Newly Discovered Parotid Lesion: What Next?

When a parotid lesion is discovered incidentally, it can be challenging for the radiologist to provide specific recommendations for the next steps. This article describes how the radiologist can play an active role in managing incidentally discovered parotid lesions. First, we explore the significance of parotid lesions. Next, the pertinent anatomy of the parotid space is presented to develop an appropriate differential diagnosis. Lastly, we discuss critical clinical and imaging characteristics the radiologist can use to provide specific recommendations.

Superficial parotidectomy for chronic parotid sialadenitis: a case series and review of the literature.

OBJECTIVES: To report the clinical outcomes of patients with chronic parotid sialadenitis treated with superficial parotidectomy, and to review the literature. METHODS: A retrospective case series was conducted of all patients undergoing parotidectomy for chronic parotid sialadenitis at our institution between 2009 and 2018. RESULTS: Eighteen superficial parotidectomies were performed, resulting in complete symptom resolution in 17 patients. There was only one recurrence, of a milder form of the disease, requiring no specific treatment. Eight temporary post-operative facial nerve palsies and one permanent palsy occurred. Further complications included post-operative wound haematoma, seroma, Frey's syndrome, neuropathic pain and wound infection. CONCLUSION: Superficial parotidectomy is sufficient to control patient symptoms, avoiding the increased morbidity associated with near-total parotidectomy. The literature does not point to a clear difference in either the incidence of recurrence or the risk of a facial nerve palsy between the two procedures. Furthermore, the symptoms attributed to recurrence are often not severe enough to warrant salvage near-total parotidectomy.

Multifocal Parotid Oncocytic Cystadenomatosis: A Rare Process that Can Mimic Malignancy.

Multifocal cystic oncocytosis (MCO) is a rare, benign process accounting for approximately 0.1% of salivary gland lesions. Salivary oncocytosis is characterized by multiple unencapsulated solid nodules of oncocytic cells derived from transformed striated ducts. MCO is a variant of salivary oncocytosis which manifests as cystically dilated striated ducts. It is difficult to obtain a definitive preoperative diagnosis of MCO; therefore, these lesions are commonly treated with surgery. We report the unique case of a 66-year-old male who previously underwent a superficial left parotidectomy for a pleomorphic adenoma. Four years later, he presented with clinical and radiographic suspicion of a multifocal recurrent pleomorphic adenoma. The patient subsequently underwent a revision parotidectomy. However, final pathology confirmed a diagnosis of MCO. Although MCO is commonly treated with surgery due to lack of a definitive preoperative diagnosis, surgery is unnecessary outside of diagnostic, functional or cosmetic considerations. Thus, if a patient with parotid oncocytosis treated by superficial parotidectomy develops disease re-manifestation in the residual deep lobe, further surgery is not indicated. There is no risk of malignant progression in this process. We report on this unusual entity as it may mimic salivary malignancy or, as in this case, recurrence of benign disease.

Clinicopathological analysis of parotid masses: six-year experience of a tertiary center.

OBJECTIVE: To analyse the clinical and histopathological characteristics of parotid gland masses at a tertiary referral centre and to compare the results with those cited in literature. METHODS: The retrospective study was conducted at Adana Numune Training and Research Hospital, Adana, Turkey, and comprised data of patients undergoing parotid surgery between January 2011 and December 2016. They were evaluated in terms of age, gender, surgery method, fine-needle aspiration biopsy results, specimen reports and complications after the surgery for one year. SPSS 20 was used for data analysis. RESULTS: Of 170 parotidectomies, 97(57.1%) had been performed on males and 73(42.9%) on females. There were 145(85.3%) benign and 25(14.7%) malignant tumours. Pleomorphic adenoma 67(39.4%) and Warthin's tumour 56(32.9%) were the two most common benign tumours. Mucoepidermoid carcinoma 7(4.1%) and adenoid cystic carcinoma 6(3.5%) were the two most prevalent malignant tumours. Superficial parotidectomy 133(78.2%) was the main type of surgical intervention. The sensitivity of fine needle aspiration cytology for identifying malignant tumours was 64.71%, the specificity was 100% and overall accuracy of the procedure was 94.92%. CONCLUSIONS: Repeated aspirations for sampling different parts of the lesion should be performed on suspicion of malignancy, especially if fine needle aspiration cytology reported pleomorphic adenoma.

Bilateral multiple oncocytic cysts of the parotid gland in type 2 diabetes patients.

