Lipomatous Lesions of the Parotid Gland: Analysis of 70 Cases

The Laryngoscope
C 2012 The American Laryngological,
V
Rhinological and Otological Society, Inc.
Lipomatous Lesions of the Parotid Gland: Analysis of 70 Cases
Sidney J. Starkman, BS; Steven M. Olsen, MD; Jean E. Lewis, MD; Kerry D. Olsen, MD; Alain Sabri, MD
Objectives/Hypothesis: To investigate presenting signs and symptoms, preoperative workup, operative therapy, and
morbidity of benign and malignant lipomatous lesions of the parotid gland.
Study Design: Medical literature review and retrospective chart review for all patients who underwent surgery for lipomatous lesions of the parotid gland at our institution from 1959 to 2009.
Methods: Seventy patients underwent surgery for such lesions. Histologic sections were stained with hematoxylin-eosin
and reviewed, and clinical information was obtained from hospital medical records for each case.
Results: Forty-nine patients (70.0%) were male and 21 (30.0%) female (mean age, 49.9 years). Of the lesions, 43
(63.2%) were intraparotid, 25 (36.8%) periparotid, 69 (98.6%) unilateral, and 1 (1.4%) bilateral (average size, 3.7 cm). Fiftynine patients were treated with superficial or partial superficial parotidectomy, 10 were treated with total parotidectomy, and
one was treated with parapharyngeal space dissection. Complications included six cases (8.6%) of facial paresis or paralysis
and two cases of hematoma. No lesions recurred.
Conclusions: We present the largest series, to our knowledge, of lipomatous lesions of the parotid gland. These masses,
although rare, should be considered in the evaluation of a parotid mass. This series provides insight into the clinical presentation, diagnostic evaluation, and surgical treatment of parotid lipomatous lesions. Surgical extent depends on lesion location in
the gland. Lipomatous masses can be effectively treated surgically with low morbidity and high cure rates.
Key Words: Fatty tumor, lipoma, neoplasms, parotid gland, tumors..
Level of Evidence: 4
Laryngoscope, 123:651–656, 2013
INTRODUCTION
Lipomatous tumors are the most common neoplasms of mesenchymal origin. Of lipomas, 13% arise in
the head and neck, with the posterior neck being the
most common subsite.1,2 Lipomas are composed of a benign collection of adipose tissue that may be surrounded
by a fibrous capsule. Diagnosis is based on clinical and
radiographic evidence and is confirmed with histopathologic analysis. Lipomas tend to exhibit slow growth, are
often asymptomatic, and on examination are generally
well-circumscribed soft lesions. Radiographic imaging—
particularly computed tomography (CT) and magnetic
resonance imaging (MRI)—can be suggestive of this
diagnosis.
Lipomas of the parotid gland are rare. The medical
literature reports that they comprise 0.5% to 4.4% of all
parotid masses. Most cases reported in the literature are
single cases, with the largest series to date reporting 32
cases of lipomatous tumors in the parotid region. We
report our institution’s experience with 70 lipomatous
lesions of the parotid gland from 1959 until 2009.
MATERIALS AND METHODS
This study was approved by the institutional review board
and was conducted in compliance with board guidelines. A retrospective chart review of 70 cases was performed. Inclusion
criteria required that patients had undergone parotid surgery
at our institution for removal of a lipomatous lesion of the parotid between 1959 and 2009. Patient data included age at
diagnosis, sex, and clinical signs and symptoms, including size,
laterality, facial nerve status, treatment extent, intraoperative
finding, histopathologic findings, and treatment morbidity and
efficacy. Follow-up was obtained either by subsequent visit at
our institution or through correspondence of medical records
with the patient’s home hospitals. Among 70 patients who
underwent treatment of parotid lesions, 16 patients were lost to
long-term follow-up. The other 54 patients had a median followup period of 68.0 months (range, 1 month–23.2 years).
