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Introduction:
Salivary gland neoplasm constitute about 10% of all head
& neck neoplasm which represent 3% of all neoplasm of
the body. The value of FNAC in the investigation of
salivary gland disease has been widely debated amongst
clinicians and cytopathologists1,5 Fine needle aspiration
cytology (FNAC) of suspected salivary gland lesions has
an established role in preoperative diagnosis and
management of patients. However diverse morphological
patterns and overlapping features make it a challenging
job, to give a precise diagnosis, at times2. The aim of the
present study is to evaluate the effectiveness of FNAC in
the diagnosis of parotid gland masses. Fine needle for
diagnostic technique that is widely employed for lesions
of the head and neck. Among head and neck sites, the
parotid gland is unique in the number, diversity, and
peculiarity of its pathological processes. This complexity
has prompted a great deal of discussion regarding the

Diagnosis of Parotid Gland Mass by the Fine Needle Aspiration Cytology
(FNAC) and it’s Histopathological Correlation - 2 Years Study in BSMMU,
Dhaka
A Allam Choudhury1, Tuhin Sultana2,  Belayat Hossain Siddique3, A. Sufi Ahmed Amin4
1Associate professor, Dept of Otolaryngology and Head Neck Surgery, 2Associate Professor Dept of Clinical Pathology,  3Professor, Dept
of Otolaryngology and Head Neck Surgery, 4Professor, Dept of Otolaryngology and Head Neck Surgery, Bangabandhu Sheikh Mujib
Medical University, Shahbag, Dhaka, Bangladesh

Abstract:
Background: Fine needle aspiration cytology is a widely practiced technique in the diagnosis of parotid lump. Fine
needle aspiration cytology (FNAC) is a simple, quick, inexpensive and minimally invasive technique used to diagnose
different types of masses. In otolaryngology, FNAC’s greatest utility is in the diagnosis of neck masses.Objectives: The
aim of this study was to assess the sensitivity and specificity of FNAC in the diagnosis of parotid mass. Parotid gland
lesions form about 2-6.5% of all head and neck neoplasms in adults. They are easily accessible by FNAC, also cytology
can provide a distinction between parotid and non-parotid lesion, benign and malignant lesions,  and specific and non
specific inflammation. Methods: 50 patients were studied prospectively over 2 years. FNAC was done using 10 cc
syringes and 20-22 G. needle and stained with papanicular stain. Histopathology was assessed on routine H & E
(haematoxylin and eosin) stained paraffin sections. Results: Sensitivity and specificity for diagnosing malignant and
benign tumours were 75%, 95.2%, and 92.5%, 80%, respectively, and 90% of benign tumours were accurately typed on
fine-needle aspiration cytology compared with 92% in the malignant group. Conclusion: Fine-needle aspiration cytology
is useful in the preoperative assessment of parotid tumours as it is more reliable than clinical examination to diagnose
malignant parotid tumours. FNA cytology is useful in avoiding surgery (inflammatory lesions) or limiting surgical
procedures (benign tumours).

Key words:  Parotid gland tumour, Fine needle cytology

[BSMMU J 2011; 4(2):65-69]

Address for Correspondence: A Allam Choudhury, Associate
Professor, Dept of Otolaryngology and Head Neck Surgery,
Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka,
Bangladesh

application of FNAC to parotid masses. Primarily focusing
on the reliability of FNAC as a diagnostic tool in guiding
patient management. Parotid gland lesions form about 2-
6.5% of all head and neck neoplasm in adults, and present
as enlarged masses which are usually accessible for
FNAC3. They are not generally subjected to incisional or
needle biopsy techniques because of the risks of fistula
formation, or in the case of neoplasm, of tumour
implantation. There is no evidence that these complications
occur with FNAC2. The present study was undertaken to
evaluate parotid gland lesions by FNAC and to correlate
the cytologic findings with histopathology.

Cytology can clearly distinguish between parotid and non
parotid lesions, benign and malignant lesions, so also
specific and non specific inflammation. Thus it provides
decisive direction for therapeutic management of the
patient. FNAC is a utility tool for subtyping of parotid
gland lesions with variable specificity and sensitivity4.

