1. The parotid gland is the largest salivary gland located below and in front of the ear. The submandibular gland is located beneath the jawbone. Saliva produced by these glands contains enzymes and antibodies that support oral health. 2. Sialography uses dye and x-rays to visualize the salivary ducts and identify any obstructions like stones. Benign tumors and infections are common salivary gland conditions. Surgery may be used to treat tumors or remove obstructions in the ducts. 3. The most common salivary gland tumor is the pleomorphic adenoma, which is generally benign. Sjögren's syndrome is an autoimmune condition that

1. SALIVARY GLANDS

2. ANATOMY

3. PAROTID GLAND ANATOMY
• It is the largest of the salivary gland, situated below the acoustic
meatus between the ramus of mandible and sternomastoid muscle.
• The deep cervical fascia splits to form a capsule (parotid capsule) to
enclose the gland.
Parts of the Parotid Gland
• Superficial part (80%)—lies over the posterior part of the ramus of
mandible.
• Deep part (20%)—lies behind the mandible and medial pterygoid
muscle; in relation to mastoid and styloid process.

4. • Parotid (Stensen’s) duct emerges from anterior surface
of the gland, runs over the surface of the masseter
muscle and opens into the oral mucosa opposite to the
crown of upper second molar tooth.
• Facial Nerve
It emerges from the stylomastoid foramen lying between
external auditory meatus and mastoid process.
• Branches are –
1. Temporal (auricularis anterior and superior part of
frontalis),
2. Zygomatic (frontalis and orbicularis oculi),
3. Upper buccal and lower buccal (buccinator,
orbicularis oris, elevators of the lip)
4. Mandibular (lower lip muscles)
5. Cervical (platysma)

5. • Blood Supply :-
It is from external carotid artery; and venous drainage is by external
jugular vein.
• Nerve Supply :-
It is from autonomic nervous system, parasympathetic is secretomotor
from auriculotemporal nerve, sympathetic is vasomotor from plexus
around the external carotid artery.
Structures within the parotid gland from deep to superficial:-
1.External carotid artery, maxillary artery, superficial temporal artery,
posterior auricular artery
2.Retromandibular vein (by maxillary and superficial temporal veins)
3.Facial nerve with its branches

6. Submandibular Salivary Gland
• It is a ‘J’ shaped salivary gland situated in the anterior
part of the digastric triangle.
Parts :-
• Superficial part: Lies in submandibular triangle,
superficial to mylohyoid and hyoglossus muscles,
between the two bellies of digastric muscle.
• Deep part is in the floor of the mouth and deep to
mylohyoid muscle.
• Venous drainage is to anterior facial vein.
• Nerve supply: Branches from the submandibular
ganglion.

7. MINOR SALIVARY GLANDS
• There are around 450 minor salivary glands
which are distributed in lips, cheeks, palate
and floor of the mouth.
• They contribute to 10% of total salivary
volume.
• Sublingual glands are minor salivary glands
one on each side; located in the anterior
aspect of the floor of the mouth.
• Gland drains directly into mucosa or through a
duct which drains into submandibular duct.
This duct is called as Bartholin duct.

8. SALIVA
• 1500 ml of saliva is secreted per day.
Saliva contains
1. lingual lipase secreted from tongue glands.
2. α amylase from salivary glands.
3. mucin, glycoproteins, immunoglobulin IgA, lysozyme, lactoferrin
which binds iron, proline rich proteins that protect enamel.
• Parotid saliva is 20% of total secretion of saliva per day and is serous
and watery.
• submandibular is 70% and is mucous and moderately viscous.
• sublingual is 5% and is mucous and viscous.

9. FUNCTIONS OF SALIVA
• Saliva facilitates swallowing, keeps mouth moist.
• Serves as solvent for taste buds.
• Facilitates speech
• Keeps oral cavity rinsed and clean.
• Antibacterial
• Neutralizes gastric acid content in regurgitation to relieve heartburn.

10. SIALOGRAPHY
• Indications
1. Salivary fistulas.
2. Sialectasis.
3. Congenital conditions.
4. Extraglandular masses.
5. Parotid duct stones
PROCEDURE:- Dye used is lipiodol or sodium diatrizoate . 24-gauge cannula is passed
into either Stensen’s duct or Wharton’s duct and 1 ml of the dye is injected into the
duct and X-ray is taken.

