Otolaryngology–Head and Neck Surgery (2008) 139, 811-815
ORIGINAL RESEARCH—HEAD AND NECK CANCER
Parotid tumors: Fine-needle aspiration
and/or frozen section
Peter Zbären, MD, Dominique Guélat, MD, Heinz Loosli, MD, and
Edouard Stauffer, MD, Berne, Switzerland
OBJECTIVE: The purpose of this study was to analyze and
compare the value of fine-needle aspiration cytology (FNAC) and
frozen section (FS) analysis in the assessment of parotid gland
tumors.
STUDY DESIGN: Chart review and cross-sectional analysis.
SUBJECTS AND METHODS: FNAC and FS analysis of 110
parotid tumors, 68 malignancies and 42 benign tumors, were
analyzed and compared with the final histopathologic diagnosis.
RESULTS: The accuracy, sensitivity, and specificity of FNAC
in detecting malignant tumors were 79 percent, 74 percent, and 88
percent, respectively. On FS analysis, the accuracy, sensitivity, and
specificity in detecting malignant tumors were 94 percent, 93
percent, and 95 percent, respectively. The histologic tumor type
was correctly diagnosed by FNAC and FS in 27 of 42 (64%) and
39 of 42 (93%) benign tumors, respectively, and in 24 of 68 (35%)
and 49 of 68 (72%) malignant neoplasms, respectively.
CONCLUSION: The current analysis showed a superiority of
FS compared with FNAC regarding the diagnosis of malignancy
and tumor typing. FNAC alone is not prone to determine the
surgical management of parotid malignancies.
© 2008 American Academy of Otolaryngology–Head and Neck
Surgery Foundation. All rights reserved.
T he standard surgical treatment for most benign tumors
in the superficial lobe was a lateral parotidectomy and
for benign tumors in the deep lobe a total parotidectomy
with facial nerve preservation.1 During the last decade, new
surgical modalities for benign tumors such as extracapsular
dissection, partial lateral parotidectomies, and deep lobe
parotidectomies with preservation of the superficial lobe are
discussed in the literature.2-4
In the early phase of growth, malignant tumors of the
parotid gland present with an asymptomatic mass. Signs and
symptoms of malignancy, such as pain, facial palsy, and
enlarged lymph nodes, are present in approximately 25
percent to 35 percent of parotid malignancies.5,6
Early (T1 and T2) primary parotid carcinomas of the
superficial lobe are treated in many centers by a total pa-
rotidectomy; in other centers, a superficial parotidectomy is
used. An elective neck dissection in cNO primary parotid
carcinomas is performed routinely only by few authors.
Received June 27, 2008; revised September 3, 2008; accepted Septem-
ber 9, 2008.
0194-5998/$34.00 © 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2008.09.013
Occult metastases are observed in 20 percent to 40 percent
of neck dissection specimens.7,8 However, most authors
advocate performing a neck dissection on the basis of the
histologic type of the carcinoma and the tumor grade.9,10
Thus, in deciding which surgical procedure would be
appropriate, it should be known at the time of surgery if a
tumor, for example, is a pleomorphic adenoma or a malig-
nancy; in many cases of malignancy, it would even be
preferable or necessary to know the histologic tumor type.
During the last decade, many studies have been published in
which the value of fine-needle aspiration cytology (FNAC)
of parotid tumors was analyzed. In contrast, the diagnostic
accuracy of intraoperative frozen-section (FS) analysis in
salivary gland tumors has been considered in the last decade
in only a few studies.11,12 According to Wong,13 FS is less
frequently requested with the advent of FNAC. However, a
comparison of findings of FNAC and FS on the same series
of parotid neoplasm was performed only in a few studies
and on small numbers of cases.11,14,15 The aim of our study
was to determine and compare the value of preoperative
FNAC and intraoperative FS analysis in recognizing malig-
nancy and tumor type.
