parotid gland and tumours

1. Dr.
Dr.BETH ESELM FINSEYOUM
WOLAITASODOUNIVERSITY
MBBS MS FIAGES FMAS FICRS DMAS
ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL AND MINIMAL ACCESS SUGERY
SHARDA INSTITUTE OF MEDICAL SCIENCES AND RESEARCH
SU 1
PAROTID GLAND
TUMOURS AND
TREATMENT
DR.KARAN R RAWAT

2. Introduction
Anatomy
Etiology
Investigation
Classification
Surgical steps
complications
Contents
2

3. Salivary glands
• exocrine glands- saliva
• have numerous lobes composedof
smaller lobules
Introduction
3

4. • .
Basicsecretory unit
4

5. absorb Naand secrete K,H2CO3
5

6. • Parotid gland -purely serous cells.
• Submandibular: mixed cells but mainlyserous
cells
• Sublingual: mostly mucouscells
Salivary Glands…
6

7. Majorsalivary glands
-paired parotid, submandibular
and sublingual glands
Minor salivary glands
-consist of 600 to 1,000glands
7

8. 85/28/2018 AccessorLIyDETpUaandrBEoTHtEiL,d gWSlUand

9. Parotid gland…
Parotid duct
9

10. • Enclosedwithin parotid sheath (capsule),
derived from investing layer of deepcervical
fascia.
clinical significance
Acute sialadenitis - pain.
Parotid abscess is palpated as firm.
Parotid gland…
10

11. • lateral surface of is almostflat.
• Deep surfacelies- lateral to the superior
constrictor of the pharynx.
- Benign or malignant neoplasms that develop
in the deep lobe presents as a swelling in the
lateral wall of the oropharynx and not as a
facial swelling.
Parotid gland…
11

12. Embedded within the substance ofparotid
gland, from superficial to deep, are
 the facial nerve (CNVII)and its branches
 retromandibular vein
 external carotid artery.
 lymph nodes
Parotid gland…
12

13. Parotid gland…
WSU 13

14. Facial nerve branches
14

15. Facialnerve divides the gland into two
surgical zones (superficial and deeplobes
15

16. • Blood supply ECAand its branches that are
adjacent to thegland.
• Veins drain into external jugularvein.
• Lymphatic vesselsdrain into nodes that areon
or in thegland.
- parotid nodes then drain into superficialand
deep cervical nodes
Vasculature of parotid glands
16

17. 17

18. • Sensory innervation -Auriculotemporal nerve
and great auricular nerve.
• Parasympathetic and – glossopharyngial
nerve with lesser petrosal nerve then- otic
ganglion -via auriculotemporal nerve.
• Sympathetic
from superior cervical plexus
Innervation of parotidgland
18

19. SensoryInnervation
19

20. Parasympathetic
20

21. Sympathetic
21

22. • Theepidemiology of salivary gland tumours is notwell
documented .
• Theglobal annual incidence when all salivary glandtumours
were considered varied from 0.4-13.5
• Malignant salivary neoplasms- 0.4-2.6 casesper 100,000
• In the U.S,malignancies accounted for 6%of head andneck
cancers, and 0.3%of all malignancies casesper 100,000
population.
• Theaverage agesfor tumours are 46 and 47years.
Epidemiology
22

23. • Themost common tumour type ispleomorphic
adenoma( 50%of all tumours.)
• mucoepidermoid carcinoma is the mostcommon
malignant Tumour
23

24. 24

25. 25

26. No etiology ,but riskfactors
Genetic- loss of alleles of chromosomes in12q, 8q, 17q.
Infective -Recurrent inflammation
Viruses -EBVin lymphoepithelial carcinomas (Asian)
Radiation- survivors of atomic bomb explosion;
mucoepidermoid carcinoma
Occupation- ( rubber manufacturing,plumbing industry
and nickel compounds)
Lifestyle and nutrition
– smoking for Warthin tumour
– deficiency of vitaminA
Aetiology
26

27. Examination
27

28. .
WSU 28

29. Ultrasound
• helpful in distinguishing solid fromcystic
lesions.
• lymphoepithelial cysts, cystic hygromas
involving the salivary glands, ranulas,sialoceles
and multiple lymphoepithelial cysts
• However, the diagnostic capabilities of this
modality are inferior to that of CTand MRIin
solid masses.
Investigations
29

