Surgical management of nonmalignant parotid masses in the pediatric population: the Montreal Children's Hospital's experience

Idiopathic Parotid Gland Abscess in a Pediatric Patient

Parotid abscesses are sequelae of acute parotitis that are rare in pediatric patients. Common inciting causes of parotid abscesses include infection, inflammatory conditions, and ductal obstruction. This case presents a parotid abscess found in an otherwise healthy four-year-old girl. Further evaluation revealed no evidence of infection, no anatomical ductal obstruction, and no evidence of autoimmune conditions that could have caused the abscess. Nonetheless, the patient was treated with an incision and drainage procedure and antibiotic therapy with full recovery. Development of a parotid abscess with no identifiable cause is exceedingly rare with limited documented instances. From this case, idiopathic parotid abscesses may be considered as a diagnosis of exclusion after ruling out common causes, though management still follows the standard of care.

Fine-Needle Aspiration Biopsy of Pediatric Salivary Gland Tumors: Analysis of Patient Tolerability, Sedation Requirement, and Procedural Complication

OBJECTIVE

Fine-needle aspiration (FNA) biopsy is the standard diagnostic tool recommended by consensus management guidelines for preoperative evaluation of salivary gland tumors in adults. However, its utility in the pediatric population remains debated due to a paucity of data and inherited challenges of pediatric management (patient cooperation, the need for sedation, and procedural complications).

METHODS

Consecutive series of 92 FNA biopsies of pediatric salivary gland lesions with available procedural data were included for retrospective analysis. Patient demographics, procedural characteristics, and complications were assessed.

RESULTS

Sixty-three patients (68%) tolerated FNA without sedation. Sedation need was significantly associated with younger age, concurrent non-FNA procedure requiring sedation, ultrasound guidance, interventional radiologist as the proceduralist, and radiology suite as the facility setting. The sedation rates for children, and early, middle, and late adolescents were 69%, 32%, 12%, and 10%, respectively, with an optimal cutoff point of ≤12 years for age derived from receiver operating characteristic curve analysis. No significant procedural complications were observed. Sedation did not provide significantly better diagnostic yield.

CONCLUSION

FNA biopsy of salivary gland tumors is safe, well tolerated by the pediatric population, and can be effectively performed in an outpatient setting without sedation in most cases. FNA biopsy is a useful tool in the preoperative management of pediatric patients with salivary gland tumors.

The application of current classification systems in pediatric cytopathology: Perspectives from the pediatric cytopathology symposium at the 20th International Congress of Cytology 2019

A pediatric cytopathology symposium was held at the recent 20th International Congress of Cytology, which convened in Sydney, Australia, in May 2019. This educational event brought together cytopathologists from different countries and different institutions to discuss some of the practical considerations when applying current diagnostic classification systems to cytopathology specimens from young (pediatric and adolescent) patients. Within the past decade, various classification systems have been developed to create more standardized terminology for cytopathology specimen reporting among institutions, which can lead to improved management guidelines based on evidence-based medicine. It is well known that a majority of the peer-reviewed publications in cytopathology discussing the usefulness of these classification schemes predominantly contain case cohorts of adult patients. Although pediatric cases are not excluded from following these diagnostic guidelines, there is less of an emphasis on this age group with respect to unique findings and management differences. Thus, discussing the role of these guidelines and their applications in pediatric cases at an international educational gathering can not only be beneficial in educating the cytopathology community about the value of applying these classification systems to pediatric populations, but also can raise awareness of unique entities in cytologic specimens obtained from young patients.

