European Archives of Oto-Rhino-Laryngology

, Volume 274, Issue 11, pp 3825–3836 | Cite as

Surgical options in benign parotid tumors: a proposal for classification

  • Miquel QuerEmail author
  • Vincent Vander Poorten
  • Robert P. Takes
  • Carl E. Silver
  • Carsten C. Boedeker
  • Remco de Bree
  • Alessandra Rinaldo
  • Alvaro Sanabria
  • Ashok R. Shaha
  • Albert Pujol
  • Peter Zbären
  • Alfio Ferlito
Review Article


Different surgical options are currently available for treating benign tumors of the parotid gland, and the discussion on optimal treatment continues despite several meta-analyses. These options include more limited resections (extracapsular dissection, partial lateral parotidectomy) versus more extensive and traditional options (lateral parotid lobectomy, total parotidectomy). Different schools favor one option or another based on their experience, skills and tradition. This review provides a critical analysis of the literature regarding these options. The main limitation of all the studies is the bias of selection for different surgical approaches. For this reason, we propose a staging system that could facilitate clinical decision making and the comparison of results. We propose four categories based on the size of the tumor and its location within the parotid gland. Category I includes tumors up to 3 cm, which are mobile, close to the outer surface and close to the parotid borders. Category II includes deeper tumors up to 3 cm. Category III comprises tumors greater than 3 cm involving two levels of the parotid gland, and category IV tumors are greater than 3 cm and involve more than 2 levels. For each category and for the various pathologic types, a guideline of surgical extent is proposed. The objective of this classification is to facilitate prospective multicentric studies on surgical techniques in the treatment of benign parotid tumors and to enable the comparison of results of different clinical studies.


Benign parotid tumors Pleomorphic adenoma Warthin’s tumor Parotidectomy Superficial parotidectomy Partial parotidectomy Extracapsular dissection 


  1. 1.
    Albergotti WG, Nguyen SA, Zenk J, Gillespie MB (2012) Extracapsular dissection for benign parotid tumors: a meta-analysis. Laryngoscope 122:1954–1960CrossRefPubMedGoogle Scholar
  2. 2.
    Foresta E, Torroni A, Di Nardo F, de Waure C, Poscia A, Gasparini G, Marianetti TM, Pelo S (2014) Pleomorphic adenoma and benign parotid tumors: extracapsular dissection vs superficial parotidectomy—review of literature and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 117:663–676CrossRefPubMedGoogle Scholar
  3. 3.
    Xie S, Wang K, Xu H, Hua RX, Li TZ, Shan XF, Cai ZG (2015) PRISMA-extracapsular dissection versus superficial parotidectomy in treatment of benign parotid tumors: evidence from 3194 patients. Medicine (Baltimore) 94:e1237CrossRefGoogle Scholar
  4. 4.
    Roh JL, Kim HS, Park CI (2007) Randomized clinical trial comparing partial parotidectomy versus superficial or total parotidectomy. Br J Surg 94:1081–1087CrossRefPubMedGoogle Scholar
  5. 5.
    Zbären P, Vander Poorten V, Witt RL, Woolgar JA, Shaha AR, Triantafyllou A, Takes RP, Rinaldo A, Ferlito A (2013) Pleomorphic adenoma of the parotid: formal parotidectomy or limited surgery? Am J Surg 205:109–118CrossRefPubMedGoogle Scholar
  6. 6.
    Triantafyllou A, Thompson LD, Devaney KO, Bell D, Hunt JL, Rinaldo A, Vander Poorten V, Ferlito A (2015) Functional histology of salivary gland pleomorphic adenoma: an appraisal. Head Neck Pathol 9:387–404CrossRefPubMedGoogle Scholar
  7. 7.
    Johnson JT, Ferlito A, Fagan JJ, Bradley PJ, Rinaldo A (2007) Role of limited parotidectomy in management of pleomorphic adenoma. J Laryngol Otol 121:1126–1128PubMedGoogle Scholar
  8. 8.