30. • FNAbiopsy is useful in establishing whethera
given lesion
is inflammatory or neoplastic,
is alymphoma or an epithelial malignancy,
is ametastasis or aprimary tumour
Therate of correctly establishing adiagnosis
asbenign or malignant ranges from 81-98%in
most recent reports.
Investigation….
30

31. • Common diagnostic pitfalls- difficulty to differentiate
between
Benign oncocytic tumors acinic cell carcinomas
pleomorphic adenomas adenoid cystic carcinomas
high-grade mucoepidermoid
carcinoma
metastatic squamous cell carcinoma
low-grade mucoepidermoid
carcinoma
Warthin’s tumor
31

32. • Open biopsy is contraindicated inparotid
tumours due to:
 Chanceof injury to facialnerve
 Seedling and high chanceof recurrence
 Chanceof parotid fistulaformation
Why not Biopsy?
32

33. CTscanto seethe deep lobe of theparotid:
• the involvement of bone, extension into the baseof
the skull; relation of tumour to internal carotid artery,
styloid process,
• Deeplobe tumour, parapharyngeal spaceextension.
• Neck nodes are better assessed.
• Bony changesin the foramina, erosions andsclerotic
margins in fissures or canals,enlarged diameter of
canal and fissure are the CTfeatures of perineural
spread.
• CTangiography for hemangeoma
33

34. 34

35. MRIis very useful to findout
• Perineural spread
Replacement of perineural fat with tumour,
contrast (gadolinium) enhancement,
increased sizeof the nerve
• Bone marrow involvement
• Internal architecture andintracranial
extensions, recurrent tumours.
35

36. WSU 36

37. .
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38. Benign Salivary Gland Tumors
38

39. Malignant Salivary GlandTumors
39

40. 40

41. .
Benign tumours
41

42. • Commonest of the salivary gland tumourin
adult ( 80%common).
• More common in parotids(80%).
• 10%in submandibular salivary gland; 0.5%in
sublingual salivary gland.
• It is mixed -myoepithelial and ductreserve
cell origin.
• Grossly it contains cartilages, cysticspaces,
solid tissues.
Pleomorphic adenoma
42

43. • Epithelial cells
• Myoepithelial cells
• Mucoid material with myxomatouschanges
• Cartilages/pseudocartilage
histologically it shows
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44. • common in females(3:1).
• age-common in 4th& 5th
• Usually unilateral.
• painless, smooth, firm lobulated,
mobile swelling in front of the parotid
with positive curtainsign
• Obliteration of retromandibulargroove
• Theear lobule islifted.
• When deep lobe is involved, swelling is
in the lateral wall of pharynx, posterior
pillar and over the softpalate—10%
• Facialnerve is not involved.
Clinical features
44

45. 5/28/2018 LIDETUand BETHEL, WSU 45

46. • Sudden onset of pain denotesmalignant
transformation
• Painis due to:
– Capsular distension by tumour
– Obstruction to free flow ofsaliva
– Nerve infiltration
– Inflammation like in Warthin’s
– Tumour necrosis
Painin salivarytumours?
, 46

47. • Surgery—first line treatment.
• Ifonly superficial lobe is involved, then superficial
parotidectomy.
• If both lobes are involved, then total conservative
parotidectomy is done by retaining facialnerve.
Enucleation ?
• is avoided asit causeshigh recurrence due toextension
of tumour outside aspseudopods acrossthecapsule.
Treatment
, 47

48. ADENOLYMPHOMA(Warthin’s Tumour,
Papillary Cystadenolymphomatosum)
• It is not malignant, it is not lymphoma.
• It is abenign tumour that occurs onlyin
parotid, usually in the lowerpole.
• It is said to be due to trapping of jugular
lymph sacsin parotid duringdevelopmental
period.
L 48

49. • aslow growing, smooth, soft,
cystic, fluctuant swelling, in the
lower pole, often bilateral andis
nontender.
• It is common in males—(4:1),
smokers, old people( 60 years),
Whites.
• It is 2nd most commonbenign
tumour.
Treatment
• Superficial parotidectomy.
Clinical Features
, 49

