The document discusses the anatomy, development, disorders, and tumors of the parotid gland. It begins by describing the location and structures of the parotid gland. It then discusses various inflammatory and infectious disorders that can affect the gland such as mumps, bacterial infections, and HIV-associated sialadenitis. Obstructive disorders from stones, strictures, or papillary obstruction are also reviewed. The majority of the document focuses on tumors of the parotid gland, describing the classification and most common tumor types as well as their presentation, investigations, and surgical management.
Anatomy of cavernous sinus, structures passing through the caveernous sinus, spread of infections, clinical features of cavernous sinus thrombosis, investigations and management of cavernous sinus thrombosis.
Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University
Salivary glands are exocrine glands that produce saliva through a series of ducts. The glands may be affected by a wide range of disorders. They can be involved with acute and chronic inflammatory processes, give rise to benign and malignant tumors, manifest congenital abnormalities or represent involvement of a systemic disorder. Further, partial or complete obstruction of the ductal element can occurs. Physical examination and diagnostic aids are presented. Current surgical managements of these disorders are discussed.
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Anatomy of cavernous sinus, structures passing through the caveernous sinus, spread of infections, clinical features of cavernous sinus thrombosis, investigations and management of cavernous sinus thrombosis.
Dr. Ahmed M. Adawy
Professor Emeritus, Dep. Oral & Maxillofacial Surg.
Former Dean, Faculty of Dental Medicine
Al-Azhar University
Salivary glands are exocrine glands that produce saliva through a series of ducts. The glands may be affected by a wide range of disorders. They can be involved with acute and chronic inflammatory processes, give rise to benign and malignant tumors, manifest congenital abnormalities or represent involvement of a systemic disorder. Further, partial or complete obstruction of the ductal element can occurs. Physical examination and diagnostic aids are presented. Current surgical managements of these disorders are discussed.
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
2. THE PAROTID GLAND
Anatomy
The parotid gland lies in a recess bounded by the
ramus of the mandible, the base of the skull and the
mastoid process.
It lies on the carotid sheath and CNs XI and XII and
extends forward over the masseter muscle.
The gland is enclosed in a sheath of dense deep
cervical fascia.
Its upper pole extends just below the zygoma and its
lower pole (tail) into the neck.
3. THE PAROTID GLAND
Anatomy
Several important structures run through the parotid
gland. These include:
● Facial nerve trunk that divides into its major five
branches;
● Terminal branch of the external carotid artery that
divides into the maxillary artery and the superficial
temporal artery;
● Retromandibular vein;
● Intraparotid lymph nodes.
4. THE PAROTID GLAND
Anatomy
The gland is arbitrarily divided into deep and
superficial lobes, separated by the facial nerve.
Eighty per cent of the parotid gland lies superficial and
20% deep to the nerve.
An accessory lobe is occasionally present lying anterior
to the superficial lobe on the masseter muscle.
6. Inflammatory disorders
Viral infections
Mumps is the most common cause of acute painful
parotid swelling and predominantly affects children.
It is spread via airborne droplets of infected saliva.
The disease starts with a prodromal period of 1–2 days,
during which the patient experiences fever, nausea and
headache.
This is followed by pain and swelling in one or both
parotid glands.
7. Inflammatory disorders
Viral infections
Parotid pain can be very severe and exacerbated by
eating and drinking.
Symptoms resolve within 5–10 days.
The diagnosis is based on history and clinical
examination; recent contact with an infected patient
with a painful parotid swelling is often sufficient to
lead to a diagnosis.
8. Inflammatory disorders
Viral infections
Atypical viral parotitis does occur and may present
with predominantly unilateral swelling or even
submandibular involvement.
A single episode of infection confers lifelong
immunity.
9. Inflammatory disorders
Viral infections
Treatment of mumps is symptomatic with regular
paracetamol and adequate oral fluid intake.
Complications of orchitis, oophoritis, pancreatitis,
sensorineural deafness and meningoencephalitis are
rare, but are more likely to occur in adults.
