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2 PAROTID MASS
Ashok R. Shaha, M.D., F.A.C.S.
There are three major salivary glands in the human body—the Nonneoplastic The causes of nonneoplastic masses include
parotid gland, the submandibular gland, and the sublingual congenital, granulomatous, infectious or inflammatory, and non-
gland—of which the parotid gland is the largest. In addition, there inflammatory conditions. Some congenital lesions (e.g., heman-
are approximately 600 to 800 minor salivary glands distributed gioma or vascular malformation) present as a vague swelling in the
throughout the entire upper aerodigestive tract, starting from the parotid region that has been present since childhood. One con-
lip and extending to the lower end of the esophagus and up to the genital lesion, a first branchial cleft cyst, presents as a mass inferi-
pulmonary alveoli. Almost half of these minor salivary glands are or to the cartilaginous ear canal, with a cyst tract that can be either
on the hard palate. Accordingly, any mass on the hard palate medial or lateral to the facial nerve and may even divide the trunk
should be considered a minor salivary gland tumor until proved of the nerve. This cyst is most commonly noted in the second
otherwise.1 through fourth decades in life.
The majority of salivary gland tumors originate in the parotid Granulomatous diseases are frequently manifested by an
gland. Approximately 75% to 80% of parotid tumors are asymptomatic, gradual enlargement of a lymph node within the
benign.2,3 In the evaluation and surgical treatment of parotid gland; often, they cannot be readily distinguished from neoplasms.
tumors, it is essential to maintain awareness of the possibility of In sarcoidosis, salivary gland involvement may cause duct obstruc-
temporary or permanent facial nerve injury [see Discussion, Prin- tion, pain associated with the duct, xerostomia, or enlargement of
ciples of Facial Reanimation, below]. Because surgery necessarily the gland. The diagnosis is supported by chest x-rays that show
entails some risk of an injury to this structure or its branches, as bilateral hilar adenopathy and by elevated levels of angiotensin-
well as because most parotid masses do not give rise to significant converting enzyme (ACE).
symptoms, many patients with parotid tumors may find the As noted (see above), infectious or inflammatory diseases
prospect of surgical therapy difficult to accept. involving the parotid, unlike neoplasms, tend to give rise to pain in
their early stages. Most such inflammatory conditions begin with
diffuse enlargement of one or more salivary glands. Although
Clinical Evaluation parotitis is generally unilateral, it may be bilateral if a systemic
causative condition is involved, and other salivary glands may be
HISTORY
affected as well.The pain reported may be related to the presence
Evaluation of a parotid mass begins of a stone in the salivary duct or to diffuse obstructive parotitis.
with a good clinical history. The most Chronic parotitis may lead to recurrent infection and inflamma-
important question is, how long has the tion.When recurrent swelling of the salivary gland does occur, it is
mass been present? If local pain and directly related to eating and increased salivation.
swelling of recent onset (i.e., within the Sialadenosis is a noninflammatory, nonneoplastic condition of
past few days) are reported, infection or unknown origin that is characterized by diffuse enlargement of the
obstruction is the likely cause. If the mass has been present for a salivary gland, with no discrete mass or inflammation.
longer period (i.e., weeks to months), a neoplasm is more likely.
Unfortunately, the presentations of some nonneoplastic condi- Lymphoepithelial Lymphoepithelial lesions may be divided
tions resemble those of neoplasms, and distinguishing one type of into lymphocytic infiltrative diseases and lymphomas. In many
condition from the other can be challenging. Thus, the history cases, patients with lymphocytic infiltrative diseases (e.g., Mikulicz
should continue with further questions focusing on local or sys- disease, sicca complex, and Sjögren syndrome) have had their
temic signs and symptoms, the presence of swelling or other mass- conditions for long periods, and they may feel that they have
es in the salivary glands, and previous medical conditions (includ- always been chubby, when in fact they have had chronic enlarge-
ing skin cancer). ment of both parotid glands. In patients with Sjögren syndrome,
Classification malignant transformation to high-grade lymphoma is known to
occur. Lymphoepithelial cysts are benign cystic lesions that may
Major salivary gland masses can be classified as nonneoplastic, arise from lymph nodes or from lymphoid aggregates in the sali-
lymphoepithelial, or neoplastic.4 vary gland. These lesions may be associated with HIV infection.
