This document provides information about parotidectomy, which is the surgical removal of the parotid gland. It discusses the different types of parotidectomy including superficial and total parotidectomy. Superficial parotidectomy involves removing the superficial lobe of the parotid gland while preserving the facial nerve. The procedure is described in detail, including identifying landmarks to locate the facial nerve and carefully dissecting the gland superficial to the nerve. Complications involving the facial nerve are also addressed.
This document discusses the history and anatomy of neck dissections for head and neck cancer. It traces developments from the late 19th century of increasingly conservative neck dissections to preserve important structures. It describes the levels and boundaries of lymph node groups involved in the neck dissection staging system, including levels I-V. Key structures like the hypoglossal nerve and spinal accessory nerve are discussed in relation to the lymph node groups.
Elevate the skin flaps superiorly to the level of the ramus of mandible. Identify and protect the external jugular vein.
Surgeon: Okay, elevating the skin flaps now. Carefully dissecting in the plane just deep to the platysma muscle. There's the external jugular vein, I'm protecting that as I elevate the flap. Almost to the level of the ramus now.
1) Parotidectomy is performed to remove tumors or treat infections of the parotid gland. It involves dissecting around the facial nerve to preserve function.
2) The facial nerve is the key anatomical structure and must be carefully identified and protected throughout the surgery. Landmarks like the tympanomastoid suture line help locate the nerve.
3) The surgery can range from partial removal of the superficial lobe for benign tumors to total removal of the entire gland for high grade malignancies. Meticulous hemostasis and drainage are important for wound healing.
This document discusses various branchial remnants and their characteristics. It describes:
- First branchial cleft cysts which can be parallel to the external auditory canal or connect to the malleus or incus.
- Second branchial cleft cysts, the most common type, which present as painless neck masses behind the sternocleidomastoid muscle.
- Preauricular pits and sinuses which can lead to interconnected cysts in front of the tragus.
- Skin tags which are usually benign but may be associated with other conditions.
- Branchial fistulas which have openings in the tonsillar fossa.
- Surgical excision is usually required to treat infected or
The document discusses the classification and techniques of neck dissection for cervical lymph node metastasis. It describes the different types of neck dissection including radical neck dissection (RND), modified radical neck dissection (MRND), and selective neck dissection (SND). It outlines the lymph node levels and boundaries involved in each procedure. Key factors in determining the appropriate procedure include the primary tumor site and extent of lymph node involvement.
The submandibular gland can be removed through either a transcervical or transoral approach. Key anatomical structures include the marginal mandibular nerve, lingual nerve, hypoglossal nerve, facial artery and vein, and Wharton's duct. The transoral approach has less risk of marginal mandibular nerve injury but a narrower surgical field. Indications for removal include recurrent enlargement, salivary stones, infection, or suspected neoplasm. Care must be taken to identify and preserve nearby nerves and vessels during dissection and removal of the gland.
A thyroglossal duct cyst is a neck mass that develops from leftover tissue from when the thyroid gland forms during embryonic development. It is most common in preschool-aged children and adolescents. Diagnostic tests include physical examination, ultrasound, and fine needle aspiration to evaluate the mass and rule out thyroid abnormalities. Treatment involves antibiotics if infected or surgical removal (Sistrunk procedure) of the entire cyst and tract to prevent recurrence, which is performed under general anesthesia as an outpatient procedure. Complications can include infection or rare chance of malignancy.
This document provides an overview of the surgical anatomy of the major salivary glands. It discusses the embryology, anatomy, functions and clinical implications of the parotid, submandibular, and sublingual glands. Specifically, it describes the locations and relationships of the parotid and submandibular glands, the branches of the facial nerve in the parotid, and the ducts of the parotid and submandibular glands. Examination of the salivary glands and their ducts is important clinically for evaluating inflammation, stones, and tumors. The lymphatics associated with the parotid can also lead to the development of certain cysts and tumors
This document discusses the history and anatomy of neck dissections for head and neck cancer. It traces developments from the late 19th century of increasingly conservative neck dissections to preserve important structures. It describes the levels and boundaries of lymph node groups involved in the neck dissection staging system, including levels I-V. Key structures like the hypoglossal nerve and spinal accessory nerve are discussed in relation to the lymph node groups.
Elevate the skin flaps superiorly to the level of the ramus of mandible. Identify and protect the external jugular vein.
Surgeon: Okay, elevating the skin flaps now. Carefully dissecting in the plane just deep to the platysma muscle. There's the external jugular vein, I'm protecting that as I elevate the flap. Almost to the level of the ramus now.
1) Parotidectomy is performed to remove tumors or treat infections of the parotid gland. It involves dissecting around the facial nerve to preserve function.
2) The facial nerve is the key anatomical structure and must be carefully identified and protected throughout the surgery. Landmarks like the tympanomastoid suture line help locate the nerve.
3) The surgery can range from partial removal of the superficial lobe for benign tumors to total removal of the entire gland for high grade malignancies. Meticulous hemostasis and drainage are important for wound healing.
This document discusses various branchial remnants and their characteristics. It describes:
- First branchial cleft cysts which can be parallel to the external auditory canal or connect to the malleus or incus.
- Second branchial cleft cysts, the most common type, which present as painless neck masses behind the sternocleidomastoid muscle.
- Preauricular pits and sinuses which can lead to interconnected cysts in front of the tragus.
- Skin tags which are usually benign but may be associated with other conditions.
- Branchial fistulas which have openings in the tonsillar fossa.
- Surgical excision is usually required to treat infected or
The document discusses the classification and techniques of neck dissection for cervical lymph node metastasis. It describes the different types of neck dissection including radical neck dissection (RND), modified radical neck dissection (MRND), and selective neck dissection (SND). It outlines the lymph node levels and boundaries involved in each procedure. Key factors in determining the appropriate procedure include the primary tumor site and extent of lymph node involvement.
The submandibular gland can be removed through either a transcervical or transoral approach. Key anatomical structures include the marginal mandibular nerve, lingual nerve, hypoglossal nerve, facial artery and vein, and Wharton's duct. The transoral approach has less risk of marginal mandibular nerve injury but a narrower surgical field. Indications for removal include recurrent enlargement, salivary stones, infection, or suspected neoplasm. Care must be taken to identify and preserve nearby nerves and vessels during dissection and removal of the gland.
A thyroglossal duct cyst is a neck mass that develops from leftover tissue from when the thyroid gland forms during embryonic development. It is most common in preschool-aged children and adolescents. Diagnostic tests include physical examination, ultrasound, and fine needle aspiration to evaluate the mass and rule out thyroid abnormalities. Treatment involves antibiotics if infected or surgical removal (Sistrunk procedure) of the entire cyst and tract to prevent recurrence, which is performed under general anesthesia as an outpatient procedure. Complications can include infection or rare chance of malignancy.
This document provides an overview of the surgical anatomy of the major salivary glands. It discusses the embryology, anatomy, functions and clinical implications of the parotid, submandibular, and sublingual glands. Specifically, it describes the locations and relationships of the parotid and submandibular glands, the branches of the facial nerve in the parotid, and the ducts of the parotid and submandibular glands. Examination of the salivary glands and their ducts is important clinically for evaluating inflammation, stones, and tumors. The lymphatics associated with the parotid can also lead to the development of certain cysts and tumors
Branchial anomalies result from improper development of the branchial apparatus during embryogenesis. They present as cysts, sinuses, or fistulas in the neck region due to failure of branchial clefts or pouches to regress normally. The definitive treatment is complete surgical excision to prevent recurrent infections while protecting important nerves like the spinal accessory and recurrent laryngeal. Second branchial cleft cysts are the most common type and manifest as neck masses anterior to the sternocleidomastoid muscle.
