The document provides information on the anatomy, pathology, clinical features, investigations, and treatment of parotid gland disorders. It describes the parotid gland's location near the ear, division into lobes, and drainage via Stenson's duct into the oral cavity. Common tumors are discussed, including pleomorphic adenoma, Warthin's tumor, and mucoepidermoid carcinoma. Surgical excision is the main treatment, with complications including facial nerve injury.

1. Dr.bharathrajh
Juniorresident
Deptofplasticsurgery

2. Parotid gland – anatomy


3. 
 The parotid glands are a pair of mainly s
e
r
o
u
s
salivary glands
 Located inferior and anterior to the external a
c
o
u
s
t
i
c
meatus, between the ramus of mandible and
sternocleidomastoid muscle.
 The gland is roughly wedge-shaped

4. 
 Gland is divided into two l
o
b
e
s
 Superficial lobe – 80%
 Deep lobe – 20 %

5.  Also called as Stenson’s duct
 It emerges from the anterior border of the gland,
superficial to the masseter muscle, then it pierces the
buccinator muscle & opens into the oral cavity on the
inner surface of the cheek, usually opposite to the
maxillary second molar.
Parotid duct


6. 

7.  Investing layer of deep fascia forms the
c
a
p
s
u
l
e
 Splits into
 Superficial lamina
 Deep lamina
Parotid capsule


8. 

9. Structures passing through
parotid gland

Artery:
External carotid enters in the posteromedial surface
Maxillary artery Superficial
temporal artery Posterior
auricular artery

10. 

11. 

12.  Parasympathetic fibres :- Secretomotor
 Preganglionic fibres arise from the inferior salivatory
nucleus
 Pass through glossopharyngeal nerve
 Relay in otic ganglion
 Postganglionic fibres reach the gland through
auriculotemporal nerve
 Sympathetic fibres :- Vasomotor
 Sensory nerves :- Auriculotemporal nerve
Nerve supply


13.  Benign
 Pleomorphic adenoma
 Warthin’s tumor
 Malignant
 Mucoepidermoid carcinoma
 Adenoid cystic carcinoma
 Acinic cell carcinoma
 Adenocarcinoma
 Squamous cell
carcinoma
Parotid neoplasia


14.  It is also known as “Mixed salivary tumor”
 It is the most common benign tumor of s
a
l
i
v
a
r
y
glands – 80 %
 Characterized by neoplastic proliferation
of parenchymatous glandular cells along
with myoepithelial components
Pleomorphic adenoma


15. 
 Distribution:
 Parotid gland: 84%
 Submandibular gland: 8%
 Minor salivary glands: 6.5%
 Widely distributed including the nasal c
a
v
i
t
y
,
pharynx, larynx, trachea
 Sublingual glands: 0.5%

16.  Swelling
 Painless
 Raised ear
lobule
 Curtain sign
p
o
s
i
t
i
v
e
Clinical features


17. 
 Common in females (3:1)
 Common in 4th and 5th decade of life
 Smooth , firm lobulated mobile swelling w
i
t
h
positive curtain sign
 Ear lobule lifted
 Obliteration of retro mandibular groove
 Deep lobe tumour passes through Patey’s
stylomandibular tunnel pushing tonsil, pharynx,
uvula
 Along with dysphagia

18.  1.5% in 5 yrs. ; 9.5% in
15 y
r
s
.
 Recent increase
in s
i
z
e
 Pain
 Nodularity
 Involvement of skin, LN , Facial nerve,
m
a
s
s
e
t
e
r
 Restriction of jaw movements
Features of malignant
change

Capsular distension
Obstruction of
saliva Nerve
infiltration Tumour
necrosis

19.  Gross:
 Cartilages
 Cystic
s
p
a
c
e
s
 Solid
tissues
Pathology


20.  They contain both epithelial and myoepithelial
(mesenchymal) tissues
 Even though it is capsulated, tumor may come out
as
pseudopods beyond the original extend of the tumor
Histology


21.  Fine needle
aspiration
 Core needle
aspiration
 USG
 CT scan
 MRI scan
Diagnosis


22. 
 USG – Hypoechoic with lobulated and d
i
s
t
i
n
c
t
borders

23. 
 CT scan – Smoothly margined or lobulated
homogeneous small spherical mass
 Small regions of calcification
 When the tumour is small, the enhancement tends
to be prominent

24. 
 MRI :
 Well-circumscribed and homogeneous
 T1: Usually of low intensity
 T2: Usually of very high intensity (especially m
y
x
o
i
d
type)
 T1 C+ (Gd): Usually demonstrates
homogeneousenhancement

25.  Surgical excision of the t
u
m
o
u
r
Treatment

 Superficial(Patey's operation)
parotidectomy
 Total parotidectomy
 Complications:
 Recurrence of 5 to 50%
 Facial nerve injury

26.  It is also called Adenolymphoma or
Papillarycystadenolymphomatosum
 It is a benign tumour occurs only in parotid, u
s
u
a
l
l
y
in the superficial lobe, lower pole.
 Second most common
Warthin’s tumour


27. 
 10 – 15 % bilateral
 Usually occurs in 6th d
e
c
a
d
e
 More common in males
4
:
1
 Associations:
 Cigarette smoking
 Irradiation

28.  Slow growing, non tender, smooth, soft, c
y
s
t
i
c
,
fluctuant swelling.
 Often multi-centric and are usually small (1-4
c
m
)
.
 Typically heterogeneous appearance
onall modalities, often with cystic
components
Morphology


29. 