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 PAROTID MASS — 2
Approach to Evaluation
of a Parotid Mass
Primary lymphoma of the salivary gland is uncommon, occur- The most common presentation of a parotid mass, whether
ring in fewer than 5% of patients with parotid masses.5 Suggestive benign or malignant, is an asymptomatic swelling in the preauric-
clinical features include (1) the development of a parotid mass in ular or retromandibular region. Occasionally, patients present with
a patient with a known history of malignant lymphoma, (2) the metastases to the intraparotid or periparotid lymph nodes. There
occurrence of a parotid mass in a patient with an immune disor- are approximately 17 to 20 lymph nodes in the substance of the
der (e.g., Sjögren syndrome, rheumatoid arthritis, or AIDS), (3) parotid and along its tail, and there may be a smaller number of
the presence of a parotid mass in a patient with a previous diag- lymph nodes within the deep lobe of the gland. These lymph
nosis of benign lymphoepithelial lesion, (4) the finding of multiple nodes may be directly affected by metastatic tumors originating
masses in one parotid gland or of masses in both parotid glands, from the anterior scalp or the temporal, periocular, or malar
and (5) the association of a parotid mass with multiple enlarged regions. Especially with elderly patients, it is extremely crucial to
cervical lymph nodes unilaterally or bilaterally.6 obtain a detailed history of any previously excised skin lesions,
some of which may have been squamous cell carcinomas (SCCs)
Neoplastic Neoplastic masses may be present for years with- that metastasized to the periparotid nodes. Generally, such metas-
out causing any symptoms. Benign salivary tumors are more com- tasis involves multiple superficial lymph nodes and presents as dif-
mon in younger persons, whereas malignant parotid lesions are fuse enlargement of the parotid parenchyma. With the massive
more common in the fifth and sixth decades of life.7 The classic involvement of the parotid gland, facial nerve palsy is not uncom-
presentation of a benign parotid tumor is that of an asymptomatic mon in this setting.The majority of metastases to the parotid gland
parotid mass that has been present for months to years. Benign derive from cutaneous SCC or melanoma; however, metastatic
neoplasms of the parotid include pleomorphic adenoma, basal cell spread from the lung, the breast, and the kidney also is known to
adenoma, myoepithelioma,Warthin tumor, oncocytoma, and cystad- occur.13
enoma. The observation of rapid growth in a long-standing pleo- The location of the parotid mass is a very important diagnostic
morphic adenoma is suggestive of malignant transformation. In a factor. The classic presentation of a benign mixed tumor is as a
2005 study of 94 patients with pleomorphic adenoma, malignant marblelike lesion in the parotid gland—a firm, mobile mass that
transformation to carcinoma was documented in 8.5% of cases.8 commonly originates in the superficial portion of the gland and
Rapid tumor growth, metastasis to lymph nodes, deep fixation, generally is not fixed to the deeper structures or to the skin.
and facial nerve weakness are all strongly suggestive of malignant Parotid tumors that originate in the deep lobe may present as a
disease and are indicators of a poor prognosis.9 Although pain is vague, diffuse swelling behind the angle of the mandible; more
more often experienced by patients with benign conditions, it is also often, however, they present as a swelling of the parapharyngeal
reported by some patients with infiltrative malignant tumors. In area accompanied by medial displacement of the tonsil or the soft
the latter patients, pain is another indicator of a poor prognosis.10 palate.
The presence of facial nerve palsy should raise the index of sus- Although physical examination of a parotid mass is a simple
picion for malignancy. Occasionally, patients present with classic process in itself, it should be accompanied by a thorough evalua-
Bell palsy. This condition is usually of viral origin, and most pa- tion of the head and neck that includes a detailed examination of
tients recover over time. If Bell palsy persists, however, further in- the oral cavity and the oropharyngeal, nasopharyngeal, hypopha-
vestigation is required, including imaging studies to rule out any ryngeal, and laryngopharyngeal areas. Occasionally, a tumor of the
obvious parotid lesion. Facial palsy occurring in association with oropharynx presents as cervical lymphadenopathy or as metastat-
parotitis and anterior uveitis is known as Heerfordt syndrome and ic disease in the tail of the parotid. In such cases, it may be diffi-
is often seen in patients with sarcoidosis. cult to determine whether the patient has a primary salivary gland
tumor or a metastatic lesion. The presence of any suspicious
PHYSICAL EXAMINATION
pathologic condition in the oropharynx or the base of the tongue
The physical examination should focus on the extent of the dis- is an indication for appropriate endoscopy and biopsy of the sus-
ease in the parotid, the neck, and the parapharynx; the localized pected primary site.