    Quer M, Guntinas-Lichius O, Marchal F, Vander Poorten V, Chevalier D, León X, Eisele D, Dulguerov P (2016) Classification of parotidectomies: a proposal of the European Salivary Gland Society. Eur Arch Otorhinolaryngol 273:3307–3312CrossRefPubMedGoogle Scholar
  9. 9.
    Quer M, Pujol A, León X, López M, García J, Orús C, Sañudo JR (2010) Parotidectomías en tumores benignos: clasificación “Sant Pau” de la extensión de la resección. Acta Otorrinolaringol Esp 61:1–5CrossRefPubMedGoogle Scholar
  10. 10.
    McFarland J (1936) Three hundred mixed tumors of the salivaryglands, of which sixty-nine recurred. Surg Gynecol Obstet 63:457–468Google Scholar
  11. 11.
    Benedict EG, Meigs JV (1930) Tumors of the parotid gland: a study of 225 cases with complete end-results in 80 cases. Surg Gynecol Obstet 51:626–647Google Scholar
  12. 12.
    Patey DH (1954) The present position of parotidectomy in the surgery of the parotid gland. Arch Middx Hosp 4:91–105PubMedGoogle Scholar
  13. 13.
    Martin H (1952) The operative removal tumors of the parotid salivary gland. Surgery 31:670–682PubMedGoogle Scholar
  14. 14.
    Laccourreye H, Laccourreye O, Cauchois R, Jouffre V, Menard M, Brasnu D (1994) Total conservative parotidectomy for primary benign pleomorphic adenoma of the parotid gland: a 25-year experience with 229 patients. Laryngoscope 104:1487–1494PubMedGoogle Scholar
  15. 15.
    McEvedy MV, Ross WM (1976) The treatment of mixed parotid tumours by enucleation and radiotherapy. Br J Surg 63:341–342CrossRefPubMedGoogle Scholar
  16. 16.
    Armitstead PR, Smiddy FG, Frank HG (1979) Simple enucleation and radiotherapy in the treatment of the pleomorphic salivary adenoma of the parotid gland. Br J Surg 66:716–717CrossRefPubMedGoogle Scholar
  17. 17.
    Gleave EN, Whittaker JS, Nicholson A (1979) Salivary tumours—experience over thirty years. Clin Otolaryngol 4:247–257CrossRefPubMedGoogle Scholar
  18. 18.
    Lyle FM (1956) Surgical consideration of parotid tumors. Am J Surg 91:332–338CrossRefPubMedGoogle Scholar
  19. 19.
    Vandenberg HJ Jr, Kambouris A, Pryzybylski T, Rachmaninoff N (1964) Salivary tumors: clinicopathologic review of 190 patients. Am J Surg 108:480–484CrossRefPubMedGoogle Scholar
  20. 20.
    Yamashita T, Tomoda K, Kumazawa T (1993) The usefulness of partial parotidectomy for benign parotid gland tumors: a retrospective study of 306 cases. Acta Otolaryngol Suppl 500:113–116CrossRefPubMedGoogle Scholar
  21. 21.
    Leverstein H, van der Wal JE, Tiwari RM, van der Waal I, Snow GB (1997) Surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland. Br J Surg 84:399–403CrossRefPubMedGoogle Scholar
  22. 22.
    O’Brien CJ, Malka VB, Mijailovic M (1993) Evaluation of 242 consecutive parotidectomies performed for benign and malignant disease. Aust N Z J Surg 63:870–877CrossRefPubMedGoogle Scholar
  23. 23.
    Martis C (1983) Parotid benign tumors: comments on surgical treatment of 263 cases. Int J Oral Surg 12:211–220CrossRefPubMedGoogle Scholar
  24. 24.
