What does facial asymmetry due to a parotid tumor look like in a child?

Facial Asymmetry in Pediatric Parotid Tumors

In a child with a parotid tumor, facial asymmetry typically manifests as a visible, unilateral facial fullness or mass in the preauricular/cheek region, creating an obvious left-right difference in facial width and contour, usually presenting as a slowly progressive, asymptomatic swelling. 1, 2

Clinical Appearance

The asymmetry presents as:

• Unilateral facial widening on the affected side, creating a noticeable left-right difference in facial width and cheek contour 3, 1
• Visible mass or fullness in the preauricular region extending into the cheek, most commonly presenting as a hard, slowly growing swelling 1, 2
• Gradual, progressive facial asymmetry that may exist for months to years before presentation, as these tumors grow slowly 1, 4
• Absence of facial nerve dysfunction in most cases—the asymmetry is due to mass effect rather than nerve paralysis, as facial nerve function typically remains intact with benign lesions 5, 2

Key Distinguishing Features

The asymmetry in parotid tumors differs from other facial asymmetries:

• The mass creates external facial contour changes rather than skeletal or soft tissue developmental asymmetries like orbital level differences, jaw rotation, or alar base tilting 3
• Most children present with an asymptomatic mass (the most common presentation in pediatric parotid tumors), without pain, facial weakness, or overlying skin changes 2, 4
• The swelling is localized to the parotid region (preauricular and cheek area), distinguishable from diffuse facial asymmetries involving the midface, orbital region, or jaw 3, 2

Critical Warning Signs

Evaluate specifically for features suggesting malignancy:

• Facial nerve weakness or paralysis—this is the most concerning sign and may indicate malignant invasion, though it occurs in only a minority of cases 5, 2
• Rapid growth or recent change in a longstanding mass 2
• Associated cervical lymphadenopathy, which may indicate malignant spread 6
• Skin fixation or overlying erythema 3

Diagnostic Approach

Initial imaging should be ultrasound to confirm the parotid origin and characterize the mass, as recommended by the American College of Radiology for pediatric neck masses 3, 6

For surgical planning or concerning features, obtain MRI with and without IV contrast to evaluate tumor extent, deep lobe involvement, and relationship to the facial nerve 3, 6, 4

Clinical Context

In the pediatric population, approximately 47.5% of parotid masses are benign (most commonly pleomorphic adenoma at 22.9%), 36.4% are infectious/inflammatory, and 16.1% are malignant 2. The typical patient is over 10 years old, though tumors can occur at any age 2. Despite the visible asymmetry, facial nerve function is preserved in the vast majority of cases, with permanent facial weakness occurring in only 9.3% after surgical treatment 2.