PATIENTS AND METHODS
Between 1987 and 2007, 838 patients with previously un-
treated parotid pathologies received surgical treatment at the
study institution. A preoperative FNAC was performed in
426 patients, and a FS analysis in 166 patients. The physi-
cians in the outpatient clinic decided, based on the clinical
tumor presentation, whether FNAC should be performed.
As for the FS, it was determined at the discretion of the
surgeon. It was performed if more information was needed
during surgery, in cases of discordance between clinical and
radiological presentation, or when there was an unclear
FNAC result. In a few cases, FS was performed to deter-
mine the extent of the tumor and to analyze the surgical
margins.
812 Otolaryngology–Head and Neck Surgery, Vol 139, No 6, December 2008

Table 1
Histologic tumor type, FNAC, and FS findings in detecting malignancy

Histology N FNAC FS

Primary parotid carcinomas 60 Tp 50 Fn 10 Tp 55 Fn 5

Salivary duct carcinoma 12 Tp 10 Fn 2 Tp 12
Mucoepidermoid carcinoma 9 Tp 8 Fn 1 Tp 6 Fn 3
Acinic cell carcinoma 9 Tp 9 Tp 8 Fn 1
Adenocarcinoma NOS 8 Tp 7 Fn 1 Tp 8
Squamous cell carcinoma 6 Tp 6 Tp 6
Carcinoma ex pleomorphic adenoma 5 Tp 1 Fn 4 Tp 4 Fn 1
Adenoid cystic carcinoma 3 Tp 3 Tp 3
Epithelial myoepithelial carcinoma 2 Tp 2 Tp 2
Undifferentiated carcinoma 1 Fn 1 Tp 1
Myoepithelial carcinoma 1 Tp 1 Tp 1
Terminal duct carcinoma 1 Fn 1 Tp 1
Sebaceous carcinoma 1 Tp 1 Tp 1
Oncocytic carcinoma 1 Tp 1 Tp 1
Lymphoepithelial carcinoma 1 Tp 1 Tp 1
Lymphoma 8 Fn 8 Tp 8
Benign tumors 38 Tn 33 Fp 5 Tn 36 Fp 2
Pleomorphic adenoma 26 Tn 22 Fp 4 Tn 24 Fp 2
Warthin tumor 6 Tn 6 Tn 6
Monomorphic adenoma 6 Tn 5 Fp 1 Tn 6
Nonneoplastic pathologies 4 Tn 4 Tn 4
Tp, true-positive; Fn, false-negative; Tn, true-negative; Fp, false-positive; NOS, not otherwise specified.

In 123 parotid tumors, FNAC as well as FS were per-
formed; seven were metastatic disease to the parotid gland.
These seven neoplasms were excluded from the study to
avoid bias with respect to the known histology of a cutane-
ous malignancy. Furthermore, six FNAC smears were non-
diagnostic and, therefore, excluded from the study. Finally,
110 patients were enrolled in the study, which was approved
by the institution’s Review Board on Clinical Investigation.
The FNAC specimens were collected by clinicians in our
department using a 22-G needle attached to a 10-mL syringe
(Lameco, London, UK). There were 42 benign pathologies
and 68 malignancies (Table 1). Fifteen benign tumors were
located in the deep parotid lobe. The 60 primary parotid
carcinomas were staged according to the International
Union Against Cancer TNM Classification 1997. Nine ma-
lignancies were classified as T1, 23 as T2, 10 as T3, and 18
as T4. The primary carcinomas were treated in six cases by
a lateral parotidectomy and in 54 cases by a total parotid-
ectomy with preservation (n ⫽ 46) or with resection (n ⫽ 8)
of the facial nerve. In 45 patients, a neck dissection was
performed: a therapeutic neck dissection in 14 patients and
an elective neck dissection in 31 patients; eight occult me-
tastases were found in eight neck dissection specimens. The
42 benign pathologies were treated by enucleation (n ⫽ 1),
superficial parotidectomy (n ⫽ 26), and total parotidectomy
with preservation of the facial nerve (n ⫽ 15).