effects of the tumor (including trismus); and the motor or senso- Physical findings suggestive of malignancy include a large and
ry deficits resulting from neural invasion. fixed mass, facial nerve weakness, lymph node metastasis, and
The mass is palpated to determine whether it is painless or skin involvement; patients with advanced parotid malignancies
painful; whether it is soft, firm, hard, or cystic; and whether it is may present with trismus. Whereas patients with benign parotid
mobile or fixed to deep tissue or skin.The skin of the scalp, the ear, tumors rarely exhibit facial nerve weakness, approximately 12%
and the face is examined for lesions. The neck is palpated for to 15% of patients with parotid malignancies have facial nerve
adenopathy. In the oral cavity, the ducts are examined for dis- dysfunction at presentation.14 The most common causes of facial
charge or saliva after the glands are milked.The pharyngeal wall is nerve weakness in this setting are adenoid cystic carcinoma,
examined for deviation, and the jaw is examined for trismus. poorly differentiated carcinoma, and SCC. Primary SCC of the
The parotid occupies a large area, starting from the zygoma and parotid is quite rare, and a diagnosis of SCC in the gland should
extending to the upper portion of the neck and behind the lead one to suspect that a tumor has metastasized to the parotid
mandible to what is commonly called the tail of the parotid. lymph nodes. Before the diagnosis of primary SCC of the paro-
Occasionally, the parotid tissue extends behind the earlobe, in tid is made, high-grade mucoepidermoid carcinoma and metasta-
which case it may be misdiagnosed preoperatively as a nonsalivary tic SCC must be excluded.
pathologic condition. Accessory parotid tissue is present along The presence of cervical lymph node metastasis may direct
Stenson’s duct in approximately 21% of persons.11 Patients some- one’s attention to the parotid mass, though only about 20% of per-
times present with a tumor (most commonly, a benign mixed sons with parotid malignancies actually have clinically apparent
tumor) of this accessory tissue.12 Attempts to excise such masses cervical lymph node metastases at the time of initial presenta-
locally must be avoided, because of the high risk of injury to tion.10 The parotid tumors most commonly associated with
branches of the facial nerve. metastatic disease to the lymph nodes at presentation are high-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 PAROTID MASS — 4
grade mucoepidermoid carcinoma, poorly differentiated carcino- uate the ductal arrangements in patients with chronic sialoadeni-
ma, and SCC. Lymph node metastases may also derive from high- tis. Currently, however, sialography is rarely used, both because
grade adenocarcinomas or malignant mixed tumors. there is a significant possibility of an infectious flare-up and
Some patients are totally asymptomatic, with the only signifi- because the study actually yields only minimal information. In the
cant physical finding being a mass visible through the open mouth, early 1980s, CT sialography became popular for a time; however,
which is suggestive of either a deep-lobe parotid tumor or a para- it was quite a complicated procedure, and clinicians eventually
pharyngeal tumor.The majority of parotid tumors develop within found that the information it yielded could easily be obtained from
the superficial lobe of the parotid—not surprisingly, given that spiral (helical) CT. Occasionally, surface-coil MRI may be helpful
between 80% and 90% of the parotid tissue is superficial to the for evaluating parotid masses deriving from subcutaneous process-
facial nerve. However, a significant minority of parotid masses— es. Sialoendoscopy has generated considerable interest, especially
about 10%—are found within the deep lobe. Most deep-lobe in Europe and Germany17; however, this sophisticated technology
parotid tumors are benign, in which case surgical treatment gen- has not yet entered everyday practice. Although sialoendoscopy
erally consists of a superficial parotidectomy with dissection and may be of some value in the assessment of salivary stone disease
preservation of the facial nerve, followed by removal of the tumor. or chronic sialectasis, it is rarely performed in the United States at
Occasionally, however, malignant deep-lobe parotid tumors do present, and its eventual role in the evaluation of parotid masses
occur. Such tumors frequently involve the facial nerve, and surgi- remains to be determined.
