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Benign cysts of the parotid gland
Benign cysts of the parotid gland
K. Antoniadis, D. Karakasis, V. Tzarou, A. Skordalaki Department of Oral and Maxillofacial Surgery University of Thessaloniki, Greece
K. Antoniadis, D. Karakasis, V. Tzarou, A. Skordalaki: Benign cysts of the parotid gland. Int. J. Oral Maxillofac. Surg. 1990; 19: 139-140. Abstract. Benign cysts o f the p a r o t i d gland are n o t frequently diagnosed. They occur in any p o r t i o n o f the p a r o t i d gland a n d m a y be difficult to diagnose. They present with considerable histological v a r i a t i o n in their linings. Three cases are presented o f unilocular b e n i g n cystic lesions o f the p a r o t i d gland t h a t h a v e been treated by superficial parotidectomy. Two o f t h e m were lined by a single or pseudostratified layer o f c u b o i d a l epithelium a n d were diagnosed as r e t e n t i o n cysts. T h e t h i r d was a lympho-epithetial cyst a n d was lined by stratified s q u a m o u s a n d partially b y pseudostratified ciliated c o l u m n a r epithelium. A review o f the relevant literature is also presented.
Benign cysts o f the p a r o t i d g l a n d are n o t as c o m m o n as other p a r o t i d t u m o u r s . YOEL22 reviewed 526 cases o f p a r o t i d gland t u m o u r s o f which only 14 were cysts. Benign cysts in the p a r o t i d gland have a n equal distribution a m o n g males a n d females, a n d usually present as a unilateral painless swelling in t h e p a r o t i d area w i t h o u t a t t a c h m e n t to the overlying skin or i n v o l v e m e n t o f the facial nerve 1"2'I°'a1'22. They show considerable v a r i a t i o n in the type o f their epithelial lining a n d can be divided into, retention, epidermoid, a n d b r a n c h i a l cysts 7'm5. T h r e e cases o f benign cystic lesions o f the p a r o t i d gland are reported: 2 retention cysts a n d one b r a n c h i a l cyst.
Case reports Case 1 A 32-year-old man was referred because of a slowly enlarging, painless swelling in the left angle of the mandible, which he had first noriced 6 years earlier (Fig. 1). There was no pain, before or after meals. Six months prior to his admission, during an upper respiratory tract i n fection, he noticed tenderness and swelling over the left angle of the jaw. The swelling decreased after antibiotic therapy. A firm but compressible mass was palpable, located in the superficial lobe of the left parotid gland. The facial nerve appeared to function normally. He had a free flow of normal saliva from Stenson's orifice. Needle aspiration produced 3cc of strawcoloured fluid. Cytologic examination was negative for malignancy. Sialography showed the gland being pushed in a posterior position by a radiolucent mass. The ultrasound investigation demonstrated a well-demarcated mass without internal echoes, characteristic of a cyst. Treatment consisted of a conventional superficial parotidectomy approach, after which a
thin-walled cystic lesion was dissected with a margin of normal parotid tissue. Gross examination showed a collapsed cyst measuring 1.5 cm in diameter with a thin wall (1 mm thick). Microscopically, the cyst was lined with low cuboidal epithelium, and the wall consisted of loose connective tissue with islands of salivary gland parenchyma. The diagnosis was simple retention cyst of the parotid gland (Fig. 2).
Case 2 A 17-year-old girl presented with a 6-year history of a mass in her right parotid region. It was entirely asymptomatic but had been increasing in size during the last month. It appeared to be a tumour involving the superficial lobe of the parotid gland, not fixed to the overlying skin, mobile, and filled with fluid. Examination revealed no other abnormalities in the head and neck region. Routine laboratory tests were unremarkable. A sialogram showed a lacunar image corresponding to the tumour. The ultrasound study showed a welt-circumscribed cyst (Fig. 3). Through a conventional parotidectomy incision a thin-walled cystic lesion was dissected. The recovery was uneventful and the facial nerve function was intact. Gross examination showed a collapsed cyst measuring 2 cm in diameter. The wall
Key words: parotid cyst; lympho-epithelial cyst; retention cyst; salivary glands.