11. FINDINGS IN SIALOGRAPHY
• Narrowing (Stricture)
• Grape-like cluster appearance (Sialectasis)
• Dilatations
• Communications (Fistulas)
• Mass lesions

12. SALIVARY CALCULUS AND SIALADENITIS
• 80% are submandibular, Calculi are more common in submandibular
gland, because the gland secretion is viscous, contains more calcium
and also, its drainage is nondependent, causing stasis
• 80% radio-opaque.
• It is commonly calcium phosphate and calcium carbonate stones.
• Stone is single in 75% of cases.

13. Acute Sialadenitis
• Features are Pain, swelling, tenderness is seen in submandibular
region and floor of the mouth.
• Dysphagia, trismus, fever.
• Double chin appearance due to spreading of oedema downwards.
• Duct is inflamed and swollen.

14. Chronic Sialadenitis
• Symptoms :-
Pain is more during mastication due to stimulation.
• Salivary colic is pain induced by obstruction to the outflow of saliva
may be ductal stone.
• During salivation size of the swelling will decrease again 2 hours after
meal/stimulation.
• Salivary secretion is more during mastication causing increase in
gland size. Firm/rubbery tender swelling is palpable bidigitally.

15. Investigations
• Intraoral X-ray (dental occlusion films) to see radio-opaque stones
(80%).
• FNAC of the gland to rule out other pathology.
• Total count and ESR in acute phase.
• USG will demonstrate stone with posterior acoustic shadow.

16. Treatment
• If the stone is in the duct, removal of the stone is done intraorally, by
making an incision in the duct.
• If stone is in the gland, excision of submandibular gland is done—
sialadenectomy.
• Approach is from submandibular region (outside).
• An incision is made on the skin in submandibular region, about 5–8 cm
length, parallel to and 2–4 cm below the mandible. Incision is deepened
through the deep fascia until the gland is visualised without raising the
flaps Facial artery is ligated twice. Lingual nerve and hypoglossal nerves
are taken care of. Mylohyoid is retracted so as to remove the deep
portion of the gland.

17. Complications of Surgery
• Haemorrhage.
• Infection.
• Injury to marginal mandibular nerve, lingual nerve, hypoglossal nerve.
• Injury to nerve to mylohyoid causing anaesthesia over submental
skin.

18. SIALOSIS
• It is enlargement of the salivary gland due to fatty infiltration, as a
result of various metabolic causes like diabetes, acromegaly, obesity,
liver disease, alcoholism, bulimia, idiopathic, drug induced
(sympathomimetics, carbimazole, thiouracil).
• It is diffuse, bilateral, non-inflammatory, non-neoplastic asymptomatic
swelling of the salivary gland mostly of parotids with fatty infiltration
and acinar cell hypertrophy.
• Clinical features: Bilateral diffuse enlargement of parotids, which is
smooth, firm, non-tender.
• Treatment: The cause is treated

19. SIALECTASIS
• It is an aseptic dilatation of salivary ductules causing grape-like
(cluster-like) dilatations.
• It is a disease of unknown aetiology with destruction of parenchyma
of gland accompanied by stenosis and cyst formation in the ductules.
• It is common in parotids; often bilateral.
• Presents as a smooth, soft, fluctuant, non-transilluminating swelling
which increases in size during mastication.
• Sialogram is diagnostic (grape or cluster-like dilatations).
• Treatment is conservative (nonsurgical).

20. PAROTID ABSCESS (SUPPURATIVE PAROTITIS)
• It is a result of an acute bacterial sialadenitis of the parotid gland.
• It is an ascending bacterial parotitis, due to reduced salivary flow,
dehydration, starvation, sepsis, after major surgery, radiotherapy for
oral malignancies and poor oral hygiene.
• Parotid fascia is densely thick and tough and so parotid abscess does
not show any fluctuation until very late stage.
• Causative organism are Staphylococcus aureus (commonest),
Streptococcus viridans and often others like gram-negative and
anaerobic organisms

21. Clinical Features
• Pyrexia, malaise, pain and trismus.
• Red, tender, warm, well-localised, firm swelling is seen in the parotid region
(brawny induration).
• Tender lymph nodes are palpable in the neck.
• Pus or cloudy turbid saliva may be expressed from the parotid duct opening.
INVESTIGATIONS:-
U/S of the parotid region.
Pus collected from duct orifice is sent for culture and sensitivity.
Needle aspiration from the abscess is done to confirm the formation of pus.