The parotid gland is located below and in front of the ear. It has two lobes and is drained by Stenson's duct which opens into the mouth. The gland has a capsule and structures like arteries pass through it. It is supplied by parasympathetic and sympathetic nerves. Common tumors include pleomorphic adenoma and Warthin's tumor. Mucoepidermoid carcinoma and adenoid cystic carcinoma are malignant tumors that can occur. Surgical excision is the main treatment for tumors but radiotherapy may also be used for malignant ones. Complications after parotidectomy include facial nerve injury and salivary fistula.
This document discusses the anatomy, etiology, clinical presentation, staging, and treatment options for carcinoma of the tongue. It notes that carcinoma of the tongue most commonly presents as a non-healing ulcer and can cause symptoms like otalgia, odynophagia, and bleeding. Treatment depends on staging and may involve surgery, radiation therapy, chemotherapy, or a combination. Prognosis decreases with more advanced stage at diagnosis.
thyroidectomy-surgical seminare, prepared by Dr. Siddharth JINDAL, third year resident in dept. of general surgery at P.D.U. Government Medical College and Civil Hospital, Rajkot, Gujarat.
Pharyngeal pouch, also known as Zenker's diverticulum, is a pulsion diverticulum that arises between the thyropharyngeus and cricopharyngeus muscles in an area of weakness. It is the most common type of posterior pharyngeal pouch. Zenker's diverticulum usually presents in older adults, affecting men more often than women. Symptoms include dysphagia, regurgitation of food, and halitosis. Treatment involves surgical excision of the diverticulum. While the exact cause is unknown, it is hypothesized to be related to the large size and oblique orientation of the pharyngeal muscles in humans, creating regions of weakness where the divert
The document provides information on the operative technique of parotidectomy. It discusses the embryology, surgical anatomy, types (partial, superficial, total, radical), procedure, and complications of parotidectomy. The procedure involves raising skin flaps and identifying landmarks like the facial nerve to fully expose and dissect the parotid gland from surrounding tissues. The main steps are identification and preservation of the facial nerve branches, ligation of duct and vessels, and removal of the gland. Complications can include hematoma, facial nerve injury, salivary fistula, cosmetic deformity, and Frey's syndrome.
A parotidectomy is the surgical removal of the parotid gland, the largest salivary gland, which is most often performed to remove benign or malignant tumors of the gland. There are several types of parotidectomy depending on the extent of gland removal, ranging from partial to total removal. The procedure involves raising skin flaps and carefully dissecting around the facial nerve branches to remove the tumor while preserving nerve function. Complications can include temporary or permanent facial nerve weakness, hematoma, seroma, salivary fistula, and Frey's syndrome.
Local and regional flaps in head and neck reconstructionSaleh Bakry
Local and regional flaps are used for head and neck reconstruction. There are several types of flaps classified by blood supply, location, configuration, tissue content, and transfer method. Local flaps use adjacent tissue while regional flaps are near but not adjacent. Free flaps completely detach tissue and reconnect blood vessels microsurgically. Examples of local and regional flaps discussed are advancement, rotation, and transposition flaps as well as pedicled and free myocutaneous flaps.
This case summary describes a 10-year-old child who presented with a swelling in the midline of the neck for the past 3 years. Examination revealed a 2cm round, smooth, mobile swelling that was diagnosed as a thyroglossal cyst. Differential diagnoses included dermoid cyst, infected lymph node, lipoma, and sebaceous cyst. An ultrasound and radioactive iodine scan were recommended to rule out ectopic thyroid tissue. A Sistrunk operation was planned to completely excise the cyst and thyroglossal tract by removing the body of the hyoid bone.
Cystic hygroma (CH), also known as cystic lymphangioma, is a benign cystic lesion of the lymphatic system that most commonly affects the head and neck region in children. It presents as soft, painless masses of cysts and can cause complications if it impinges on surrounding structures. Treatment involves complete surgical excision when possible, though this is not always feasible due to the involvement of critical structures. Other options include sclerotherapy or watchful waiting for asymptomatic cases. CH is associated with genetic conditions like Down syndrome and its cause involves abnormalities in lymphatic development and connections.
THYROIDECTOMY- Operative Surgery
Dear viewers,
Greetings from “Surgical Educator”
Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries. I have already uploaded two videos on open and Laparoscopic Appendicectomy. In this video today, I have discussed Thyroidectomy Surgery. However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery. Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful. This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the videos.
1) Solitary thyroid nodules are common and usually detected by palpation or ultrasound. Evaluation is needed to rule out malignancy given the risk of cancer in solitary nodules.
2) Ultrasound and fine needle aspiration biopsy are important diagnostic tools, with ultrasound assessing features suggestive of malignancy and FNAB providing cytology results.
3) Treatment depends on FNAB and risk factor results, ranging from observation for benign nodules to surgery for malignant or suspicious nodules. Surgery type depends on cancer risk and includes lobectomy or total thyroidectomy.
This document provides information on nasal fractures, including:
- Nasal fractures are the most common facial fracture, caused by physical assaults, falls, motor vehicle accidents, or contact sports.
- Left untreated, nasal fractures can lead to long-term deformities, obstruction, and other complications. Proper evaluation and management can reduce these risks.
- Evaluation involves history, examination of external and internal nasal structures, and sometimes imaging like x-rays or CT scans.
- Initial treatment focuses on controlling bleeding and drainage. Closed reduction is preferred but open reduction may be needed for severe fractures.
- Proper timing of reduction is important to realign fragments before fibrous tissue forms. Anest
Papillary thyroid cancer is the most common type of thyroid cancer, accounting for 85% of cases. It is more common in females than males and often spreads to lymph nodes in the neck. Follicular thyroid cancer is the second most common type, making up around 17% of cases. Both types are generally treated with total thyroidectomy followed by radioactive iodine therapy and thyroid hormone suppression treatment. Long term surveillance of thyroid cancer involves monitoring thyroglobulin levels via blood tests and imaging scans to detect any recurrence or metastasis.
The document discusses thyroidectomy, including:
- Types of thyroidectomy such as hemithyroidectomy, subtotal thyroidectomy, and total thyroidectomy.
- Surgical anatomy of the thyroid gland and related structures like the recurrent laryngeal nerve.
- Preoperative preparation, the surgical procedure, and postoperative management of complications like hemorrhage and recurrent laryngeal nerve injury.
This document describes the 7 levels of cervical lymph nodes in the neck. It provides details on the boundaries, drainage patterns, and involved pathology for each level. The levels extend from the skull base superiorly to the clavicle inferiorly. Each level contains specific nodal groups and may have sublevels. The document defines the clinical, radiologic, and surgical boundaries for each lymph node level to aid in neck dissection and evaluation of cervical lymphadenopathy.
This document provides an overview of parotidectomy surgery, including:
- Types of parotidectomies such as superficial and total parotidectomy.
- Surgical anatomy of the parotid gland and its relations to surrounding structures like the facial nerve.
- Preoperative evaluation and investigations.
- Technique for performing a superficial parotidectomy, including identification and preservation of the facial nerve branches.
- Potential complications of parotidectomy like hematoma, infection, and facial nerve injury.
This document discusses the management of cerebellopontine angle tumors. It covers the history of CP angle tumor surgery, current management options, indications for CSF diversion and conservative management, surgical approaches including translabrynthine and middle fossa, complications, and the role of radiosurgery. Key points include that the goal of modern surgery is to preserve cranial nerve function while completely removing tumors, indications for pre- versus post-operative CSF diversion, and the reduction of radiosurgery doses over time to decrease side effects.
Branchial anomalies result from improper development of the branchial apparatus during embryogenesis. They present as cysts, sinuses, or fistulas in the neck region due to failure of branchial clefts or pouches to regress normally. The definitive treatment is complete surgical excision to prevent recurrent infections while protecting important nerves like the spinal accessory and recurrent laryngeal. Second branchial cleft cysts are the most common type and manifest as neck masses anterior to the sternocleidomastoid muscle.
