International Journal of Gerontology 11 (2017) 114e117

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International Journal of Gerontology

journal homepage: www.ijge-online.com

Original Article

Clinical Analysis of Parotid Tumors in Patients Over 60-year-old:

A Retrospective Study of 78 Cases
Dong Hoon Lee a, b, Tae Mi Yoon a, b, Joon Kyoo Lee a, b *, Sang Chul Lim a, b
a b
Department of Otolaryngology-Head and Neck Surgery, Chonnam National University Medical School, Hwasun, South Korea, Chonnam National
University Hwasun Hospital, Hwasun, South Korea

a r t i c l e i n f o s u m m a r y

Article history: Background: The aim of this study was to review the epidemiologic characteristics, management and
Received 5 November 2015 treatment outcome of elderly parotid tumors.
Received in revised form Methods: From January 2010 to December 2013, Seventy-eight patients
60-year-old with a diagnosis of
28 April 2016
parotid tumor were identified based on their medical records.
Accepted 8 May 2016
Available online 17 May 2017
Results: The 78 patients comprised 38 males and 40 females. Sixty-seven (85.9%) patients had a benign
tumor and 11 (14.1%) patients had a malignant tumor. The most common benign tumor was Warthin
tumor (n ¼ 26) and the most common malignant tumor was salivary duct carcinoma (n ¼ 5). Fine needle
Keywords:
elderly,
aspiration cytology had a diagnostic sensitivity of 100%, positive-predictive value of 97.0%, and accuracy
fine needle aspiration, of 97.3% for diagnosing benign parotid tumors.
parotid gland, Conclusions: Warthin tumor was the most common benign tumor, and salivary duct carcinoma was the
parotid tumor, most frequent malignant tumor in this study. Surgical treatment is the mainstay treatment for benign
surgical procedures and malignant parotid tumors.
Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier
Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction This study presents our 4-year experience, such as preoperative

Salivary gland tumors are uncommon, accounting for less than
3% of all tumors of the head and neck and 0.6% of all neoplasms of
the body.1e4 About 80% of all salivary gland tumors have been
occurred in the parotid gland, followed by submandibular gland,
sublingual gland, and minor salivary gland. Of parotid tumors, 80%
are benign and the pleomorphic adenoma is the most common
type, followed by Warthin tumor. Malignant tumors are compara-
tively rare, and among these the most common primary neoplasms
are mucoepidermoid carcinomas followed by adenoid cystic
carcinoma.1e4
However, because of the low incidence and various histopath-
ologic types of parotid tumors, worldwide epidemiologic series
show geographic variation in the relative incidence of parotid gland
tumors, with discrepancies among clinical and histologic aspects.4
In addition, in the head and neck, malignant tumors become
more frequent in old age and those occurring in the parotid space
increase.5
* Correspondence to: Joon Kyoo Lee, Department of Otolaryngology-Head and
Neck Surgery, Chonnam National University Medical School and Hwasun Hospital,
160 Ilsimri, Hwasun, Jeonnam, 519-809, South Korea. Fax: þ82 62 228 7743.
E-mail address: joonkyoo@jnu.ac.kr (J.K. Lee).
diagnosis method, surgical type, and treatment modality with 78
cases of parotid tumors occurring in elderly patients
60-year-old.
The aim of this study was to review the epidemiologic character-
istics, management and treatment outcome of elderly parotid
tumors.
2. Materials and methods
After obtaining approval from the Institutional Review Board of
Chonnam National University Hwasun Hospital, a retrospective
review was performed to evaluate patients with a diagnosis of
parotid tumor at the hospital's Department of Otolaryngology-
Head and Neck Surgery from January 2010 to December 2013.
Seventy-eight patients
60-year-old with a diagnosis of parotid
tumor were identified based on their medical records. Clinico-
pathologic data of parotid tumors were reviewed including age,
sex, symptoms, duration of symptoms, results of histopathologic
tumor examination, surgical procedures and complications.
All patients had computed tomography (CT) scan performed
before the operation to assess the extent of the lesion and help in
planning treatment. All patients except four underwent fine-needle
aspiration cytology (FNAC).