22. TREATMENT
• Antibiotics are started depending on culture report.
• When it is severely tender and localised, incision and drainage is done
under G/A.
• Proper hydration, mouth wash using povidone iodine/potassium
permanganate solutions, nutritio

23. PAROTID FISTULA
• Parotid fistula arise from parotid gland or duct or ductules.
• It may open inside the mouth as internal fistula; or open outside onto
the skin as external fistula.
• Fistula from the duct has profuse discharge. Fistula from the gland often
shows only minimal discharge
1. Duct fistula forms after superficial parotidectomy. It is profuse and
often persisting.
2. Gland fistula occurs from the raw surface after superficial
parotidectomy. It is mild and symptom subsides in a month with
anticholinergic drugs.

24. Causes
• After superficial parotidectomy.
• After drainage of parotid abscess, ruptured abscess.
• After biopsy.
• Trauma.
• Recurrence of malignant tumour.
Clinical Features :-
1. Discharging fistula in the parotid region of the face, and discharge is
more during eating.
2. Tenderness and induration.
3. Trismus.

25. Diagnosis
• Sialography to find out the origin of the fistula whether from parotid
gland or duct or ductules.
• Fistulogram or CT fistulogram.
• Discharge study.
• MRI.

26. TREATMENT
• Anticholinergics—hyoscine bromide (probanthine).
• Radiotherapy.
• Repair or reinsertion of the duct into the mucosa.
• Newman Seabrock’s operation—probe is passed into the parotid duct
through the opening in the mouth. Another probe is passed through the
fistula. Duct and fistula are dissected over the probe. After removal of the
fistula track severed duct ends are identified; and ends are trimmed.
• If still persists, auriculotemporal nerve which supplies secretomotor
component of parotid is cut.
• If there is stenosis at the orifice of the Stenson’s duct, papillotomy at the
orifice may help.
• Total conservative parotidectomy is done in failed cases.

27. SJÖGREN’S SYNDROME
• It is an autoimmune disease causing progressive destruction
of salivary and lacrimal glands, leading to
keratoconjunctivitis sicca (dry eyes), and xerostomia (dry
mouth).
• Types
1. Primary Sjögren’s Syndrome (Primary Glandular Sicca
Syndrome)
2. Secondary Sjögren’s Syndrome

28. 1. Primary Sjögren’s Syndrome (Primary Glandular Sicca
Syndrome)
• Severe dry mouth.
• Severe dry eyes.
• Widespread dysfunction of exocrine glands.
2. Secondary Sjögren’s Syndrome
• Dry mouth.
• Dry eyes.
• With association of connective tissue disorders like:
Primary biliary cirrhosis (near 100%). SLE (30%).
Rheumatoid arthritis (RA) (15%)

29. Clinical Features
• It is common in middle aged females who present with dry eyes, dry
mouth, enlarged parotids and enlarged lacrimal glands.
• Often they are tender.
• Superadded infections of the mouth, Candida albicans is common.

30. INVESTIGATIONS
• Autoantibody estimation—rheumatoid factor, antinuclear factor,
salivary duct antibody.
• Sialography.
• Estimation of salivary flow.
• Slit lamp test of eyes.
• Schirmer test—to detect lack of lacrimal secretion.
• FNAC of parotids and lacrimal glands.
• 99Technetium pertechnetate scan for gland function.

31. TREATMENT
It is conservative.
• Artificial tears.
• Artificial saliva.
• Frequent drinking of water.
• Treat the cause.

32. MIKULICZ DISEASE
• It is a clinical variant of Sjögren’s syndrome.
• It is an autoimmune disorder of salivary and lacrimal glands, resulting
in infiltration of the glands with round cells.
• It may be due to or associated with sarcoidosis, Sjögren’s syndrome,
leukaemia, lymphoma.
Triad of MIKULICZ disease
1. Symmetrical and progressive enlargement of all salivary glands
2. Narrowing of palpebral fissures due to enlargement of the lacrimal
glands
3. Parchment-like dryness of the mouth

