Indian J Otolaryngol Head Neck Surg

(JulySeptember 2012) 64(3):257260; DOI 10.1007/s12070-011-0297-4

ORIGINAL ARTICLE

Value of Fine-Needle Aspiration Cytology in the Evaluation

of Parotid Tumors
Morteza Javadi Alimohamad Asghari
Fatemeh Hassannia

Received: 21 December 2010 / Accepted: 12 August 2011 / Published online: 27 August 2011
 Association of Otolaryngologists of India 2011

Abstract Fine needle aspiration cytology (FNAC) is

commonly used in the study of parotid masses; however
controversy exists regarding its diagnostic accuracy. The
objective of this study was to evaluate the effectiveness of
FNAC as a preoperative diagnostic tool of parotid tumors.
Sixty-five patients had satisfactory preoperative FNAC and
underwent subsequent surgery to the parotid between
March 2002 and July 2009 at our institution. The results of
the FNAC were compared to the permanent histopathological diagnosis. The sensitivity, specificity, positive predictive value, negative predictive value, and the overall
accuracy of FNAC for parotid masses were 57.9, 97.8,
91.7, 84.9, and 86%, respectively. FNAC is useful in the
preoperative assessment of parotid tumors and surgical
planning. The non-diagnostic and false-negative results are
the limitations of FNAC that should be reduced to improve
its usefulness in the evaluation of parotid tumors.
Keywords Fine-needle aspiration
Parotid tumor

Salivary gland
Preoperative evaluation

False-negative results

surgeons in the assessment of thyroid and neck masses but

its use in the evaluation of parotid tumors has not been
uniformly accepted. Batsakis et al. [1] believe that most
parotid masses ultimately require surgery and the preoperative FNAC has little influence on clinical management.
Furthermore, the sensitivity and specificity of FNAC for
parotid tumors is between 5798 and 86100%, respectively, and hence, some authors believe that it is not accurate enough to influence the decision-making process [2, 3].
By other authors, FNAC permits the distinction between
reactive inflammatory processes, which may not require
surgery, and benign and malignant neoplasms [4, 5].
The diagnosis obtained from FNAC is a valuable aid in
planning the operating time and approach to intervention,
especially in cases in which the need for radical surgery
will have substantial implications for esthetic and functional outcomes [6]. The preoperative cytological evaluation of the lesion obtained from FNAC can be used in
counseling the patient regarding the nature of their disease
and the treatment options available [7].
The objective of this study is to assess the sensitivity and
specificity of FNAC in the diagnosis of malignant and
benign neoplasms of parotid.

Introduction
Fine-needle aspiration cytology (FNAC) has gained widespread acceptance and popularity among head and neck

M. Javadi
A. Asghari (&)
F. Hassannia

Department and Research Center of Otolaryngology, Head and
Neck Surgery, Tehran University of Medical Sciences, Hazrate
Rasoul Akram Hospital, Niayesh St., Satarkhan Ave, Tehran,
Iran
e-mail: [email protected]; [email protected]

Materials and Methods

From March 2002 to July 2009, a total of 170 parotidectomies were carried out in the Department of Otolaryngology, Head and Neck Surgery at the Hazrat Rasoul
Akram Hospital.
From these subjects, a subset of 70 patients (41.1% of
the total) who underwent preoperative FNAC was selected.
Preoperative cytological findings were classified as benign
and malignant.

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Indian J Otolaryngol Head Neck Surg (JulySeptember 2012) 64(3):257260

We compared the histopathology of the surgical specimens with the preoperative cytology of FNAC specimens
and calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and
overall accuracy of FNAC for diagnosing of benign and
malignant parotid masses. The obtained results were analyzed using SPSS (version 11.0). This study has gained
ethical approval from Ethical Research Committee of
Otolaryngology, Head and Neck Research Center, Tehran
University of Medical Sciences.

masses) and mucoepidermoid carcinoma (14.3% of all

masses) were respectively the most benign and malignant
parotid masses in our cases (Table 2).
In this series, the sensitivity of FNAC was 57.9%, the
specificity 97.8%, the PPV 91.7% and the NPV 84.9%.
Overall accuracy of FNAC in diagnosis of parotid masses
was 86%.

Discussion
Results
Five patients with inadequate smears were excluded from
this series. So 65 patients had both preoperative satisfactory FNAC and final histological diagnosis and made up
our study group. There were 35 male and 30 female with
mean age of 39 years.
All of the patients had unilateral parotid masses. The
preoperative FNAC and final histopathological results are
shown in Table 1. Pleomorphic adenoma (49% of all

