Dr Samreen Younas, King Edward Medical UNiversity Lahore.

1. Dr Samreen Younas
PGR (FCPS) OMFS
King Edward Medical
University, Lahore

2. OUTLINE
 Normal anatomy
 Classification of parotid gland tumors
 Important features and management.
 Parotidectomy and its Complications
 Take home message

3. Parotid Gland
Stenson’s
duct
Buccinator
Masseter
Facial
Nerve

4. Glossopharyngeal n.
Tympanic b
Tympanic
Plexus
Lesser petrosal
Otic
Auriculo-
temporal

6. CLASSIFICATION OF
TUMORS
Adenomas
Carcinomas
Miscellaneous
Tumor like lesions

7. Gland Frequency % Malignant %
Parotid 65 25
Submandibular 10 40
Sublingual <1 90
Minor Glands 25 50
Incidence

8. INCIDENCE
 Pleomorphic adenoma is most common
benign tumor in all major and minor
salivary glands.
 Most common malignancy in Parotid is
Mucoepidermoid CA while in
Submandibular It’s Adenoid Cystic CA.

10. MULTICELLULAR
THEORY
• Acinous tumorAcinar cells
• Mixed tumor
Intercalated
cells
• Mucoepidermoid CA
• Squamous cell CA
Excretory
duct cells

11. BICELLULAR THEORY
• Mixed tumor
• ACC
Intercalated
duct stem
cells
• Mucoepidermoid CA
• Squamous cell CA
Excretory
duct stem
cells

12. ETIOLOGY
Radiation
Epstein Barr Virus
Genetic abnormalities
Other Factors e.g smoking

14. 1) Detailed history and
clinical examination
2) Ultrasonography
3) Radiology
4) FNAC
5) Incisional Biopsy

15. A sudden increase in size:
1. Infection
2. cystic degeneration
3. hemorrhage inside the mass
4. malignant transformation
MALIGNANT INDICATORS ARE:
1. Facial nerve paresis or paralysis.
2. Weakness or numbness of the tongue or
in distribution of branches of trigeminal
nerve
3. Pain
4. Fixation
5 Cervical adenopathy

17. Parotid most commonly
involved
Deep lobe tumor
90%

18.  Well circumscribed, encapsulated
incomplete infilterations
 Is composed of glandular
epithelium and
myoepithelial cells with a
mesenchyme like
background.

19. 1) Superficial / Lateral / Patey’s
2) Total conservative
3) Radical
4) Suprafacial

20. Modified Blair Incision Face lift incision

21.  Inverted ‘T’ incision  Modified ‘Y’ incision

22. IDENTIFICATION OF FACIAL
NERVE
Antegrade / Retrograde
 Peripheral branch
 Digastric muscle
 Tragal pointer
(Conley)
 Styloid process
 Tympanomastoid
suture line
 Mastoid process

23.  Best treated with surgical excision
 SUPERFICIAL LOBE; Superficial
parotidectomy saving facial nerve.
 DEEP LOBE; Total parotidectomy.
 95% cure rate.
 5% malignant transformation.

24.  Slowly growing, painless,
nodular mass
 Firm or fluctuant
 Tail of parotid
 tendency to occur
bilaterally 5-7%
 6th and 7th decade
 > in males, associated
with smoking

25. Lymphocyte
infilterate
Bilayer epithelium

26.  Surgical removal is treatment of choice.
 6-12% recurrence
 Malignant Warthin tumors have been
reported but are rare..

28. Is most common salivary malignancy.
 Is most common in parotid gland usually
appears as asymptomatic swelling.
 Pain/ facial nerve palsy occurs with Hi grade
tumor.
 Peak age 2-7th decade

29.  In minor Palate
Asymptomatic blue/ red color,
can be mistaken for mucocele

30. 1. Mucous
2. Squamous
3. Intermediate cells
1. Relative numbers of mucous,
squamous and intermediate cells
2. Amount of cyst formation
3. Degree of cytologic atypia

32. – Mucus = squamous
– Fewer and smaller
cysts
– Increasing
pleomorphism
and mitotic figures

33. – Squamous > mucus
– Solid islands of
squamous
and intermediate cells
- inc. pleomorphism
and mitotic activity
– Mistaken for SCCA

34. Influenced by location, Grade and stage of
tumor.
PAROTID; Early stage subtotal
parotidectomy, saving facial nerve
Advanced tumors total parotidectomy,
sacrificing facial nerve .