Other viral agents that produce parotitis include
Coxsackie A and B, parainfluenza 1 and 3, Echo and
lymphocytic choriomeningitis.
10. Inflammatory disorders
Bacterial infections
Acute ascending bacterial sialadenitis is historically
described in dehydrated elderly patients following
major surgery.
Reduced salivary flow secondary to dehydration results
in ascending infection via the parotid duct into the
parotid parenchyma.
The more common picture today is an acute bacterial
parotitis associated with a salivary calculus.
11. Inflammatory disorders
Bacterial infections
The patient presents with a tender, painful parotid
swelling that arises over several hours .
There is generalized malaise, pyrexia and occasional
cervical lymphadenopathy.
The pain is exacerbated by eating or drinking.
The parotid swelling may be diffuse, but often
localizes to the lower pole of the gland.
Intraoral examination may reveal pus exuding from
the parotid gland papilla
12.
13. Inflammatory disorders
Bacterial infections
The infecting organism is usually Staphylococcus
aureus or Streptococcus viridans, and treatment is
with appropriate intravenous antibiotics.
If the gland becomes fluctuant, ultrasound may
identify abscess formation within the gland that may
require aspiration with a large-bore needle or formal
drainage under general anesthesia.
14. Inflammatory disorders
Bacterial infections
In the latter procedure, the skin incision should be
made low to avoid damage to the lower branch of the
facial nerve.
Blunt dissection using sinus forceps is preferred, and
the cavity is opened to facilitate drainage.
15. Inflammatory disorders
Bacterial infections
A drain is inserted and left in situ for 24–72 hours.
Sialography is contraindicated during acute infection.
Chronic bacterial sialadenitis is rare in the parotid
gland.
16. Recurrent parotitis of childhood
Recurrent parotitis of childhood is a distinct clinical
entity of unknown etiology and variable prognosis.
It is characterized by rapid swelling of one or both
parotid glands, in which the symptoms are made worse
by chewing and eating.
Systemic upset with fever and malaise is variable.
17. Recurrent parotitis of childhood
The symptoms usually last from 3 to 7 days, and are
then followed by a quiescent period of weeks to several
months.
Children usually present between the ages of 3 and 6
years, although symptoms have been reported in
infants as young as 4 months.
18. Recurrent parotitis of childhood
The diagnosis is based on the characteristic history
and can be confirmed by Sialography.
This shows a characteristic punctate sialectasis likened
to a ‘snowstorm’ .
The condition is difficult to manage if it becomes
established and so the initial treatment is important.
20. Recurrent parotitis of childhood
The condition responds to regular endoscopic
washouts and long courses of antibiotics.
The suspicion is that in some cases the condition is
caused by an incompetent punctum that leads to
soiling of the parotid ducts with contaminated oral
fluids.
21. Human immunodeficiency virus-associated
sialadenitis
Chronic parotitis in children may signify human
immunodeficiency virus (HIV) infection.
The presentation of HIV-associated sialadenitis is very
similar to classical Sjögren’s syndrome in adulthood
Although HIV-associated sialadenitis and Sjögren’s
syndrome are histologically similar, the former
condition is usually associated with a negative
autoantibody screen.
22. Human immunodeficiency virus-associated
sialadenitis
Other presentations of salivary gland disease in HIV-
positive patients include multiple parotid cysts, which
cause gross parotid swelling and facial disfigurement.
CT and MRI demonstrate the characteristic ‘Swiss
cheese’ appearance of multiple large cystic lesions.
The swollen glands are usually painless and may
regress on the institution of antiviral therapy.
Cysts can be aspirated
23. Obstructive parotitis
There are several causes of obstructive parotitis, which
produces intermittent painful swelling of the parotid
gland, particularly at mealtimes;
Stone formation and strictures
Papillary obstruction
24. Obstructive parotitis
Stone formation and strictures
Sialolithiasis is less common in the parotid gland
(20%) than in the submandibular gland (80%).