The parotid gland is located below and in front of the ear. It has two lobes and is drained by Stenson's duct which opens into the mouth. The gland has a capsule and structures like arteries pass through it. It is supplied by parasympathetic and sympathetic nerves. Common tumors include pleomorphic adenoma and Warthin's tumor. Mucoepidermoid carcinoma and adenoid cystic carcinoma are malignant tumors that can occur. Surgical excision is the main treatment for tumors but radiotherapy may also be used for malignant ones. Complications after parotidectomy include facial nerve injury and salivary fistula.
This document discusses the anatomy, etiology, clinical presentation, staging, and treatment options for carcinoma of the tongue. It notes that carcinoma of the tongue most commonly presents as a non-healing ulcer and can cause symptoms like otalgia, odynophagia, and bleeding. Treatment depends on staging and may involve surgery, radiation therapy, chemotherapy, or a combination. Prognosis decreases with more advanced stage at diagnosis.
thyroidectomy-surgical seminare, prepared by Dr. Siddharth JINDAL, third year resident in dept. of general surgery at P.D.U. Government Medical College and Civil Hospital, Rajkot, Gujarat.
Pharyngeal pouch, also known as Zenker's diverticulum, is a pulsion diverticulum that arises between the thyropharyngeus and cricopharyngeus muscles in an area of weakness. It is the most common type of posterior pharyngeal pouch. Zenker's diverticulum usually presents in older adults, affecting men more often than women. Symptoms include dysphagia, regurgitation of food, and halitosis. Treatment involves surgical excision of the diverticulum. While the exact cause is unknown, it is hypothesized to be related to the large size and oblique orientation of the pharyngeal muscles in humans, creating regions of weakness where the divert
The document provides information on the operative technique of parotidectomy. It discusses the embryology, surgical anatomy, types (partial, superficial, total, radical), procedure, and complications of parotidectomy. The procedure involves raising skin flaps and identifying landmarks like the facial nerve to fully expose and dissect the parotid gland from surrounding tissues. The main steps are identification and preservation of the facial nerve branches, ligation of duct and vessels, and removal of the gland. Complications can include hematoma, facial nerve injury, salivary fistula, cosmetic deformity, and Frey's syndrome.
A parotidectomy is the surgical removal of the parotid gland, the largest salivary gland, which is most often performed to remove benign or malignant tumors of the gland. There are several types of parotidectomy depending on the extent of gland removal, ranging from partial to total removal. The procedure involves raising skin flaps and carefully dissecting around the facial nerve branches to remove the tumor while preserving nerve function. Complications can include temporary or permanent facial nerve weakness, hematoma, seroma, salivary fistula, and Frey's syndrome.
Local and regional flaps in head and neck reconstructionSaleh Bakry
Local and regional flaps are used for head and neck reconstruction. There are several types of flaps classified by blood supply, location, configuration, tissue content, and transfer method. Local flaps use adjacent tissue while regional flaps are near but not adjacent. Free flaps completely detach tissue and reconnect blood vessels microsurgically. Examples of local and regional flaps discussed are advancement, rotation, and transposition flaps as well as pedicled and free myocutaneous flaps.
This case summary describes a 10-year-old child who presented with a swelling in the midline of the neck for the past 3 years. Examination revealed a 2cm round, smooth, mobile swelling that was diagnosed as a thyroglossal cyst. Differential diagnoses included dermoid cyst, infected lymph node, lipoma, and sebaceous cyst. An ultrasound and radioactive iodine scan were recommended to rule out ectopic thyroid tissue. A Sistrunk operation was planned to completely excise the cyst and thyroglossal tract by removing the body of the hyoid bone.
Cystic hygroma (CH), also known as cystic lymphangioma, is a benign cystic lesion of the lymphatic system that most commonly affects the head and neck region in children. It presents as soft, painless masses of cysts and can cause complications if it impinges on surrounding structures. Treatment involves complete surgical excision when possible, though this is not always feasible due to the involvement of critical structures. Other options include sclerotherapy or watchful waiting for asymptomatic cases. CH is associated with genetic conditions like Down syndrome and its cause involves abnormalities in lymphatic development and connections.
THYROIDECTOMY- Operative Surgery
Dear viewers,
Greetings from “Surgical Educator”
Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries. I have already uploaded two videos on open and Laparoscopic Appendicectomy. In this video today, I have discussed Thyroidectomy Surgery. However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery. Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful. This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for watching the videos.
1) Solitary thyroid nodules are common and usually detected by palpation or ultrasound. Evaluation is needed to rule out malignancy given the risk of cancer in solitary nodules.
2) Ultrasound and fine needle aspiration biopsy are important diagnostic tools, with ultrasound assessing features suggestive of malignancy and FNAB providing cytology results.
3) Treatment depends on FNAB and risk factor results, ranging from observation for benign nodules to surgery for malignant or suspicious nodules. Surgery type depends on cancer risk and includes lobectomy or total thyroidectomy.
This document provides information on nasal fractures, including:
- Nasal fractures are the most common facial fracture, caused by physical assaults, falls, motor vehicle accidents, or contact sports.
- Left untreated, nasal fractures can lead to long-term deformities, obstruction, and other complications. Proper evaluation and management can reduce these risks.
- Evaluation involves history, examination of external and internal nasal structures, and sometimes imaging like x-rays or CT scans.
- Initial treatment focuses on controlling bleeding and drainage. Closed reduction is preferred but open reduction may be needed for severe fractures.
- Proper timing of reduction is important to realign fragments before fibrous tissue forms. Anest
Papillary thyroid cancer is the most common type of thyroid cancer, accounting for 85% of cases. It is more common in females than males and often spreads to lymph nodes in the neck. Follicular thyroid cancer is the second most common type, making up around 17% of cases. Both types are generally treated with total thyroidectomy followed by radioactive iodine therapy and thyroid hormone suppression treatment. Long term surveillance of thyroid cancer involves monitoring thyroglobulin levels via blood tests and imaging scans to detect any recurrence or metastasis.
The document discusses thyroidectomy, including:
- Types of thyroidectomy such as hemithyroidectomy, subtotal thyroidectomy, and total thyroidectomy.
- Surgical anatomy of the thyroid gland and related structures like the recurrent laryngeal nerve.
- Preoperative preparation, the surgical procedure, and postoperative management of complications like hemorrhage and recurrent laryngeal nerve injury.
This document describes the 7 levels of cervical lymph nodes in the neck. It provides details on the boundaries, drainage patterns, and involved pathology for each level. The levels extend from the skull base superiorly to the clavicle inferiorly. Each level contains specific nodal groups and may have sublevels. The document defines the clinical, radiologic, and surgical boundaries for each lymph node level to aid in neck dissection and evaluation of cervical lymphadenopathy.
This document provides an overview of parotidectomy surgery, including:
- Types of parotidectomies such as superficial and total parotidectomy.
- Surgical anatomy of the parotid gland and its relations to surrounding structures like the facial nerve.
- Preoperative evaluation and investigations.
- Technique for performing a superficial parotidectomy, including identification and preservation of the facial nerve branches.
- Potential complications of parotidectomy like hematoma, infection, and facial nerve injury.
This document discusses the management of cerebellopontine angle tumors. It covers the history of CP angle tumor surgery, current management options, indications for CSF diversion and conservative management, surgical approaches including translabrynthine and middle fossa, complications, and the role of radiosurgery. Key points include that the goal of modern surgery is to preserve cranial nerve function while completely removing tumors, indications for pre- versus post-operative CSF diversion, and the reduction of radiosurgery doses over time to decrease side effects.