    Prichard AJ, Barton RP, Narula AA (1992) Complications of superficial parotidectomy versus extracapsular lumpectomy in the treatment of benign parotid lesions. J R Coll Surg Edinb 37:155–158PubMedGoogle Scholar
  25. 25.
    Natvig K, Soberg R (1994) Relationship of intraoperative rupture of pleomorphic adenomas to recurrence: an 11–25 year follow-up study. Head Neck 16:213–217CrossRefPubMedGoogle Scholar
  26. 26.
    Hancock BD (1999) Clinically benign parotid tumours: local dissection as an alternative to superficial parotidectomy in selected cases. Ann R Coll Surg Engl 81:299–301PubMedPubMedCentralGoogle Scholar
  27. 27.
    Marti K, Zografos GC, Martis C (2000) Extracapsular excision of small benign tumors of the parotid gland. J Surg Oncol 75:208–209CrossRefPubMedGoogle Scholar
  28. 28.
    Witt RL (2002) The significance of the margin in parotid surgery for pleomorphic adenoma. Laryngoscope 112:2141–2154CrossRefPubMedGoogle Scholar
  29. 29.
    McGurk M, Thomas BL, Renehan AG (2003) Extracapsular dissection for clinically benign parotid lumps: reduced morbidity without oncological compromise. Br J Surg 89:1610–1613Google Scholar
  30. 30.
    Uyar Y, Caglak F, Keles B, Yildirim G, Salturk Z (2011) Extracapsular dissection versus superficial parotidectomy in pleomorphic adenomas of the parotid gland. Kulak Burun Bogaz Ihtis Derg 21:76–79CrossRefPubMedGoogle Scholar
  31. 31.
    Van Niekerk JL, Wobbes TH, Monstrey S, Bruaset I (1987) The management of parotid tumors: a ten-year experience. Acta Chir Belg 87:1–5PubMedGoogle Scholar
  32. 32.
    McGurk M, Renehan A, Gleave EN, Hancock BD (1996) Clinical significance of the tumor capsule in the treatment of parotid adenomas. Br J Surg 83:1747–1749CrossRefPubMedGoogle Scholar
  33. 33.
    Laskawi R, Schott T, Mirzaie-Petri M, Schroeder M (1996) Surgical management of pleomorphic adenomas of the parotid gland: a follow-up study of three methods. J Oral Maxillofac Surg 54:1176–1179CrossRefPubMedGoogle Scholar
  34. 34.
    Leverstein H, Van Der Wal JE, Tiwari RM, Van Der Waal I, Snow GB (1997) Surgical management of 246 previously untreated pleomorphic adenomas of the parotid gland. Br J Surg 84:399–403CrossRefPubMedGoogle Scholar
  35. 35.
    Henriksson G, Westrin KM, Carlsöö B, Silfverswärd C (1998) Recurrent primary pleomorphic adenomas of salivary gland origin: intrasurgical rupture, histopathologic features, and pseudopodia. Cancer 82:617–620CrossRefPubMedGoogle Scholar
  36. 36.
    Ghosh S, Panarese A, Bull PD, Lee JA (2003) Marginally excised parotid pleomorphic salivary adenomas: risk factors for recurrence and management. A 12.5-year mean follow-up study of histologically marginal excisions. Clin Otolaryngol 28:262–266CrossRefPubMedGoogle Scholar
  37. 37.
    O’Brien CJ (2003) Current management of benign parotid tumors: the role of limited superficial parotidectomy. Head Neck 25:946–952CrossRefPubMedGoogle Scholar
  38. 38.
    Piekarski J, Nejc D, Szymczak W, Wronski K, Jeziorski A (2004) Results of extracapsular dissection of pleomorphic adenoma of parotid gland. J Oral Maxillofac Surg 62:1198–1202CrossRefPubMedGoogle Scholar
  39. 39.