http://dx.doi.org/10.1016/j.ijge.2016.05.008
1873-9598/Copyright © 2017, Taiwan Society of Geriatric Emergency & Critical Care Medicine. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Elderly Parotid Tumors
The type of surgery performed depended on the pre-operative
diagnosis based on FNAC and radiological scans as well as the
clinical presentation of the parotid tumor. Partial superficial
parotidectomy was performed if a tumor located in the parotid tail.
Superficial parotidectomy was performed if a tumor was located in
the superficial lobe, and total parotidectomy was performed if it
was in the deep lobe or in a tumor diagnosed as malignant by
FNAC. Tumor enucleation was not performed. In the malignant
tumors, neck dissection was performed if enlarged neck lymph
nodes were found by preoperative evaluation, such as FNAC and
radiologic examination. Management of malignant tumors
depended on the tumor stage and histological grade. Drainage was
performed and maintained by aspiration. All cases of parotid tu-
mors were confirmed histopathologically.
The complication of postoperative facial palsy was evaluated by
the House Brackmann grade. Intraoperative facial nerve monitor
was usually used. Fisher's exact test was used in the statistical
analysis using SPSS version 14.0. Statistical significance was defined
as a p-value < 0.05.
3. Results
This group of 78 patients included 38 (48.7%) males and 40
(51.3%) females (male-to-female ratio of 1:1.1). The age of the pa-
tients ranged between 60 and 82 years with a mean of 68.0 ± 6.2
years. Most tumors (51/78, 65.4%) presented in patients 60e69-
year-old. There were 22 (28.2%) patients between 70 and 79-
year-old, and only 5 (6.4%) patients
80-year-old.
Most patients (61/78, 78.2%) presented with a slowly enlarging
mass within the parotid gland. The remaining patients were inci-
dentally diagnosed by radiologic examinations, such as CT (n ¼ 4),
ultrasonography (n ¼ 5) and positron emission tomography-CT
(PET-CT, n ¼ 8). The majority of the lesions were asymptomatic.
The duration of symptoms ranged from 0.3 to 360 months with a
mean of 42.0 ± 91.3 months.
The most common surgical procedure instituted was superficial
parotidectomy, performed in 57.7% (n ¼ 45). Partial superficial
parotidectomy and only total parotidectomy were performed in
21.8% (n ¼ 17) and 12.8% (n ¼ 10), respectively. Total parotidectomy
with neck dissection was performed in 7.7% (n ¼ 6) of malignant
tumors. Among the 45 patients who underwent superficial paro-
tidectomy, 43 patients had benign tumors and two had malignant
tumors.
Sixty-seven of the 78 tumors (85.9%) were benign (Table 1).
Twenty-six patients had a Warthin tumor, followed by pleomorphic
adenoma (n ¼ 16), basal cell adenoma (n ¼ 13), lymphoepithelial
cyst (n ¼ 5), tuberculosis (n ¼ 2), myoepithelioma (n ¼ 2),
schwannoma (n ¼ 1), oncocytoma (n ¼ 1) and ductal ectasia with
mucinous metaplasia (n ¼ 1).
Eleven cases (14.1%) were malignant (Table 1), including salivary
duct carcinoma (n ¼ 5), carcinoma ex pleomorphic adenoma
(n ¼ 2), epithelial-myoepithelial carcinoma (n ¼ 1), Lymphoepi-
thelial carcinoma (n ¼ 1), mucoepidermoid carcinoma (n ¼ 1) and
Table 1
Histopathologic type of benign and malignant parotid tumors.
Benign (N ¼ 67)
Warthin tumor (N ¼ 26, 38.8%)
Pleomorphic adenoma (N ¼ 16, 23.9%)
Basal cell adenoma (N ¼ 13, 19.4%)
Lymphoepithelial cyst (N ¼ 5, 7.5%)
Tuberculosis (N ¼ 2, 3.0%)
Myoepithelioma (N ¼ 2, 3.0%)
Schwannoma (N ¼ 1, 1.5%)
Oncocytoma (N ¼ 1, 1.5%)
Ductal ectasia (N ¼ 1, 1.5%)
115
polymorphous low grade adenocarcinoma (n ¼ 1). Ten patients
who had pathologically confirmed malignant tumors except one
with low-grade mucoepidermoid carcinoma underwent radiation
therapy.
FNAC had a diagnostic sensitivity of 100%, diagnostic specificity
of 80%, positive-predictive value of 97.0%, negative-predictive value
of 100% and accuracy of 97.3% for diagnosing benign parotid tumors
(Table 2). No specific complications were observed after FNAC.
Fourteen patients showed postoperative complications. Five
(6.4%) patients developed saliva leakage. The saliva leakage
resolved by conservative treatment. Nine (11.5%) patients had facial
