 100000 per year. Uncertainty exists over the optimal treatment of such tumours, some favouring conservative surgery followed by radiotherapy, others preferring parotidectomy as the treatment of choice3s4. Although parotidectomy is currently the generally recommended therapeutic option for all parotid tumours, a recent review of clinical practice in the UK revealed that local excision of such tumours is still commonly performed’. Parotidectomy has been the treatment of choice for parotid tumours in this institution, and this report gives details of this experience over the past 19 years.
Records of all those undergoing surgery for a parotid mass at this hospital during the period 1972-1990 were reviewed. Missing and follow-up data were obtained by questioning the patients by telephone or questionnaire. I n 150 patients undergoing operation for a parotid mass, 142 procedures were performed by one surgeon (J.D.K.M.). Follow-up data were obtained from 116 patients with a mean follow-up of 7.7 (range 1.0-18.6) years. Recent data were not obtained from 34 patients: 15 had died and 19 could not be contacted.
Results Figure 1 shows the final diagnosis after histological examination of the resected parotid mass for all 150 patients. The histological diagnosis of malignant tumours according to the World Health Organization International Classification’ is shown in Table 1 . The median age of patients with a pleomorphic adenoma was 43 (range 14-77) years; the median age of those with Whartin’s tumour was 61 (range 39-76) years. This tumour occurred predominantly in men, the ma1e:female ratio being 6.5: 1. Symptoms Preoperative symptoms leading to parotid surgery were a growing mass and pain. Growth of the mass was found equally in patients with a pleomorphic adenoma (57 per cent), Whartin’s tumour (52 per cent) or a malignant tumour ( 5 3 per cent). Pain was a major symptom in patients with a malignancy ( 3 5 per cent), but occurred less frequently in those with a pleomorphic adenoma (8 per cent) o r Whartin’s tumour (17 per cent). Paralysis of the facial nerve before surgery occurred in one patient with an undifferentiated carcinoma. The median duration of swelling before surgery was 24 months for pleomorphic adenoma, 12 months for Whartin’s tumour and 5 months for malignant tumour.
0 1992 Butterworth-Heinemann
L l
PIeornor p hic
adenorna (n=92)
Figure 1 Histological diagnosis ofparotid tumours. Values are numbers of patients
Patients and methods
0007-1323/92/111159-03
Malignant tumour
Other turnours
Ltd
Diagnosis
No. of patients
Adenocarcinoma Adenoid cystic carcinoma Undifferentiated carcinoma Squamous cell carcinoma Carcinoma in pleomorphic adenoma Acinic cell carcinoma Mucoepidermoid carcinoma Malignant lymphoma
Table 2
Results ofpreoperrrtiw
e.yutnitici/ioti
Result Examination
No. of patients*
Positive
Negative
Sialography Scintigraphy Computed tomography Aspiration cytology
89 32 48 35
59 28 44 26
30 4 4 9
(66) (88) (92) (74)
(34) (12) (8)
(26)
Values in parentheses are percentages. *Number in whom the results of examination could be traced
Diagnosis Table 2 shows the results of preoperative examination. Aspiration cytology correctly predicted the diagnosis in 17 of 21 patients (81 per cent) with a pleomorphic adenoma.
1159
Parotidectomy for tumours: J. M. H . Debets and J. D. K. Munting
Type of pxotidectomy -~
--
~
D I a g n os1s
Superficial
Totdl
Partial
Totdl
Pleomorphic adenoma Whartin's tumour Malignant tumour Other tumours
71 29
16
5 I
92
0 5 I
10 9
3
30 17
1
I1
Auriculotemporal nerve resection Performed
Frey's syndrome .
~~
Present Absent
~
_
_
_
38 48
.
Not performed .
~
~
26
25
The presence or absence of Frey's syndrome was unknown in four patients undergoing resection of the auriculotemporal nerve and in nine in whom this was not performed. z' = 0.59. I d.f.. P > 0.5 Operritiori The type of operation performed in relation to the final pathological diagnosis is shown in Tnhle 3. Thirteen patients with a malignant tumour received radiotherapy and one with an adenocarcinoma underwent radical neck dissection. In nine patients a peroperative frozen section examination of the tumour was performed, and in seven the diagnosis from this was correct.