Both the major and the minor salivary glands develop as buds of oral ectoderm.
The epithelial bud proliferates into the adjacent mesenchyme, enlarging at its most distal end to form alveoli, with the epithelial cords becoming hollow to form ducts.The epithelial buds that form the parotid and submandibular glands appear during the sixth week of embryonic life, and those for the sublingual glands appear during the seventh to eighth week.
The major salivary glands are subject to many anomalies.Accessory glands and glands ectopically placed within the body of the mandible have been noted. Also in the vicinity of a line running from the ear by way of the parathyroid to inner end of the clavicle.
Major salivary ducts may be congenitally atretic or, rarely, imperforale.Small lymph nodes are normally found within the confines of the parotid glands, usually near its surface, but not in the submandibular or sublingual glands. Approximately 5 to 10 of these nodes are usually present, having salivary ducts and often some acini in their medullary regions, otherwise they resemble normal lymph nodes. Sebaceous glands, unassociated with hair follicles, are sometimes found in the mucosa of the cheek. The presence of occasional typical sebaceous glands in the parotid gland has been reported.There are four main salivary glands-two submandibular glands and two parotids. There are 300-400 minor salivary glands occurring elsewhere in the upper respiratory tract especially in the hard palate and lateral pharyngeal wall.
The minor salivary glands are mucuo-secreting glands situated throughout the upper respiratory tract. There are about 250 glands on the hard palate, 100 on the soft palate and 10 on the uvula.Other glands are found in the submucosa of the inner surface of the lips, around the opening of the parotid duct, in the mucous membrane of the cheek, in the floor of the mouth, in the palatoglossal folds, on the inferior surface of the tongue, near the frenulum and within the palatine tonsilAbout 1500 ml of saliva is secreted per day. pH is slightly less than 7.0 but during active secretion, it 8.0.
Saliva contains two digestive enzymes: lingual lipase, secreted by glands on the tongue, and salivary a-amylase secreted by the salivary glands.Saliva also contains mucins, glycoproteins that lubricate the food and protect the oral mucosa.
It also contains IgA, the first immunologic defense against bacteria and viruses; lysozym.es, which attacks the walls of bacteria; lactoferrinwhich binds iron arid is bacteriostatic; and proline-rich proteins that protect tooth enamel and bind toxic tannins.Etiology.
Clinical Picture:
It usually affects children, incubation period is 3 weeks,
It starts unilateral but in a few days it affects the other side,
Preceded by a prodromal influenza-like syndrome.
It causes fever & painful swelling which is soft & tender.
There is difficulty in mastication.
It never suppurates.
It may b
This document provides information on various vocal fold surgeries and procedures. It begins with definitions and assessments used for vocal fold surgery. It then discusses different surgical techniques like microlaryngoscopy, vocal fold injections, and laryngeal framework surgery. Specific procedures for conditions like nodules, polyps, Reinke's edema, and papillomas are described. The document also covers topics like laser vs other instruments, anesthesia considerations, post-op voice rest, and complications of procedures. Key surgical principles and the advantages of microlaryngoscopy are highlighted. Different materials used for vocal fold injections and medialization thyroplasty are also discussed.
1) Parotid gland tumors are relatively uncommon, accounting for less than 1% of reported malignancies. Pleomorphic adenoma is the most common parotid gland tumor, comprising 60% of cases.
2) The document outlines the classification, presentation, diagnostic evaluation, surgical and treatment options for parotid gland tumors. It also presents representative cases from the author's experience.
3) Superficial parotidectomy with preservation of the facial nerve is the most common surgical intervention undertaken and was performed in 95% of cases. Post-operative complications included transient or permanent facial nerve weakness.
The document discusses disorders of the salivary glands, focusing on the parotid and submandibular glands. It describes the anatomy of the major salivary glands and their duct systems. Common disorders are then outlined, including developmental abnormalities, infections (viral like mumps, bacterial), obstructions (stones), and tumors. Treatment options are provided for various disorders like parotidectomy for removal of tumors while preserving the facial nerve. Complications of parotid surgery are also summarized.
Spinal cord ependymomas are the most common intramedullary tumor in adults, arising from ependymal cells lining the central canal. They present with back pain and dysesthesias without sensory loss. MRI shows a well-defined intramedullary mass that is hyperintense on T2-weighted imaging. Gross total resection results in a low recurrence rate less than 10%; subtotal resection is associated with a higher recurrence rate of around 20-30% even with postoperative radiation. Radiotherapy may be used after subtotal resection to reduce recurrence.
1. Juvenile nasopharyngeal angiofibroma is a rare, benign tumour that occurs primarily in adolescent males and is highly vascular.
2. It originates from the posterior nasal cavity near the sphenopalatine foramen and can extend into local structures like the sinuses, orbit and cranium.
3. Treatment involves preoperative embolization followed by surgical excision via various approaches depending on tumour extent. Endoscopic removal is used for smaller tumours while more extensive approaches are needed for larger or invasive tumours.
CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGYPaul George
This document discusses carcinoma of the maxilla, including epidemiology, histology, clinical presentation, staging, investigations, management, and prognosis. Squamous cell carcinoma is the most common type, presenting more in men in the 5th-6th decade. Clinical evaluation includes imaging like CT and MRI to determine extent. Treatment involves surgery like maxillectomy with clear margins followed by postoperative radiation therapy to improve outcomes. Prognosis remains poor at a 5-year survival of 35-45% even with multimodality treatment. A case example is presented of a 58-year-old female smoker found to have cT2N0M0 carcinoma of the left maxilla who underwent subtotal maxillectomy followed
Juvenile angiofibroma is a rare, benign and highly vascular tumor that develops almost exclusively in adolescent males within the sphenopalatine foramen. It presents with recurrent severe nosebleeds and progressive nasal obstruction. Imaging such as CT and MRI are used to determine the extent of the tumor. While surgery is the primary treatment, preoperative embolization and endoscopic resection are often used for early-stage tumors to reduce bleeding and complications. Advanced tumors may require open approaches like mid-facial degloving. Recurrence rates remain high due to the invasive nature of the tumor.
Metastasis of Neck Node with Unknown Primary Himanshu Soni
1) An unknown primary is defined as squamous cell carcinoma presenting in cervical lymph nodes with no identifiable primary tumor site after examination. This clinical entity is known as carcinoma of unknown primary (CUP).
2) Evaluation involves physical examination, imaging like PET-CT, and panendoscopy with biopsies of suspicious sites to identify the occult primary tumor. Bilateral tonsillectomy and tongue base biopsy can identify occult tumors in the tonsillar crypts in many cases.
3) Treatment depends on tumor stage but often involves combined modality treatment with surgery, radiation, and/or chemotherapy aimed at locoregional control while minimizing morbidity.
The document provides information on surgical procedures for the oral cavity, including preoperative evaluation and planning, operative techniques, and postoperative care. Key points include:
- Wide surgical margins of 1-2 cm are needed to adequately treat oral cavity cancers. Reconstruction aims to close defects primarily when possible to maintain tongue mobility, sensation, and oral competence.
- For anterior glossectomy, either orotracheal or nasotracheal intubation may be used depending on the approach and resection extent. A tracheostomy is recommended for significant postoperative swelling risk.
- Anterior glossectomy exposure is achieved transorally or through a lip-splitting mandibulotomy incision. Re
1) Parotidectomy involves surgically removing all or part of the parotid gland located in front of and below the ear.
2) The procedure begins by making incisions and developing skin flaps to expose the gland. The facial nerve is then identified, either at its main trunk or branches.
3) Dissection then proceeds along the plane of the facial nerve to remove portions of the gland while preserving the nerve branches. Hemostasis is achieved and any duct divisions are managed. Deep lobe tumors require additional care near the nerve.
