Slow-growing mobile lump below the ear
44-year-old female
§Chief complaint
Painless lump in front of and below the left ear for 3 years
§Medical & dental history
- 01No radiation exposure; otherwise well
- 02Unremarkable
§Clinical examination
- 01Firm, mobile, non-tender 30 mm mass at the left parotid tail
- 02Overlying skin normal; no fixation to skin or deep tissue
- 03Facial nerve function normal in all branches (House-Brackmann I)
- 04No cervical lymphadenopathy; clear saliva from Stensen duct
§ figuresFigures (2)
Fig. 1Micrograph of Pleomorphic Adenoma of Salivary gland. The section shows a cellular area interspersed with islands of lighter stained bluish myxoid tissue. The cellular area is the epithelial element and is composed of cel
“Pleomorphic Adenoma Salivary gland 10x” · Calicut Medical College · CC BY-SA 4.0 · Wikimedia Commons
Fig. 2Micrograph of a pleomorphic adenoma. Pap stain. See also Image:Adenoid cystic carcinoma cytology.jpg
“Pleomorphic adenoma - cytology” · Nephron · CC BY-SA 3.0 · Wikimedia Commons
Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Pleomorphic Adenoma figures pending faculty review.
§Differential diagnosis
§Final diagnosis
Pleomorphic adenoma of the left superficial parotid lobe
A slow-growing, mobile, painless parotid mass with a normal facial nerve, a well-defined lobulated mass with high T2 signal on MRI, and FNAC showing epithelial and myoepithelial cells in a chondromyxoid stroma is diagnostic.
§Investigations
- 01Ultrasound-guided fine needle aspiration cytology
- 02MRI of the parotid to define depth and relationship to the facial nerve plane
- 03No incisional biopsy — risk of tumour seeding and fistula
§Radiology
- 01Ultrasound — well-defined lobulated hypoechoic 30 mm mass in the superficial lobe
- 02MRI — homogeneous high T2 signal with a capsule; no deep lobe or parapharyngeal extension
§Treatment plan
- 01Superficial parotidectomy with facial nerve preservation
- 02Avoid enucleation — high recurrence from pseudopodia through the capsule
- 03Long-term follow-up for recurrence and rare carcinoma ex pleomorphic adenoma
§Surgical procedure
- 01Modified Blair incision, skin flap raised, facial nerve identified at the tragal pointer and tympanomastoid suture
- 02Superficial lobe dissected off the nerve branches with a nerve monitor; tumour removed with a cuff of normal gland
- 03Drain placed; layered closure
§Histopathology report
Encapsulated tumour with biphasic epithelial and myoepithelial proliferation forming ducts and sheets within a chondromyxoid stroma; focal capsular pseudopodia, no invasion, no atypia. Margins clear. Pleomorphic adenoma.
§Follow-up & outcome
- 01Day 1 — facial nerve intact, mild lower branch weakness resolving by week 4
- 026 months — no Frey syndrome symptoms
- 03Annual review for 10 years
Outcome: Complete excision with preserved facial nerve function and no recurrence at 3 years.
§Discussion
- 01Pleomorphic adenoma is the commonest salivary gland tumour, and 80% arise in the parotid, mostly in the superficial lobe.
- 02Carcinoma ex pleomorphic adenoma develops in long-standing untreated lesions, which is one reason for excision rather than observation.
- 03Complications of parotidectomy include facial nerve injury, Frey syndrome, sialocele, and greater auricular nerve numbness.
§Clinical pearls / learning points
- 01Never enucleate a pleomorphic adenoma — capsular pseudopodia cause multinodular recurrence.
- 02Facial weakness or pain in a parotid mass suggests malignancy.
§Viva questions
How do you identify the facial nerve during parotidectomy?
Tragal pointer, tympanomastoid suture, posterior belly of digastric, and retrograde dissection from a peripheral branch.
What is Frey syndrome?
Gustatory sweating from aberrant reinnervation of sweat glands by parasympathetic secretomotor fibres after parotid surgery.
§MCQs
Q1The commonest salivary gland tumour is:
Q2Recurrence after enucleation of pleomorphic adenoma is caused by:
§ evidenceReferences & Evidence
Current Classification
WHO Classification of Head and Neck Tumours
5th Edition — Volume 9
WHO Classification of Tumours Editorial Board · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
Evidence summary
Highest level of evidence linked to this page: WHO / Official Classification.
- L1 · Classification — 3
- L3 · Systematic review — 1
- L6 · Textbook — 3
2 linked sources were published from 2024 onwards. Where guidance is limited or contested, rely on the higher-level sources above rather than this summary. Educational use only — not a substitute for clinical judgement.
Content last reviewed
September 2026
Evidence last reviewed
September 2026
Next scheduled review
September 2027
Review status
EVIDENCE REVIEWED
Search latest PubMed evidence
Last literature search: 7 September 2026
Current Classification
WHO Classification of Tumours Editorial Board. IARC / World Health Organization · 2022
The authoritative international classification of head and neck, odontogenic and salivary gland tumours. Current terminology on this site follows this edition.
Skálová A, Hyrcza MD, Leivo I. Head and neck pathology · 2022 · 16(1):40-53
Summary of changes to salivary gland tumours in the 5th edition WHO classification of head and neck tumours.
IARC / WHO. IARC · 2022
Continuously updated online edition of the WHO head and neck tumour classification.
Systematic Reviews & Meta-Analyses
Salzano G, Scocca V, Troise S et al.. Medical sciences (Basel, Switzerland) · 2025 · 13(3)
Comparative review of extracapsular dissection versus superficial parotidectomy outcomes.
Histopathology References
Barnes L. CRC Press · 2008
Detailed histopathological reference for head and neck diagnostic criteria.
Textbook References
Neville BW, Damm DD, Allen CM et al.. Elsevier · 2024
Standard reference textbook of oral and maxillofacial pathology used throughout this atlas.
Rajendran R, Sivapathasundharam B. Elsevier · 2020
Undergraduate and postgraduate oral pathology textbook widely used in BDS and FCPS curricula.
Additional sources cited on this page
- WHO Classification of Head and Neck Tumours, 5th edition, 2022.
- Witt RL et al. Etiology and management of recurrent parotid pleomorphic adenoma. Laryngoscope 2015.
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