Parotid duct stones are usually radiolucent and rarely
visible on plain radiography.
They are frequently located at the confluence of the
collecting ducts, at the point the duct courses over the
masseter muscle or in the distal aspect of the parotid
duct adjacent to the parotid papilla.
25. Obstructive parotitis
Stone formation and strictures
The stones are easily demonstrated on ultrasound.
The same rules for treatment apply to parotid stones as
to submandibular duct stones. Small stones (~4 mm)
can be retrieved by baskets, slightly larger stones up to
8 mm can be broken with lithotripsy and stones over 8
mm diameter should be removed by endoscopic
assisted surgery while preserving the gland.
26. Obstructive parotitis
Stone formation and strictures
The stones are easily demonstrated on ultrasound.
The same rules for treatment apply to parotid stones as
to submandibular duct stones. Small stones (~4 mm)
can be retrieved by baskets, slightly larger stones up to
8 mm can be broken with lithotripsy and stones over 8
mm diameter should be removed by endoscopic
assisted surgery while preserving the gland.
27. Obstructive parotitis
Stone formation and strictures
Strictures are common in the parotid gland and are
responsible for about 20% of obstructive cases.
The symptom complex is a little different as the
obstruction is due to mucus plugs.
These form after periods of stagnation.
Classically, the patient complains of a meal-time
syndrome starting at breakfast and the saliva cannot
seep past the mucus plug so the swelling persists.
28. Obstructive parotitis
Stone formation and strictures
Massage eventually releases the plug with a gush of
salty saliva.
Infection is uncommon unless there is stone
formation.
Strictures respond to dilatation and endoscopic
washouts with steroid solutions.
29. Papillary obstruction
Obstructive parotitis, can be caused by trauma to the
parotid papilla.
The subsequent inflammation and edema obstructs
salivary flow, particularly at mealtimes.
This is a rare but real entity.
30. Papillary obstruction
The partial obstruction over a protracted period leads
to dilation of the duct and an entity called ‘mega-duct’.
A large dilated duct is visible coursing over the
patient’s cheek.
Drainage has to be re-established.
31. Papillary obstruction
This can be done by progressive dilatation of the
punctum and the insertion of a stent that is kept in
position for many weeks.
Surgical attempts to refashion the punctum are
unlikely to be successful.
32. Papillary obstruction
Papillotomy should not be performed as this often
leads to stricture formation and a life time of
problems.
This is not the case with the submandibular gland.
33. Tumors of the parotid gland
The parotid gland is the most common
site for salivary tumors.
Most tumors arise in the superficial lobe
and present as slow-growing, painless
swellings
below the ear
in front of the ear or
in the upper aspect of the neck.
34. Tumors of the parotid gland
Less commonly, tumors may arise
from the accessory lobe and
present as persistent swellings
within the cheek.
Rarely , tumors may arise from
the deep lobe of the gland and
present as a parapharyngeal mass.
35. Benign tumour of the left parotid gland producing
characteristic deflection of the ear lobe.
37. Deep lobe tumour of the right parotid presenting with a swelling of the right soft
palate.
38. Magnetic resonance imaging scan revealing a large deep lobe tumour (arrow) of
the right parotid gland, occupying the parapharyngeal space.
39. Tumors of the parotid gland
Symptoms include difficulty in swallowing and
snoring.
Clinical examination reveals a diffuse firm swelling in
the soft palate and tonsil.
Some 80–90% of tumours of the parotid gland are
benign, the most common being pleomorphic
adenoma.
40. Tumors of the parotid gland
Malignant salivary
gland tumors are
divided into two
distinct sub-groups:
41. Tumors of the parotid gland
1 Low-grade malignant
tumors (e.g. acinic cell
carcinoma) are
indistinguishable on
clinical examination
from benign neoplasms.
42. Tumors of the parotid gland
2 High-grade malignant
tumors usually present
as rapidly growing, often
painless swellings in and
around the parotid
gland.