Ca external and middle ear staging to management1Dr Durgesh Kumar
Tumors of the external ear most commonly occur in patients aged 60-70, while tumors of the middle ear and mastoid are more common in patients aged 40-60. More women have middle ear tumors, while more men have external ear tumors. The most common types are basal cell carcinoma for external ear tumors and squamous cell carcinoma for middle ear, mastoid, and external auditory canal tumors. Treatment depends on the location and stage of the tumor, and may involve surgery, radiation therapy, or a combination. Potential complications of treatment include facial nerve dysfunction, infection, hemorrhage from surgery, and osteoradionecrosis or cartilage necrosis from radiation therapy.
This document provides information on juvenile nasopharyngeal angiofibroma (JNA), including its epidemiology, pathology, theories of origin, clinical features, diagnosis, staging systems, treatment options, surgical approaches, and complications. JNA is a benign but locally aggressive tumor most commonly seen in adolescent males. Surgical removal is the primary treatment, with endoscopic approaches used for early-stage tumors and open approaches for more advanced cases. Recurrence rates remain high due to the tumor's vascular and invasive nature, though preoperative embolization and thorough resection of the pterygoid wedge can help reduce this. Radiation and hormonal/chemotherapy may be considered for unresectable or residual disease.
This document provides information on juvenile nasopharyngeal angiofibroma (JNA), including its epidemiology, pathology, theories of origin, clinical features, diagnosis, staging systems, treatment options, surgical approaches, and complications. JNA is a benign but locally aggressive tumor most commonly seen in adolescent males. Surgical removal is the primary treatment, with endoscopic approaches used for early-stage tumors and open approaches for more advanced cases. Recurrence rates remain high due to the tumor's vascularity and location near vital structures, so adjuvant therapies may also be used.
Anesthesia consideration for parotidectomyTayyab_khanoo9
This document summarizes anesthesia considerations for parotidectomy surgery. It discusses the anatomy of the parotid gland and facial nerve. Parotidectomy is usually indicated for parotid tumors and may require facial nerve monitoring. The document presents a case of performing parotidectomy under local anesthesia in a high-risk patient with hypertension. It describes blocking the maxillary and cervical plexus nerves along with local infiltration to anesthetize the area. The surgery was performed successfully without complications under local anesthesia. Advantages of this technique include avoiding risks of general anesthesia and facilitating identification and protection of the facial nerve.
1) The frontal sinus and surrounding anatomy can vary significantly between individuals. Abnormal structures like agger nasi cells can obstruct the frontal sinus and contribute to sinusitis.
2) Surgical approaches to the frontal sinus include trephination, endoscopy, and various external and endonasal procedures. The goal is to establish drainage while preserving surrounding structures.
3) Common pathologies of the frontal sinus discussed include osteomas, fibrous dysplasia, and inverted papillomas. Surgical techniques aim to completely remove tumors while preserving function and minimizing recurrence risk.
The parapharyngeal space lies laterally on either side of the pharynx and contains fat and connective tissue. It is divided into prestyloid and poststyloid compartments. Tumors in this space can be salivary gland tumors, usually pleomorphic adenomas arising from the deep lobe of the parotid gland in the prestyloid compartment. Neurogenic tumors like schwannomas and paragangliomas commonly involve the poststyloid compartment. Symptoms include a neck mass or bulging in the pharynx. Imaging helps characterize the tumor and surgical approaches aim to completely remove the tumor while preserving nearby structures.
This document discusses surgical management of rhinosinusitis, including different approaches to endoscopic sinus surgery and their indications. It describes techniques for uncinectomy, ethmoidectomy, maxillary antrostomy, and opening the frontal sinus and sphenoid. Local or general anesthesia can be used. Post-operative management involves cleaning the surgical cavity, antibiotics, steroids, and follow-up visits. Antral lavage is discussed as a treatment for acute rhinosinusitis and as an adjunct to external drainage of orbital complications.
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2. CONTENTS
1. INTRODUCTION
2. SURGICAL ANATOMY
3. TYPES OF PAROTIDECTOMY
4. PREOPERATIVE EVALUATION
5. SUPERFICIAL PAROTIDECTOMY
6. TOTAL PAROTIDECTOMY
7. EXTENDED TOTAL PAROTIDECTOMY
8. COMPLICATIONS
9. REFERENCES
3. INTRODUCTION
A parotidectomy is the surgical excision (removal) of
the parotid gland, the major and largest of the salivary
glands.
The procedure is most typically performed due to benign
or malignant tumors.
The majority of parotid gland tumors are benign,
however 20% of parotid tumors are found to be
malignant.
4. Rule of 80’s:
-80% of parotid tumors are benign
-80% of parotid tumors are pleomorphic adenomas
-80% of salivary gland pleomorphic adenomas
occur in the parotid
-80% of parotid pleomorphic adenomas occur in the
superficial lobe
-80% of untreated pleomorphic adenomas remain
benign
5. SURGICAL ANATOMY
Parotid gland
The paired parotid glands
are the largest of the major
salivary glands
weigh, on average, 15–30
g.
Preauricular region
9. Superficial Muscular Aponeurotic
System (SMAS)
SMAS is a fibrous network that
invests the facial muscles, and
connects them with the dermis.
Platysma inferiorly;
Zygomatic arch superiorly
Facial nerve courses deep to the
SMAS and the platysma.
Parotid fascia
10. Facial nerve and
branches
Structures within the parotid gland
13. Lymphatics:
Superficial nodes drains
auricle, anterior part of
scalp, upper part of face
Deeper nodes receives
lymph from external
acoustic meatus, middle
ear, auditory tube, nose,
palate and deep parts of
cheek.
Cervical lymphnodes
15. TYPES OF PAROTIDECTOMY
Partial parotidectomy: Resection of parotid
pathology with a margin of normal parotid tissue.
This is the standard operation for benign pathology
and low grade malignancies
Superficial parotidectomy: Resection of the entire
superficial lobe of parotid and is generally used for
metastases to parotid lymph nodes e.g. from skin
cancers, and for high grade malignant parotid
tumors.
16. Total parotidectomy: This involves resection of the
entire parotid gland, usually with preservation of the
facial nerve
Extended Total Parotidectomy: Removal of the
superficial and deep parotid gland also may be
extended to involve adjacent structures.
17. PREOPERATIVE EVALUATION
A thorough history is obtained prior to consideration
for surgery.
Symptoms of sensory loss, trismus and facial
weakness are worrisome for local tumor invasion by
a malignant neoplasm.
The past medical history should include information
regarding any prior cutaneous lesions or
malignancies.
18. In addition, the patient should be queried about any
prior radiation exposure to the head and neck
including dental radiographs.
Smoking is associated with Warthin’s tumor and,
therefore, should be investigated.
This tumor can also occur bilaterally, thus any
history of a prior parotid tumor should be elicited.
19. Cranial nerve function should be examined and
facial nerve function should be evaluated carefully.
Facial nerve paralysis is usually an indication of
nerve invasion by a malignant tumor.
Fixation to the overlying skin, limited mobility of the
mass, and associated cervical lymphadenopathy
are other signs suggestive of malignancy.
20. FINE-NEEDLE ASPIRATION BIOPSY (FNAB)
It is an accurate and useful investigation for the
diagnosis of a parotid mass.
FNAB allows for improved patient selection for
surgery since it can identify conditions such as
reactive lymph nodes or cysts that might mimic
parotid neoplasms clinically.
The information gained by FNAB is useful for
patient counseling, surgical timing and planning,
and guiding the direction of preoperative
consultation
21. RADIOLOGY
Radiological investigation is not routinely required
with parotid tumors.
It is recommended for surgical planning with tumors
that are large, fixed, and are associated with facial
nerve involvement, trismus, and parapharyngeal
space involvement.