33. WHO CLASSIFICATION OF SALIVARY
NEOPLASM

34. ETIOLOGY
• Genetic—loss of alleles of chromosomes in 12q, 8q, 17q
• Infective—mumps, Epstein-Barr virus, chronic
• Radiation—mucoepidermoid carcinoma is more in these patients.
• Smoking—adenolymphoma of Warthin’s shows 40% risk in smokers.
• Sex—benign tumours and many malignancies are common in females;
Warthin’s and some malignancies are common in males.
• Environment and diet—Arctic-Eskimos show dietary deficiency of
vitamin A and develop salivary tumour. Industrial agents like nickel,
cadmium, hair dyes, silica, preservatives increase the risk of salivary
tumours

35. PLEOMORPHIC ADENOMA (Mixed Salivary
Tumour)
• Commonest of the salivary gland tumour in adult.
• It is 80% common.
• More common in parotids (80%). 10% in submandibular salivary
gland; 0.5% in sublingual salivary gland.
• It is mesenchymal, myoepithelial and duct reserve cell origin.
• Grossly it contains cartilages, cystic spaces, solid tissues.
• Microscopically it is biphasic in nature with epithelial and stromal
components. Benign tumours will usually not show necrosis.

36. CLINICAL FEATURES
• Swelling, pain, ulceration, dysphagia (if deep lobe is involved)
• Raised ear lobule
• Cannot be moved above the zygomatic bone—curtain sign
• Deviation of uvula and pharyngeal wall towards midline in case of
deep lobe tumour
• Facial nerve, masseter, skin, lymph node and bone involvement
eventually occurs in case of malignancy

37. Complications
• Recurrence—5–50%.
• Malignancy.
3–5% in early tumours & 10% in long duration (15 or more years)
tumours.
Investigations
FNAC .
CT scan to know the status of deep lobe, local extension and spread.
MRI

38. TREATMENT
• Surgery—first line treatment.
• If only superficial lobe is involved, then superficial parotidectomy is
done wherein parotid superficial to facial nerve is removed.
• If both lobes are involved, then total conservative parotidectomy is
done by retaining facial nerve

39. ADENOLYMPHOMA (Warthin’s Tumour,
Papillary Cystadenoma Lymphomatosum)
• It is a misnomer. It is not malignant, it is not lymphoma.
• It is a benign tumour that occurs only in parotid, usually in the lower
pole. It is said to be due to trapping of jugular lymph sacs in parotid
during developmental period.
• It composed of double layer of columnar epithelium, with papillary
projections into cystic spaces with lymphoid tissues in the stroma.
• It usually involves only superficial lobe of parotid gland. It may also be
multicentric.
• Smoking (40%/8 times more risk than nonsmokers) and radiation
exposure may be the cause.

40. Features
• It presents as a slow growing, smooth, soft, cystic, fluctuant swelling,
in the lower pole, often bilateral and is nontender.
• It is common in males—4:1.
• Common in smokers.
• Common in old people – 60 years.
• Its incidence is 10%. Common in Whites.
• It is 2nd most common benign tumour.
• It is often bilateral—10%.

41. Investigations
• Adenolymphoma produces a “hot spot” in 99Technetium
pertechnetate scan—it is diagnostic (Due to high mitochondrial
content).
• FNAC. Adenolymphoma does not turn into malignancy. But
occasionally it can simultaneously be associated with pleomorphic
adenoma, carcinoma or lymphoma of parotid.
Treatment
• Superficial parotidectomy

42. ONCOCYTOMA (Oxyphil Adenoma)
• It is <1% of salivary tumours.
• Usually benign, originating from oncocytes (oxyphilic cells).
• Radiation and occupational hazards are the causes.
• Common in parotid; but rarely can occur in submandibular salivary
gland.
• Gross—small, tan coloured, well circumscribed encapsulated solid
tumour.
• Microscopy—large oncocytes with swollen granular cytoplasm due to
abundant mitochondria. Tyrosine crystals are present in glandular
spaces.

43. BASAL CELL ADENOMA
• It is rare, benign, now classified under monomorphic adenoma
containing isomorphic basaloid cells with basal layer and basement
membrane.
• It is common in minor salivary glands; in major salivary glands it is
multicentric.
• Grossly it looks like lymph node.
• Microscopy—isomorphic basaloid cells with solid/trabecular/
tubular/membranous pattern.