50. • Hemangiomas are benign proliferations of
vesselsclosely resembling normal vessels.
• Their similarity to normal vesselsis sogreatthat
it is unclear whether they represent vessel
malformations, true neoplasms, or
hamartomatous overgrowths.
• congenital and represent vascular
malformations.
• typically found in the pediatric agegroup.
• 90%are seenin the parotid gland
• Themajority are of the cavernous type andless
likely the capillarytype.
• Theyare typically slow flow lesions and maynot
be angiographically evident.
Hemangiomas
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52. • Plain Xray may show multiple calcified
phelebolith.
• ultrasonography may reveal heterogeneous,
hypoechoic lesions with calcified
pheleboliths.
• CTscanshows tumor with enhancing quality
of blood vessels.
• However the soft tissue density of the
tumor, its homogeneity, and any areasof
extension are best demonstrated byMRI.
52

53. • Treatment modalities
Include;
surgical resection followed by regular followup.
In children –watch
• Chemotherapy -propranolol
• corticostirodes
• laser, cryotherapy and corticosteroids.
53

54. Malignant tumours
, 54

55. • glandular epithelial neoplasm characterizedby
mucous, intermediate and epidermoid cells,
with columnar, clear cell and oncocytoid
features.
• (MEC)is the most common primary salivary
gland malignancy in both adults andchildren
Mucoepidermoid carcinoma
55

56. • Most tumours present asfirm,
fixed and painlessswellings.
• Sublingual gland
 pain
blue-red colour and mimic amucocele orvascular
lesion.
• Cortical bone is sometimes superficially eroded.
• Symptoms caninclude pain,
otorrhoea,paraesthesia, facial nerve palsy,
dysphagia, bleeding and trismus
Clinical features
56

57. 57

58. • For small, low-grade tumors acomplete
resection by parotidectomy is adequate..
• For high-grade mucoepidermoid carcinomas,
treatment is more aggressive and radiation
therapy is indicated
• Dueto ahigh rate of occult neckmetastases,
an elective neck dissection even for with an
N0 neck.
Treatment
58

59. • Most patients haveafavorable outcome.
• In one study, 8%of patients died of disease:
11%and 5%for major and minor gland
tumours, respectively.
• Death correlated with high-grade
Prognosis
59

60. • Abasaloid tumour consisting of epithelial and
myoepithelial cells
• Comprise - 10%of all epithelialsalivary
neoplasms
• frequently involve the parotid.
Adenoid cystic carcinoma
60

61. • Clinical features
• Themost common symptom is aslow growing
massfollowed by pain due to the propensity
of these tumours for perineuralinvasion.
• Facial nerve paralysis may also occur.
61

62. • Wide local and radical surgical excisionswith
and without post-operative radiation is the
treatment of choice
treatment
62

63. • The5- year survival rate 35%
• Eighty to 90%of patients die of diseasein10-
15 years
• Thelocal recurrence -16-85%.
• Theincidence of distant metastasisis
estimated to range from25-55%.
prognosis
63

64. •very rare and constitute about 2–5%ofall
salivary gland neoplasms.
• Most casesinvolve the major salivaryglands,
parotid (50–93%).
• These neoplasms may arise from anintraparotid
lymph node or in the glanditself.
•predominantly B-cell type lymphomas
• Salivary gland T-cell lymphomas (Hodgikins) are
very rare
Lymphomas
64

65. • Painlessswelling
• progressive growth
clinically
65

66. • Surgery-diagnostic
• Radiation
• Chemotherapy
prognosis
• Poor prognosis
Treatment
66

67. 5 yearssurvival
67

68. • Surgery
• Radiotherapy
• chemotherapy
General Treatment modalities
68

69. Carcinomacan be:
• Lowgrade (acinic cell; low grade
mucoepidermoid) .
• Highgrade (adenocarcinoma; adinoid cystic
;squamous cell carcinoma; high grade
mucoepidermoid)
, 69