MRI is a valuable investigation with recurrence of
pleomorphic adenoma as it is often multifocal.
22. PREOPERATIVE CONSENT
Scar
Anesthesia in the greater auricular distribution
Facial nerve weakness
Facial contour
Prominence of auricle
Frey’s syndrome (gustatory sweating)
23. PREOPERATIVE CONSENT
Scar
Anesthesia in the greater auricular distribution
Facial nerve weakness
Facial contour
Prominence of auricle
Frey’s syndrome (gustatory sweating)
24. SUPERFICIAL PAROTIDECTOMY
Superficial lobe parotidectomy describes removal of all
or a portion of the parotid gland superficial to the facial
nerve.
The most common indications are:
1. Benign or low grade tumor of the superficial lobe of the
parotid gland
2. metastases to parotid lymph nodes from adjacent sites
of skin cancer or melanoma, or from cancer of the
external auditory meatus.
25. 3. Access to the deep lobe of the gland or other
structures deep to the facial nerve.
4. Chronic inflammation of parotid gland, resistant to
conservative treatment.
26. ANAESTHESIA
General anaesthesia
Short-acting muscle relaxation for intubation only,
so that facial nerve may be stimulated and/or
monitored
No perioperative antibiotics unless specifically
indicated
Hyperextend the head, and turn to opposite side
27. Infiltrate with vasoconstrictor along planned skin
incision,
Keep corner of eye and mouth exposed so as to be
able to see facial movement when facial nerve
mechanically or electrically stimulated.
28. TECHNIQUE
A modified Blair incision
An alternative incision is
a modified face-lift
incision.
29. The ipsilateral face is
prepared with an antiseptic
solution and the surgical
field is draped with a
transparent adhesive
sterile drape.
Nerve electrodes are
placed in the ipsilateral
facial muscles and tested
for electrical integrity.
30. The skin incision is
made through the
subcutaneous tissues
and platysma muscle.
Greater auricular
nerve.
31. An anterior flap is
elevated superficial to
the greater auricular
nerve and the parotid
fascia.
Anterior flap- the
peripheral branches of
the facial nerve.
A posterior, inferior flap-
expose the tail of the
32. The tail of the parotid gland is dissected
off of the sternocleidomastoid muscle
by dissecting deep to the posterior
branch of the greater auricular nerve.
Next, the posterior belly of the digastric
muscle is exposed with further
elevation of the tail of the parotid gland
The posterior belly of the digastric
muscle serves as a landmark for the
facial nerve.
During elevation of the tail of the
parotid, the integrity of the posterior
facial vein also is preserved if possible.
33. The preauricular space is
opened by division of the
attachments of the parotid
gland to the cartilaginous
external auditory canal
with blunt and sharp
dissection.
This plane of dissection
exposes the tragal
cartilage pointer which
serves as another
landmark for the facial
34. A wide plane of
dissection from the
zygoma to the digastric
muscle is created to
facilitate exposure of the
facial nerve.
The gland is carefully
retracted anteriorly.
This exposes the
operative field for
identification of the facial
35. The facial nerve is
identified using
anatomic landmarks:
1. Posterior belly of the
digastric muscle
2. Mastoid tip
3. Tragal cartilage pointer
4. Tympanomastoid
suture.
36. If the proximal segment
of the facial nerve is
obscured, retrograde
dissection of one or
more of the peripheral
facial nerve branches
may be necessary to
identify the main trunk.
37. When necessary, the
facial nerve can be
identified in the
mastoid bone by
mastoidectomy and
followed peripherally.
38. Once the facial nerve is
identified, the parotid
gland superficial to the
facial nerve is divided
carefully, preserving the
integrity of the nerve.
The exact location of the
facial nerve should
always be determined
prior to division of the
gland tissue.
39. The facial nerve is
followed peripherally,
the desired portion of
the gland is dissected
from facial nerve
branches and the
specimen removed.
40. The facial nerve is preserved except in cases when
confirmed malignancy is found invading the nerve.
In instances of facial nerve invasion by carcinoma,
facial nerve resection is performed.
Proximal and distal margins of the resected nerve are
examined histologically by frozen section to ensure
clear surgical margins.
41. If the tumor involves the stylomastoid foramen,
mastoidectomy is performed to identify the proximal
facial nerve in the fallopian canal to achieve a clear
margin.
Immediate nerve reconstruction by a nerve
interposition graft is usually indicated if facial nerve
resection is performed.
42. After the superficial
portion of the gland is
removed.
The wound is carefully
inspected and bleeding
sites are controlled with
bipolar electrocautery
or ligatures
43. The integrity of the
facial nerve is
confirmed visually and
by electrical stimulation
of the main trunk of the
facial nerve and all the
peripheral branches.
44. A neck dissection is performed for clinically positive
nodes.
For the clinically negative neck, the first echelon
nodes are inspected.
Enlarged or suspicious nodes are examined and a
neck dissection is performed if metastatic disease
is confirmed by frozen section.
45. The wound is irrigated,
realigned, and closed in
layers over a closed-
suction drain.
The drain is usually
removed on the first
postoperative day and
the skin sutures are
removed within one
week.
46. Adjuvant radiation therapy is recommended for
select malignancies including
i. metastatic cutaneous squamous cell carcinoma
ii. high-grade and advanced parotid malignancies
47. TOTAL PAROTIDECTOMY
Total parotidectomy is the total removal of the
superficial and deep parotid gland.
The operation may involve sparing or sacrifice of
the facial nerve branches or trunk depending on
tumor extent to the nerve.
48. INDICATIONS:
1. Metastasis to a superficial parotid node from a
primary parotid tumor or an extraparotid
malignancy
2. Parotid malignancy that indicates metastasis by
involvement of cervical lymph nodes
3. High-grade parotid malignancy with a high risk of
metastasis.
49. 4. Primary parotid malignancies originating in the
deep lobe and for primary malignancies that
extend outside the parotid gland.
5. Multifocal tumors, such as oncocytomas, to
ensure complete removal
50. EXTENDED TOTAL PAROTIDECTOMY
Removal of the superficial and deep parotid gland
also may be extended to involve adjacent
structures such as the overlying skin, the underlying
mandible, the temporal bone and external auditory
canal, or the deep musculature of the
parapharyngeal space.
These extensions are dictated by tumor growth and
behavior.
52. 5. Removal of superficial gland
6. Deep parotidectomy
7. Total Parotidectomy with Facial Nerve Sacrifice
8. Resection of Adjacent Structures and
Reconstruction
53. PREPARATION
The operation is performed with the patient under
general endotracheal anesthesia.
Endotracheal tube is positioned and taped to the
oral commissure and cheek opposite to the lesion.
The patient is placed in a 45° reverse-
trendelenburg position or lounge-chair position with
the head higher than the heart.
54. The head is turned to the opposite side of the
lesion, and the neck is extended by placement of a
rolled sheet under the shoulders.
The patient is prepared by sterile scrub and draped
so that the ear, lateral corner of the ipsilateral eye,
ipsilateral oral commissure, and entire ipsilateral
neck are visible in the field.
55. If facial nerve monitoring is to be used, the nerve
monitor is placed in the orbicularis oris and
orbicularis oculi muscles to ensure upper and lower
division monitoring.
The surgeon stands on the side of the patient
ipsilateral to the gland to be dissected, the assistant
stands at the head and opposite the surgeon, and
the scrub technician stands on the side of the
surgeon.
66. A small curved clamp is oriented perpendicular to
the anticipated direction of the facial trunk to
elevate tissues layer by layer.
Scissors are never used for dissection down to the
nerve, and no tissue is cut in this area until the
nerve is seen.
Blunt dissection proceeds posterior to anterior until
the surgeon identifies the nerve as a white cord 2–3
mm wide.
67.