nerve palsy. Six of these patients presented a spontaneous
improvement from 1 to 6 months after surgery. Three patients had
complete facial nerve palsy (House Brackmann Grade VI), because
in all patients the facial nerve was deliberately sacrificed due to its
involvement by the malignant tumor. Four facial disorders occurred
in the partial or superficial parotidectomy group (6.5%) versus five
in the total parotidectomy group (31.3%), there were a statistically
significantly different for the facial nerve palsy occurrence between
the two groups (p ¼ 0.02).
All patients except two were alive and free of recurrent disease
at the time of the last follow-up. Two patients diagnosed as salivary
duct carcinoma developed lung metastasis despite postoperative
radiation therapy and chemotherapy, and were died.
The mean follow period after surgery was 34.6 ± 14.1 months
with the range of 13e59 months.
4. Discussion
The most common benign parotid tumor is pleomorphic ade-
noma, and the most common malignant tumor is mucoepidermoid
carcinoma.1e3 However, the incidence of parotid tumors may be
difference according to the race and age. Pleomorphic adenoma
was reported as the most common benign parotid tumor in Korea.4
However, another study based on a Chinese population demon-
strated that Warthin tumor was the most common benign parotid
tumor.6 In addition, Chan et al reported that Warthin tumor was
prevalent in older patients.7 In this study, 67 of the 78 tumors
(85.9%) were benign and the most common benign tumor was
Warthin tumor, which was even more common than pleomorphic
adenoma. It seems that Warthin tumor is more prevalent in elderly
Korean populations, but the exact reason is unknown. Genetic
factor, EpsteineBarr virus, or cigarette smoking should be
considered.7e9
Frequency of malignant parotid tumors varies. Many studies
reported that the most common malignant tumor is mucoepi-
dermoid carcinoma.1e3 However, adenocarcinoma was reported as
the most common type in Japan and Netherlands.4,10 Lee
et al reported that the most frequent malignant tumor in the pa-
rotid gland was squamous cell carcinoma.4 In contrast to the pre-
vious reports, in this study the most common malignant tumor was
salivary duct carcinoma (5/11, 45.5%). This is considered to be the
Malignant (N ¼ 11)
Salivary duct carcinoma (N ¼ 5, 45.5%)
Carcinoma ex pleomorphic adenoma (N ¼ 2, 18.2%)
Epithelial-myoepithelial carcinoma (N ¼ 1, 9.1%)
Lymphoepithelial carcinoma (N ¼ 1, 9.1%)
Mucoepidermoid carcinoma (N ¼ 1, 9.1%)
Polymorphous low grade adenocarcinoma (N ¼ 1, 9.1%)
116
Table 2
Results of fine needle aspiration cytology and histopathologic examination for
benign tumors.
Histopathologic results
Benign Malignant
tumor (n ¼ 64) tumor (n ¼ 10)
FNAC results Benign tumor (n ¼ 66) 64 2 nerve unless there is a tumor adhesion to the facial nerve.
Malignant tumor (n ¼ 8) 0 8
Total 74 64 10
FNAC, Fine needle aspiration cytology.
epidemiologic characteristics and rarity of malignant parotid
tumor.4
The most common symptom of parotid tumors is a slowly
enlarging mass within the parotid gland. In this study, most of
patients presented with slowly growing palpable mass within the
parotid gland. The interesting finding of our study was that 17
(21.8%) patients were incidentally diagnosed by radiologic exami-
nation for heath examination or metastasis evaluation of other
cancers without symptoms or signs. Sixteen of the 17 patients
(94.1%) who had incidentally detected were benign, and one pa-
tient was diagnosed as polymorphous low grade adenocarcinoma.
It could be related to the present longer lifespan and concern of
heath. Woods et al11 reported that symptoms such as pain, facial
nerve palsy and rapid growth of tumor are more frequently found
in malignant parotid tumors. However, it was not seen in any of the
patients in our series.
Imaging helps to delineate the depth of tumor invasion and
surrounding structures, especially those located in the deep lobe
and tumors extending into the parapharyngeal space.11,12 CT is the
imaging modality of choice for most parotid lesions.13,14 In this
study, all patients had CT scan performed before the operation to
