Parotid gland tumours

1. PRESENTATION AND OUTCOME OF
PAROTID GLAND TUMOURS
Muhammad Saaiq,

2. INTRODUCTIONINTRODUCTION

3. INCIDENCE
Salivary gland tumours are relatively uncommon,
accounting for less than 1% of all reported
malignancies.
In USA parotid tumours claim 650 lives annually.
In UK 40 new cases are reported annually.
Parotid gland is the most common site of neoplasms
among these (75% - 80%) and account for 3-4% of
all head and neck tumours. They display
considerable variation in their biological behaviour
and even histology is not a good prognostic
indicator.

4. CLASSIFICATION

5. A) EPITHELIAL TUMOURSA) EPITHELIAL TUMOURS
a)a) BenignBenign
b)b) MalignantMalignant
B) NONB) NON--EPITHELIAL TUMOURSEPITHELIAL TUMOURS

6. A) EPITHELIAL TUMOURS:
a) BENIGN :
Pleomorphic adenoma (mixed parotid tumour)
Monorphic adenomas
Warthins tumours (Adenolymphoma or Papillary cystadenoma
lymphomatosum)
Benign lymphoepithelial tumour (Goodwin’s tumour)
Oxiphil adenoma (oncocytoma)
Basal cell tumour
Others
b) MALIGNANT
Mucoepidermoid CA
Adenoid cystic CA (Cylindroma)
Acinic cell CA
Adeno CA
CA ex-pleomorphic adenoma
Lympho epithelioma
Rare tumours: Sqamous cell carcinoma, Metastatic tumors, Anaplastic CA
CLASSIFICATION

7. B)NON EPITHELIAL TUMOURS:
Lymphoma
Hemangioma
Lymphangioma
Neurofibroma
Lipoma
CLASSIFICATION
(Cont’d)

8. PAROTID TUMOURS
INCREASING ORDER OF MALIGNANCY
Anaplastic, Adeno CA
Cylindroma
Mucoepidermoid tumour
Fast growing CAs
Add Your Text
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Acinic cell tumour
Pleomorphic adenoma

9. SO THE INCREASING ORDER OFSO THE INCREASING ORDER OF
MALIGNANCY IS AS FOLLOWSMALIGNANCY IS AS FOLLOWS

10. 1) Pleomorphic adenoma
2) Acinic cell tumour
3) Mucoepidermoid
tumour
4) Cylindroma
5) Fast growing CA
Adeno CA
Anaplastic CA

11. PLEOMORPHIC ADENOMA

12. Most common of all parotid tumours (60 % of all)
Patient is usually around 45 years .
It is important for three reason:
a.Close proximity to Facial Nerve that can be damaged
during surgery.
b.May recurr if tumour is damaged at operation
c.Can become CA ex-pleomorphic adenoma

13. PRESENTATION OFPRESENTATION OF
PLEOMORPHIC ADENOMAPLEOMORPHIC ADENOMA

14. Usually as a painless slow growing lump on the side of
the face in front of the ear.
Pleomorphic adenoma is usually firm to hard, mobile,
well circumscribed lump. Very rarely it arises from
deep lobe and then develop within parapharyngeal
space.

15. REPRESENTATIVE CASES:
Left sided pleomorphic Adenoma:

16. REPRESENTATIVE CASES:
Pleomorphic Adenoma

17. REPRESENTATIVE CASES:
Right sided pleomorphic Adenoma:

18. REPRESENTATIVE CASES
Left sided pleomorphic Adenoma:

19. Mucoepidermoid tumour
Commonest malignant tumour.
Vary in degree of differentiated.
Well differentiate (low grade), intermediate, poorly
differentiated (high grade), more likely to recur.
Mostly slow growing & limited invasion, occasionally
metastasize
Clinically harder.

20. RECURRENT MIXED TUMOUR

21. Is characterized by presence of multiple, round, well-
circumscribed nodules growing in salivary gland tissue, in
adipose tissue adjacent to gland or in the scar of previous
surgery.
History of same previous benign tumour.
Carcinoma may arise in these therefore each nodule should
be examined microscopically.
Nodules in recurrent mixed tumour do not exhibit the
features of cell anaplasia and invasiveness that characterize
malignant mixed tumour.

22. Adenoma Lymphoma
Warthin’s tumour, Papillary cystadenoma lymphatosum is
slow growing, soft sometimes fluctuant, bilateral 10%, hot
spot on Tc99 pertechnictate scan
Treatment excision.