RESULTS
From the Department of Otolaryngology–Head and Neck Surgery
(S.M.O., K.D.O.), Division of Anatomic Pathology (J.E.L.), and Mayo Medical
School, College of Medicine (S.J.S.), Mayo Clinic, Rochester, Minnesota; and
Department of Otolaryngology–Head and Neck Surgery (A.S.), American
University of Beirut, Beirut, Lebanon.
Editor’s Note: This Manuscript was accepted for publication
August 13, 2012.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Alain Sabri, MD, Department of Otolaryngology–Head and Neck Surgery, American Academy of Beirut Medical
Center, Cairo Street, Beirut, Lebanon. E-mail: as71@aub.edu.lb
DOI: 10.1002/lary.23723
Laryngoscope 123: March 2013
Patient Demographic Characteristics
The male to female ratio was 2.5:1. Age range at
lesion diagnosis was 7.4 through 89.5 years (mean age
at symptom onset, 49.9 years) (Table I). Patients
included three children younger than 16 years. Across
the cohort, most patients were white. No patient had a
family history positive for lipomas. However, 18 patients
(25.7%) had at least one medical comorbidity, and eight
(11.4%) had a history of diabetes mellitus, 10 (14.3%)
had hypercholesterolemia, and one (1.4%) had polycythemia vera. Eleven patients were current smokers, 26
Starkman et al.: Lipomatous Lesions of the Parotid Gland
651
TABLE I.
Demographic Characteristics of 70 Patients
With Lipomatous Masses.
Characteristic
TABLE III.
Lesion Characteristics (N 5 70).
Location
Patients, No. (%)
Ethnicity (n ¼ 68)*
White
67 (98.5)
Asian
Age range, yr
1 (1.5)
Children, 16
3 (4.3)
67 (95.7)
Male
49 (70.0)
Female
21 (30.0)
Presentation of Neck Mass
Table II summarizes the presenting symptoms of
the patients. Sixty-six patients (94.3%) presented with
neck mass as their chief concern. One patient had facial
nerve symptoms, which included facial twitching without clinically evident facial nerve weakness. The mean
duration of symptoms before presentation was 3.3 years
(range, 1 month–30 years).
Lesion Characteristics
Among all patients, 50.0% had right parotid
involvement, 48.6% had left parotid involvement, and
one patient (1.4%) had bilateral involvement (Table III).
Lipomatous masses involved only the superficial lobe in
92.5% of cases; the involved area was unrecorded in
three cases. In 36.8% of cases, the mass was extraparotid, arising from periparotid subcutaneous fat tissue but
adjacent to or involving parotid tissue. Average dimensions of the lipomas were 3.7 2.8 1.6 cm (smallest,
0.8 0.8 0.8 cm; largest, 16.5 7.5 2.5 cm) (Fig. 1).
Six patients also had a lipoma at other sites (the back [n
¼ 3], the trunk [n ¼ 2], and the neck [n ¼ 1]).
TABLE II.
Presenting Symptoms of Patients With Lipomatous
Masses (N 5 70).
Patients, No. (%)
66 (94.3)
43 (61.4)
Pain
3 (4.3)
Facial nerve signs
1 (1.4)
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652
25 (36.8)
Superficial lobe†
Deep lobe†
62 (92.5)
3 (4.5)
Right parotid gland
Left parotid gland
2 (3.0)
35 (50.0)
34 (48.6)
1 (1.4)
*Two patients had indeterminate intra- or periparotid location (n ¼
68).
†
Three patients had unrecorded superficial or deep lobe involvement
(n ¼ 67).
were past smokers, and 33 were never smokers. Patients
with a history of smoking had an average pack-year history of 24.8 (range, 2–80 pack-years). Among the 67
patients who reported their drinking history, 20 were
nondrinkers, 13 reported one drink per month, 13
reported several drinks per month, 12 reported several
drinks per week, and nine reported more than several
drinks per week.
Neck mass
Lesion size progression
43 (63.2)
Periparotid*
Bilateral parotid glands
*Two patients had no ethnicity recorded.