44. MUCOEPIDERMOID TUMOUR
• It is the commonest malignant tumour in parotid.
• It occurs both in major as well as minor salivary glands. Parotid is the
commonest site; palate is the commonest minor salivary gland site (In the
palate adenoid cystic carcinoma is common).
• Radiation is the commonest etiological factor.
• Gross—unencapsulated solid tumour with cystic spaces.
• Microscopy—biphasic with mucin secreting (+ve for PAS, – ve for diastase)
low grade and epidermoid with high grade; clear cell with intermediate
type.

45. TYPES
• Low grade—mucous cells mainly—spreads to regional nodes.
• Intermediate—clear cell variety.
• High grade—epidermoid cells mainly—spreads to regional nodes and
also shows high propensity for distant spread.
FEATURES
• Swelling in the salivary (parotid or submandibular) region, slowly
increasing in size, eventually attaining a large size, which is hard,
nodular, often with involvement of skin and lymph nodes

46. ADENOID CYSTIC CARCINOMA
• It is most common tumour in submandibular and sublingual salivary
gland.
• It is slow growing but highly malignant with remarkable capacity for
recurrence. But it is classified under low grade malignancy.
• Microscopy: Cribriform, tubular, and solid are 3 types .
• It has got high affinity for perineural spread along mandibular and
maxillary divisions of trigeminal (common) nerve and facial nerve.
• Radical parotidectomy/wide or radical excision of submandibular and
sublingual glands with neck nodal dissection and postoperative RT is
the treatment of choice

47. ACINIC CELL TUMOUR
• It is a rare, slow growing tumour that occurs almost always in parotid
and is composed of cells alike serous acini.
• It is more common in women. It occurs in adult and elderly.
• It is 3% of salivary tumours; 90% occurs in parotid.
• Microscopically, it can be microcystic (commonest), papillary,
follicular, medullary etc.
• It can involve facial nerve or neck lymph nodes.
• Clinically, it is of variable consistency with soft and cystic areas.

48. MALIGNANT MIXED TUMOUR (MMT)
• It is 10% of salivary malignancy in incidence with epithelial and
mesenchymal elements.
• It carries worst prognosis.
TYPES
• Carcinoma ex pleomorphic adenoma: It is the commonest type. It is the
most aggressive salivary malignancy. Radical parotidectomy is the
treatment.
• Primary malignant mixed tumour: It shows components of both carcinoma
and sarcoma.
• Metastasizing mixed tumours: It contains structures typical of benign
mixed tumour both at original and at metastases sites.

49. ADENOCARCINOMA OF SALIVARY GLANDS
• It is 3% of parotid and 10% of submandibular and minor salivary gland
tumours.
• It is equal in both sexes.
• It is common in children
• It can be tubular, papillary and undifferentiated.
• 20% involve facial nerve clinically.
• Undifferentiated type is aggressive.

50. SQUAMOUS CELL CARCINOMA OF SALIVARY GLANDS
• It is rare in salivary glands.
• In salivary glands, parotid is the common site.
• It occurs in 6th or 7th decade. It is aggressive nonencapsulated
tumour arising from ductal system.
• It grows rapidly causing pain, facial palsy, skin fixity, ulceration.
• It spreads commonly to neck nodes and carries poor prognosis.
• Radical parotidectomy and RT is the treatment of choice.

51. SUBMANDIBULAR SALIVARY GLAND TUMOURS
Benign tumours:
• They are commonly pleomorphic adenomas, are smooth, firm or hard,
bidigitally palpable, without involving adjacent muscles or hypoglossal
nerve or mandible bone.
• Diagnosis is by FNAC, Orthopantomogram (OPG) and CT scan.
• Excision of both superficial and deep lobes of the gland is done.
Malignant tumours of submandibular salivary gland:
• They are hard, nodular, often get fixed to skin, muscles, hypoglossal
nerve and mandible.
• Diagnosis is by FNAC of primary tumour and of lymph nodes when
involved, CT scan and OPG.

52. TREATMENT
• Wide excision, with removal of adjacent muscle, soft tissues and
mandible.
• If lymph nodes are involved, block dissection of neck (Classical neck
dissection) is done

53. TNM Staging of Malignant Salivary Tumours (AJCC, 7th
Edition, 2010, Clinical Staging)
T—Tumour
Tx —Tumour cannot be assessed.
T0 —No evidence of primary tumour.
T1 —Tumour < 2cm without extraparenchymal spread
T2 —Tumour 2–4 cm, without extraparenchymal extension
T3 —Tumour >4 cm. —or with extraparenchymal spread. —but no facial
nerve spread
T4a —Spread to facial nerve, skin, mandible, ear canal
T4b—or spread to base of skull, pterygoid plates, encased external carotid
artery.

