Comparison of Parotidectomy With Observation for Treatment of Pleomorphic Adenoma in Adults

Antibiotics or Tonsillectomy for Adult Recurrent Tonsillitis: Analyzing the Lesser of Two Evils

OBJECTIVE

To determine the best timing for surgical intervention for adults with recurrent tonsillitis (RT).

METHODS

A Markov model was constructed using variables and ranges based upon a literature review. A 1-way sensitivity analysis was performed to evaluate the number of yearly bouts at which each algorithm (antibiotics or tonsillectomy) would be favored. A Monte-Carlo probabilistic sensitivity analysis was calculated for gains and cost. Model outcomes were measured with quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICER) for tonsillectomy versus repeat antibiotic treatment.

RESULTS

Patients expected to sustain a single annual tonsillitis event will have a negative QALY of 0.02 if treated with surgery and those with 2 annual events will have a QALY gain from undergoing tonsillectomy of 0.01, 3 events = 0.03, 4 events = 0.05, 5 events = 0.07, 6 events = 0.09, 7 events = 0.1, and 8 events = 0.11. These gains became meaningful only after 2 years of recurrent bouts. The average cost of tonsillectomy was 3,238 USD, and the overall average cost of RT was 7,069 USD (an incremental cost of 3,831 USD). The ICER of tonsillectomy over antibiotic treatment for 1 QALY gain was 44,741 USD.

CONCLUSION

Adult patients who sustain more than 3 annual bouts of tonsillitis over a period of at least 2 years will gain QALY after tonsillectomy. These gains increase proportionally to the number of yearly events and perennial episodes. The incremental costs of tonsillectomy fail to meet the NICE guidelines but are within other acceptable reference ranges.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2153-2161, 2024.

Risk of Carcinoma in Pleomorphic Adenomas of the Parotid

Importance

Surgery is the mainstay of treatment for pleomorphic adenomas (PAs) of the parotid to prevent further growth and potential future malignant transformation. While historical case series have reported transformation rates as high as 10%, there is a lack of contemporary methodologically sound data.

Objective

To examine the rate of carcinoma ex pleomorphic adenoma (CXPA) detection in untreated PAs and investigate factors associated with malignant neoplasm.

Design, Setting, and Participants

This cohort study reviewed all cases of primary PAs managed at a quaternary referral center between December 1990 and January 2015. Patients whose clinical presentation was compatible with a primary benign PA and whose history indicated tumor duration of over 1 year were included. Data were analyzed from January to April 2023.

Exposure

Untreated PA.

Main Outcomes and Measures

Rate of CXPA detection among untreated PAs and association of tumor duration with rates of CXPA detection. Pathology slides of patients who underwent surgery were reviewed by a single expert pathologist for the presence of CXPA. Univariable logistic regression was performed to evaluate possible factors associated with CXPA.

Results

A total of 260 patients (median age, 47 years [IQR, 38-60 years]; 174 [66.9%] female) had a median tumor duration of 3.2 years (range, 1-30 years; mean [SD], 5.7 [5.5] years). Patients were divided into 4 groups by tumor duration: 1 to 4 years (158 [60.7%]), 5 to 9 years (47 [18.1%]), 10 to 14 years (27 [10.4%]), and 15 to 30 years (28 [10.8%]). In 156 of 170 patients who underwent preoperative fine-needle aspiration (91.8%), a benign tumor was diagnosed; 5 of these patients (3.2%; 95% CI, 1.4%-7.3%) were later diagnosed with CXPA on pathology after eventual excision, and the rate of high grade CXPA was 1.3%. None of the patients had permanent facial nerve paralysis. Tumor size at presentation (odds ratio [OR], 1.66; 95% CI, 1.22-2.24) and incremental (per year) increase in age (OR, 1.04; 95% CI, 1.01-1.08) were found to be associated with CXPA, whereas tumor duration was not (OR, 1.00; 95% CI, 1.00-1.01).

Conclusions and Relevance

In this study, the rate of malignant neoplasm detection among initially untreated PA was 3.2%. The results suggest that tumor size and older age are associated with the development of CXPA, while tumor duration is not. Observation of PA for longer periods was not associated with serious permanent complications.

Solitary Scalp Metastases of Parotid Pleomorphic Adenoma: A Case Report

Pleomorphic adenoma (PA) of the parotid gland is considered one of the commonest benign salivary gland neoplasms in both adults and pediatrics. However, metastatic pleomorphic adenoma (MPA) is extremely rare. In the past three decades, multiple cases were reported in the literature of MPA, where the metastatic phase has been preceded by a local recurrence for the majority of the cases. Metastases to the lungs, liver, bone, head and neck were reported. This paper will discuss a rare case presentation of MPA that metastasised solely to the face and scalp subcutaneous tissue with no other sites of metastases in a male adult.

Primary Extrapulmonary Rifampicin Mono-Resistant Tuberculosis of the Parotid Gland in an Indian Female: The World's First Case

Tuberculosis at extrapulmonary sites is relatively uncommon. A case of isolated involvement of the salivary gland is even rare and primary rifampicin mono-resistant tuberculosis of the parotid gland is rarest of rare with no such report ever documented in the medical literature. In this case report, the author presents a case of primary extrapulmonary rifampicin mono-resistant tuberculosis of the parotid gland in a 44-year-old Indian female. She presented with complaints of a painless swelling in the right parotid region and underwent a detailed diagnostic work-up including fine needle aspiration cytology, cartridge-based nucleic acid amplification test, computed tomography scan of head and neck, and culture, and was diagnosed with primary extrapulmonary rifampicin mono-resistant tuberculosis of the parotid gland. The patient was initiated on a WHO-recommended regimen per the national guidelines. After nine months of treatment, she had no symptoms and was declared as treatment completed. With no such case ever reported, this case emphasizes the importance of a high degree of suspicion for rare presentations of common diseases like tuberculosis even in the absence of a history, contacts, or other constitutional symptoms.

Observation Rather than Surgery for Benign Parotid Tumors: Why, When, and How

Surgery is the preferred treatment of benign parotid lesions, but it carries a risk of complications. Therefore, the approach toward the surgery of these lesions should seek to avoid complications. There are no guidelines or recommendations for when not to operate. Integration of comorbidities and other factors shift the scales from surgery toward observation in a small subset of patients presenting with parotid tumors. When observation is chosen, the patient should be followed frequently and cautiously, and the surgeon should be prepared to change strategy to surgical excision if in doubt.

Postoperative Management of Salivary Gland Tumors

OPINION STATEMENT

Salivary gland tumors represent a heterogeneous group of neoplasms characterized by varied histologies and disease outcomes. Initial treatment for the primary and gross nodal disease is usually surgery. Management of the clinically node-negative neck depends upon the risk of lymph nodal involvement. This is usually determined by the AJCC "T" stage and histology. Both surgery and radiation may be utilized to address the lymph nodes at risk. This is especially important for minor salivary gland tumors. Radiation plays an important role in the adjuvant management of salivary gland tumors by reducing the risk of locoregional recurrence. Certain histologies like adenoid cystic carcinoma have a predilection for neurotropic spread to the skull base. Radiation is particularly important in controlling disease at the skull base. The role of concurrent chemotherapy in the adjuvant treatment of salivary gland tumors is not established and remains an area of active research. Certain histologies like salivary duct carcinoma exhibit readily identifiable molecular targets amenable to targeted therapy. Finally, advanced testing of these tumors using next-generation sequencing can also potentially identify molecular targets amenable to therapy. While useful in the management of metastatic disease, the role of these therapies in the adjuvant setting remains unknown.