The overall accuracy of fine needle aspiration cytology
was 87%, false-positive and false-negative rates for
malignant disease both being 4%. The sensitivity,



specificity and accuracy of fine needle cytology for
malignant parotid tumours was 66%, 95%, and 91%,
respectively, that of benign tumours (pleomorphic
adenoma or Warthin’s tumour) being

88%, 83% and 87%, respectively. Sensitivity, specificity
and accuracy for the remaining principally inflammatory
parotid diseases was 100%, 95% and 96% respectively.
The predictive value of a positive test for malignant
tumours, benign tumours and inflammatory conditions was
66%, 94% and 75%, respectively. The negative predictive
value for these conditions was 95%, 71% and 100%,
respectively 3.

The benefit of fine needle aspiration cytology in parotid
diseases is debated, some claiming it alters clinical decision
making in over one third of cases1,4.  Improvements in
radiological assessment have occurred with the use of
ultrasound and CT scanning, nuclear magnetic resonance
imaging and digital subtraction sialography 6.

Fine-needle aspiration cytology (FNAC) has gained
widespread acceptance and popularity among head and
neck surgeons in the assessment of thyroid and neck
masses but its use in the evaluation of parotid tumours
has not attained similar enthusiasm. The main reason in
the belief that the presence of a paroitid lump is an
indication for its removal.7 Further more, the sensitivity
and specificity of FNAC for parotid tumours is between
57-98% and 86-100%, respectively, and hence, some
authors believe that it is not accurate enough to influence
the decision-making process.8  The objective of this study
is to assess the sensitivity and specificity of FNAC in the
diagnosis of malignant and benign neoplasms and to
evaluate its usefulness in an algorithm in the management
of parotid tumours.

If the correlation of FNAC and histological diagnosis is
significant then by doing the preoperative cytological
diagnosis the clinician can start the initial treatment and
plan the mode of treatment. Also it can prevent excess
morbidity associated with over treatment

Methods:
This a prospective study done in Department of
Otolaryngology-Head & Neck Surgery and Pathology,
BSMMU from July 2007 to August 2009. 50 cases of parotid
mass were selected by method of randomization which
were later on operated. FNAC were carried out in 50 cases
preoperatively and findings were correlated with final

histopathological report. Detailed clinical history, results
of local examination, general examinations and systematic
examination were recorded in each case.

FNAC was done using 10 cc syringes with 20-22 G. needles
after taking informed consent of the patient. Smears were
stained with papanicolous stain. Excisional biopsy
specimens were fixed in 10% formalin. Gross and
microscopic examination were performed in each case. H&
E stain was done in all cases.

Fine-needle aspiration cytology results were classified into
the following categories: benign, malignant and non-
neoplastic lesions.

The corresponding cytological and histological diagnosis
were reviewed retrospectively and analysed. Study design
included a comparison between results of preoperative
FNAC with final histopathological diagnoses. Data
analysis was calculated sensitivity and specificity of
FNAC in differentiating between benign and malignant
lesions.

Results:
50 patients having both preoperative FNAC and final
histopathological diagnosis constituted the study group.
There were 32 men and 18 women in an age range of 12-77
years (mean 48.7 years). 41 patients underwent superficial
parotidectomy, and 9 total parotidectomy.

Most of the benign tumour are pleomorphic adenoma
(68%) Fig-1 shows a patient of pleomorphic adenoma of
parotid gland. Fig-2 shows fine needle aspiration cytology
picture of pleomorphic adenoma.

Fig-1: Pleomorphic adenoma of parotid gland.

Diagnosis of Parotid Gland Mass by the Fine Needle Aspiration Cytology (FNAC) Choudhury et al

66



Most of the malignant tumours are adenocystic (10%) &
then mucoepidermoid (6%) carcinoma. Fig-3 & 4 show
adenocystic and mucoepidermoid carcinoma FNAC picture
respectively.

The results of FNAC showed that 39 (78%) were benign,
9(18%) were malignant and 2(4%) non-neoplastic lesion.
Final histological diagnosis confimed the presence of 8
(16%) malignancies, 40 (80%) benign tumours 2 (4%) non-
neoplastic lesion. (Table-I).

Fig-2:  FNAC picture of pleomorphic adenoma.

Fig-3: FNAC picture of adenocystic carcinoma

Fig-4:  FNAC picture of  mucoepidermid carcinoma.