23. Acinic Cell Tumour
Rare, slow growing, more common in women

24. Adenoid Cystic Carcinoma
Elderly, slow growing, hard, fixed painful, areas of
anaesthesia and paralysis of muscles due to
involvement of related nerves. Infilterates for long
distances in the perineural tissues of adjacent nerves
and may invade maxillary bone.
Metastasis to lymph nodes and hematogenous to long
bones may occur.

25. FEATURES SUGGESTIVE OF
PAROTID CA

26. 1) Sudden rapid growth in previously slowly
growing tumour.
2) Mild intermittent pain, tenderness.
3) Nerve involvement/Facial weakness
4) Skin ulceration, tethered skin etc.
5) Symptoms due to surrounding structure
involvement e.g dysphagia
6) Unremarkable mass at the site of origin.

27. DIFFERENTIAL DIAGNOSES OF PAROTID
SWELLING:
1) Idiopathic hypertrophy of masseter muscle.
2) Pre-auricular lymphadenopathy.
3) TB
4) Reticulosis
5) Calculus(rare)
6) Miscellaneous
Ch. parotitis
Hemangioma
Cysts etc.

28. CLINICAL EXAMINATIONCLINICAL EXAMINATION

29. 1) LOCAL EXAM. INCLUDING BIMANUAL
EXAMINATION (Compare with the opposite side).
a) Inspect the gland from outside
b) Palpate the gland from outside:
- main body of gland consistency, tenderness.
- anterior limit
- superior third of the gland
- inferior third of the gland
- postero inferior part of the gland

30. Contd:
c) Inspect the Stensen’s duct orifice from inside. Apply
pressure over gland from without.
d) Palpate the duct
e) deep lobe of the gland from inside.
2) TEST THE FACIAL NERVE
3) EXAMINE THE CERVICAL NODES
4) EXAMINE OTHER SALIVARY GLANDS
5) PERFORM SYSTEMIC EXAM.

31. DIFFERENTIAL DIAGNOSES OFDIFFERENTIAL DIAGNOSES OF
PAROTID SWELLINGPAROTID SWELLING

32. 1) Idiopathic hypertrophy of masseter muscle.
2) Pre-auricular lymphadenopathy.
3) TB
4) Reticulosis
5) Calculus(rare)
6) Miscellaneous
Ch. parotitis
Hemangioma
Cysts etc.

33. DIAGNOSTIC INVESTIGATIONSDIAGNOSTIC INVESTIGATIONS

34. 1) BIOPSY
a) FNAC (90% accuracy)
b) Trucut biopsy
c) Frozen section biopsy
d) Wedge biopsy
e) Histopathology

35. Contd.
2) CT scan
3) MRI
4) U/S
5) Sialography
6) CXR
7) Angiography
8) Plain radiography
9) Radio isotope scan
10) Gallium scan
11) Others

36. SURGICAL OPTIONS

37. SuperficialSuperficial parotidectomyparotidectomy
TotalTotal parotidectomyparotidectomy
RadicalRadical parotidectomyparotidectomy
Functional /Radical neck dissectionFunctional /Radical neck dissection
enucleation/wide excision uptill
1950’

38. The objective of Surgery is to eliminate all the tumour
with minimum of deformity(by preserving the facial
nerve) and to reconstruct any residual defect.

39. INCISIONS FOR PAROTIDECTOMY

40. FACIAL NERVE IDENTIFICATION:
1) Tragal pointer of cartilage of external auditory canal--
----1 cm deep, slightly inferior & ant. to tragal
pointer.
2) 6-8 mm deep to inferior end of tympanomastoid
suture line.
3) Between the styloid process & the attachment of
diagastric to diagastric ridge of mastoid process.

41. 4) Follow the posterior facial vein superiorly as it
enters the parotid gland & here marginal
mandibular nerve crosses superficial to post.
Facial vein which is followed posteriorly to main
trunk.
5) “V”Sulcus between bony external auditory canal
and mastoid process. Identify buccal branch as it
courses parallel to the parotid duct which is
identified anteriorly as it crosses the masseter
muscle.
7) Remove the mastoid tip and identify the facial
nerve as it exits to the styloid mastoid canal.
8) IdentifyIdentify buccalbuccal branch as it courses parallel to thebranch as it courses parallel to the
parotid duct which is identifiedparotid duct which is identified anteriorlyanteriorly as itas it
crosses thecrosses the massetermasseter muscle.muscle.