    Guntinas-Lichius O, Kick C, Klussmann JP, Jungehuelsing M, Stennert E (2004) Pleomorphic adenoma of the parotid gland: a 13-year experience of consequent management by lateral or total parotidectomy. Eur Arch Otorhinolaryngol 261:143–146CrossRefPubMedGoogle Scholar
  40. 40.
    Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E (2006) Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations. Laryngoscope 116:534–540CrossRefPubMedGoogle Scholar
  41. 41.
    Smith S, Komisar A (2007) Limited parotidectomy: the role of extracapsular dissection in parotid gland neoplasms. Laryngoscope 117:1163–1167CrossRefPubMedGoogle Scholar
  42. 42.
    Takahama Junior A, Almeida OP, Kowalski LP (2009) Parotid neoplasms: analysis of 600 patients attended at a single institution. Braz J Otorhinolaryngol. 75:497–501CrossRefPubMedGoogle Scholar
  43. 43.
    Chan WH, Lee KW, Chiang FY, Ho KY, Chai CY, Kuo WR (2010) Features of parotid gland disease and surgical results in Southern Taiwan. Kaohsiung J Med Sci 26:483–492CrossRefPubMedGoogle Scholar
  44. 44.
    Shehata EA (2010) Extracapsular dissection for benign parotid tumours. Int J Oral Maxillofac Surg 39:140–144CrossRefPubMedGoogle Scholar
  45. 45.
    Riad MA, Abdel-Rahman H, Ezzat WF, Adly A, Dessouky O, Shehata M (2011) Variables related to recurrence of pleomorphic adenomas: outcome of parotid surgery in 182 cases. Laryngoscope 121:1467–1472CrossRefPubMedGoogle Scholar
  46. 46.
    Barzan L, Pin M (2012) Extra-capsular dissection in benign parotid tumors. Oral Oncol 48:977–979CrossRefPubMedGoogle Scholar
  47. 47.
    Zhang SS, Ma DQ, Guo CB et al (2013) Conservation of salivary secretion and facial nerve function in partial superficial parotidectomy. Int J Oral Maxillofac Surg 42:868–873CrossRefPubMedGoogle Scholar
  48. 48.
    Orabona GD, Bonavolonta P, Iaconetta G et al (2013) Surgical management of benign tumors of the parotid gland: extracapsular dissection versus superficial parotidectomy-our experience in 232 cases. J Oral Maxil Surg 71:410–413CrossRefGoogle Scholar
  49. 49.
    Iro H, Zenk J, Koch M et al (2013) Follow-up of parotid pleomorphic adenomas treated by extracapsular dissection. Head Neck 35:788–793CrossRefPubMedGoogle Scholar
  50. 50.
    Huang G, Yan G, Wei X et al (2015) Superficial parotidectomy versus partial superficial parotidectomy in treating benign parotid tumors. Oncol Lett 9:887–890PubMedGoogle Scholar
  51. 51.
    Witt RL, Rejto L (2009) Pleomorphic adenoma: extracapsular dissection versus partial superficial parotidectomy with facial nerve dissection. Del Med J 81:119–125PubMedGoogle Scholar
  52. 52.
    Cristofaro MG, Allegra E, Giudice A, Colangeli W, Caruso D, Barca I, Giudice M (2014) Pleomorphic adenoma of the parotid: extracapsular dissection compared with superficial parotidectomy—a 10-year retrospective cohort study. Sci World J 2014:564053CrossRefGoogle Scholar
  53. 53.
    Kadletz L, Grasl S, Grasl MC, Perisanidis C, Erovic BM (2017) Extracapsular dissection versus superficial parotidectomy in benign parotid gland tumors: the Vienna Medical School experience. Head Neck 39:356–360CrossRefPubMedGoogle Scholar
  54. 54.
    Medberya R, Yousemb DM, Needhama MF, Kligermana MM (2000) Variation in parotid gland size, configuration, and anatomic relations. Radiother Oncol 54:87–89CrossRefGoogle Scholar
  55. 55.