Presenting Symptom
Intraparotid*
Superficial and deep lobe†
Adults, >16
Sex
Patients, No. (%)
Treatment
Eighteen patients underwent preoperative imaging
(11 had CT and seven had MRI). Among the 52 patients
without preoperative imaging, only 19.2% had the appropriate preoperative diagnosis of lipoma. Among those
who had CT, a statistically significant improved rate of
preoperative diagnosis was achieved, with 63.6% of
patients receiving an accurate diagnosis (P ¼ .003). Of
patients with MRI preoperatively, an improved rate of
diagnosis was seen, but results did not achieve statistical significance, with 42.9% of lipomas correctly
identified (P ¼ .42). Ten patients had fine-needle aspiration (FNA) of the parotid mass; five results were
indeterminate, three were suggestive of another benign
mass, one was correctly suggestive of lipoma, and one
was correctly suggestive of liposarcoma.
The performed surgical procedures were superficial
parotidectomy (n ¼ 51), total parotidectomy (n ¼ 10),
partial superficial parotidectomy (n ¼ 8), and parapharyngeal space dissection (n ¼ 1). Ages at surgery ranged
from 14.7 to 89.6 years (mean, 56.5 years). At the time
of the surgical operations, 100% of patients had the parotid masses completely removed.
Pathologic Findings
Pathologic examination showed standard lipoma
histologic features in 63 cases (Table IV). Variations
included sialadenosis, fibrolipoma, sialolipoma, angiolipoma, and liposarcoma. Of the lipomatous lesions, 54
were without a completely enveloping capsule and 16
were fully encapsulated. Pathologic investigation showed
that the locations were intraparotid in 43 cases, extraparotid in 25 cases, and indeterminate in two cases.
Follow-up
Short-term treatment morbidities included two
cases of hematoma, four cases of transient facial paresis,
and two cases of transient facial paralysis, with full
recovery of facial nerve function in all cases at last
follow-up (Table V). Eight of 61 patients who underwent
superficial or total parotidectomy had some immediate
postoperative sequelae, although none of the nine
Starkman et al.: Lipomatous Lesions of the Parotid Gland
Fig. 1. Intraoperative image of intraparotid lipoma. [Color figure can be
viewed in the online issue, which is
available at wileyonlinelibrary.com.]
patients who underwent partial superficial parotidectomy or parapharyngeal space dissection had
postoperative sequelae. In addition, two (10.0%) of 20
patients with a correct preoperative diagnosis had shortterm postoperative complications, and six (12.2%) of 49
patients with unspecific preoperative diagnoses had
complications.
Among the 54 cases with follow-up for more than
one month, there were no recurrences for patients
treated at our institution (median follow-up, 68.0
months; range, 1 month–23.2 years). One patient had a
tumor incompletely resected at an outside institution
and presented to our institution for surgical management after tumor persistence. After complete removal,
the tumor did not recur. Among the three pediatric
patients, there were no cases of postoperative morbidity
or recurrence.
DISCUSSION
Lipoma is the most common soft tissue tumor in the
body. It has been reported in virtually every organ,1
with 13% of cases presenting in the head and neck area2
and mainly in the posterior neck.3 Lipomas are believed
to develop as a result of hypertrophy from increased
uptake of acetate and increased fatty synthesis.4
Another theory on the cause of lipoma is proliferation of
misplaced islands of lipoblasts or a metaplastic transformation of connective tissue into fatty tissue.5 These
lesions rarely undergo lipolysis in cases of severe malnutrition or cachexia.4,6,7
Lesion Presentation
Only rarely do lipomatous masses present in the parotid area. Our experience represents, to our knowledge,
the largest report of parotid lipomas to date. A previous
review of 14 studies reported 76 cases of lipomas identified from a total of 6,101 parotid tumors (a prevalence
rate of 1.2%).8 The largest individual series focusing on
lipomas from the parotid gland reported 32 cases.9
Parotid lipomas are more common in males than
females. The male to female ratio in our series was
2.5:1, a lower ratio than in the previous largest series of
parotid lipomas, which reported a ratio of 10:1.9. Lipomatous tumors are generally found in adults, with a small
percentage occurring in the pediatric population (4.3%
TABLE V.