cal treatment may require sacrifice of the facial nerve in select cir- For a classic benign mixed tumor presenting in the form of a
cumstances. Most patients who have undergone surgical treat- small nodule in the superficial lobe of the parotid gland, imaging
ment of a malignant deep-lobe tumor will require postoperative is not required.
radiation therapy. Currently, the role of positron emission tomography (PET) in
the initial evaluation of a parotid mass remains undefined. This
modality may, however, be of some value in the evaluation of sus-
Investigative Studies pected recurrent parotid cancers, lymph node metastases, or dis-
The majority of parotid masses can tant metastases.
easily be evaluated with a careful history
FINE-NEEDLE ASPIRATION BIOPSY
and a thorough physical examination.
Nevertheless, it sometimes happens that Routine use of FNA biopsy in the evaluation of a parotid mass
even after these measures have been car- [see Table 1] continues to be controversial. One reason for the
ried out, there remains some clinical controversy is that cytologic evaluation is difficult. Another is
uncertainty regarding whether the patho- that the extent of surgical treatment can easily be defined by
logic process is of parotid or of nonsali- means of the clinical assessment. The main argument against
vary origin. A number of nonsalivary tumors (e.g., neurofibromas, routine use of FNA biopsy is based on the standard approach to
lipomas, lymphadenopathies, metastatic cutaneous lesions, and most parotid masses, which is a superficial parotidectomy that
lymphomas) are known to present in the parotid region on occa- includes identification and preservation of the facial nerve.
sion. These tumors may be difficult to evaluate clinically, and fur- Nevertheless, FNA biopsy can be quite helpful, especially for the
ther diagnostic studies may therefore be required. purposes of preoperative consultation with patients regarding
the suspected pathologic process and the extent of surgical ther-
IMAGING
apy. FNA biopsy has an overall accuracy that exceeds 90%,18,19
Generally, parotid masses are imaged with either computed and it is considered a good investigational tool as long as it is
tomography or magnetic resonance imaging.15 CT is superior to used in the appropriate clinical context.
MRI for evaluation of the bony structures, whereas MRI may be In the case of a classic benign mixed tumor, which presents as
more helpful in distinguishing between inflammatory conditions a mobile, confined, superficial nodule in the parotid gland, FNA
and salivary neoplasms. CT scanning is indicated in patients with biopsy is not required for further treatment. However, in cases
diffuse enlargement of the parotid gland, tumor extension beyond where the clinical picture is not definitive and one cannot deter-
the superficial lobe, facial nerve weakness, trismus, or deep-lobe mine whether the pathologic process is of parotid origin or not,
parotid tumors that are difficult to evaluate clinically. If the parotid FNA biopsy is extremely important. Besides distinguishing be-
mass appears to be fixed to the deeper structures, it is appropriate tween benign and malignant conditions, FNA biopsy can also
to proceed with CT to evaluate the extent and parapharyngeal distinguish between salivary and nonsalivary processes [see Table
extension of the disease. MRI is indicated in patients with facial
nerve paralysis. Occasionally, it may be necessary to perform both
CT and MRI. Both imaging methods are helpful and accurate in
distinguishing deep-lobe parotid tumors from other parapharyn- Table 1 Uses of FNA Biopsy in Evaluation
geal masses. They are also useful for evaluating suspicious lymph of Parotid Mass
nodes and the periphery of the mass (specifically with respect to
determining whether the lesion is encapsulated or has irregular To identify suspected malignancy
To diagnose metastatic carcinoma
borders).