54. N—Lymph node
Nx — Nodes not assessed.
N0 — Regional nodes not involved.
N1 — Single ipsilateral node < 3 cm.
N2a — Single ipsilateral node 3–6 cm.
N2b — Multiple ipsilateral nodes < 6 cm.
N2c — Bilateral or contralateral nodes < 6 cm.
N3 — Single node spread > 6 cm.

55. M—Metastases
M0 — No blood spread.
M1 — Blood spread present.
Staging
Stage I – T1N0M0
Stage II – T2N0M0
Stage III – T3N0/N1Mo
Stage IVA – T4aN2N1N0M0
Stage IVB – T4b any NM0; any T N3M0
Stage IVC – Any T any N M1 Note

56. SPECIFIC INVESTIGATIONS:-
FNAC:-
• FNAC confirms possibility of (35% of patients)
lymphoma/inflammatory masses.
• FNAC allows preoperative counselling regarding nature of tumour,
likely extent of resection (conservative/radical), management of facial
nerve (high grade adenoid cystic), and likelihood of neck dissection
(high grade).

57. MRI
• It is very useful to find out perineural spread, bone marrow
involvement, skull bones, internal architecture and intracranial
extensions, recurrent tumours
CT SCAN:-
• It is to see the deep lobe of the parotid: the involvement of bone,
extension into the base of the skull; relation of tumour to internal
carotid artery, styloid process, deep lobe tumour, parapharyngeal
space extension. Neck nodes are better assessed.

58. TREATMENT
SURGERY
• T1, T2, T3 tumours of low grade—total conservative parotidectomy
• T4 tumours, high grade tumours, SCC—radical parotidectomy It
includes facial nerve sacrifice, may involve resection of skin,
mandibular ramus, masseter muscle, infratemporal fossa dissection,
subtotal petrosectomy.

59. COMPLICATIONS
• Haemorrhage
• Infection, flap necrosis
• Fistula
• Frey’s syndrome
• Facial nerve palsy
• Facial numbness
• Numbness in ear lobule due to injury to great auricular nerve
• Sialocel

60. • Postoperative radiotherapy It is quite useful to reduce the chances of
relapse. Usually, external radio therapy is given. It is given in all carcinomas
Indications for radiotherapy
• T3, T4 tumours
• High grade tumours
• Perineural spread
• Adenoid cystic carcinomas
• Deep lobe tumour
• Vascular involvement
• Close clearance margin
• Multiple neck nodes involvement
• Recurrent malignant tumours.

61. • CHEMOTHERAPY
5 FU, cisplatin, doxorubicin, epirubicin, cetuximab are used.
• PREOPERATIVE RADIOTHERAPY
It is given in large tumours to reduce the size and make it better
operable, i.e. to down stage the disease.

62. MINOR SALIVARY GLAND TUMOURS
• It is 10% of salivary tumours.
• It is common in — palate (40%) — lip — cheek — sublingual glands.
• Palate is the commonest site.
• 10% are benign—commonly pleomorphic adenomas.
• 90% are malignant—commonly adenoid cystic carcinomas.
• They present as swelling with ulcer over the summit.
• If it is malignant, then extension into the palate, maxilla, pterygoids
can occur often with involvement of the lymph node

63. Investigations
1. Incision biopsy.
2. CT scan.
3. X-ray maxilla.
4. FNAC of lymph node.

64. Treatment
• Wide excision often with palatal excision or maxillectomy is done—for
malignancy.
• If the tumour is less than 1 cm in size excision biopsy is done with 1
cm clearance margin.
• If the tumour is more than 1 cm in size, initially incision biopsy is done
and then wide excision is done.
• Reconstruction by dental plates, skin grafting, or flaps are done.
• Lymph node block dissection of the neck is done if involved.

65. PAROTID LYMPHOMA
• Parotid lymphoma can occur from the lymph nodes in the gland or
from parotid parenchyma.
• It can occur in HIV patients; lymphoepithelial diseases and in
Sjögren’s syndrome.
• Disease may be confined to parotid gland or may involve other nodes
in neck, mediastinum.
• When it is confined to parotid,total parotidectomy with radiotherapy
and later chemotherapy is the treatment..