30. 

31.  Ultrasound :
 A well defined, ovoid, hyper echoic mass.
 In some cases anechoic internal cystic areas
maybe present. They are often hyper vascular
 CT scan:
 Can be often well defined , bilateral tumor
 Classic appearance is a cystic lesion posteriorly
within t
h
e
parotid with a focal tumour nodule
 Cystic changes appear as intralesional lower
attenuation
 No calcification
Investigations


32. 

33. 
 Adenolymphoma produces a “Hot
spot“ in Technetium99-pertechnetate scan
 Diagnostic – due to high mitochondrial
c
o
n
t
e
n
t

34.  Surgical excision is curative
 Rate of recurrence is
almost nil
 No malignant change
Treatment


35.  Commonest type of malignant salivary tumor
in adults
 Commonest malignant tumor of parotid
in childhood
 Common in middle age (35-65 years of age)
 Female predilection
Mucoepidermoid tumor


36. 
 Parotid is the most common site of tumor
 2nd common is palate minor salivary gland
 Radiation – etiological factor
 t(11;19)(q21;p13) chromosome translocation
resultingin a MECT1-MAML2 fusion gene

37. 
 Presents as painless, slow-growing mass that
is f
i
r
mor hard.
 Grossly – Un encapsulated mass with cystic
spaces
 Facial nerve involvement in late stages

38.  The tumours are composed of a mixture
of:
 Mucus secreting cells (muco- )
 Squamous cells (-epidermoid)
 Lymphoid infiltrate often also present
Histology


39.  Low grade:
 Well-differentiated cells with little cellular a
t
y
p
i
a
 High proportion of mucous cells
 Prominent cyst formation
 Intermediate grade: intermediate features
 High grade:
 Poorly differentiated with cellular pleomorphism
 High proportion of squamous cells
 Solid with few if any cysts
Grade of tumor


40. 
 USG :- well-circumscribed hypo echoic lesion, w
i
t
h
a partial or completely cystic appearance
 CT scan :- Low-grade tumors appear as
w
e
l
l
-circumscribed masses, usually with cystic
components. Calcification may be present
 High-grade tumors are poorly defined m
a
r
g
i
n
s
,
infiltrate locally and appear solid.

41.  Low grade – wide local excision or superficial
parotidectomy without any adjuvant radiotherapy
 High grade requires complete or radical
parotidectomy, often with sacrifice of the facial
nerve, neck dissection (as nodal metastases
are common) and adjuvant radiotherapy
Treatment


42.  It is also called as cylindromatous carcinoma
 Low grade tumor
 Wide distribution and mainly occur in relation to
the airways, salivary glands, lacrimal glands and
breast
 Tendency for perineural extension is high
Adenoid cystic
carcinoma


43. 
 Common in females 3:1
 Occurs in 5th & 6th decade of life
 Slow growing tumor but highly malignant
 High affinity for perineural transmission
[Anterograde and retrograde]
 Maxillary and mandibular branch of trigeminal n
e
r
v
e
 Facial nerve
 Reaches Gasserian trigeminal ganglion,
pterygopalantine ganglion & cavernous sinus

44. 
 Microscopy:-
 Cribriform – Swiss cheese pattern
 Tubular
 Solid
 It involves periosteum and bony m
e
d
u
l
l
a

45. 

46.  Radical parotidectomy with adjucvant radiotherapy
 Fast neutron therapy
 Chemotherapy
Treatment


47. 
 Recurrence is common
 5 years survival rate is 89 %
 15 years survival rate is 40 %
 Positive margin, perineural spread, solid type c
a
r
r
y
poor prognosis

48.  Indications:
 Chronic parotitis
 Salivary calculi
 Parotid abscess
 Parotid tumors
 T1,T2,T3 – Total conservative parotidectomy
 T4 – Radical parotidectomy
Parotidectomy


49. 
 Types:
 Superficial parotidectomy
 Total conservative
parotidectomy
 Radical parotidectomy
 Suprafacial parotidectomy

50.  Facial nerve is 1cm deep and below the tip of i
n
f
e
r
i
o
r
portion of cartilaginous canal – conley’s point
 By nerve stimulator
 It is inferomedial to the tragal point
 Deep to digastric muscle
 Nerve is just lateral to styloid process
 Tracing branch from distal to proximal (Hamilton
bailey technique)
Identification of facial nerve


51.  Preoperative weakness / paralysis of nerve
 Intraoperative evidence of gross invasion
 Tumors transgressing through facial
nerve f
r
o
msuperficial to deep lobe
 Nerve stump is checked for frozen section f
o
r
negative margins, if positive, mastoidectomy &
nerve dissection is required
Indication for nerve sacrifice


52. 

53. 

54. 

55. 

56. 

57. 

58. 
 Facial nerve injury
 Hemorrhage
 Salivary fistula
 Infection – flap necrosis is c
o
m
m
o
n
 Frey’s syndrome
 Sialocele
 Injury to greater auricular nerve
Complications of
parotidectomy

59. 