Table-I
Histopathological & cytological diagnoses of 50 cases

Histological Cytological
diagnosis diagnosis

Benign 80% 78%
Pleomorphic Adenoma 35 33(2 adenocystic carcinoma)
Warthin’s 4 3 (1 diagnosed as tubercular lesion)
Lipoma 1 1
Malignant 16% 18%
Carcinoma in pleomorphic adenoma 1 (1 diagnosed as pleomorphic adenoma)
Adonocystic carcinoma 4 3(1Diagnosed as malignant neoplasm \of uncertain type
Mucoepidermoid carcinoma 3 3
Non-neoplastic 4% 4%
Benign lymphoepithelial cyst 1 1
Tubercular intraparotid lymph node 1 (1 diagnosed as Warthin’s tumour)
Total 50 50

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67



Fine-needle aspiration cytology did not correlate with 6
specimens of which 3 were benign, 3 were malignant. So
accuracy of benign tumour by FNAC was 90% & malignant
tumour was 92%.

Sensitivity and specificity of benign tumour 92.5% and
80% & malignant tumour 75% & 95.2%. So cytological
diagnosis were 88% correlate with histological diagnosis.
(Table-II).

Table-II
Histopathological & cytological analysis of 50 cases.

Sensitivity Specificity Accuracy
Benign 92.5% 80% 90%
Malignant 75% 95.2% 92%

Discussion:
Fine-needle aspiration (FNA) is a safe diagnostic
technique that is widely employed in the examination of
parotid masses at relatively low cost and minimal risk to
the patient. Preoperative diagnosis of benign and
malignant tumour are important for the surgeons .The
standard surgical treatment for most benign tumours in
the superficial lobe is lateral parotidectomy, while benign
tumours in the deep lobe are usually treated by total
parotidectomy with facial nerve preservation. 6
Conservative surgical modalities for benign tumours, such
as extracapsular dissection, partial lateral parotidectomy,
and deep lobe parotidectomy with preservation of the
superficial lobe, have been discussed in the literature. 7,9
Early primary parotid carcinomas of the superficial lobe
are treated in many centres by total parotidectomy, while
superficial parotidectomy is performed in other centres.
Elective neck dissection for primary parotid carcinomas of
the clinically negative neck is performed routinely by only
a few authours.2 However, most authors advocate neck
dissecion on the basis of the histological type of the
carcinoma and tumour grade.

Therefore, Selection of appropriate surgical procedure is
dependent upon whether a tumour is benign or malignant
on preoperative cytological diagnosis. In the present
study, male preponderance was observed. There were 40
(80%) benign neoplastic cases. The incidence of benign
neoplasm has been reported as 40%, 61% and 69% by
different authors.3,4,6 16% of our cases were malignant
lesions as against 6%, 37% and 13% reported by other
authors(2,4,6). 4% percent of cases were non neoplastic.
Most common benign tumour was pleomorphic adenoma

and most common malignant tumour was adenoid cystic
carcinoma in this study. Among the parotid malignancy, 3
were mucoepidermoid carcinoma & 1 was carcinoma in
pleomorphic adenoma. Mucoepidermoid tumour in this
study was the second common malignant tumour which
correlates with others study. 2.8

Neoplasm of salivary gland may occur at any age, Marshall
and Miles (1974) showed malignant tumours usually
appear in later age group but may be seen in the
adolescents. In this study highest number of patients were
in the 5th decade (26%) which correlate with other studies.
2,7 Regarding the sex distribution of different neoplasms,
benign parotid tumours was more common in male
(M:F=1.8:1). malignant parotid neoplasms was also more
common in male (M:F= 1.8:1).

The benign tumour generally have no pain or other
distressing symptoms for which they do not care for it.
Moreover they fear for the operative treatment. In under
developed countries like us, due to poor socioeconomic
conditions and non availability of modernized hospital
facilities nearby-patient often report to local quackes and
village doctors for their treatment before attending to a
concerned specialist, for this reasons patient often reports
late and sometimes with complication of the disease. in
present series, most patients reported-within 4 to 8 years
of the diseases. In the present series, all the cases
presented with swelling. Size of the swelling in most
pleomorphic adenoma were more than 2 cm and malignant
tumours varied between 2 to 4 cm. Patient with longer
duration & larger swelling presented in more advanced
stage. Most of the patient of malignant tumours admitted
in the hospital at stage-3 is supported by others.8

Regarding investigation in present series, FNAC was done
in all 50 cases (100%). out of which 44 cases of cytological
diagnosis correlate with histological diagnosis. Post
operatively 50 cases were confirmed by histopathological
examination.

