Mid-17th century – Anatomy of the parotid

gland and the role of the main ducts.

Greeks called "para-auricular swellings" -

described findings associated with calculi and

inflammation.

1650-1750 , salivary gland surgery was limited to

the treatment of ranulas and oral calculi.

Bertrandi in 1802 - The concept of surgical

excision of a parotid tumor

Initial surgeries - serious disfiguration and disability

By1850, the focus shifted toward

dissection and the intimate relationship

between the FN and the parotid gland

Codreanu (1892) - First total parotidectomy with

facial nerve preservation.

Early 1950s - Grafting of the facial nerve after

resection.

Beahrs and Adson (1958) - Surgical technique of

current parotid gland surgery.

*They stressed surgical landmarks for avoiding injury FN

*Advocated complete removal of the superficial portion for

benign lesions confined to that portion of the gland

Largest salivary gland. (wt. 15gms)

Enclosed by investing layer of deep cervical fascia.

FN divides the gland into the superficial (80 %) and deep lobe (20%)

Parotid duct (Stensons) is 5 cm long and opens opposite the upper second molar.

Lymphatic drainage – periparotid/intraparotid

Accessory parotid lobe – Present in 20% of patients

Branches of the facial nerve

Terminal branch of the external carotid artery that divides into the maxillary artery and the superficial temporal artery

Retromandibular vein

Intraparotid lymph nodes

Parotid glands

Superficial lobe – 80% of the glandular mass

80% of all salivary tumors occur in the parotid

gland.

80% arise in the superficial lobe.

80% are benign

80% are pleomorphic adenomas.

Paired salivary glands -

lie below the mandible

Larger superficial and a

smaller deep lobe -

around the posterior

border of the mylohyoid

The deep part lies on

the hyoglossus muscle

Deep cervical fascia which splits to enclose it.

Wharton’s duct(5 cm) emerges from deep surface

It drains into the anterior floor of the mouth at the sublingual papilla

Paired set of salivary glands

Anterior part of the floor of mouth between the mucous membrane, the mylohyoidmuscle and the body of the mandible close to the mental symphysis

Numerous excretory ducts - open either directly into the oral cavity or indirectly via ducts that drain into the submandibularduct

pleomorphic adenomas originate from the intercalated duct cells and myoepithelial cells

oncocytic tumors originate from the striated duct cells

acinous cell tumors originate from the acinarcells

Mucoepidermoidtumors and squamouscell carcinomas develop in the excretory duct cells.

Mixed tumour

(Pleos – many : morphus – form)

Commonest benign salivary tumour in adult

Common in parotid (80%)

Common in females

Pseudocapsule, Pseudopodal extensions

Epithelial ,mesenchymal and

myoepithelial components,

Abundant matrix mucoid,myxoid or

chondroid supporting tissue

Contains cartilages, cystic spaces, solid

tissues.

Dumb bell tumor –

if deep lobe is

involved

Lobulated , painless swelling, Long duration

Neither adherent to skin/ masseter muscle

Generally firm / variable consistency

Raised ear lobule

Curtain sign – swelling cannot be moved above zygomatic bone

Curtain sign deflected ear lobule

FNAC

CT Scan

MRI Scan

Incisional biopsy is contraindicated !!!!

Surgery is the TOC

Superficial parotidectomy- if only

superficial lobe is involved

Total conservative parotidectomy- if

both lobes are involved.

Adenolymphoma (misnomer)

Second most common tumor in the salivary glands.

Warthin in 1929

Slow growing , painless cystic neoplasm –

exclusively in the parotid gland.

Typically- lower pole

Proliferation of lymphoid tissues of intra/peri parotid LN

Predisposing factor – smoking, radiation exp and EBV

Round to oval Swelling , well

circumscribed encapsulated

masses

Multicentric or multifocal disease

Soft ,fluctuant

Fifth to seventh decades of life

Male : female :: 10:1

Elderly males , smokers

Bilateral 10%

No Malignant potential

Investigations

FNAC

Tc99 scan – hot spot

(due to high mitochondrial content)

Treatment

Superficial parotidectmy with preservation

of facial nerve

Enucleation

Observation

<1% of salivary tmrs

More common in females

Exclusively in parotid

Composed of oncocytes ,arranged in

chords or sheets

Descrete well encapsulated

Hot spot on Tc 99 scan

Rare

Females > males

Composed of columnar cells arranged in

double layer

Slow growing ,well circumscribed firm

nodule with cystic spaces

MC parotid tmr in children

Present at birth

Soft, compressible, fluctuant with typical

bluish hue

Usually spontaneous resolution (5-6 yrs)

Oral prednisolone

Surgery only in complicated cases

MC malignant tumor of salivary gland

MC malignant tumor to occur in parotid

F > M

Slow growing

Pain , facial palsy

Arises from excretory ducts of glands

Presence of mucin prosucing cells, squamous cells of ducts or acini.