assess the extent of tumor and planning of further treatment.
However, imaging studies have not distinguished a benign tumor
from a malignant lesion.12,14 The interesting finding of our study
was that about a quarter among elderly patients were incidentally
diagnosed by radiologic examination for heath examination or
metastasis evaluation of other cancers.
The main objective of early cytological diagnosis of parotid tu-
mors is the differential diagnosis between benign and malig-
nancy.15 We performed FNAC before performing a surgery, which is
a safe, minimally invasive and almost inexpensive procedure.15,16 In
this study, FNAC had a diagnostic sensitivity of 100%, diagnostic
specificity of 80%, positive-predictive value of 97.0%, negative-
predictive value of 100% and accuracy of 97.3% for diagnosing
benign parotid tumors. FNAC is very useful for diagnosing malig-
nancies of the parotid gland.15,16 The low specificity might also have
reflected the somewhat small sample size. In our study, two false
positive results occurred. One case was diagnosed with a pleo-
morphic adenoma, which eventually proved to be an epithelial-
myoepithelial carcinoma, and other case diagnosed with a reac-
tive lymphadenopathy, which proved to be a low-grade mucoepi-
dermoid carcinoma. This result may be due to sampling errors, lack
of adequate material or difficulty in distinguishing reactive cells
from malignant cells.
Surgical treatment remains the mainstay treatment for benign
and malignant parotid tumors.4,7 The type of surgery performed
depended on the pre-operative diagnosis based on FNAC and
radiological scans. The most common surgical procedure instituted
was superficial parotidectomy, performed in 57.7% (n ¼ 45). Partial
superficial parotidectomy was performed if a benign tumor of the
parotid tail was preoperatively suspected. In partial superficial
parotidectomy groups (n ¼ 17), two patients were finally diagnosed
to malignant tumor after surgery. One patient underwent partial
D.H. Lee et al.
superficial parotidectomy because of the false positive result of
FNAC. Another patient underwent partial superficial parotidectomy
because the patient refused FNAC and had a benign looking tumor
by CT and ultrasonography. Total parotidectomy (n ¼ 16) was per-
formed if it was in the deep lobe (n ¼ 9) or in a tumor diagnosed as
malignant (n ¼ 7) by FNAC. We preserve the integrity of the facial
Malignant parotid tumor usually requires a combination of
treatment modality.12,14,17 If malignant tumors were high-grade,
they were managed by parotidectomy and postoperative radia-
tion therapy. In this study, 10 of 11 patients who had pathologically
confirmed malignant tumors underwent radiation therapy. Simul-
taneous neck dissection is recommended only when neck metas-
tasis are clinically detected because of the rarity of occult
metastasis.7 In our series, neck dissection was performed in six
cases of malignant parotid tumors with confirmed malignancy by
preoperative evaluation.
The most common postoperative complications were temporary
facial nerve palsy.7,13 The incidence of temporary facial nerve palsy
in our study was 7.7%. The incidence of facial nerve palsy may be
increased by radical surgical approach, such as total parotidectomy
than superficial or partial superficial parotidectomy. Recently, the
use of facial nerve monitoring or neurophysiological intraoperative
monitoring has improved the functional preservation of the facial
nerve.15,16,18
The limiting factors of this study are the small sample size,
unequal distribution of the region, and retrospective review.
Therefore, a prospective or multicenter study is needed.
5. Conclusion
Warthin tumor was the most common benign tumor, and sali-
vary duct carcinoma was the most frequent malignant tumor in this
study. Preoperative FNAC is a useful and accurate technique for
preoperative evaluation of elderly parotid tumors and guidance in
preoperative planning. Surgical treatment is the mainstay treat-
ment for benign and malignant parotid tumors.
Conflict of interest
No sponsorships or competing interests have been disclosed for
this article.
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