AIMS: The hallmarks of type 2 diabetes (T2D) are hyperglycaemia and insulin resistance. These factors, at the cellular level, are associated with mitochondrial dysfunction and increased glucose uptake. Such events are poorly explored in the context of the salivary glands. In this study, we present a series of eight cases of a distinct salivary gland lesion characterised by multiple oncocytic cysts, and we provide new pathological insights regarding its pathogenesis. METHODS AND RESULTS: Seven patients (87.5%) had confirmed T2D, and obesity was identified in five (62.5%) patients. Clinically, the patients showed bilateral parotid gland swelling with recurrent episodes of pain and enlargement. Imaging examination revealed multiple cystic lesions in both parotid glands. Microscopically, the parotid glands showed multiple cysts of different sizes, lined by oncocytic epithelial cells. Intraluminally, strongly eosinophilic glass-like crystalloid material was observed. Immunohistochemical studies were performed, and the most notable finding was glucose transporter 1 (GLUT1) overexpression in the oncocytic cysts which is not observed in any other oncocytic lesion of patients without T2D. In addition, high expressions of mitochondrial antigen, fission 1 protein and mitofusin-2 were observed in the oncocytic epithelium of the cysts. Furthermore, most of the oncocytic cysts showed a pattern of cytokeratin expression consistent with striated ducts. CONCLUSIONS: These results strongly suggest that T2D is associated with alterations in GLUT1 expression in the cells of striated ducts with mitochondrial dysfunction, causing a hyperplastic process characterised by multiple oncocytic cysts. For this lesion, the designation of 'diabetes-associated-bilateral multiple oncocytic cysts of the parotid gland' is proposed.

An unusual case report of unilateral parotid gland sarcoidosis with spontaneous remission.

RATIONALE: Parotid gland sarcoidosis is a well-recognized, but uncommon disease entity. Parotidectomy is most commonly performed to establish the diagnosis and most patients are treated with corticosteroids. PATIENT CONCERNS: A young female patient presented with right parotid enlargement and developed symptoms of facial nerve palsy during diagnostic investigation. DIAGNOSES: A fine-needle aspiration cytology showed granulomatous inflammation. The diagnosis of sarcoidosis was eventually established based on the demonstration of the characteristic lambda and panda signs by a Gallium-67 scintigraphy. INTERVENTIONS: No specific pharmacologic therapy was initiated. OUTCOMES: The patient's symptoms regressed completely over a period of 3 months. Additionally, she remains asymptomatic 2 years later. LESSONS: This case underlines the importance of not initiating corticosteroids in all patients with parotid gland sarcoidosis and suggests that parotidectomy can be avoided in the presence of characteristic for sarcoidosis imaging findings.

Kimura's disease involving bilateral lacrimal glands and extraocular muscles along with ipsilateral face: A unique case report.

A 23 year female presented with bilateral recurrent swelling of eyelids along with ptosis and proptosis for last 3 years. She also had swellings over the right cheek, parotid gland, and retro auricular area along with regional lymphadenopathy. Systemic laboratory workup revealed raised serum IgE and a high peripheral eosinophil count. Computed tomography and magnetic resonance imaging showed bilateral enlargement of extraocular muscles, lacrimal glands, and ipsilateral parotid gland. Excision biopsy of the retro-auricular lymph node was suggestive of Kimura's disease (KD). The patient responded well to systemic corticosteroid. KD rarely affects orbit, but it should be included in the differential diagnosis of inflammatory diseases of the orbit. To our knowledge, this is the first reported case of KD from India involving the orbit, lacrimal gland, extraocular muscles, parotid gland and buccal area.

Drain-free parotidectomy: a pilot study using ARTISS fibrin sealant.

PURPOSE: Parotidectomy is the definitive procedure for diagnosis and treatment of most parotid masses but, due to the risk of haematoma and seroma formation, has traditionally included a drain. The drain itself comes with its own risks and, in most hospitals, the need for overnight admission, which has significant cost implications (Mallon et al. Ann R Coll Surg Engl 95(4):258-262; 2013). Fibrin glue, with its haemostatic and adhesive properties, reduces the risk of collection or haematoma and therefore may negate the need for a drain. This is the first study to look at the use of ARTISS as an alternative to drains in parotidectomy. METHODS: We performed a retrospective study of all the patients who underwent a partial parotidectomy over a 4-year period from 2014 until 2018 under the same senior surgeon. Patients were divided into those that had a drain and those that had ARTISS. Their operative record, inpatient notes and clinic letters were reviewed to record information regarding length of stay, histology, complications and recurrence. RESULTS: A total of 34 patients were identified; 17 ARTISS and 17 drain patients. We showed that the mean length of stay improved significantly from 1.6 days with the drain to 0.5 days with ARTISS (Fig. 1) but without a difference in complication rate (Fig. 2), which was 5/17 (29%) in each group. CONCLUSIONS: In conclusion, parotidectomy can be undertaken safely as a day-case procedure with the application of ARTISS. This new approach to parotid surgery not only offers less morbidity for patients but also positive financial revenue for public health institutions.