Coniplicritior is Complications in the immediate postoperative period were a haematoma or seroma in seven patients ( 5 per cent), wound infection in three ( 2 per cent) and a temporary salivary fistula in four ( 3 per cent ). After operation, 106 patients (71 per cent) had partial or total paralysis of the facial nerve. This was temporary in 76 patients (72 per cent ), permanent in 11 ( 10 per cent ) and in 19 ( 1 8 per cent) of unknown duration. The median duration of temporary paralysis was 3 months. Permanent paralysis occurred most frequently after surgery for malignant tumours (six of 17 rersus five of 133). and in four patients the facial nerve was resected and replaced by a s u r d nerve transplant. The global palsy partially recovered in all patients. Permanent partial facial paralysis after resection of benign lesions was attributed to intraoperative damage of one or more fascicles in four of five patients. In these patients the palsy was partial, affecting primarily the mouth area. Frey's syndrome was seen in 64 patients (43 per cent). To prevent the development of this syndrome the auriculotemporal nerve was resected in 90 patients. T ~ i h l e4 shows the incidence of Frey's syndrome related to resection of the auriculotemporal nerve. Nineteen patients ( I3 per cent ) had a painful scar, sometimes accompanied by a neuroma of the greater auricular nerve. This nerve was saved in 65 per cent of patients, thereby avoiding loss of sensation in the ear lobe. Recurrence In five patients the original malignant tumour recurred; no recurrence of a benign neoplasm was reported.
Discussion The de Wever Hospital is a large regional centre serving a population of approximately 200000-250000: no patient came from outside the region. The estimated incidence of parotid tumours was 3.2-3.9 per I00000 per year, which is higher than that reported by others'.6. but in agreement with the incidence
1160
of 4 per I00000 per year reported by Lennox et d.for eastern Scotland'. The proportion of malignant tumours ( I I per cent) was lower than that reported by others8 I". Over-representation of malignant tumours in other series may derive from specialist referral. Computed tomography ( C T )proved to be the most accurate preoperative method of examination. Magnetic resonance imaging, which is reported to give more detailed anatomical information and to define the position of a parotid mass relative to the facial nerve better' ' - I 3 , may surpass CT. Sialography has been replaced by CT; scintigraphy may be useful in that Whartin's tumours take up technetium-99m pertechnetate. The sensitivity of fine-needle aspiration cytology was 74 per cent for all tumours in which it was performed and 81 per cent for pleomorphic adenoma; these results are comparable to those obtained by others'". Failure of aspiration cytology to give an accurate diagnosis was attributed to insufficient material in the biopsy specimen in six of nine patients. The sensitivity of peroperative frozen section examination was only 78 per cent, but this method is known to be associated with false-negative results in 5-25 per cent of Superficial or total parotidectomy was performed in 94 per cent of patients. All benign tumours were completely excised and, after a mean follow-up of 7.7 years, no recurrence has occurred. Excision of the lesion with sufficiently wide tumour-free margins precludes recurrence. Rates for recurrence of pleomorphic adenoma range between 3 and 8 per cent for enucleation with radiotherapy3.16,and zero and 2 per cent for parotidectomy4.'7.18.Five malignant tumours recurred despite postoperative radiotherapy; two tumours were incompletely excised and in two tumour spilling occurred. Those who advocate enucleation or limited resection of benign parotid tumours in combination with radiotherapy argue that this reduces the incidence of complications. especially facial nerve injury. Eleven patients ( 7 per cent) had an established permanent facial paralysis, six having a malignant and five a benign lesion. Permanent facial paralysis occurred in 4 per cent of patients with benign tumours, comparable to other result^*^^^'^-^^ . Permanent facial paralysis in four of five patients was attributed to deliberate sacrifice of one or more fascicles to permit radical tumour excision. In all these patients facial paralysis was partial. resulting in only minor disability. Peroperative resection of the auriculotemporal nerve did not lower the incidence of gustatory sweating: resection of the auriculotemporal nerve to prevent Frey's syndrome is not justified. Symptoms were mild in almost all patients and could be alleviated by topical application of an anticholinergic agent'".
References I.
2. 3.
Chapnik JS. The controversy of Whartin's tumour. Laryngoscope 1983; 93: 695-716. Gunn A, Parrott NR. Parotid tumours: a review of parotid tumour surgery in the Northern Regional Health Authority of the United Kingdom 1978-1982. Br J Surg 1988; 75: 1144-6. McEvedy BV. Ross W M . The treatment of mixed parotid tumours by enucleation and radiotherapy. Br J S i i y 1976: 63:
341-2. 4. 5.
6.
Stevens KL. Hobsley M. The treatment of pleomorphic adenomas by Cormal parotidectomy. Br J S m / 1982: 69: 1-3. Seifert G. Brocheriou C. Cardcsa A. Evcson J W . WHO International Classification of Tumours: tentative histological classification of salivary gland turnours. f c i r h d Rc.\ frcic.t 1990: 186: 555-81. Evans R W. Cruickshank A H , eds. Epirliclictl
Tiiriioiir.\ O /
rhc.
Scilircirj. G/o/rc/.Philadelphia: W B
7.
8.
Saunders. 1970: I I -26. Lennox B. Clarke JA, Drake F. Ewcn SWB. Incidence ofsalivary gland turnours in Scotland: accuracy of national records. B M J 1978: i: 687-9. Woods JE. Chong GC. Beahrs OH. Experience with 1360 primary parotid tumours. Ani J Stir