In cases of Warthin’s tumour, Cristallinins showed 90.1%
FNAC correlation with histopathological examination10.
In our series, we diagnosed 4 cases of Warthins tumour
by FNAC and one case was diagnosed as tubercular
lesion.3 Later on 4 cases were confirmed as Warthin’s
tumour on histopathology. In Cristallinins study, a
diagnosis of non neoplastic lesion was given in two cases,
which tuned out to be Warthin’s Tumour on histology.9

But in this study, out of two non neoplastic lesions one
was diagnosed as Warthin’s tumour on histopathology.

Diagnosis of Parotid Gland Mass by the Fine Needle Aspiration Cytology (FNAC) Choudhury et al

68



In this study sensitivity and specificity for diagnosing
malignant and benign tumours were 75%, 95.2%, and
92.5%, 80%, respectively, and 90% of benign tumours were
accurately typed on fine-needle aspiration cytology
compared with 92% in the malignant group. Accuracy of
benign tumour 90% and malignant tumour 92%.

Other study shows sensitivity and specificity of malignant
and benign were 80%, 100% & 98.5% 87.5%,1 66%, 95% &
88%, 83% respectively.2 FNAC has a sensitivity &
specificity of neoplastic lesion 94.54%,80.95%,6 and 79%,
84% respectively.3 In some report, the accuracy rate for
detecting malignant parotid tumours ranged from 79% to
97%, sensitivity from 54% to 95%, and specificity from
86% to 100%.9 Many authors have reported its usefulness
as a diagnostic tool, with documented accuracy rates
ranging from 97% to 98% for the large and diverse group
of neoplastic and inflammatory lesions involving the
parotid gland, 1,5 Recent studies have reported overall
accuracy rates of FNA for parotid masses ranging from
90% to 95% well within the range of 81% to 98% established
in earlier studies. In fact, Das et al, reported that FNAC
recognised the malignant nature of only 60% of salivary
gland carcinomas, even though the specificity and
accuracy of FNAC were excellent 95% and 90%
respectively. In some comparative study, Zbaren et al.
analysed 110 parotid tumours, 68 malignancies, and 42
benign tumours and reported that the accuracy, sensitivity,
and specificity of FNAC for detecting malignant tumours
were 97%, 74% and 88%, respectively.10

Regardless of one’s position regarding the use of FNAC as
a routine or selective tool for evaluating parotid masses,
utilisation should be moderated by a number of general
principles. First, the primary value of FNAC is to establish
the need for definitive surgery, not to establish a specific
diagnosis. Second, for decisions regarding the extent of
parotid surgery, such as whether to spare or sacrifice the
facial nerve, FNAC diagnosis plays a subordinate role to
intraoperative findings. Third, in those instances in which
cytological and clinical impressions deverge, intraoperative
frozen section findings remain an important arbitrator.

FNAC is a safe, cost effective, quick and easy diagnostic
procedure that causes little discomfort to the patient. Fine
needle aspiration cytology is a valuable adjunct to
preoperative assessment of parotid masses as save,
noninvasive procedure, almost without contraindications.
The high rate of specifity of FNAC presents low
possibility that benign cytological diagnosis of parotid
tumors become malignant in final histopathological
diagnosis. Preoperative recognition of malignant tumors
may help prepare both the surgeon and patient for
appropriate surgical procedure.

Conclusion:
The use of FNAC in the pre-operative evaluation of the
patient with a parotid mass is likely to influence
management where the clinical features suggest the
possibility of a benign or malignant. Fine-needle aspiration
cytology is useful in the preoperative assessment of
parotid tumours as it is more reliable than clinical
examination along to diagnose malignant parotid tumours.
Although it may not accurately type the malignant
tumours, the diagnosis of malignant tumours
preoperatively may allow for appropriate surgical planning
by the surgeon.

FNAC was found to be simple, noninvasive and cost
effective and rapid diagnostic tool for parotid gland
lesions. It plays a key role in evaluation of parotid gland
tumours thus helping further surgical management of the
patient.

We recommend that, where clinical teams use the results
of FNAC to influence management of a primary parotid
neoplasm, caution should be exercised and on going audit
of the performance of FNAC is required within each
institution.

References:
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KST. ‘Role of fine-needle aspiration cytology in the evaluation
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2 . Gordon TD, Kevin B, Roy A J S. An audit of surgery of the
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3 . Balakrishnan K, Mcmahon J, Imric J, Feeley KM, Parker AJ,
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4 . Howlett DC. Diagnosing a parotid lump: fine needle aspiration
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6 . Khandekar MM, Kavatkar AN, Patankar SA, Bagwan IB,
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