The FNAC and FS findings were classified into the
following categories: true-negative (absence of malignancy
correctly diagnosed), true-positive (presence of malignancy
correctly diagnosed included specimens that were inter-
preted as suspect for malignancy), false-negative (the cyto-
logic specimen failed to diagnose a malignancy), and false-
positive (the cytologic specimen was incorrectly considered
or suspect for malignancy).
The histologic diagnoses of all neoplasms were reviewed
by an experienced staff pathologist and were classified ac-
cording to the 2005 World Health Organization Classifica-
tion System.
If the histologic type could not be determined unequiv-
ocally, a decision was made by the consensus of three staff
pathologists. In two cases, an additional evaluation was
performed by a referral center for salivary gland pathologies
(Department of Pathology, University of Hamburg, Ger-
many). The initial cytologic diagnoses as well as the FS
diagnoses were not reviewed deliberately because the ob-
jective of the current study was an analysis of findings of a
genuine clinical practice.
RESULTS
FNAC
The cytologic finding was true-positive in 50 (45%), true-
negative in 37 (34%), false-positive in five (4%), and false-
negative in 18 (16%) cases. The accuracy, sensitivity, and
specificity of FNAC in detecting malignant tumors were 79
percent, 74 percent, and 88 percent, respectively (Tables 1
and 2). The positive and the negative predictive values were
91 percent and 67 percent, respectively. The eight lympho-
mas in our study were not recognized as malignant neo-
plasms by FNAC but as normal lymph nodes (n ⫽ 2) or
unspecific lymphadenitis (n ⫽ 6). The histologic tumor type
Zbären et al Parotid tumors: Fine-needle aspiration . . .
Table 2
Diagnostic abilities of FNAC and FS
FNAC (95% CI) FS (95% CI)
Accuracy 79% (70-86) 94% (88-98)
Sensitivity 74% (61-83) 93% (85-98)
Specificity 88% (74-96) 95% (84-99)
PPV 91% (80-97) 97% (89-100)
NPV 67% (53-79) 89% (78-97)
PPV, positive predictive value; NPV, negative predictive
value; 95% CI, 95% confidence interval.
was correct, false, or not mentioned in 24 of 50 (48%), 12
of 50 (24%), and 14 of 50 (28%) true-positive neoplasms,
respectively, and correct, false, or not mentioned in 27 of 37
(73%), 5 of 37 (13.5%), and 5 of 37 (13.5%) true-negative
findings. Thus, in the current series, the exact histologic
type was diagnosed by FNAC in 27 of 42 (64%) benign
tumors and in 24 of 68 (35%) malignant neoplasms (P ⬍
0.05).
FS
On FS analysis, 63 (57%) findings were true-positive, 40
(36%) were true-negative, two (2%) were false-positive,
and four (4%) were false-negative (Table 1). In one FS
specimen, it was not possible to determine if the tumor was
benign or malignant. The permanent section finding was an
acinic cell carcinoma. The accuracy, sensitivity, and speci-
ficity in detecting malignant tumors were 94 percent, 93
percent, and 95 percent, respectively (Table 2). The positive
and negative predictive values were 97 percent and 89
percent, respectively. The histologic tumor type was cor-
rect, false, or not mentioned in 49 of 63 (78%), in 4 of 63
(6%), and in 10 of 63 (16%) true-positive neoplasms, re-
spectively, and correct or false in 39 of 40 (97%) and in one
of 40 (3%) true-negative neoplasms. Thus, in the current
series, the histologic type was diagnosed in 49 of 68 (72%)
malignant and in 39 of 42 (93%) benign tumors (P ⬍ 0.05).