High grade(predominantly squamous

cells)

Intermediate grade,

low grade (predominantly mucous cells)

Low grade can be managed similar to that of pleomorphic adenoma

Positive margin- post op RT

Intermediate grade- total conservative parotidectomy

High grade- more aggressive treatment

Total parotidectomy with resection of involved facial N br. And nerve grafting

Neck dissection,full course of post op RT

2nd MC malignant tmr of parotid

MC malignant tmr of SM & SL gland

Cystic or Cribriform arrange ment- “Swiss

Cheese pattern”

Perineural invasion

Tubular , cribriform, solid

(prgnosis best to worst)

Treatment – Aggressive resection of the gland

Any nerve in the path of tmr should be resected.

Recurrences – skull base ,cranial nerves as the tmr spreds into CNS

Resistant to RT, recurrence cannot be cured with RT

Malignant tmr of acinic cells

Slow growing, almost always in parotid

Finger like extension into adjacent tissues

LN involvement is common.

Trtmnt – aggressive resection with TP , resection of FN, nerve grafts, complete ND if nodes are palpable.

Hard infiltrating mass often associated with

FN involvement

Cervical node mets

Systemic organ mets

Treamment – surgery f/b post op RT

Poor prognosis

Parotid is common site

High grade tmr

M> F

High propensity for regional nodal

spread

Poor prognosis

Almost always in parotid (only SG which

contain LN or lymphatic tissue)

Primary (NHL) or secondary

Local manifestation of syst disease

Often found in pts with AIDS

MC involved SG – parotid (rich lymphoid

tissue)

Arise from malignant neoplasm of head

and neck area

Melanoma > Sq cell ca >others

Hematogenous spread– parotid is MC

site– MC from Ca of thyroid

Superficial Parotidectomy

Total parotidectomy with or with out FN

conservation

‘Lazy S’ pre auricular mastoid-cervical

incision

Development of skin

flap

Mobilisation of gland

Development of

avascular plane

Identification of facial

nerve

* 1cm deep and

inferior to Conley’s

pointer

* Immediately superior

to upper border of

post belly of digastric

muscle

Dissection of the

gland off the FN (in

the perineural plane

with scissors)

Closure with a suction drain

1) Tmr with peri neural invasion

Adenoid cystic Ca

2) MC SG tmr in adults

Pleomorphic adenoma

3) MC parotid tmr in children

Hemangioma

4) Male smoker with Tc 99 hot spot

warthins

5) MC malignant tmr of parotid

Mucoepidermoid Ca

6) MC malignant tmr of SM/SL

Adenoid cystic Ca

7)MC parotid tmr

Pleomorphic adenoma

8)Mets MC from

Head and neck tmr (MC- Ca Thyroid)

Adenolymphoma of parotid gland is

primarily NHL

False

Adenoid cystic ca recurrence can be

easily treated by post operative RT

false

3) TOC for hemangioma of parotid is

superficial parotidectomy

False

4) Salivary gland lymphoma almost always

involves parotid as it is the only SG that

contain lymphoid tissue

True

The most common parotid tumor is

› A. Pleomorphic adenoma

› B. Mucoepidermoid carcinoma

› C. Adenoid cystic carcinoma

› D. Detroit tigers

Most parotid tumors are ___________

› A. Benign 60%

› B. Benign 80%

› C. Malignant 60%

› D. Malignant 80%

All of the following are true regarding

adenoid cystic carcinoma except?

› A. It rarely spreads to Lymph nodes

› B. It is a common minor salivary tumor

› C. It typically does not involve nerves

› D. 40% develop pulmonary metastasis

What is the most common tumor of

minor salivary glands

› A. Pleiomorphic Adenoma

› B. Adenoid cystic carcinoma

› C. Mucoepidermoid carcinoma

› D. Squamous cell carcinoma

What seperates the superficial parotid

from the deep lobe?

› Facial Nerve