Risk stratification of fine-needle aspiration cytology of parotid neoplasms based on the Milan system-Experience from a tertiary center in Asia.

BACKGROUND: The recently described Milan system provides a unified way of categorizing salivary gland fine-needle aspiration (FNA) cytology. We aim to use this system to stratify risk of malignancy in parotid FNAs. METHODS: In this retrospective case series, 376 FNAs were preoperatively performed for 573 parotidectomies over 14 years. RESULTS: Risk of malignancy on FNA is as follows: nondiagnostic 14.5%, non-neoplastic 26.7%, atypia of undetermined significance 29.3%, benign neoplasm 2.7%, neoplasm of uncertain malignant potential 19.1%, suspicious for malignancy 87.5%, and malignant 100%. The specific diagnoses of pleomorphic adenoma and Warthin tumor on FNA have high positive predictive value of 97.5% and 96.6%, respectively. Multivariate regression associates smaller size of lesion with a nondiagnostic or indeterminate result. Seniority of operator is associated with a lower likelihood of a nondiagnostic result. CONCLUSIONS: This large Asian series validates the Milan system as a valuable tool in stratifying malignancy risk of parotid FNAs.

Crystalloid Granuloma of Parotid Gland: A Case Report With Review of the Literature.

Crystalloid granuloma (CG) of salivary gland is an extremely rare inflammatory disease, and only 6 cases have been reported in the English literature. CG is histologically characterized by a granulomatous reaction to amylase crystalloid deposition. A 73-year-old woman presented with a painful left neck mass. Computed tomography depicted a mass located in the lower pole of the left parotid gland, suspicious for a tumoral lesion. Preoperative fine needle aspiration cytology found amylase crystalloid deposition with a few inflammatory cells. Surgical sections of the mass revealed formation of a granuloma containing abundant eosinophilic but glassy and transparent amorphous crystalloids, suggestive of α-amylase crystalloid. No neoplastic elements were detected. The case was eventually diagnosed with CG in the parotid gland. Our findings suggest that when we identify amylase crystalloids in fine needle aspiration cytology smears from the salivary gland, CG should be considered even if neoplasm is clinically or radiographically suspected.

Lesions of the Parotid Gland and Buccal Artery After Buccal Fat Pad Reduction.

The significant increase in esthetic surgery, especially buccal fat pad reduction, has led to a corresponding increase in lesions and postoperatory after-effects from this surgical procedure. The aim of this study is to discuss the immediate and mediate risks of removing the Bichat ball, as well as describing a clinical study in which this surgical procedure resulted in lesions of the parotid gland and buccal artery, which was confirmed via nuclear magnetic resonance. The facial lesions were remedied via exploratory surgery by opening a new orifice of the glandular duct in the buccal cavity followed by drainage and compressive surgical bandages.

Isolated Light Chain Amyloidosis Involving the Parotid Gland: A Case Report.

Amyloidosis in the parotid gland is rare and is usually associated with systemic amyloidosis. Localized amyloidosis in the parotid gland is extremely rare. We present a case of localized light chain amyloidosis of the parotid gland without systemic involvement. A 70-year-old woman presented with an asymptomatic swelling of the right parotid region. The findings of a physical examination, hematologic and biochemical investigations, imaging, and cytology were inconclusive. The patient underwent an extracapsular dissection of the right parotid gland. Histologic analysis showed that the tissue of the right parotid gland mostly consisted of amyloid deposition. The amyloid stained with antibodies to lambda light chains. Additional investigations showed no systemic involvement. The patient is asymptomatic 5 months after surgery. Clinicians should be aware of the possibility of localized amyloid light chain amyloidosis in the parotid gland, especially if magnetic resonance imaging, computed tomography imaging, and ultrasound findings are inconclusive, and they should recognize, evaluate, and treat it accordingly.