Approach

• Sit / kneel to be at the same level as the patient's face
• Examine as for any lump

1. Inspect
   • Swelling in the region of the parotid gland (lies wedged between the sternocleidomastoid and the mandible) and the submandibular gland (at the angle of the jaw, wedged between the mandible and mylohyoid)
   • Look for scars and the opening of a fistula (can follow parotidectomy or long-standing parotid traumatic injury)
   • Stand back and look for facial asymmetry which occurs if the VIIth nerve is involved with a parotid lesion.
2. Palpate from behind
   • Walk behind the patient and enquire about tenderness before palpating the swelling
   • Unilateral or bilateral?
   • Fixity? - ask patient to clench teeth
   • examine for other features as for any lump
   • check cervical lymphadenopathy
3. Other tests
   • Look inside mouth with pen torch at opening of parotid duct (Stensen's duct): opposite upper 2nd molar and opening of submandibular duct (Wharton's duct)
   • Look for inflammation and pus, or the presence of a stone
   • Palpate the parotid duct and submandibular duct openings wearing a pair of gloves
   • Palpate the submandibular gland bimanually with a finger in the mouth and another finger below the angle of the jaw

Completion

1. Test the facial nerve
2. Perform a full ENT examination

Differential diagnoses of a unilateral swelling of the parotid gland

Features to suggest a parotid swelling is malignant in nature

1. Rapid growth and pain
2. Hyperaemic skin
3. Hard consistency
4. Fixed to skin and underlying muscle
5. Irregular surface or ill-defined edge
6. Facial nerve involvement 

Parotid Tumours

• Adenomas of several varieties
• Two most important are pleomorphic adenoma (commonest) and Warthin's tumour (second most common)

Salivary gland tumours

• 80% salivary gland tumours occur in the parotid gland, 80% of which are benign, with 80% being pleomorphic adenomas
• 10% salivary gland tumours occur in the submandibular gland, with 60% being benign
• Risk factors: exposure to radiation
• Commonest malignant salivary gland tumour is the mucoepidermoid tumour, which is most common in the parotid gland
• Commonest malignant salivary gland tumour occur in the submandibular gland is adenoid-cystic carcinoma
• Treatment of malignant salivary gland tumours involves total excsion of the involved gland with preservation of associated nerves unless there is direct infiltration of the nerve by tumour

Management of Parotid lumps

1. History
2. Examination
3. Investigations
   • FNAC - cytology for diagnosis
   • MRI to exclude deep lobe involvement
4. Treatment
   • Superficial parotidectomy

Complications of Parotidectomy

1. Immediate
   • Facial nerve injury
   • Reactionary haemorrhage
2. Early
   • Wound infection
   • Temporary facial weakness (neuropraxia)
   • Salivary fistula
   • Division of the greater auricular nerve (loss of sensation to the pinna)
3. Late
   • Wound dimple
   • Frey's syndrome: increased sweating of the facial skin when eating due to reinervation of divided sympathetic nerves to the facial skin by fibres of the secretomotor branch of the auriculotemporal nerve