To identify suspected lymphoma
Ultrasonography can be useful for determining the location of To distinguish between salivary and nonsalivary lesions
the lesion and for guiding fine-needle aspiration (FNA) biopsy. In To facilitate conservative management of Warthin tumor or pleomorphic
the past, technetium-99m scanning was commonly employed for adenoma in a poor-risk patient
the diagnosis of oncocytoma and Warthin tumor.16 To confirm preoperatively suspected malignancy in a patient with facial
Various other diagnostic studies are available for evaluation of palsy
To evaluate bilateral tumors
parotid masses. At one time, sialography was commonly employed
to assess patients with suspected salivary stones, as well as to eval-
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 PAROTID MASS — 5
100
Percent
Regional lymph node metastases
Deep-lobe cancer 50
Gross residual tumor after resection
Recurrent tumor after resection
Invasion of facial nerve by tumor
25
Neck Dissection
Overall, about 20% of patients with malignant parotid tumors 0 5 10
present with clinically detectable cervical lymphadenopathy
(cN+).10 There is wide agreement that these patients require either Time (Years)
a comprehensive or a modified neck dissection [see 2:7 Neck
Dissection], depending on the extent of the disease, but there con- Stage I, II Stage I, II with RT
tinues to be controversy regarding the management of patients
with salivary malignancies who have no clinically detectable cervi- Stage III, IV Stage III, IV with RT
cal lymphadenopathy (cN0). In one study, approximately 14% of
the patients were in cN+ status; however, approximately 12% were Figure 1 Depicted is the impact of postoperative radiation therapy
in cN0 status but presented with pathologically positive nodes (RT) on overall outcome for patients with stage I or II tumors and
(pN+).28 In view of the low frequency of occult metastasis in the patients with stage III or IV tumors.
group as a whole, the investigators generally did not recommend
routine elective treatment of the neck. They did find that certain
RADIATION THERAPY
histologic grades were associated with a higher incidence of
metastatic disease to the neck nodes: the incidence of occult Patients who present with advanced-stage (stage III or IV) dis-
metastasis was about 49% in patients with high-grade lesions, ease, a large primary tumor, close margins, perineural spread, soft
compared with 7% in those with intermediate-grade or low-grade tissue extension, facial nerve dysfunction, or cervical lymph node
lesions. In addition, the incidence of having occult metastatic dis- metastasis invariably require postoperative radiation therapy [see
ease was more than 20% in patients with tumors larger than 4 cm, Table 7].31,32 In general, this means that postoperative radiation
compared with 4% in those with smaller tumors. therapy is indicated for all patients except those with T1 or T2
The incidence of lymph node metastasis is affected not only by malignant tumors of low-grade histology and clear margins.Thus,
the size and histologic grade of the tumor but also by the histologic the decision whether to employ such therapy depends largely on
type, the primary tumor stage, the presence of facial nerve palsy, the intraoperative findings and the final pathology report. A 1990
the patient’s age, the extraparotid extension of the disease, and the analysis showed that postoperative radiation therapy had a major
degree of perilymphatic invasion.29 In a multivariate analysis, the impact on overall outcome in patients with stage III or IV tumors
variables that showed the highest correlation with the incidence of but conferred no statistically significant benefit on patients with
lymph node metastasis were the histologic type (i.e., adenocarci- stage I or II tumors [see Figure 1].33
noma, undifferentiated carcinoma, high-grade mucoepidermoid Currently, there is substantial interest in the potential role of
carcinoma, SCC, or salivary duct carcinoma) and the T stage.30 neutron therapy as a primary treatment modality for parotid
Thus, elective neck dissection may be considered in patients malignancies, especially advanced inoperable parotid cancers and
with advanced-stage primary tumors, those whose tumors are of adenoid cystic carcinomas. A group from the University of
high histologic grades, and those whose tumors are of certain spe- Washington demonstrated that neutron therapy exerted a benefi-
cific histologic types. A selective neck dissection may be performed cial effect when used as the sole treatment of advanced parotid
to remove the lymph nodes of the submandibular triangle, level II, cancers.34 Although these results are extremely promising, the
level III, and the upper part of level V for the purposes of staging.29 patients treated with this modality clearly experienced an
However, a comprehensive neck dissection that encompasses lev- increased incidence of complications. Nevertheless, for patients
els I through V may be necessary in patients who present with clin- with inoperable parotid cancer, neutron therapy may be the best
ically obvious cervical metastases. option currently available.