68. REMOVAL OF THE SUPERFICIAL GLAND
The gland is separated at its edge, the temporal or
marginal branches being followed to the periphery.
The thickest fascia is encountered
posterosuperiorly; this must be divided sharply or
the surgeon will make tunnels into the gland along
the nerve.
Posteriorly- branches of the superficial temporal
vein may be encountered.
69. Vessels directly adjacent to the nerve branches should
not be cauterized until the superficial lobe is completely
mobilized.
After following a nerve branch to its peripheral
emergence from the parotid gland, the surgeon returns
to a proximal position along that nerve and searches
for another branch to follow.
Dissection progresses from posterior to anterior and
either superiorly or inferiorly until the superficial gland
has been completely separated from the facial nerve
and the deep parotid gland.
70. At this point, the surgeon should have a clear
impression of the relationship of the tumor to the
facial nerve, superficial gland, deep gland, and
surrounding structures.
It may be necessary to dissect along the tumor
capsule to separate it from the deep gland and
facial nerve.
Careful retraction and meticulous dissection can
prevent rupture of the tumor capsule, which is often
71. The gland is now left attached to only the parotid
duct.
The surgeon inspects this area to ensure that no
buccal branches are adherent to the duct.
The duct is divided and ligated, and the specimen is
sent for examination by the pathologist.
The wound should now be irrigated and the field
inspected for bleeding vessels, which are ligated.
75. The gland is completely freed from attachment to any
adjacent structures and sent for frozen-section
pathologic examination.
Small vessels around the deep gland adjacent to the
mastoid and trunk can be cauterized using the bipolar
forceps.
The wound is irrigated, and meticulous hemostasis is
achieved.
If necessary, the incision can be extended for neck
dissection at this time.
76. At the conclusion of the operation, a suction drain is
placed in the wound through a separate stab
incision in the postauricular skin and sewn into
place.
The wound is closed with interrupted absorbable
sutures
Dressing or antibiotic ointment can be applied.
Patient is awakened and extubated.
77. TOTAL PAROTIDECTOMY
WITH FACIAL NERVE SACRIFICE
If facial nerve function is normal preoperatively,
even in patients with malignancy, then the nerve
can be preserved with careful dissection of the
tumor off the nerve sheath.
If the nerve is paretic or fully paralyzed
preoperatively, then it is involved with tumor and is
normally resected during tumor resection.
78. Nerve that is clearly invaded by high-grade
malignant tumor should be resected with the
specimen to negative proximal and distal margins.
This may necessitate sacrificing peripheral
branches, divisions, or even the main trunk of the
facial nerve.
Intraoperatively, a nerve that is infiltrated with tumor
will appear swollen and usually darker than the
normal glistening white appearance of normal facial
79. After negative proximal and distal facial nerve
margins are obtained, the nerve is reconstructed
with primary neurorraphy or grafting.
Mastoidectomy and nerve mobilization may be
necessary to attain proper length of the facial nerve
for tension-free anastomosis.
80. Appropriate grafts include:
i. ipsilateral greater auricular nerve if it is not
involved with tumor
ii. ipsilateral sural nerve graft.
Peripheral branches can be grafted
i. proximal facial nerve
ii. ipsilateral hypoglossal nerve
81. RESECTION OF ADJACENT STRUCTURES
AND RECONSTRUCTION
The operation may be extended to involve resection
of adjacent structures that are involved with tumor.
It may include
i. lateral or subtotal temporal bone resection,
ii. partial mandibular resection,
iii. resection of the overlying skin,
iv. resection of portions or all of the auditory canal,
and
v. resection of surrounding musculature.
82. Options for reconstruction include
i. primary closure,
ii. dermal fat grafting,
iii. muscle transposition with loco regional flaps of
the sternocleidomastoid or pectoralis muscles,
iv. micro vascular cutaneous, musculocutaneous,
and innervated muscular flaps.
Again, the reconstruction will be guided by the
functional and aesthetic goals of the surgeon and
patient.
84. Inadequate hemostasis before
closure.
Suction drain reduces
possibility of postoperative
hematoma.
Treatment:
i. Evacuation of hematoma
ii. Control of bleeding points
iii. Reinsertion of suction drain
and closure.
HEMATOMA
85. Infection is rare
Some tumors presents with obstructive symptoms if
infected.
Prophylactic antibiotics are given if operating on an
infected gland.
INFECTION
86. Temporary or permanent
Partial or total
Neuropraxia- due to
stretching of the nerve.
If the nerve is intact at the
end of procedure-
recovery within few weeks.
FACIAL NERVE PALSY
87. If the palsy is severe and recovery is prolonged-
transcutaneous nerve stimulation of facial muscles.
Problems with eye closure-
i. protective glasses or tape the eyelid to prevent
exposure keratitis.
ii. Temporary tarsorrhaphy or paralysis of eyelid
elevator with botulinum toxin to allow closure of
upper eyelid.
88. When palsy is due to partial or total loss of facial
nerve:
i. reconstruction
ii. rehabilitation of face
89. Presents after suture
removal at the suture
line and posterior to
ear lobule.
Pressure dressing.
Drains
Anticholinergic drugs-
to reduce salivary
secretion
SALIVARY FISTULA
90.
91. Auriculotemporal
syndrome.
60% of all
parotidectomy cases.
Discomfort, localized
facial sweating and
flushing during
mastication.
FREY’S SYNDROME
92. Due to parasympathetic
and sympathetic
secretomotor stimuli
misdirected to
cholinergic receptors of
sweat glands during
healing after parotid
surgery.
93. The iodine test administered
by applying an alcohol–
iodine–oil solution (3 g
iodine, 20 mL castor oil, and
200 mL absolute alcohol)
described by Laage-Hellman
The solution was applied on
the lateral portion of the face
that had been surgically
treated and the upper region
of the neck.
94. The solution was allowed
to dry and was covered
lightly with starch
powder.
The patients received
lemon candy for a
gustatory stimuli for 10
minutes.
Discoloration of the
starch iodine mixture
was interpreted as a
95. There is no effective treatment, but various options
are described:
i. Injection of Botulinum Toxin
ii. Surgical transection of the nerve fibers
iii. Application of an ointment containing
an anticholinergic drug such as scopolamine
96. Incision mark
Sunken cheek due to
loss of parotid gland and
fat.
Rotation of
sternomastoid muscle
flap at the time of
surgery.
Free flaps.
COSMETIC DEFORMITY
97. REFERENCES
1. Salivary Gland Disorders: Eugene N. Myers, Robert
L. Ferris; Springer.
2. Parotidectomy : Johan Fagan : Open Access Atlas
Of Otolaryngology, Head & Neck Operative Surgery
3. Maxillofacial Surgery: Second Edition; Volume 1:
Peter Wardbooth.
4. Operative Maxillofacial Surgery; John D Langdon
and Mohan F Patel.
5. Internet
The paired parotid glands are the largest of the major salivary glands and weigh, on average, 15–30 g.
Located in preauricular region and along the posterior surface of the mandible
The parotid gland is bounded superiorly by the zygomatic arch.
Inferiorly, the tail of the parotid gland extends down and abuts the anteromedial margin of the sternocleidomastoid muscle.
This tail of the parotid gland extends posteriorly over the superior border of the sternocleidomastoid muscle toward the mastoid tip.
The deep lobe of the parotid lies within the parapharyngeal space
The parotid duct exits the gland anteriorly, crosses the masseter muscle, curves medially around its anterior margin, pierces the buccinator muscle, and enters the mouth opposite the 2nd upper molar tooth.
The superficial lobe, overlying the lateral surface of the masseter.
The deep lobe is medial to the facial nerve and located between the mastoid process of the temporal bone and the ramus of the mandible.
An accessory parotid gland may also be present lying anteriorly over the masseter muscle between the parotid duct and zygoma.