66. PAROTIDECTOMY
Types
1. Superficial parotidectomy: It is the removal of superficial lobe of the
parotid (superficial to facial nerve). Done in case of benign diseases of
superficial lobe of the parotid.
2. Total conservative parotidectomy: It is done in benign diseases of parotid
involving either only deep lobe or both superficial and deep lobes. Here both
lobes are removed with preservation of facial nerve.
3. Radical parotidectomy: Both lobes of parotid are removed along with
facial nerve, fat, fascia, muscles (masseter, pterygoids and buccinator), lymph
nodes. It is done in case of carcinoma parotid. Later facial nerve reconstruction
is done using great auricular nerve graft.
4. Suprafacial parotidectomy is done in lower pole parotid tumours wherein
all branches of the facial nerve need not be dissected.

67. STEPS IN PAROTIDECTOMY
• Lazy ‘S’ incision—modified Blair's/Sistrunk's approach and raising the skin flaps
• Mobilisation of the gland
• Flap is reflected in front just up to anterior margin of the parotid. After
identification of sternocleidomastoid great auricular nerve is identified
• Location of stylomastoid branch of posterior auricular artery is anterior to
facial nerve trunk which enters the stylomastoid foramen.
• Identification of facial nerve trunk.
• Dissection of the gland off the facial nerve
• Removal of parotid—superficial/both.
• Distilled water irrigation to kill spilled tumour cells.
• Haemostasis and closure with a suction drain.

68. Complications of parotidectomy
• Facial nerve injury
• Haemorrhage
• Salivary fistulas
• Infection—Flap necrosis is common
• Frey’s syndrome

69. FREY’S SYNDROME (Auriculotemporal Syndrome,
Gustatory Sweating)
• Occurs in 10% of cases.
• It is due to injury to the auriculotemporal nerve, wherein postganglionic
parasympathetic fibres from the otic ganglion become united to
sympathetic nerves from the superior cervical ganglion (Pseudosynapsis).
• Auriculotemporal nerve has got two branches.
Auricular branch supplies external acoustic meatus, surface of tympanic
membrane skin of auricle above external acoustic meatus.
Temporal branch supplies hairy skin of the temple.
• Sweating and hyperaesthesia occurs in this area of skin

70. CAUSES
• Surgeries or accidental injuries to the parotid.
• Surgeries or accidental injuries to temporomandibular joint

71. CLINICAL FEATURES
• Flushing, sweating, erythema, pain and hyperaesthesia in the skin
over the face innervated by the auriculotemporal nerve, whenever
salivation is stimulated (i.e. during mastication). .
• Involved skin is painted with iodine and dried. Dry starch applied
over this area will become blue due to more sweat in the area in
Frey’s syndrome—Minor's Starch iodine test.

72. TREATMENT
• Reassurance
• Jacobsen neurectomy (tympanic)
• Injection of botulinum toxin to the affected skin
• Antiperspirants like aluminium chloride
• Syndrome can be prevented on table by placing muscle
(sternomastoid) or fascial (temporalis) flaps or artificial membranes
over parotid bed, under the skin

73. FACIAL NERVE INJURY (Lower Motor Nerve
Lesion, Surgically Related)
Causes:-
• Trauma
• Surgery—parotidectomy, drainage of parotid abscess.
• Compression of facial nerve—Bell’s palsy.
• Temporary/transient facial nerve palsy after parotidectomy.

74. Clinical Features
• Inability to close the eyelid.
• Difficulty in blowing and clenching.
• Drooping of the angle of the mouth.
• Obliteration of nasolabial fold.
• Loss of forehead wrinkles.
• Wide palpebral fissure.
• Epiphora

75. TREATMENT
• Nerve grafting using greater auricular nerve, sural nerve, lateral
cutaneous nerve of thigh or hypoglossal nerve.
• Suspension of angle of mouth to zygomatic bone using temporal
fascia sling.
• Lateral tarsorrhaphy—to prevent corneal ulceration.
• Medial canthus reconstruction—to reduce epiphora.
• Cross-facial nerve transplantation from opposite side using its
insignificant branches.
• Dynamic neurovascular muscle graft.
• Upper lid gold weights to protect cornea