Discussion
Implications of Histopathologic Classification of Parotid World Health Organization.36 The most common types of parotid
Gland Cancer tumor are mucoepidermoid carcinoma, adenoid cystic carcinoma,
Alhough considerable controversy and debate continue to sur- adenocarcinoma, malignant mixed tumor, acinic cell carcinoma,
round the histopathologic classification of malignant parotid and primary SCC [see Figure 2].
tumors, most clinicians currently prefer either the classification As noted (see above), primary SCC of the parotid gland is quite
system of the Armed Forces Institute of Pathology35 or that of the rare, and most diagnoses of parotid SCC represent skin cancer
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 PAROTID MASS — 8
References
1. Beckhardt RN,Weber RS, Zane R, et al: Minor sali- 5. Batsakis JG: Primary lymphomas of the major sali- 9. Wong DS: Signs and symptoms of malignant pa-
vary gland tumors of the palate: clinical and patho- vary glands. Ann Otol Rhinol Laryngol 95:107, rotid tumours: an objective assessment. J R Coll Surg
logic correlates of outcome. Laryngoscope 105:1155, 1986 Edinb 46:91, 2001
1995 6. Barnes L, Myers EN, Prokopakis EP: Primary malig- 10. Spiro RH, Huvos AG, Strong EWL: Cancer of the
2. Eneroth CM: Salivary gland tumors in the parotid nant lymphoma of the parotid gland. Arch Otolaryn- parotid gland: a clinicopathologic study of 288 pri-
gland, submandibular gland and the palate region. gol Head Neck Surg 124:573, 1988
mary cases. Am J Surg 130:452, 1975
Cancer 27:1415, 1971 7. Kane WJ, McCaffrey TV, Olsen KD, et al: Primary
11. Frommer J:The human accessory parotid gland: its
3. Spiro RH: Salivary neoplasms: overview of a 35- parotid malignancies. A clinical and pathologic re-
year experience with 2,807 patients. Head Neck view. Arch Otolaryngol Head Neck Surg 117:307, incidence, nature, and significance. Oral Surg Oral
Surg 8:177, 1986 1991 Med Oral Pathol 43:671, 1977
4. Fu YS, Wenig BM, Abemayor E, et al: Head and 8. Friedrich RE, Li L, Knop J, et al: Pleomorphic ade- 12. Rodino W, Shaha AR: Surgical management of
Neck Pathology With Clinical Correlations. noma of the salivary glands: analysis of 94 patients. accessory parotid tumors. J Surg Oncol 54:153,
Churchill Livingstone, New York, 2001, p 234 Anticancer Res 25:1703, 2005 1993
© 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
2 HEAD AND NECK 2 PAROTID MASS — 9
13. Batsakis JG, Bautina E: Metastases to major salivary noma: external validation using the nationwide Oncol Biol Phys 27:235, 1993
glands. Ann Otol Rhinol Laryngol 99:501, 1990 1985–1994 Dutch Head and Neck Oncology 35. Ellis GL, Auclair PL: Tumors of the Salivary
14. O’Brien CJ, Fracs MS, Adams JR: Surgical man- Cooperative Group database. Cancer 97:1453, Glands. Atlas of Tumor Pathology, series 3, fascicle
agement of the facial nerve in the presence of malig- 2003 17. Armed Forces Institute of Pathology, Washing-
nancy about the face. Curr Opin Otolaryngol Head 26. Nussbaum M, Bortikner D: Facial nerve preserva- ton, DC, 1996
Neck Surg 9:90, 2001 tion in parotid carcinoma. Bull NY Acad Med 36. Seifert G, Sobin LH: The World Health Organiza-
15. Rabinov JD: Imaging of salivary gland pathology. 62:862, 1986 tion’s histological classification of salivary gland
Radiol Clin North Am 38:1047, 2000 27. Heller KS, Attie JN, Dubner S: Accuracy of frozen tumors: a commentary on the second edition. Can-
16. Higashi T, Murahashi H, Ikuta H, et al: Identifica- section in the evaluation of salivary tumors. Am J cer 70:379, 1992
tion of Warthin’s tumor with technetium-99m per- Surg 166:424, 1993 37. Shemen LJ, Huvos AG, Spiro RH: Squamous cell
technetate. Clin Nucl Med 12:796, 1987 28. Armstrong JG, Harrison LB, Thaler HT, et al: The carcinoma of salivary gland origin. Head Neck Surg