    El-Nagar AK, Chan JKC, Grandis JR, Takata T, Slootweg PJ (eds) (2017) World Health Organization classification of head and neck tumours, 4th edn. IARC Press, LyonGoogle Scholar
  56. 56.
    Espinoza S, Felter A, Malinvaud D, Badoual C, Chatellier G, Siauve N, Halimi P (2016) Warthin’s tumor of parotid gland: surgery or follow-up? Diagnostic value of a decisional algorithm with functional MRI. Diagn Interv Imaging 97:37–43CrossRefPubMedGoogle Scholar
  57. 57.
    Ethunandan M, Pratt CA, Higgins B, Morrison A, Umar T, Macpherson DW, Wilson AW (2008) Factors influencing the occurrence of multicentric and ‘recurrent’ Warthin’s tumour: a cross sectional study. Int J Oral Maxillofac Surg 37:831–834CrossRefPubMedGoogle Scholar
  58. 58.
    Schwalje AT, Uzelac A, Ryan WR (2015) Growth rate characteristics of Warthin’s tumours of the parotid gland. Int J Oral Maxillofac Surg 44:1474–1479CrossRefPubMedGoogle Scholar
  59. 59.
    Witt RL, Iacocca M, Gerges F (2015) Contemporary diagnosis and management of Warthin’s tumor. Del Med J 87:13–16PubMedGoogle Scholar
  60. 60.
    Thangarajah T, Reddy VM, Castellanos-Arango F, Panarese A (2009) Current controversies in the management of Warthin tumour. Postgrad Med J 85:3–8CrossRefPubMedGoogle Scholar
  61. 61.
    Reddy VM, Thangarajah T, Castellanos-Arango F, Panarese A (2008) Conservative management of Warthin tumour. J Otolaryngol Head Neck Surg 37:744–749PubMedGoogle Scholar
  62. 62.
    Iwai H, Yamashita T (2005) Local excision procedure for Warthin’s tumor of the parotid gland. Otolaryngol Head Neck Surg 132:577–580CrossRefPubMedGoogle Scholar
  63. 63.
    Leverstein H, Van der Wal JE, Tiwari RM, Van der Waal I, Snow GB (1997) Results of the surgical management and histopathological evaluation of 88 parotid gland Warthin’s tumours. Clin Otolaryngol Allied Sci 22:500–503CrossRefPubMedGoogle Scholar
  64. 64.
    Peter Klussmann J, Wittekindt C, Florian Preuss S, Al Attab A, Schroeder U, Guntinas-Lichius O (2006) High risk for bilateral Warthin tumor in heavy smokers—review of 185 cases. Acta Otolaryngol 126:1213–1217CrossRefPubMedGoogle Scholar
  65. 65.
    Domenick NA, Johnson JT (2011) Parotid tumor size predicts proximity to the facial nerve. Laryngoscope 121:2366–2370CrossRefPubMedGoogle Scholar
  66. 66.
    Ichihara T, Kawata R, Higashino M, Terada T, Haginomori S (2014) A more appropriate clinical classification of benign parotid tumors: investigation of 425 cases. Acta Otolaryngol 134:1185–1191CrossRefPubMedGoogle Scholar
  67. 67.
    Witt RL, Eisele DW, Morton RP, Nicolai P, Poorten VV, Zbären P (2015) Etiology and management of recurrent parotid pleomorphic adenoma. Laryngoscope 125:888–893CrossRefPubMedGoogle Scholar
  68. 68.
    Wittekindt C, Streubel K, Arnold G, Stennert E, Guntinas-Lichius O (2007) Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients. Head Neck 29:822–828CrossRefPubMedGoogle Scholar
  69. 69.
    Mantsopoulos K, Koch M, Klintworth N, Zenk J, Iro H (2015) Evolution and changing trends in surgery for benign parotid tumors. Laryngoscope 125:122–127CrossRefPubMedGoogle Scholar
  70. 70.