Morbidity Incidence Rates in Various Surgical Events.
Transient Facial
Nerve Paresis/
Paralysis, %
Hematoma,
%
Total
Morbidity
Incidence, %
Superficial
parotidectomy
(n ¼ 51)
9.8 (n ¼ 5)
3.9 (n ¼ 2)
13.7 (n ¼ 7)
Total parotidectomy
(n ¼ 10)
10.0 (n ¼ 1)
0
10.0 (n ¼ 1)
Partial superficial
parotidectomy
(n ¼ 8)
0
0
0
Parapharyngeal
space
dissection (n ¼ 1)
0
0
0
Surgical Event
TABLE IV.
Lesion Variants (N 5 70).
Variant
Lipoma
Patients, No. (%)
63 (90.0)
Sialadenosis
2 (2.9)
Fibrolipoma
Sialolipoma
2 (2.9)
1 (1.4)
Angiolipoma
1 (1.4)
Liposarcoma
1 (1.4)
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Starkman et al.: Lipomatous Lesions of the Parotid Gland
653
in our study). They occur with equal frequency on the
right and left sides of the body and rarely are identified
bilaterally. Our study did not find a significant correlation between the incidence of lipomatous tumor and a
history of smoking or alcohol use. Likewise, this relationship has not been reported in the literature.
Clinically, lipomatous masses generally manifest as
relatively asymptomatic masses. In this series, the most
common presenting symptom was a parotid mass, with
more than half having progressed in size. Fewer than
5% of patients noticed pain or facial nerve symptoms.
On examination, lipomas are soft compressible
masses with normal overlying skin. They often display a
positive ‘‘slippage sign’’ when the fingers are slid gently
over the edge of the tumor.1 Lipomas will be felt to slip
aside when under pressure, rather than a sebaceous cyst
or abscess that is tethered to surrounding tissues. Neurologic findings, including hypoesthesia and paresis, are
rare,10,11 with only one case of facial paresis reported.12
These tumors are rarely considered in the differential diagnosis of parotid tumors when diagnosis is based on
clinical findings only. Before any imaging is performed,
the most commonly reported preoperative clinical diagnoses are pleomorphic adenoma and Warthin tumor.8,9,13
location without exposing the patient to the ionizing
radiation of a CT scan.19,20 MRI also can identify the tumor capsule, enabling the clinician to distinguish tumor
from surrounding fatty tissue.21
Although ultrasonography was not used in this
study, the literature has demonstrated the effectiveness
of this modality in preoperative evaluation of lipomatous
masses. A recent study determined that sensitivity for
the diagnosis of lipoma increased from 54.8% after palpation to 88.1% after ultrasonography.22 An elongated
echogenic mass in the subcutaneous tissues should suggest the diagnosis of lipoma. This echogenic pattern is
very similar to the pattern of subcutaneous adipose tissue. Striated echoes in the tumor, which correspond to
the septa, increase the possibility of lipoma.
This study showed that FNA is an inaccurate
means of identifying parotid lipomas. Among 10 parotid
lipomatous lesions that underwent FNA, an accurate diagnosis was obtained in only 22% (2/9) of cases.
Previously, FNA has been described as inaccurate for diagnosis of parotid lipomas, largely because fat cells from
lipomas are histologically indistinguishable from normal
subcutaneous fat, which is expected in the FNA of a parotid mass.23 In another study, only five of nine parotid
lipomatous lesions yielded an accurate diagnosis on
FNA.13
Preoperative Workup
Preoperative imaging and FNA of parotid masses
are selectively used at our institution. We generally
reserve imaging for cases of suspected malignancy or
cases with suspected deep lobe or parapharyngeal
involvement. In addition, FNA is generally used when
malignancy is suspected or when either parotid surgery
is contraindicated or the patient elects for observation.