Accepted for publication 15 January 1990
was 1 mm thick with a smooth yellow surface. Microscopically, the cyst was lined with one or more layers of cuboidal epithelium, and the wall consisted of loose connective tissue. The diagnosis was retention cyst.
Case 3 A 54-year-old woman was referred because of a painless swelling in the right parotid area. She had noticed it some months previously, and since then the swelling had progressively increased in size. A lump could be palpated superficially in the lower pole of the right parotid gland. It was not painful on palpation and there were no signs of inflammation. Ultrasound examination showed a well-demarcated parotid cyst. The patient underwent complete excision of the mass beneath the capsule of the gland. The nerve was identified and preserved. The patient tolerated the procedure well and had an uncomplicated recovery. Gross examination showed a cystic mass measuring 2.5 cm in diameter filled with serosanguineous fluid. The thickness of the wall ranged from 1 to 2 mm. The inner surface was granular. Microscopically, the cyst was lined with stratified squamous and partially, with pseudostratified ciliated columnar
Fig. 1. Swelling in the left angle of the man-
Fig. 2. Wall of retention cyst of parotid gland,
dible.
H&E X 400
140
Antoniadis et al.
Fig. 3. Ultrasound scan ofparotid cyst showing a well-circumscribed retention cyst.
Fig. 4. Lympho-epithelial cyst wall, H&E X 400
epithelium. Beneath the epithelium there was abundant lymphoid tissue with germinal centers. The diagnosis was lympho-epithelial cyst of the parotid gland (Fig. 4). Discussion
The parotid gland is affected more frequently by cysts and congenital lesions than any of the other salivary glands I,zS. A cystic lesion can occur in any region of the parotid gland and m a y be difficult to diagnose, particularly if it is located deep to the facial nerve 11,14,18. They are usually unilateral, simulating a parotid tumour]3, 22. Simple intraparotid retention cysts have been seen in patients with intermittent obstruction of a duct from strictures, calculi, mucous plugs, neoplasms, trauma, and parasites 7,13. Retention of secretion may lead to the development of retention cysts 1,3,12.Epithelial-lined retention cysts may be distinguished from
pseudocysts, lined with granulation tissue. They represent an extravasation of mucous into the salivary parenchymal,5,7,14.Retention cysts are often located in the superficial lobe of the gland. They are lined with either single layered or stratified cuboidal epithelium sometimes with mucous-containing goblet cells. The cuboidal ductal epithelium may show metaplasia to squamous epithelium7'21,as seen in the cases presented. Rare intraparotid cysts are the 1st branchial cleft cysts or lympho-epithelial cysts. They are less frequently seen than the branchial cysts of the neck, originating from the cervical sinus 1'4'7'9.U p to 1986, only 52 cases have been reported 13,17,19,2°. The lining of a branchial cyst consists usually of squamous epithelium, but combinations ofcuboidal, columnar, ciliated columnar and mucin-producing epithelia have also been reported 1,9.In the present case, the epithelium was stratified squamous and partially pseudostratified ciliated columnar. The epithelium was encased in lymphoid tissue composed of small lymphocytes, plasma cells and germinal centres: morphological features characteristic of branchial cysts. The management of a patient with a swelling of the parotid region requires careful clinical evaluation. Needle aspiration or biopsy is always required for a definite diagnosis. Plain film, sialogram, computerized tomography and ultrasound scans may also be helpful 11,14,1s.We have found ultrasound scanning of parotid lumps of the superficial portion of the gland to be valuable in the pre-operative evaluation. This method is non-invasive, harmless, painless and relatively quick. Surgical excision of parotid cysts with a sufficient margin of normal tissue, has shown to be the most acceptable method of managing salivary gland cysts. References
i. BATSAK1SJG. Tumors of the head and neck. Baltimore: Williams and Wilkins, 1979: 116-17. 2. BATSAKISJG, REGEZ JA, BLOCHA. The pathology of head and neck tumors: salivary glands, part 3. Head Neck Surg 1979: 1: 260-73. 3. BRAUN TW, SOTEREANOSGC. Cervical ranula due to an ectopic sublingual gland. J Maxillofac Surg 1982: 10: 56-8. 4. GAISEORDJC, ANDERSONVS. First branchial cleft cysts and sinuses. Plast Recontr Surg 1975: 55: 299-304. 5. GATES GA. Diseases of the salivary glands. In: Bluestone CD, Stool SE, eds. Pediatric otolaryngology Vol. II. Philadelphia: W. B. Saunders 1983: 1023-37.