43. Tumors of the parotid gland
The tumour presents as either
a discrete mass with
infiltration into the overlying
skin or
a diffuse but hard swelling of
the gland with no discrete
mass.
44. Tumors of the parotid gland
Presentation with
advanced disease is
common, and cervical
lymph node metastases
may be present.
45. Tumors of the parotid gland
Among primary parotid malignant
tumors, mucoepidermoid carcinoma
is the most common, followed by
adenocystic carcinoma.
The latter is notorious for its proclivity
for perineural invasion and metastatic
potential so surgery is normally
supported by adjuvant radiotherapy to
gain local control of the disease.
46. Classification of salivary gland tumours
(simplified).
I Adenoma
Pleomorphic : Pleomorphic adenoma
Monomorphic : Adenolymphoma (Warthin’s
tumour)
48. Classification of salivary gland tumours
(simplified).
III Non-epithelial tumors
Haemangioma, lymphangioma
IV Lymphomas Primary lymphomas
Secondary lymphomas
Non-Hodgkin’s lymphomas
Lymphomas in Sjögren’s syndrome
V Secondary tumors
Local : Tumors of the head and neck especially
Distant: Skin and bronchus
49. Classification of salivary gland tumours
(simplified).
VI Unclassified tumors
VII Tumour-like lesions
Solid lesions
Benign lymphoepithelial lesion
Adenomatoid hyperplasia
Cystic lesions
Salivary gland cysts
50. Malignant tumour of the left parotid gland with
invasion of the overlying skin.
51. Investigations
The initial imaging modality of choice is ultrasound as
it demonstrates if the lump is intrinsic to the parotid
or not.
It also facilitates accurate sampling of the lesion by
FNAC or True-Cut biopsy.
Subsequently, CT and MRI are the most useful
imaging techniques .
52. Investigations
Open surgical biopsy is contraindicated unless
evidence of gross malignancy is present, and
preoperative histological diagnosis is required as a
prelude to radical parotidectomy.
54. Parotidectomy
The aim of superficial parotidectomy is to remove the
tumour with a cuff of normal surrounding tissue.
The most important structure traversing the parotid
gland is the facial nerve.
Parotid tumour excision techniques are classified
based on the approach onto the facial nerve.
55. Parotidectomy
Essentially the traditional parotidectomy is in reality a
dissection of the facial nerve.
A parotidectomy is
conservative when the nerve is spared ,
radical when the nerve is excised en bloc with the
tumour.
56. Parotidectomy
A superficial parotidectomy is when the part of the
gland superficial to the facial nerve is removed.
A deep lobe parotidectomy is when the part of the
gland beneath the nerve is removed and
Total parotidectomy is when both are dissected and
removed.
57. Parotidectomy
Superficial parotidectomy can be partial in relatively
small tumors that are removed with a cuff of clinically
normal parenchyma without removal of the entire
superficial portion of the gland.
An alternative surgical approach is to focus on the
tumour itself as the principal procedure and not facial
nerve dissection.
58. Parotidectomy
Extracapsular dissection is now an established
alternative to parotidectomy.
It does not require formal facial nerve dissection and is
a less invasive technique with reduced morbidity.
Temporary facial nerve injury rates are 7% compared
with 25% for superficial parotidectomy.
59. Superficial parotidectomy
Superficial parotidectomy is the most common
procedure for parotid gland pathology.
Surgery is performed under endotracheal general
anesthesia, which may or may not be accompanied by
hypotensive anesthesia to facilitate dissection, improve
the visual surgical field and reduce blood loss.
The operation has several distinct phases.
60. INCISION AND DEVELOPMENT OF A
SKIN FLAP
The most commonly used incision is the ‘lazy S’ pre-
auricular–mastoid–cervical.
The incision is marked out and three points identified
along its length to facilitate closure.
Infiltration with local anesthetic and adrenaline is
optional, but does aid in the development of the skin
flap, improves visibility and reduces blood loss in the
initial phase.