Thus, the majority of patients in this series did not
undergo preoperative imaging or FNA.
Preoperative use of CT in the present study showed
a significantly higher rate of accurate preoperative diagnosis of parotid lipoma (P ¼ .003). MRI also improved
the rate of accurate preoperative diagnosis over baseline
(preoperative rate vs. baseline, 42.9% vs. 19.2%),
although the results did not reach statistical significance. The lack of significance is likely due to the small
sample (n ¼ 7); a larger sample may yield a more significant result.
CT imaging of lipomas reveals a hypodense mass
(between 150 and 50 Hounsfield units), which is considered diagnostic by most investigators.3,14,15 The
exception is fibrolipoma, which may show a contradictory high density on CT scan, secondary to the increased
amount of fibrotic tissue in the tumor.16 Lipomas do not
enhance with injection of contrast medium except in
cases of angiolipomas.17 In addition to aiding in diagnosis, CT scan helps in defining the location and extent of
the tumor.18
On MRI, lipomas show a high T1 and low T2 signal
characteristic of fatty tissue that is comparable in signal
intensity to subcutaneous fat. The fat suppression
sequence of lipomatous lesions demonstrated on MRI
clearly distinguishes these masses from other types of
tumors. MRI provides information about tumor size and
Laryngoscope 123: March 2013
654
Histologic Features
Of lipomatous tumors in the parotid gland, 90%
were pathologically determined to be standard lipomas;
the others were classified as different variants. Histologically, parotid lipomas consist of circumscribed masses of
mature adipose tissue, often with a thin fibrous capsule
at the margin, differentiating them from simple aggregations of adipose tissue.8,24,25 We found that 22.9% (16/70)
of lesions were well encapsulated, a finding determined
histologically.
Several unusual variants of lipomatous masses
were found. Our series included two cases of sialadenosis—one case in an adult with diabetes mellitus and the
other case in an otherwise-healthy 15-year-old child. In
each case, the patient underwent complete lesion excision and had no complications or recurrence.
Sialadenosis is defined by characteristic swelling of the
acini, together with changes in the cytoplasm of the acinar cells. In cases of longer duration, fatty infiltration
becomes predominant.26 Sialadenosis can occur secondary to a metabolic disease (e.g., diabetes, alcoholism,
malnutrition, drug adverse effect)3,13 but has also been
reported as a congenital condition.27
Other uncommon variants of lipomatous tumors
that our series included were two cases of fibrolipoma,
one case of angiolipoma, and one case of sialolipoma.
Sialolipomas are rare salivary gland tumors defined histologically by mature adipocytes encasing normal
salivary glandular components.28 They most commonly
affect the parotid gland and present in adults as a slowgrowing, asymptomatic swelling. Angiolipomas have
been reported as a congenital mass.17 Chondrolipoma
and myelolipoma are lipoma variants that have not been
Starkman et al.: Lipomatous Lesions of the Parotid Gland
reported in the parotid gland. Multiple rare parotid lipoma variants have been described in the literature,
including fibrolipoma, angiolipoma,29 spindle cell lipoma,30 pleomorphic lipoma (believed to be a variant of
spindle cell lipoma),31,32 lipoblastoma (an immature fatty
tumor),14,33 and osteolipoma.34 Molecular biological analysis has been useful in evaluation and diagnosis of these
tumor subtypes. For example, lipoblastomas are pediatric neoplasms resulting from transformation of
adipocytes, originating with PLAG1 activation (presumably resulting from transcriptional upregulation).35
One case of liposarcoma was found in the present
study, occurring in an 89-year-old woman and presenting
as a progressive mass over 6 months. This patient
underwent complete surgical tumor excision and did not
show any signs of subsequent recurrence. Liposarcomas
are believed to develop de novo, rather than as malignant transformation of benign fatty tissue.5 Few cases of
liposarcoma have been reported in the literature. Stewart et al.36 found three cases reported in the literature.