70. Parotid Indications for surgery.
• T1,T2,T3tumours of low grade—total
conservative parotidectomy.
• T4tumours, high grade tumours, radical
parotidectomy -It includes facial nerve
sacrifice, may involve resection of skin,
mandibular ramus, masseter muscle,
infratemporal fossadissection, subtotal
petrosectomy.
Treatment
70

71. • Preoperative paralysis of nerve
• Intraoperative evidence of grossinvasioneven
in presence of normal preoperativefunction.
• Nerve stump is checked for frozen section for
negative margins
• if positive- mastoidectomy and nerve
dissection in temporal bone isneeded
Indications for facial nervesacrifice
71

72. • Facial nerve is reconstructed using greater
auricular nerve, or suralnerve.
• Nerve graft is not acontraindication forfuture
RT(do RTafter 6 weeks)
72

74. Indications
• T3,T4tumours
• High grade tumours
• Perineural spread , Adenoid cysticcarcinomas.
• Deeplobe tumour.
• Vascular involvement.
• Closeclearance margin.
• Multiple neck nodesinvolvement.
• Recurrent malignant tumours.
• Recurrent pleomorphic adenoma.
Radiotherapy
74

75. • Theproclivity for distant recurrence displayed by
adenoid cystic carcinoma and high-grade
adenocarcinoma, highlights the need for effective
systemic chemotherapy.
• Standard cytotoxic chemotherapies, including
platinum or taxane-based regimens, havebeen
studied in patients with ACCand other
histological sub-types.
• BUTthe benefit of chemotherapy is not found
CHEMOTHERAPY
75

76. SURGICALAPPROACHESTO
PAROTIDGLANDS
.
76

77. 77
Types
• 1. Superficial parotidectomy
• 2 Totalconservative parotidectomy
• 3 Radicalparotidectomy
• 4 Microparotidectomy
• 5 Extracapulardissection
PAROTIDECTOMY

78. Radical parotidectomy :
• Both lobes of parotid are removed along with
facial nerve, fat, fascia, muscles (masseter,
pterygoids and buccinator), lymph nodes.
78

79. Suprafacial parotidectomy
is done in lower pole parotid tumours
wherein all branches of thefacial nerve need
not bedissected.
79

80. • Lazy‘S’ incision—modified
Blair's/Sistrunk's approach raisingthe
skin flaps reflected in front just up to
anterior margin of the parotid; never
beyond.
• Mobilisation of the gland identification
of sternocleido-mastoid great auricular
nerve is identified and canbesacrificed.
• Posterior belly of digastric is identified.
• Divide the external
jugular vein
Stepsin parotidectomy
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81. • Tragalpointer (nerve 1 cm deepand
inferior)
• Anterior aspect of mastoidbone
• Tympanomastoid suture line
(leads directly to stylomastoid
foramen)
• Posterior belly of digastric muscle
(Facial nerve at same depth, just
above muscle)
• Palpate the styloid process
• Branch of occipitalartery
Identification of facialnerve
81

82. • a retro-grade dissection may
be required after locating the
temporal branch where it
crosses the zygoma, the
buccal branches which lie
parallel to the parotid duct .
• The marginal mandibular
branch where it crosses the
facial artery and vein just
below or at the inferior
margin of the mandible,
where it is just deep to
platysma.
Tracing branch from distal to proximal
(Hamilton-Bailey technique)
82

83. • The deep lobe can be deli-vered from
the parapharyngeal spaceby blunt
dissection
• divide the ECA, deep TFA and STA
and the RMV and STV,when they are
encountered during dissection
• Obtain meticulous haemostasis.
• Employ aValsalvamaneuvre to identify
venous bleeding .
• Sealed suction drain: Until drainage
<50ml/24 hrs
83

84. If facial n. isremoved,
• Graft with greatauricular
• Sural
• Hypoglosal Nerves
84

85. COMPLICATIONSOFPAROTIDGLANDTUMORSURGERY
• Hematoma.
• Infection.
• Salivary–cutaneous fistula
• Facialnerve injury
• Lossof ear sensation
• F‘EY’S SYND‘OME(gustatory sweating)
• Skinnecrosis.
, 85

86. References
Clinicallyoriented
anatomy, 6th edition
Netter – Atlas of human
anatomy
Grays Anatomy
86

87. ?
87