Its ducts empty directly into the parotid duct through one tributary
SMAS is a fibrous network that invests the facial muscles, and connects them with the dermis.
It is continuous with the platysma inferiorly; superiorly it attaches to the zygomatic arch.
In the lower face, the facial nerve courses deep to the SMAS and the platysma.
The parotid glands are contained within two layers of parotid fascia, which extend from the zygoma above and continue as cervical fascia below.
Enters through posteromedial surface and exits through anteromedial surface of the parotid gland
Main trunk divides into the upper temporofacial and lower cervicofacial divisions approximately 1.3 cm from the stylomastoid foramen.
The upper temporofacial division forms the frontal, temporal, zygomatic, and buccal branches.
The lower cervicofacial division forms the marginal mandibular and cervical branches.
It gives off the transverse facial artery inside the gland before dividing into the internal maxillary and the superficial temporal arteries
The maxillary and superficial temporal veins merge into the retro-mandibular vein within the parotid gland, but are not responsible for draining the gland.
Venous drainage of the parotid itself is to tributaries of external and internal jugular veins.
Parotid lymphnodes are embedded in the gland, especially near its superficial surface.
Both groups drain to cervical lymphnodes.
Scar: Usually very good healing ex-cept over the mastoid where some scarring may occur
Anaesthesia in the greater auricular distribution: Skin of inferior part of auricle, and overlying the angle of the mandible
Facial nerve weakness: Temporary weakness common (<50%); permanent weakness rare
Facial contour: loss of parotid tissue leads to a more defined angle of mandible, and deepening of retromandibular sulcus
Prominence of auricle: This is probably due to loss of innervation of the postauricular muscles and preauricular scarring
Frey’s syndrome (gustatory sweating): Although common, it only very rarely is bad enough to require treatment with Botox injection
A modified Blair incision is planned in a preauricular crease coursing around the ear lobule and then into an upper neck crease
Methylene blue can be used to mark points along the proposed incision, which facilitates proper wound alignment and closure.
The ipsilateral face is prepared with an antiseptic solution and the surgical field is draped with a transparent adhesive sterile drape to allow visualization of facial motion.
If electrophysiologic facial nerve monitoring is to be used intraoperatively, nerve electrodes are placed in the ipsilateral facial muscles and tested for electrical integrity.
The skin incision is made with a scalpel and carried down through the subcutaneous tissues and platysma muscle.
Care is taken to avoid division of the greater auricular nerve.
An anterior flap is elevated superficial to the greater auricular nerve and the parotid fascia (Fig. 14.4).
Elevation of a thick flap is desirable to reduce the occurrence of Frey’s syndrome while carefully avoiding violation of any neoplasm at the surface of the gland.
As the flap is elevated toward the anterior aspect of the gland, the peripheral branches of the facial nerve are carefully avoided.
A posterior, inferior flap is also elevated to expose the tail of the parotid gland.
After elevation, the flaps are retracted with silk sutures or selfretaining hooks.
The facial nerve usually courses superficial to this vessel and division of this structure can contribute to increased venous bleeding during dissection of the gland.
Occasionally some or all of the branches of the facial nerve will be found deep to the vein.
Care must be taken to avoid pressure or traction injury of the facial nerve during retraction of the gland.
Anatomic distortion by a neoplasm or operative manipulation must be considered.
In cases of previous parotid surgery or recurrent tumor, the usual dissection described above is not always possible.
If any injured facial nerve branches are identified, they are repaired immediately using a microscopic repair technique.
The incision site is marked with a surgical marker.
The incision begins in the preauricular crease at the superior root of the helix and curves gently below the lobule, and then turns anteriorly to run horizontally in a skin crease approximately two finger widths below the angle of the mandible
The surgeon may crosshatch the incision lines superficially with a no. 10 or 15 blade to assist in precise realignment during closure.
The incision is then made from superior to inferior through the skin into the subcutaneous tissue with the scalpel.
Flap should be raised immediately over the parotid fascia, which is recognizable as a white fibrous layer deep to the subcutaneous fat and superficial musculoaponeurotic system layer.
Care should be taken not to enter a superficial tumor or the substance of the gland during flap elevation.
Flap elevation continues with Jones scissors spread open perpendicularly along the parotid
fascia; the scissors opens tunnels along the parotid gland
which are then connected with blunt and sharp dissection
over the parotid fascia
The anterior edge of the sternocleidomastoid muscle is identified, and the greater auricular nerve and external jugular vein, located just anterior to the nerve, are identi-
The parotid gland is next separated from the anterior sternocleidomastoid muscle by sharp dissection.
The gland is secured with Kocher clamps along its inferior border away from any tumor and retracted superomedially to assist in dissection.
The gland also is separated bluntly from the tragal cartilage by spreading with Jones scissors parallel to the plane of the cartilage down to the level of the tragal cartilaginous pointer.
After the parotid gland has been completely separated from the sternocleidomastoid muscle and the tragus, the posterior belly of the digastric muscle should be identified.
The search for this muscle should not be too low in the surgical field, thereby putting the internal jugular vein or accessory nerve at unnecessary risk.
too anterior in the field, puts the marginal branch of the facial nerve at risk.
The mastoid tip and the posterior border of the angle of the mandible serve as landmarks for the posterior digastric muscle.
Once the muscle belly is identified immediately deep to the angle of the mandible, the remainder of the parotid gland is freed with blunt dissection.
At this point, entire inferior surface of the parotid gland, the posterior belly of the digastric muscle, mastoid tip and tragal cartilage is exposed.
The main trunk of the facial nerve exits the stylomastoid foramen immediately posterior to the styloid process.
The nerve gives off branches to the posterior belly of the digastric muscle and postauricular muscles before it turns anterolaterally and enters the parotid gland just anterior to the border where the digastric muscle inserts into the mastoid.
Tumors may thin the nerve or displace the trunk, but the position where the nerve enters the gland is constant.
Placing a finger on the mastoid tip, the surgeon uses the position of the cartilaginous tragal pointer and superior edge of the digastric muscle to identify the position of the facial nerve.
It may be helpful to identify deeper structures such as the styloid process or tympanomastoid suture line to aid in nerve identification.
Further mobilization is performed by separating gland from the nerve, proceeding anteriorly; often the assistant will notice some twitching of the face during this separation
The surgeon should dissect distally along the nerve to identify the pes and confirm that the main trunk has been identified proximal to any significant branches.
these veins can be cauterized with bipolar cautery or ligated depending on their size.
The essence of deep parotidectomy is vascular control.
Once the surgeon has made the decision to perform deep parotid gland removal, the intraglandular segments of the external carotid artery and deep veins are ligated and divided.
The superficial temporal artery and vein are ligated at the superior periphery of the gland.
The posterior facial vein is divided and ligated.
The transverse facial artery is divided at the superior anterior periphery of the gland.
The only vascular structures remaining at this point are the internal maxillary artery and venous tributaries to the pterygoid musculature located at the posterior border of the masseter muscle and mandibular ramus.
After control of the intraglandular vessels is obtained, the facial nerve trunk and branches are mobilized off of the underlying tumor.
After complete mobilization of the nerve, the gland can be bluntly dissected from the deep bed with retraction and separation of the fascial attachments with a small curved clamp.
The gland is separated from the temporomandibular joint, bony ear canal, condyle of the mandible, and styloglossus and stylopharyngeus muscles.
The graft should be harvested with meticulous technique, freshened, and approximated without tension or redundancy with minimal use of well-placed 9-0 nylon sutures.
ipsilateral hypoglossal nerve by placement of an interpositional jump graft to preserve facial tone.
Infection is rare if the gland is not chronically infected
placement of an angiocatheter from behind the ear into the pocket of saliva. A scopolamine patch is also placed to decrease salivary gland flow.