The literature identified 12 cases of salivary gland liposarcomas. Nine of these cases were in the parotid gland
and three were in the submaxillary gland.37–41 Radiologic studies may demonstrate features suggestive of a
malignancy by exhibiting areas of heterogeneous density
in the lipomatous mass. Histologic subtype is the most
important prognostic factor for malignant lipomatous
tumors.
The five liposarcoma subtypes are atypical lipomatous tumor/well-differentiated, dedifferentiated, myxoid,
pleomorphic, and mixed-type liposarcomas. More favorable prognoses were found with well-differentiated,
dedifferentiated, and myxoid liposarcomas. Pleomorphic
and mixed-type liposarcomas, which make up <10% of
all liposarcomas, carried the worst prognoses, with 5year survival rates of <25%.37
A rare lipomatous disorder that we did not encounter in our study was Madelung deformity (benign
symmetrical lipomatosis). This condition is characterized
by large, subcutaneous, fatty masses distributed around
the neck, shoulders, upper extremities, and upper dorsal
regions, mainly affecting middle-aged men (male to
female ratio, 15:1) with a history of alcoholism.42 It has
been found to present bilaterally in the parotid
regions.43 The pathogenesis of Madelung deformity is
unclear.
Treatment
This study showed the efficacy of surgical treatment
of lipomatous masses. Every lesion was treated with
complete surgical excision through parotidectomy, partial superficial parotidectomy, or parapharyngeal space
dissection. No cases of recurrence were found among the
70 lipomatous lesions. The sole case of liposarcoma was
treated with total parotidectomy and had no recurrence.
Prior cases of parotid liposarcoma have been treated
with complete surgical excision successfully and without
recurrence.40,44
We believe that the extent of surgery should be
determined at the time of operation with dual goals of
Laryngoscope 123: March 2013
complete mass resection (when possible, with a cuff of
normal parotid tissue around the mass) and facial nerve
preservation. The amount of parotid gland removed is
dictated by lesion size and location and the prior two operative factors. We do not advocate intraparotid
lumpectomy alone. Most investigators recommend superficial parotidectomy for tumors located within the
superficial lobe, with dissection and preservation of the
facial nerve 8,15,45 and total parotidectomy for deep lobe
tumors. We and other investigators also recommend partial parotidectomy for select masses (e.g., parotid tail
lesions) in the superficial lobe and the deep lobe.45 For
certain tumors, the superficial lobe can also be repositioned over the nerve after resection of a deep lobe
tumor, to prevent facial depression.46 Management of
periparotid lesions is less debatable, with complete excision cited as an effective treatment.15
Postoperative complications in the present study
were uncommon. The nine patients who had postoperative morbidity had received parotidectomy procedures
for intraparotid lipomas rather than simple excision of
periparotid tumors. Postoperative complications were
similar to other studies of parotidectomies for benign
tumors, including transient facial nerve weakness and
Frey syndrome.47 Of note, the prevalence of Frey syndrome in our study was lower than would be expected.
The medical literature has found the incidence of Frey
syndrome after parotidectomy to be about 23.5%.48 This
lower rate could be due to the referral basis of our institution with follow-up performed at other centers.
Additionally, approximately half of Frey syndrome cases
can be subclinical and may not have been reported. Facial nerve weakness has been shown to be more common
after resection of deep lobe tumors.21
CONCLUSION
We present, to our knowledge, the largest series of
lipomatous lesions of the parotid gland. The most common presentations of these lesions were painless masses,
with progression in size over time. FNA was noticeably
inaccurate in preoperative diagnosis. However, CT and
MRI can be useful for diagnosis. Preoperative imaging
can be particularly useful in identifying size, location,
and even the histologic characteristics of lipomatous
lesions. Imaging can assist in planning the extent of the
surgery, particularly in periparotid lesions that require
extracapsular dissection. Treatment of benign lipomatous lesions is indicated to correct cosmetic reports due
to unpleasant physical appearance or when preoperative
diagnosis is inconclusive. Intraparotid lipomas require
standard parotidectomy procedures. Complications are
rare and recurrences even more so.
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