6. GERBERD, HUGOEN. Branchial cleft cyst in parotid gland. Ann Plast Surg 1982: 9: 413-14. 7. COHEN MN, RAO U, SHEDD DE Benign cysts of the parotid gland. J Surg Oncol 1984: 27: 85-8. 8. LEONARD JR, MARAN AG, HUFFMAN WC. Branchial cleft cysts in the parotid #and: facial nerve anomaly. Plast Reconstr Surg 1968: 41: 493-6. 9. MCRAE RG, LEE K J, GOERTZENE. First brancial cleft anomalies and the facial nerve. Otolaryngol, Head Neck Surg 1983: 91: 197-202. 10. MIHALYKAEE. Congenital bilateral polycystic parotid glands JAMA 1962: 181: 634-5. 11. PARTIDGEM, LANGDONJD, BORTHWICKCLARKE A. Diagnostic techniques for parotid disease. Br J Oral Maxillofac Surg 1986: 24: 311-22. 12. Quick CA, LOWELLSH. Ranula and the sublingual salivary glands. Arch Otolaryngol, 1977: 103: 397-400. 13. RICHARDSONGS, CLAIRMONTAA, ERICKSONER. Cystic lesions of the parotid gland. Plast Reconstr Surg 1978: 61: 364-70. 14. SEIFERT G, MmHLKE A, HAUBRICH J, CHILLAR. Disease of the salivary glands. Stuttgart: Georg Thieme 1986: 164-7, 322-3. 15. SHAHEEN NA, HARBOYAN GT, NASSIFI RJ. Cysts of the parotid gland. Review and report of two unusual cases. J Laryng Otol 1975: 89: 435-44. 16. STEWART S, LEVY R, KARPEL J, STOOPACK J. Lymphoepithelial (branchial) cyst of the parotid gland. J Oral Surg 1974: 32: 100-6. 17. UNGERECHTK. Parotiszyste mit branchiogenem Anteil als Relikt der 1. Kiemenfurche und Aquivalent einer Hals Ohrfistel. Laryng-Rhinol 1981: 60: 225-30. 18. WARD-BOOTHRP, WILLIAMSEP, FAULKNER TPJ, EARLPD. Ultrasound a simple noninvasive examination of cervical swellings. Plast Reconstr Surg 1984: 73: 577-81. 19. WEIDNER N, GEISINGERKR, STERLING RT, MILLERTR, YES B. Benign lymphoepithelial cysts of the parotid gland. Am J Clin Pathol 1986: 85: 395-401. 20. WEITZNER S. Lymphoepithelial (branchial) cyst of parotid gland. Oral Surg 1973: 35: 85-8. 21. WORK WP. Cysts and congenital lesions of the parotid gland. Otolaryngol Ctin North Am. 1977: 10: 339-43. 22. YOELJ. Pathology and surgery of the salivary glands. Springfield: CC Thomas 1975: 394-401. Address: K. Antoniadis Department of Oral and Maxillofacial Surgery University of Thessaloniki Greece
K. Antoniadis, D. Karakasis, V. Tzarou, A. Skordalaki Department of Oral and Maxillofacial Surgery University of Thessaloniki, Greece
K. Antoniadis, D. Karakasis, V. Tzarou, A. Skordalaki: Benign cysts of the parotid gland. Int. J. Oral Maxillofac. Surg. 1990; 19: 139-140. Abstract. Benign cysts o f the p a r o t i d gland are n o t frequently diagnosed. They occur in any p o r t i o n o f the p a r o t i d gland a n d m a y be difficult to diagnose. They present with considerable histological v a r i a t i o n in their linings. Three cases are presented o f unilocular b e n i g n cystic lesions o f the p a r o t i d gland t h a t h a v e been treated by superficial parotidectomy. Two o f t h e m were lined by a single or pseudostratified layer o f c u b o i d a l epithelium a n d were diagnosed as r e t e n t i o n cysts. T h e t h i r d was a lympho-epithetial cyst a n d was lined by stratified s q u a m o u s a n d partially b y pseudostratified ciliated c o l u m n a r epithelium. A review o f the relevant literature is also presented.