Table 1 Comparison between histological and cytological results

Histological diagnosis
Benign

Malignant

Total

FNAC
Benign
Malignant
Total

45

53

11

12

46

19

65

Table 2 Histological diagnoses

of parotid masses

Histology

Numbers

Pleomorphic
adenoma

32

Warthins tumor
Vascular tumors

Sialoadenitis

Mucoepidermoid
carcinoma

Adenoid cystic
carcinoma

Adenocarcinoma

Acinic cell
carcinoma

Squamous cell
carcinoma

Malignant mixed
tumor

Total

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65

FNAC is a safe and easy diagnostic procedure that causes

little discomfort to the patient. Previous concerns regarding
FNAC included risks of hemorrhage, facial nerve trauma,
acute parotitis and the risk of tumor seeding [810]. These
concerns have been mostly discounted and replaced by
concerns as to whether the test is useful and whether it
actually affects treatment decisions [9]. For practical purposes, the most important goal of FNAC is to distinguish a
benign parotid mass from a malignant one. With this preoperative diagnostic information, the surgeon may consider
adjunctive or more extensive surgical strategies for parotidectomy [11]. Accurate tumor typing is less important and
may be deferred to the definitive histological examination
[2].
In our series, the sensitivity of FNAC was 57.9%, the
specificity 97.8%, the PPV 91.7% and the NPV 84.9%.
Overall accuracy of FNAC in diagnosis of parotid masses
was 86%. Lurie et al. [12] found in their study the sensitivity, specificity and the accuracy of FNAC for parotid
masses were 66, 100 and 69.2% respectively. The sensitivity, specificity, PPV, NPV and the accuracy of FNAC for
parotid lumps in Zbarens study were 64, 95, 83, 87 and
86%, respectively [2]. Lim et al. [3] found the sensitivity
and specificity of FNAC in the diagnosis of malignant
tumors 80 and 100%, respectively. In another study Stow
et al. [13] noted that the sensitivity, specificity and accuracy in their series were 86.9, 96.3 and 92.3%, respectively.
In the Aversas study [6], the sensitivity was 83%, the
specificity and the accuracy were reported as 100 and 97%
respectively.
In the recent literature, the sensitivity has ranged from
54 to 95%, the specificity from 86 to 100%, and the
accuracy from 84 to 97% [2, 3, 6, 12, 13]. Our findings are
comparable to previous published series.
Cytological diagnosis of parotid mass is affected by
two important problems. In one side, non-diagnostic
specimen, which is defined as inadequate material
obtained for cytologic diagnosis. On the other side, misdiagnosis, that may be related to low experience of
pathologist and the kinds of cells in specimen. Nondiagnostic and inadequate smears have been reported in

Indian J Otolaryngol Head Neck Surg (JulySeptember 2012) 64(3):257260

210% of cases in the literature [2]; in our cases we

observed 5 of 70 (7%) inadequate smears.
We excluded these inaccurate results from the statistical
analysis the same as several previous studies [8, 9, 14, 15]. In
those studies, a test was interpreted just when it was done
properly. Those authors believed that the accuracy of cytologic diagnosis of a mass could be calculated when enough
specimen has been obtained. Other studies have included
non-diagnostic specimens in the statistical analysis which
consequently led to the relatively high rate of false negative
results [2, 3, 6, 9, 12, 13]. In other words, the sensitivity of
FNAC is affected by this high false negative rate.
The most important reasons that lead to non-diagnostic
samples are:

Low experience of the clinician who takes the specimen

[2, 9].
Cyst formation, necrosis and hemorrhage within a
parotid mass [2, 6].
Very firm lesions with low cellularity [6].
Taking specimen from small nodules [6].

The most important reasons that lead to misdiagnosis and

high rate of false negative are:

Low experience of the pathologist who interprets the

specimen [2, 9].
The histopathology of parotid tumors is diverse and
heterogeneous that makes it difficult to diagnose based
solely on FNAC. Atypical cells can be found in both
benign and malignant tumors [3].
Chronic reactive sialoadenitis may frequently be associated with several types of malignancy. Therefore, in
some malignant cases, reactive sialoadenitis may be
diagnosed by FNAC [6].
Diagnosing lymphoma is difficult, even among experienced cytopathologist. It is due to the difficulties in
cytologically distinguishing small neoplastic lymphocytes of a low grade lymphoma from small reactive
lymphocytes [3, 12, 13].

How could we improve FNAC results for diagnosis of

parotid masses? Low percentages of non-diagnostic smears
are achieved by considering following points:

Smears are examined immediately by a cytopathologist

and the procedure is repeated in the case of inadequate
material [2, 16].
Specimens should be taken by well experienced
clinicians [2, 9].
Specimens, especially from small, deep, cystic, hemorrhagic and necrotic masses, are better to be taken
under ultrasound guide [12].
In cystic, hemorrhagic and necrotic masses, it is better
to tap the fluid before taking the material for FNAC.

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All parotid masses clinically suspected for malignancy

with a non-diagnostic or negative finding on FNAC,
must be aspirated again [2].

Diagnosing malignant parotid tumors based solely on

clinical features is difficult. Most malignancies present in a
similar fashion as benign tumors. Signs and symptoms of
malignancy, such as pain, facial nerve palsy, enlarged
cervical lymph nodes are only present in approximately
2535% of patients [17]. Preoperative diagnosis of malignancy helps the surgeon to choose the best treatment plan
[3, 6, 18]. Therefore, we believe that FNAC has a definite
role in the evaluation of parotid masses and should be
incorporated as part of the holistic management in patients
who present with a parotid mass. Attempts to reduce nondiagnostic and false negative results should be considered
by clinicians and pathologists.

Conclusion
FNAC is a reliable method in the evaluation of parotid
masses with an acceptable specificity and sensitivity rate.
This method bears unquestionable value in cases of
differential diagnosis between glandular, lymph node,
inflammatory, and neoplastic diseases and between benign
and malignant neoplasms. It is a rapid, cost-effective, easyto-perform, and well-tolerated procedure which carries a
low risk of complications. The non-diagnostic and falsenegative results are the limitations of FNAC that should be
reduced to improve its usefulness in the evaluation of
parotid tumors.
Conflict of Interest
of interest.

The authors declare that they have no conflict

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