A 68yo male presented with swelling in the lower pole of the parotid gland for the last 10yrs.
Exam: firm in consistency. What’s the most probable dx?
a. Pleomorphic adenoma
b. Adenolymphoma
c. Mikulicz’s disease
d. Parotiditis
e. Frey’s syndrome
answer: A
Parotid Gland Neoplasms
Clinical Features
• 80% benign (pleomorphic adenoma: most common), 20% malignant (mucoepidermoid: most
common)
• if bilateral, suggests benign process (Warthin’s tumor, Sjögren’s, bulimia, mumps) or possible
lymphoma
Pleomorphic adenoma
Clinical features
The patient presents with a slow - growing swelling anywhere within the parotid gland, but usually
in the lower pole and in the region of the angle of the jaw. The lump is well defined, usually firm or hard but sometimes cystic in consistency. It is usually placed in the superficial part of the gland but may occasionally be in its deep prolongation and indeed may project into the pharynx. The facial nerve is never involved, except by frankly malignant tumours.
Treatment
Wide excision of the tumour and the surrounding parotid tissue, with careful preservation of the fibres of the facial nerve (superficial parotidectomy). Where the tumour involves one of the other salivary glands, complete excision of the gland is performed. Enucleation is not recommended as it is highly liable to recurrence.
Adenolymphoma
Adenolymphoma (Warthin’s tumour) accounts for about 10% of parotid tumours, and is very rare
elsewhere. Adenolymphomas usually occur in men over the age of 50 years, and are occasionally
bilateral. Macroscopically, the tumour is soft and cystic. Microscopically, it consists of columnar cells forming papillary fringes, which project into cystic spaces and which are supported by a lymphoid stroma. These tumours probably arise from the salivary duct epithelium, the lymphoid tissue originating from the lymphoid aggregates that are present in the normal parotid gland. Presence of the lymphoid tissue may lead to confusion with lymphoproliferative disorders. Prognosis is excellent after local removal.
Parotid Carcinoma
Clinical features
Sex distribution is equal, and the patients are usually over the age of 50 years. The tumour is hard and infiltrating. Clinically, the diagnosis is based on rapid growth, pain and involvement of the facial nerve and regional lymph nodes. Eventually, surrounding tissues are infi ltrated and the overlying skin becomes ulcerated.
Treatment: Radical Parotidectomy with sacrifice of facial nerve
Mikulicz’s syndrome
Mikulicz’s syndrome is characterized by enlargement of the salivary and lacrimal glands, and is
associated with dry eyes, leading to conjunctivokeratitis, and dry mouth (xerostomia). It may occur
in the following conditions:
• sarcoid (commonest);
• lymphoma, particularly non-Hodgkins lymphoma;
• tuberculosis;
• Sjögren’s syndrome, principally affecting middle - aged women and associated with connective tissue disorders such as rheumatoid arthritis and systemic lupus erythematosus.
Frey’s syndrome is a post-operative complication characterized by sweating from the cheeks in response to food related stimuli. It is due to aberrant innervation of cutaneous sweat glands by parasympathetic nerve fibers that are divided during surgery.
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