Benign cysts o f the p a r o t i d g l a n d are n o t as c o m m o n as other p a r o t i d t u m o u r s . YOEL22 reviewed 526 cases o f p a r o t i d gland t u m o u r s o f which only 14 were cysts. Benign cysts in the p a r o t i d gland have a n equal distribution a m o n g males a n d females, a n d usually present as a unilateral painless swelling in t h e p a r o t i d area w i t h o u t a t t a c h m e n t to the overlying skin or i n v o l v e m e n t o f the facial nerve 1"2'I°'a1'22. They show considerable v a r i a t i o n in the type o f their epithelial lining a n d can be divided into, retention, epidermoid, a n d b r a n c h i a l cysts 7'm5. T h r e e cases o f benign cystic lesions o f the p a r o t i d gland are reported: 2 retention cysts a n d one b r a n c h i a l cyst.
Case reports Case 1 A 32-year-old man was referred because of a slowly enlarging, painless swelling in the left angle of the mandible, which he had first noriced 6 years earlier (Fig. 1). There was no pain, before or after meals. Six months prior to his admission, during an upper respiratory tract i n fection, he noticed tenderness and swelling over the left angle of the jaw. The swelling decreased after antibiotic therapy. A firm but compressible mass was palpable, located in the superficial lobe of the left parotid gland. The facial nerve appeared to function normally. He had a free flow of normal saliva from Stenson's orifice. Needle aspiration produced 3cc of strawcoloured fluid. Cytologic examination was negative for malignancy. Sialography showed the gland being pushed in a posterior position by a radiolucent mass. The ultrasound investigation demonstrated a well-demarcated mass without internal echoes, characteristic of a cyst. Treatment consisted of a conventional superficial parotidectomy approach, after which a
thin-walled cystic lesion was dissected with a margin of normal parotid tissue. Gross examination showed a collapsed cyst measuring 1.5 cm in diameter with a thin wall (1 mm thick). Microscopically, the cyst was lined with low cuboidal epithelium, and the wall consisted of loose connective tissue with islands of salivary gland parenchyma. The diagnosis was simple retention cyst of the parotid gland (Fig. 2).
Case 2 A 17-year-old girl presented with a 6-year history of a mass in her right parotid region. It was entirely asymptomatic but had been increasing in size during the last month. It appeared to be a tumour involving the superficial lobe of the parotid gland, not fixed to the overlying skin, mobile, and filled with fluid. Examination revealed no other abnormalities in the head and neck region. Routine laboratory tests were unremarkable. A sialogram showed a lacunar image corresponding to the tumour. The ultrasound study showed a welt-circumscribed cyst (Fig. 3). Through a conventional parotidectomy incision a thin-walled cystic lesion was dissected. The recovery was uneventful and the facial nerve function was intact. Gross examination showed a collapsed cyst measuring 2 cm in diameter. The wall
Key words: parotid cyst; lympho-epithelial cyst; retention cyst; salivary glands.