Comparison between FNAC and FS
The concordance between the FNAC and FS results in
detecting malignancy are shown in Table 1. In 17 of 18
tumors with false-negative FNAC results, FS was correct
for malignancy. In all five tumors with false-positive FNAC
results, FS was correct for benign tumors. In 36 FNAC
results with incorrect or unmentioned tumor type, FS anal-
ysis revealed the correct tumor type in 29 cases. The eight
lymphomas, missed as malignancy by FNAC, were recog-
nized as malignant tumors and correctly typed as lympho-
mas by FS. Finally, of 60 primary parotid carcinomas, the
tumor was known to be malignant by FNAC in 50 of 60
(83%) cases and by FS in 55 of 60 (92%) cases (P ⫽ 0.17).
The exact tumor type of malignancy was correct in 24 of 60
(40%) primary carcinomas by FNAC and in 41 of 60 (68%)
cases by FS (P ⬍ 0.05). The two false-positive FS findings
813
were both recognized correctly as benign neoplasm by
FNAC. Furthermore, four of five false-negative or undeter-
mined FS findings were recognized as malignant by FNAC.
The accuracy, sensitivity, specificity, positive predictive
value, and negative predictive value of FNAC and FS are
compared in Table 2.
DISCUSSION
FNAC
In the recent literature, the accuracy in detecting malignant
parotid tumors has ranged from 84 percent to 97 percent, the
sensitivity from 54 percent to 95 percent, and the specificity
from 86 percent to 100 percent.11 In the current series, the
accuracy, sensitivity, and specificity were 79 percent, 74
percent, and 88 percent, respectively. The relative high rate
of false-negative findings (18 tumors in our series) has been
described in many studies and has been reported to range
from 14 percent to 48 percent.11 In our study, the malig-
nancy of two tumor types was especially difficult to recog-
nize by FNAC (12 of 18 false-negative findings). Four of
five carcinoma ex pleomorphic adenomas and all eight lym-
phomas were not recognized as malignancies in the current
study. False-negative FNAC findings in carcinoma ex ple-
omorphic adenoma are reported several times in the litera-
ture.16,17 As for lymphomas, Zurrida et al18 reported five
false-negative findings in seven lymphomas, whereas in the
series of Al-Khafaji et al,19 all 10 lymphomas were accu-
rately diagnosed. Several false-negative findings in the cur-
rent series were probably caused by sampling errors rather
than the misinterpretation of cytologic smears most likely
because the FNAC was performed by clinicians. With re-
gard to exact tumor typing by FNAC, the accuracy for
benign tumors was significantly higher than for malignant
tumors, 64 percent versus 35 percent (P ⬍ 0.05). This is not
surprising because, on the one hand, cytopathologists have
more experience with benign parotid tumors than with ma-
lignancies, and, on the other hand, there are only a few
different histologic types of benign tumors with a majority
of pleomorphic adenoma. The typing of primary parotid
carcinoma by FNAC is a considerable diagnostic challenge
because they are relatively rare and there are 24 different
histologic types according to the 2005 World Health Orga-
nization tumor classification.
FS
The number of articles that have evaluated the value of
FS findings of parotid tumors during the last decade is
limited.11,12,15 The accuracy, sensitivity, and specificity in
detecting malignancies are reported from 88 percent to 95
percent, 62 percent to 100 percent, and 88 percent to 100
percent, respectively.12,13,15 The false-negative findings of
FS have been reported between 9 percent and 24 percent.11
In the current series, four of 110 (4%) FS findings were
814 Otolaryngology–Head and Neck Surgery, Vol 139, No 6, December 2008
false-negative. False-positive findings are reported in the
range of 0 percent to 12 percent.13 In our series, two of 110
(2%) FS findings were false-positive. The accuracy of tumor
typing of primary parotid carcinoma by FS reportedly is
between 36 percent and 80 percent.11 In the current series,
39 of 42 (93%) benign tumors and 49 of 68 (72%) malig-
nant tumors were typed accurately. The rate of correct
typing was higher for benign tumors than for malignancies.