42. OTHER METHODS:
Staining method (injection of Methylene blue in
salivary duct).
Nerve stimulator.
Anatomical identification with mechanical stimulation.

43. FACIAL NERVE:

44. TRAGAL POINTER

45. FACIAL NERVE POSITION

46. DEEP LOBE TUMOUR

47. NERVE DISSECTION

48. FACIAL NERVE BRANCHES

49. RETROMANDIBULAR VEIN

50. FACIOVENOUS PLANE

51. RETROMANDIBULAR PARAPHARYNGEAL
SPACE

52. REPRESENTATIVE CASE:
Right sided pleomorphic Adenoma:

53. REPRESENTATIVE CASE:
Right sided pleomorphic Adenoma:

54. REPRESENTATIVE CASE:
Right sided pleomorphic Adenoma:

55. SUMMARY:
PRINCIPLES OF PAROTID CA MANAGEMENT:
1) T 1 & T 2 low grade Mucoepidermoid CA &Acinic cell CA -----
Superficial or total parotidectomy with Facial N. presevation
2) T 1 & T2 high grade Adeno CA, malignant pleumorphic adenoma,
undifferentited Ca, Sq-Cell CA----
Total parotidectomy with resection of first echelon of lymph nodes

56. Contd.
3) T 3 N* or N+ Any recurrent tumour not in group IV.-----Radical
parotidectomy, sacrifice of Fascial N. with immediate
reconstruction, neck dissection for N+ neck + post op
radiotherapy
4) T4-----Radical parotidectomy with resection of skin, madible
muscles as indicated. Sacrifice of Facial N. with immediate
reconstruction, neck dissection, post op irradiation.

57. POSTOP RADIOTHERAPY:
Radiotherapy may be used as an adjunct to surgery or as palliation in
inoperable cases.
In benign mixed tumours:
- presence of residual disease
- following excision of recurrent tumour.
b) In malignancy for:
- recurrent tumour
- positive margins after surgery
- narrow margin on facial nerve
- multiple nodal metastasis
- perineural invasion

58. PAROTID GLAND TUMOURS,
Our Experience at PIMS

59. Objective: To document the presentation and outcome of
parotid gland tumours in our set up.
Study Design: Descriptive study.
Place of the Study : This study was carried out in the
Department of Surgery, Pakistan Institute of Medical
Sciences (PIMS), Islamabad.
Duration of the Study: Jan 01, 2003 to Dec 31, 2007.
Subjects and Methods:
All patients with parotid gland tumours.
Convenience sampling technique.
Initial assessment and diagnosis was made by history,
physical examination and fine needle aspiration
cytology (FNAC). Local extent of tumour was assessed
with CT scan in selected patients with FNAC proven
malignancy..
Data Collection Instrument and Processing:

60. INTERVENTIONS UNDERTAKENINTERVENTIONS UNDERTAKEN
(n=63)(n=63)
SURGERYSURGERY No. of
PATIENTS/ %
1 Superficial Parotidectomy 60 (95.23%)
2 Total Parotidectomy 3 (4.77%)
3 Postoperative Radiotherapy. 6 (9.54%)

61. COMPLICATIONS OBSERVED (n=9)COMPLICATIONS OBSERVED (n=9)
COMPLICATION No. of PATIENTS/ %
1 Transient facial nerve
weakness
2 (3.17%)
2 Permanent facial nerve palsy 2 (3.17%)
3 Symptomatic Numbness of
Great auricular nerve area
2 (3.17%)
4 Frey's syndrome 2 (3.17%)
5 Flap tip necrosis 1 (1.58%)

62. Parotid gland tumours constitute a significant source of morbidity and
hospitalization in our relatively younger population. In our set up,
pleomorphic adenoma constitutes the leading type. Painless lump in the
parotid region, of a relatively longer duration is the usual presenting
feature. Superficial parotidectomy with preservation of facial nerve is the
most frequently instituted definitive treatment.
Parotid gland tumour though less common are encountered in our country.
Problems in their management are largely related to the facial nerve. A
proper consent should therefore be taken from the patient preoperatively
and such patients should perfectly be managed where expertise to handle
complications of surgery can be tackled in a proper and judicious way.
Conclusions

63. Thank YouThank You