An Exceptional Case of Intraparotid Plexiform Neurofibroma Originating from Autonomic Fibers of the Auriculotemporal Nerve

Plexiform neurofibromas are benign tumors that tend to occur in patients suffering from neurofibromatosis type 1 (NF-1). This report addresses a rare case where the tumor affected the parotid gland, deriving almost exclusively from the peripheral portion of the facial nerve. A 6-year-old male was referred to us complaining about a gradually enlarging swelling over the right parotid area. Imaging localized the lesion to the superficial lobe of the parotid gland, suggesting a neurofibroma. Cosmetic disfigurement and a functional deficit led us to perform complete surgical resection. Meticulous surgical dissection as well as auriculotemporal nerve origin made complete extirpation possible with almost zero morbidity and ensured alleviation of both aesthetic impairment and pain. This is the first case of an intraparotid PN in a pediatric NF-1 patient, which originated from branches of the auriculotemporal nerve and particularly from fibers of the autonomic nervous system. Radical surgical excision was decided according to established decision-making algorithms.

Unexpected pathologies in pediatric parotid lesions: management paradigms revisited

OBJECTIVES

To present case vignettes of unusual pediatric parotid pathologies and discuss management paradigms in the context of these lesions.

STUDY DESIGN

Retrospective case series.

SETTING

Free-standing, academic tertiary care pediatric hospital.

METHODS

All patients over the past 18 months undergoing parotidectomy for a parotid mass were reviewed (N=5).

RESULTS

Ages ranged from 17 months to 16 years. All presented with a remarkably similar clinical course, consisting of a persistent parotid mass for more than 3 months which was usually painless. Most (4/5 patients) had been treated with antibiotics prior to Otolaryngology consultation. Fine-needle aspiration (FNA) was performed on 3 patients and was diagnostic in one. Complete excision of the mass was performed in each child through a parotidectomy approach (3 total, 2 lateral lobe). The final pathology showed metastatic neuroblastoma (17 months old), undifferentiated primitive sarcoma (22 months old), mucoepidermoid carcinoma (11 years old), nodular fasciitis (12 years old), and hyperplastic lymph node (16 years old). The patient with neuroblastoma died from complications of bone marrow transplant.

CONCLUSIONS

The differential diagnosis for a persistent pediatric parotid mass is expansive and differs from that found in the adult population. As this series highlights, in many cases, it is impossible to discern the pathology, or rule out malignancy, based upon the clinical course, imaging, or FNA results. Surgical excision remains the standard for management of these patients and is both diagnostic and therapeutic. Our anecdotal case series highlights the importance of having a low threshold for parotidectomy in these children.

Intra-parotid facial nerve multiple plexiform neurofibroma in patient with NF1

INTRODUCTION

Primary neurogenic tumours of facial nerve are uncommon with the majority found intra-temporally. Intracranial and intra-parotid neoplastic involvement of cranial nerve VII is much less common. There are 11 reported cases, in the English-language literature, of intra-parotid facial nerve plexiform neurofibromas with eight of them associated with NF1.

MATERIALS AND METHODS

A child, 10 years old, with NF1, reached us for a cheek swelling, slowly increased in previous 8 years. At the age of 3 years, a plexiform neurofibroma was diagnosed by biopsy of the lesion. Clinical examination and NMR showed in the sub-cutaneous tissue of the right cheek, two contiguous nodular lesions, about 2 cm x 1.5 cm in diameter; a third neoformed lesion, about 1cm in diameter, was located above the ipsilateral labial commissure. No facial nerve impairment was seen. The patient underwent superficial parotidectomy with removal of the lesions and preservation of the facial nerve.

RESULTS

The patient had a considerable regional swelling in the immediate post-operative course; no facial nerve impairment was observed. The swelling of the cheek did not show a fully regression in the post-operative course. Ultrasonography at 3 months showed a recurrence of disease.

DISCUSSION

Plexiform neurofibromas should be distinguished due to their risk of malignant transformation seen in up to 15% of patients affected by NF1. Surgery is the only effective option currently available for the treatment of PNF. However, success of surgical intervention is limited by the infiltrating nature of the tumours, resulting in a high rate of tumour re-growth. Facial nerve preservation during surgery is unlikely and significant morbidity can result from their excision. The age of the patient at surgical resection seemed to influence outcome: tumours resected before age 10 years recurred in 60% of cases compared with only 30% recurrence in patients older than the age of 10 years.