35.  Slow growing mass
 Pain is common and important finding
 In parotid tumors facial nerve paralysis may
develop

36. Clinical features
 Smooth surfaced or ulcerated
 Minor salivary gland 50-60%
 Parotid 2-3%
 Submandibular 12-17%
 Middle aged adults
50-60%

37. – Most common
– “swiss cheese”
appearance

38. TUBULAR PATTEREN
 Layered cells
forming duct like
structures
 Basophillic
mucinous substance
SOLID PATTEREN
Solid nests of cells
without cystic spaces

39. A highly characteristic feature of ACC is to
show
finding of pain
TUMOR CELLS
NERVE

40. is treatment of choice
is poorest for tumors arising
in maxillary sinus and submandibular gland
and for tumors with solid histopathologic
pattern.
occurs in aprox.35% cases
most frequently to lungs and bones.
42%

41. Cells show serous acinar
differentiation.
 85% occur in parotid
 9% minor salivary glands
 2nd-7th decade
 Females> males
85% 9%

42. Treatment And Prognosis
 Best treated with surgical excision
 Approx. 1/3rd of the patients have
recurrences
 Metastasis develop in 10-15 % cases

44. ; no clinical evidence of primary tumour
; Up to 2 cms diameter without
extraparenchymal extension
; 2 – 4 cms without extraparechymal extension
; > 4.0 cms and / or extraparenchymal
extension
;
a) Tumor invades adjacent st. skin, ear canal,
mandible, nerve
b) Invades skull base, pterygoid plates or
encases carotid artery

45.  NX: Lymph nodes (LN) can’t be
assessed
 N0: no nodal involvement
 N1: metastasis in only one LN ipsilateral
to the tumor with up to 3 cm
 N2a: LN of 3 to 6 cm, ipsilateral
 N2b: multiple ipsilateral LNs
 N2c: bilateral or contralateral LN’s
o N3: LN’s larger than 6 cm

46. TNM STAGING
 M0 no distant mets
 M1 distant mets eg., bone, lung

47. STAGING
 Stage I T1NoMo
 Stage II T2NoMo
 Stage III T3NoMo or
T1-3,N1Mo
 Stage IVA T4aNo-1M0 or
T1-4aN2M0
 Stage IVB T4bNxM0 or
TxN3M0
 Stage IVC TxNxM1

48.  Metastatic cervical L.A.P.
 But there is controversy about
management of clinically negative neck
nodes
 High-grade or large tumor occult
regional disease elective or
selective neck dissection
 In low-grade malignancy the elective
neck disection not recommended

49.  Microscopically positive margin
 High grade including adenoid cystic
 Involvement of skin, bone, nerve
 LN spread
 Large tumors requiring radical resection
 Tumor spillage
 Recurrence

50. INTRA-
OPERATIVE
EARLY POST OP LATE POST OP
Hemorrhage Nerve paralysis Facial sinkinesis
Nerve transaction Hemorrhage/
Hematoma
Numbness of ear
lobule
Incomplete tumor
resection
Infection Recurrent tumor
Capsule Rupture Flap necrosis Soft Tissue Defect
Cosmetic
Deformity
Frey’s syndrome
Salivary fistula
formation

51. SALIVARY FISTULA
 Pressure dressing
 Antisialagogues
 Total parotidectomy
 Tympanic neurectomy
 Radiation therapy
 Botulinum toxin
 Fibrin glue

52. FREY’S SYNDROME
(Gustatory sweating,
Auriculotemporal syndrome)
 10-20% in parotidectomy
 Topical scopolamine
gel 1-3%
 AlCl3 hexahydrate gel
 Botulinum toxin
 Tympanic neurectomy
 Fascia lata or SCM flaps

53.  Salivary gland tumors have diverse
pathology.
 Principal treatment of salivary gland
tumors is surgical resection with safe
margins.
 Used either as a single modality or in
conjunction with adjuvant radiotherapy.

54. THANK YOU