Accepted for publication 15 January 1990
was 1 mm thick with a smooth yellow surface. Microscopically, the cyst was lined with one or more layers of cuboidal epithelium, and the wall consisted of loose connective tissue. The diagnosis was retention cyst.
Case 3 A 54-year-old woman was referred because of a painless swelling in the right parotid area. She had noticed it some months previously, and since then the swelling had progressively increased in size. A lump could be palpated superficially in the lower pole of the right parotid gland. It was not painful on palpation and there were no signs of inflammation. Ultrasound examination showed a well-demarcated parotid cyst. The patient underwent complete excision of the mass beneath the capsule of the gland. The nerve was identified and preserved. The patient tolerated the procedure well and had an uncomplicated recovery. Gross examination showed a cystic mass measuring 2.5 cm in diameter filled with serosanguineous fluid. The thickness of the wall ranged from 1 to 2 mm. The inner surface was granular. Microscopically, the cyst was lined with stratified squamous and partially, with pseudostratified ciliated columnar
Fig. 1. Swelling in the left angle of the man-
Fig. 2. Wall of retention cyst of parotid gland,
dible.
H&E X 400
140
Antoniadis et al.
Fig. 3. Ultrasound scan ofparotid cyst showing a well-circumscribed retention cyst.
Fig. 4. Lympho-epithelial cyst wall, H&E X 400
epithelium. Beneath the epithelium there was abundant lymphoid tissue with germinal centers. The diagnosis was lympho-epithelial cyst of the parotid gland (Fig. 4). Discussion
The parotid gland is affected more frequently by cysts and congenital lesions than any of the other salivary glands I,zS. A cystic lesion can occur in any region of the parotid gland and m a y be difficult to diagnose, particularly if it is located deep to the facial nerve 11,14,18. They are usually unilateral, simulating a parotid tumour]3, 22. Simple intraparotid retention cysts have been seen in patients with intermittent obstruction of a duct from strictures, calculi, mucous plugs, neoplasms, trauma, and parasites 7,13. Retention of secretion may lead to the development of retention cysts 1,3,12.Epithelial-lined retention cysts may be distinguished from
pseudocysts, lined with granulation tissue. They represent an extravasation of mucous into the salivary parenchymal,5,7,14.Retention cysts are often located in the superficial lobe of the gland. They are lined with either single layered or stratified cuboidal epithelium sometimes with mucous-containing goblet cells. The cuboidal ductal epithelium may show metaplasia to squamous epithelium7'21,as seen in the cases presented. Rare intraparotid cysts are the 1st branchial cleft cysts or lympho-epithelial cysts. They are less frequently seen than the branchial cysts of the neck, originating from the cervical sinus 1'4'7'9.U p to 1986, only 52 cases have been reported 13,17,19,2°. The lining of a branchial cyst consists usually of squamous epithelium, but combinations ofcuboidal, columnar, ciliated columnar and mucin-producing epithelia have also been reported 1,9.In the present case, the epithelium was stratified squamous and partially pseudostratified ciliated columnar. The epithelium was encased in lymphoid tissue composed of small lymphocytes, plasma cells and germinal centres: morphological features characteristic of branchial cysts. The management of a patient with a swelling of the parotid region requires careful clinical evaluation. Needle aspiration or biopsy is always required for a definite diagnosis. Plain film, sialogram, computerized tomography and ultrasound scans may also be helpful 11,14,1s.We have found ultrasound scanning of parotid lumps of the superficial portion of the gland to be valuable in the pre-operative evaluation. This method is non-invasive, harmless, painless and relatively quick. Surgical excision of parotid cysts with a sufficient margin of normal tissue, has shown to be the most acceptable method of managing salivary gland cysts. References
i. BATSAK1SJG. Tumors of the head and neck. Baltimore: Williams and Wilkins, 1979: 116-17. 2. BATSAKISJG, REGEZ JA, BLOCHA. The pathology of head and neck tumors: salivary glands, part 3. Head Neck Surg 1979: 1: 260-73. 3. BRAUN TW, SOTEREANOSGC. Cervical ranula due to an ectopic sublingual gland. J Maxillofac Surg 1982: 10: 56-8. 4. GAISEORDJC, ANDERSONVS. First branchial cleft cysts and sinuses. Plast Recontr Surg 1975: 55: 299-304. 5. GATES GA. Diseases of the salivary glands. In: Bluestone CD, Stool SE, eds. Pediatric otolaryngology Vol. II. Philadelphia: W. B. Saunders 1983: 1023-37.