    Mantsopoulos K, Scherl C, Iro H (2017) Investigation of arguments against properly indicated extracapsular dissection in the parotid gland. Head Neck 39:498–502CrossRefPubMedGoogle Scholar
  71. 71.
    Silvoniemi A, Pulkkinen J, Grénman R (2010) Parotidectomy in the treatment of pleomorphic adenoma—analysis of long-term results. Acta Otolaryngol 130:1300–1305CrossRefPubMedGoogle Scholar
  72. 72.
    Vlantis AC, Ng SK, Mak CK, Cheung JM, Chan AB, van Hasselt CA (2016) If cytology of Warthin tumor is accurate, can management be conservative? Ear Nose Throat J 95:185–188PubMedGoogle Scholar
  73. 73.
    de Bree R, van der Waal I, Leemans CR (2007) Management of Frey syndrome. Head Neck 29:773–778CrossRefPubMedGoogle Scholar
  74. 74.
    Witt RL (2016) Extracapsular dissection with facial nerve dissection for benign parotid tumors. Otolaryngol Head Neck Surg 154:572–574CrossRefPubMedGoogle Scholar
  75. 75.
    Scarpini M, Amore Bonapasta S, Ruperto M, Vestri A, Bononi M, Caporale A et al (2009) Retrograde parotidectomy for pleomorphic adenoma of the parotid gland: a conservative and effective approach. J Craniofac Surg 20:967–969CrossRefPubMedGoogle Scholar
  76. 76.
    Postema RJ, van Velthuysen ML, van den Brekel MW, Balm AJ, Peterse JL (2004) Accuracy of fine-needle aspiration cytology of salivary gland lesions in the netherlands cancer institute. Head Neck 26:418–424CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Miquel Quer
    • 1
    • 2
    Email author
  • Vincent Vander Poorten
    • 2
    • 3
  • Robert P. Takes
    • 4
  • Carl E. Silver
    • 5
  • Carsten C. Boedeker
    • 6
  • Remco de Bree
    • 7
  • Alessandra Rinaldo
    • 8
  • Alvaro Sanabria
    • 9
  • Ashok R. Shaha
    • 10
  • Albert Pujol
    • 1
  • Peter Zbären
    • 2
    • 11
  • Alfio Ferlito
    • 12
  1. 1.Department of Otolaryngology-Head and Neck SurgeryUniversity Hospital de la Santa Creu i Sant Pau, Universitat Autonòma de BarcelonaBarcelonaSpain
  2. 2.European Salivary Gland SocietyGenevaSwitzerland
  3. 3.Otorhinolaryngology-Head and Neck Surgery and Department of Oncology, Section Head and Neck OncologyUniversity Hospitals Leuven, KU LeuvenLeuvenBelgium
  4. 4.Department of Otolaryngology-Head and Neck SurgeryRadboud University Medical CenterNijmegenThe Netherlands
  5. 5.Department of SurgeryUniversity of Arizona College of MedicinePhoenixUSA
  6. 6.Department of Otorhinolaryngology-Head and Neck SurgeryHELIOS HanseklinikumStralsundGermany
  7. 7.Department of Head and Neck Surgical Oncology, Utrecht Cancer CenterUniversity Medical Center UtrechtUtrechtThe Netherlands
  8. 8.University of Udine School of MedicineUdineItaly
  9. 9.Department of Surgery, School of MedicineUniversidad de Antioquia, Fundación Colombiana de Cancerología -Clínica VidaMedellinColombia
  10. 10.Head and Neck Service, Memorial Sloan-Kettering Cancer CenterNew YorkUSA
  11. 11.Department of Otorhinolaryngology-Head and Neck SurgeryUniversity HospitalBerneSwitzerland
  12. 12.Coordinator of the International Head and Neck Scientific Group, International Head and Neck Scientific GroupPaduaItaly

Personalised recommendations