17. Gundlach P, Hopf J, Linnarz M: Introduction of a indications for elective treatment of the neck in can- 9:235, 1987
new diagnostic procedure: salivary duct endoscopy cer of the major salivary glands. Cancer 69:615, 38. Batsakis JG, Luna MA: Histopathologic grading of
(sialendoscopy) clinical evaluation of sialendoscopy, 1992 salivary gland neoplasms: I. Mucoepidermoid carci-
sialography, and x-ray imaging. Endosc Surg Allied 29. Ferlito A, Shaha AR, Rinaldo A, et al: Management nomas. Ann Otol Rhinol Laryngol 99:835, 1990
Technol 2:294, 1994 of clinically negative cervical lymph nodes in pa- 39. Vrielinck LJ, Ostyn F, van Damme B, et al:The sig-
18. Qizilbash AH, Sianos J,Young JE, et al: Fine needle tients with malignant neoplasms of the parotid nificance of perineural spread in adenoid cystic car-
aspiration biopsy cytology of major salivary glands. gland. ORL J Otorhinolaryngol Relat Spec 63:123, cinoma of the major and minor salivary glands. Int
Acta Cytol 29:503, 1985 2001 J Oral Maxillofac Surg 17:190, 1988
19. Stewart CJ, MacKenzie K, McGarry GW, et al: 30. Regis De Brito Santos I, Kowalski LP, Cavalcante 40. Vikram B, Strong EW, Shah JP, et al: Radiation
Fine-needle aspiration cytology of salivary gland: a De Araujo V, et al: Multivariate analysis of risk fac- therapy in adenoid-cystic carcinoma. Int J Radiat
review of 341 cases. Diagn Cytopathol 22:139, tors for neck metastases in surgically treated parotid Oncol Biol Phys 10:221, 1984
2000 carcinomas. Arch Otolaryngol Head Neck Surg
127:56, 2001 41. Spiro RH: Distant metastasis in adenoid cystic car-
20. Shaha AR, Webber C, DiMaio T, et al: Needle aspi- cinoma of salivary origin. Am J Surg 174:495, 1997
ration biopsy in salivary gland lesions. Am J Surg 31. Tullio A, Marchetti C, Sesenna E, et al: Treatment
of carcinoma of the parotid gland: the results of a 42. Reddy PG, Arden RL, Mathog RH: Facial nerve
160:373, 1990 rehabilitation after radical parotidectomy. Laryn-
multicenter study. J Oral Maxillofac Surg 59:263,
21. Kesse KW, Manjaly G,Violaris N, et al: Ultrasound- 2001 goscope 109:894, 1999
guided biopsy in the evaluation of focal lesions and 43. Pillsbury HC, Fisch U: Extratemporal facial nerve
diffuse swelling of the parotid gland. Br J Oral 32. Harrison LB, Armstrong JG, Spiro RH, et al:
Postoperative radiation therapy for major salivary grafting and radiotherapy. Arch Otolaryngol 105:
Maxillofac Surg 40:384, 2002 441, 1979
gland malignancies. J Surg Oncol 45:52, 1990
22. Gross M, Ben-Yaacov A, Rund D, et al: Role of 44. McGuirt WF, McCabe BF: Effect of radiation ther-
open incisional biopsy in parotid tumors. Acta Oto- 33. Armstrong JG, Harrison LB, Spiro RH, et al:
Malignant tumors of major salivary gland origin: a apy on facial nerve cable autografts. Laryngoscope
laryngol 124:758, 2004 87:415, 1977
matched-pair analysis of the role of combined sur-
23. AJCC Cancer Staging Manual, 6th edition. gery and postoperative radiotherapy. Arch Otolaryn- 45. Conley J, Baker DC: Hypoglossal-facial nerve anas-
Springer-Verlag, New York, 2002 gol Head Neck Surg 116:290, 1990 tomosis for reinnervation of the paralyzed face. Plast
24. Vander Poorten VL, Balm AJ, Hilgers FJ, et al: The 34. Laramore GE, Krall JM, Griffin TW, et al: Neutron Reconstr Surg 63:63, 1979
development of a prognostic score for patients with versus photon irradiation for unresectable salivary 46. Levine RE, Shapiro JP: Reanimation of the para-
parotid carcinoma. Cancer 85:2057, 1999 gland tumors: final report of an RTOG-MRC ran- lyzed eyelid with the enhanced palpebral spring or
25. Vander Poorten VL, Hart AA, van der Laan BF, et domized clinical trial. Radiation Therapy Oncology the gold weight: modern replacements for tarsor-
al: Prognostic index for patients with parotid carci- Group. Medical Research Council. Int J Radiat rhaphy. Facial Plast Surg 16:325, 2000