Comparison between FNAC and FS
The details are summarized in Tables 1 and 2. Thus far, to
our knowledge, only a few articles with small patient col-
lectives to date have compared FNAC findings with FS
findings of the same patient setting.11 The largest series up
to now was reported by Seethala et al15 who analyzed 57
parotid lesions by FNAC and FS. In detecting malignancy,
they observed a higher accuracy and sensitivity for FNAC
than for FS and a higher specificity for FS than for FNAC.
In contrast, we found a higher accuracy, sensitivity, and
specificity for FS than for FNAC. Furthermore, the values
of accuracy, sensitivity, and specificity in the current series
were lower for FNAC and higher for FS than in Seethala’s
study,15 in which an on-site evaluation was performed by
the cytopathologist for FNAC specimen adequacy and pre-
liminary diagnosis in each case.
The correct tumor type was detected by FNAC and FS in
64 percent and 93 percent respectively for benign tumors
and in 35 percent and 72 percent respectively for malignant
tumors. The rate of correct tumor typing was higher for
benign tumors by FNAC as well as by FS. In the series of
Layfield et al,14 no difference was observed between FNAC
and FS in tumor typing.
FNAC and/or FS
FNAC is a safe and easy diagnostic procedure that causes
little discomfort to the patient. It has an irrevocable appli-
cation in the initial assessment of parotid masses. Important
questions concerning a mass in the parotid gland can be
answered by FNAC. Is the mass of salivary gland origin? Is
the mass inflammatory or neoplastic? FNAC can play a role
in the treatment decision-making process; surgery can be
avoided for inflammatory processes or postponed in patients
with benign neoplasms and a high operative risk. According
to the literature, pleomorphic adenoma, the most frequent
parotid neoplasm, is correctly typed in 90 percent to 94
percent.20,21 Therefore, FNAC permits a limited surgery
such as partial lateral parotidectomy3 or an extracapsular
dissection2 in selected cases. Thus, FNAC is prone to avoid
surgery or to limit surgical procedures for benign neo-
plasms. Because of the relatively low sensitivity, FNAC is
not qualified to plan the extent of surgical procedure in
primary parotid carcinoma.
FS is recommended when cytology and/or clinical find-
ings are suggestive of malignancy, in instances of discor-
dance between FNAC findings on the one hand and clinical
and radiologic findings on the other, and in instances in
which FS is going to offer information that could alter the
extent of the surgical procedure (elective neck dissection or
no, lateral, or total parotidectomy). As in several centers, the
indication for an elective neck dissection or a total paroti-
dectomy for early tumors (T1/T2) is dependent on the his-
tologic type and/or grade. Furthermore, FS is indicated for
the assessment of resection margins and recognition of
tumor involvement of critical anatomic structures such as
nerves or vessels.
CONCLUSION
Our institutional experience showed the superiority of FS
over FNAC in detecting malignancy and tumor typing. For
planning the extent of surgery of malignant parotid tumors,
the histologic subtype and/or grade should be known;
therefore, a histologic diagnosis by FS analysis is re-
quested. FNAC is useful in avoiding surgery (inflamma-
tory lesions) or limiting surgical procedures (benign tu-
mors); FS can help to determine the extent of surgery in
cases of malignancy.
AUTHOR INFORMATION
From the Departments of Otorhinolaryngology–Head and Neck Surgery
(Drs Zbären and Guélaz) and Pathology (Drs Loosli and Stauffer), Uni-
versity Hospital.
Corresponding author: Peter Zbären, MD, Otorhinolaryngology–Head and
Neck Surgery, University Hospital, CH-3000 Berne, Switzerland.
E-mail address: peter.zbaeren@insel.ch.
Presented at the Annual Meeting of the American Academy of Otolaryn-
gology–Head Neck Surgery, Chicago IL, September 21-24, 2008.
AUTHOR CONTRIBUTIONS
Peter Zbären, study design, writer, data collection; Dominique Guélaz,
study design, data collection; Heinz Loosli, cytologic analysis, manuscript
review; Edouard Stauffer, histologic analysis, manuscript review.
FINANCIAL DISCLOSURE
None.
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