6. GERBERD, HUGOEN. Branchial cleft cyst in parotid gland. Ann Plast Surg 1982: 9: 413-14. 7. COHEN MN, RAO U, SHEDD DE Benign cysts of the parotid gland. J Surg Oncol 1984: 27: 85-8. 8. LEONARD JR, MARAN AG, HUFFMAN WC. Branchial cleft cysts in the parotid #and: facial nerve anomaly. Plast Reconstr Surg 1968: 41: 493-6. 9. MCRAE RG, LEE K J, GOERTZENE. First brancial cleft anomalies and the facial nerve. Otolaryngol, Head Neck Surg 1983: 91: 197-202. 10. MIHALYKAEE. Congenital bilateral polycystic parotid glands JAMA 1962: 181: 634-5. 11. PARTIDGEM, LANGDONJD, BORTHWICKCLARKE A. Diagnostic techniques for parotid disease. Br J Oral Maxillofac Surg 1986: 24: 311-22. 12. Quick CA, LOWELLSH. Ranula and the sublingual salivary glands. Arch Otolaryngol, 1977: 103: 397-400. 13. RICHARDSONGS, CLAIRMONTAA, ERICKSONER. Cystic lesions of the parotid gland. Plast Reconstr Surg 1978: 61: 364-70. 14. SEIFERT G, MmHLKE A, HAUBRICH J, CHILLAR. Disease of the salivary glands. Stuttgart: Georg Thieme 1986: 164-7, 322-3. 15. SHAHEEN NA, HARBOYAN GT, NASSIFI RJ. Cysts of the parotid gland. Review and report of two unusual cases. J Laryng Otol 1975: 89: 435-44. 16. STEWART S, LEVY R, KARPEL J, STOOPACK J. Lymphoepithelial (branchial) cyst of the parotid gland. J Oral Surg 1974: 32: 100-6. 17. UNGERECHTK. Parotiszyste mit branchiogenem Anteil als Relikt der 1. Kiemenfurche und Aquivalent einer Hals Ohrfistel. Laryng-Rhinol 1981: 60: 225-30. 18. WARD-BOOTHRP, WILLIAMSEP, FAULKNER TPJ, EARLPD. Ultrasound a simple noninvasive examination of cervical swellings. Plast Reconstr Surg 1984: 73: 577-81. 19. WEIDNER N, GEISINGERKR, STERLING RT, MILLERTR, YES B. Benign lymphoepithelial cysts of the parotid gland. Am J Clin Pathol 1986: 85: 395-401. 20. WEITZNER S. Lymphoepithelial (branchial) cyst of parotid gland. Oral Surg 1973: 35: 85-8. 21. WORK WP. Cysts and congenital lesions of the parotid gland. Otolaryngol Ctin North Am. 1977: 10: 339-43. 22. YOELJ. Pathology and surgery of the salivary glands. Springfield: CC Thomas 1975: 394-401. Address: K. Antoniadis Department of Oral and Maxillofacial Surgery University of Thessaloniki Greece