CONCLUSION

Indication and timing of surgery, in paediatrics patients with NF1, are complex. To avoid eventual physical and psychological consequences, it seems prudent to delay surgery as long as it is feasible for otherwise asymptomatic paediatric patients with facial plexiform neurofibroma.

The Benign Lymphoepithelial Cyst and a Classification System for Lymphocytic Parotid Gland Enlargement in the Pediatric HIV Population

OBJECTIVES/HYPOTHESIS

The objectives of this study are to present a series of parotid gland benign lymphoepithelial cysts (BLEC) in HIV-positive children and to propose a three-tiered classification system for HIV-associated lymphocytic parotid gland enlargement.

STUDY DESIGN

The authors conducted a retrospective case series and literature review.

METHODS

The authors conducted a retrospective chart review of four pediatric patients with HIV-associated parotid gland BLEC who presented to a tertiary care university medical center.

RESULTS

Four pediatric HIV-positive patients (four girls; age range, 7-17 years [mean age, 12.8 years]) were diagnosed with parotid gland BLEC. Two patients presented with acute parotitis and the others presented with asymptomatic enlargement of the parotid glands. Three patients had bilateral parotid gland BLEC. The other patient demonstrated persistent generalized lymphadenopathy (PGL) of the intraparotid and cervical lymph nodes and early BLEC limited to the left parotid gland. One patient also displayed parotid gland microcalcifications and cystic changes in the adenoids, neither of which have been described previously in the setting of HIV-associated BLEC. Computed tomography was performed on all patients, and one patient underwent fine needle aspiration to confirm the diagnosis. All patients opted for observation and antiretroviral medication therapy as long-term treatment. Based on these findings and a review of the literature, we propose a three-tiered classification system for lymphocytic parotid gland enlargement in the HIV population: 1) PGL, 2) benign lymphoepithelial lesions (BLEL), and 3) BLEC.

CONCLUSIONS

This series equals the largest pediatric series of HIV-associated parotid gland BLEC in the English literature. One patient in our series also demonstrated PGL; there were no cases of BLEL. A classification system based on morphology is proposed to help resolve the confusion in terminology used to describe this entity. Most pediatric HIV-infected patients with parotid gland BLEC can be treated with observation and antiretroviral medication therapy. For others, who are symptomatic or more concerned about their cosmetic appearance, sclerotherapy may offer a reasonable option. Radiation therapy and surgery should be reserved for select cases.

Nontuberculous mycobacteria-induced parotid lymphadenitis successfully limited with clarithromycin and rifabutin

OBJECTIVES/HYPOTHESIS

Nontuberculous mycobacterial adenitis of the parotid gland is often difficult to diagnose. The rarity of these infections in the parotid region and the lack of specific guidelines pose a treatment challenge to the clinician. Three cases of nontuberculous mycobacterial adenitis are presented, with clinical response to antibiotics before surgery.

STUDY DESIGN

Retrospective chart review was made of children up to 18 years of age presenting with a parotid mass diagnosed as nontuberculous mycobacterial infection.

METHODS

Three patients (age range, 15 to 30 mo) with nontuberculous mycobacteria-induced parotid lymphadenitis were treated with a combination antibiotic regimen of clarithromycin and rifabutin or with clarithromycin alone.

RESULTS

All three patients responded clinically to the antibiotic treatment as evidenced by a smaller mass size and resolution of the overlying discoloration. Subsequent parotidectomy or biopsy appeared to be easier to perform because of decreased inflammation and edema and a more readily dissectible facial nerve.

CONCLUSION

Children with nontuberculous mycobacteria-induced parotid lymphadenitis should be started on a trial of antibiotic treatment before surgery. Although surgery remains the definitive treatment modality, a larger study of preoperative antibiotic use against nontuberculous mycobacterial adenitis of the parotid in children is necessary.