61. (a) Landmarks and cervical–mastoid preauricular
incision for superficial parotidectomy.
62. INCISION AND DEVELOPMENT OF A
SKIN FLAP
The skin flap is developed in an anterior direction by
either scalpel or scissors dissection.
The plane of dissection is well below the hair follicles,
just above the parotid fascia.
The skin flap is developed forwards to the anterior
border of the gland.
Posterior undermining of the incision in the cervical
region facilitates access to the anterior border of the
sternomastoid muscle.
63. MOBILISATION OF THE GLAND
This phase of the dissection aims to free the posterior
margin of the gland, allowing identification of the
facial nerve.
Clips are applied along the fascia overlying the
sternomastoid muscle, with the assistant applying
traction anteriorly.
By sharp dissection along the anterior border of the
sternomastoid, an avascular plane is developed, which
requires elective transection of the great auricular
nerve.
64. (b) Development of the avascular plane
along the anterior border of the sternomastoid
prior to sacrifice of the great auricular nerve.
65. MOBILISATION OF THE GLAND
At the lower end of the dissection, the external jugular
vein is often encountered and ligated.
The gland is gradually mobilized by sharp dissection
up to and on to the anterior aspect of the mastoid
process, identifying the posterior belly of the digastric
muscle.
A second avascular plane is developed along the
anterior border of the cartilaginous and bony external
auditory meatus immediately anterior to the tragus.
66. MOBILISATION OF THE GLAND
The two avascular planes are then connected by blunt
and sharp dissection.
By developing two broad avascular planes,
identification of the facial nerve trunk is facilitated.
It is best achieved by scissors dissection in the line of
the facial nerve trunk.
Intraoperative use of a facial nerve stimulator is
recommended.
68. LOCATION OF THE FACIAL NERVE
TRUNK
The main methods of facial nerve trunk localization
can be divided into antegrade and retrograde.
The former utilizes anatomical landmarks to identify
the nerve trunk after its exit from the stylomastoid
foramen, which is then traced distally.
69. LOCATION OF THE FACIAL NERVE
TRUNK
Landmarks commonly used are:
1 the inferior portion of the cartilaginous canal.
This is termed Conley’s pointer (tragal pointer) and
indicates the position of the facial nerve, which lies 1
cm deep and inferior to its tip;
2 the upper border of the posterior belly of the
digastric muscle.
70. LOCATION OF THE FACIAL NERVE
TRUNK
Identification of this muscle not only helps to mobilize
the parotid gland, but also exposes an area
immediately superior, in which the facial nerve is
usually located;
3 the squamotympanic fissure;
4 the styloid process (the nerve is superficial to it);
5 the mastoid process can be drilled and the nerve
identified more proximally.
71. LOCATION OF THE FACIAL NERVE
TRUNK
Retrograde techniques rely on the identification of one
of the nerve main branches (buccal in relation to the
parotid duct, marginal mandibular in relation to the
facial vessels, temporal branch), which is then traced
proximally until the main trunk is identified.
These techniques can be useful in revision cases where
the anatomy is altered or postradiotherapy when
significant fibrosis distorts the planes of dissection.
Once the facial nerve trunk has been identified, gentle
traction anteriorly facilitates further mobilization.
72. LOCATION OF THE FACIAL NERVE
TRUNK
Control of hemorrhage at this stage is vital as bleeding,
no matter how minor, significantly impedes visibility
for the surgeon.
Hemostasis can be achieved with bipolar diathermy,
although caution is necessary, particularly as the facial
nerve is approached.
73. LOCATION OF THE FACIAL NERVE
TRUNK
Damage to the stylomastoid artery, which lies
immediately lateral to the nerve, can result in
troublesome bleeding immediately prior to
identification.
Pledget swabs soaked in adrenaline are sometimes
helpful in reducing the ooze associated with this phase
of the dissection.
74. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
Once the facial nerve trunk is identified, further
exposure of the branch of the facial nerve can be
achieved by scissors dissection in the perineural plane
immediately above the nerve.
The tunnel thus created is then laid open, and
divisions and branches of the facial nerve are followed
to the periphery in a sequential manner, usually
beginning with the upper division.
75. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
The upper division divides into a temporal and a
zygomatic branch, and
the lower division into mandibular and cervical
branches.
In this way, the superficial lobe and its associated
tumour are mobilized in a superior to inferior
direction.
76. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
The upper division of the nerve is frequently tortuous
in its course and it can be damaged unless great care is
taken during perineural dissection.
It is often not necessary to dissect all branches of the
facial nerve completely, as adequate tumour clearance
can be achieved with a more conservative resection of
the superficial lobe.
77. DISSECTION OF THE GLAND OFF
THE FACIAL NERVE
When a branch of the facial nerve is adherent to the
tumour or running through the tumour, it may require
elective division.
With the exception of the buccal branch, the
transected nerve should be repaired immediately with
a cable graft, harvested from the great auricular nerve.
78. (e) Branches of the facial nerve and retromandibular
vein following delivery of the tumour.
79. CLOSURE
The patient is placed into a Trendelenburg position to
identify any residual bleeding vessels.
A suction drain is applied for a period of 24–48 hours
and the wound closed in layers.
(f) Wound closure with a vacuum drain.
80. Extracapsular dissection
Extracapsular dissection is an oncologically sound
technique for benign parotid gland tumors.
The recurrent rates of pleomorphic adenomas excision
with extracapsular dissection compare favorably with
traditional superficial parotidectomies (extracapsular
dissection 1.3–1.5% vs superficial parotidectomy 2–
2.4%) and complication rates are less (temporary facial
nerve palsy 7% vs 25%: Frey’s syndrome 0 vs 60%)
81. Extracapsular dissection
A preauricular incision is made, the length and
position of which is adapted to the size and site of the
tumour.
The dissection proceeds in the plane just immediately
above the ‘shining’ parotid fascia (the SMAS or
superficial muscular aponeurotic system layer) and
continues in continuity with the platysma muscle.
83. Extracapsular dissection
The skin flap should extend past the lump for at least 1
cm .
The circumference of the tumour is marked with ink
and a cruciate incision marked over the surface.
The legs of the cruciate incision should extend 1 cm
past the edge of the tumour.
This is an essential part of the technique.
85. Extracapsular dissection
Four small artery clips are then placed where the two
lines bisect.
The artery clips are used to tent up the parotid fascia,
which is then divided along the cruciate lines.
Small rounded end scissors are then used to
commence a dissection through the parotid gland.
The dissection advances in a blunt fashion and only
when the scissors blades are visible through the fascia
may the tissue bridge be divided.
86. (c) Cruciate incision through parotid fascia.
The leaves of parotid fascia (arrows) have been raised exposing the
underlying glandular parenchyma that contains the tumour.
87. Extracapsular dissection
As the dissection proceeds around the tumour, the
presence of a facial nerve is easy to discern.
It is prudent to use continuous facial monitoring
during the operation, which helps alert the surgeon to
the presence of a facial nerve.
It is not difficult to recognise a branch of the nerve as
long as the basic principle is adhered to that no
parotid parenchyma is diathermised or cut unless one
can see through the tissues.
88. (d) Exposure of tumour. The arrow depicts a branch of the facial nerve.
90. Extracapsular dissection
The key to the extracapsular dissection technique is to
place traction on the artery clips, which pulls the
parotid tissue away from the lump and normally
reveals a plane through which the surgeon can work 2–
3 mm away from the tumour.
When a branch of the facial nerve is observed, it is not
necessarily dissected unless in close vicinity to the
tumour capsule.
91. Extracapsular dissection
Retractors can be used on the normal parotid gland to
improve exposure of the tumour, but direct pressure
on the tumour should be avoided to minimise the risk
of rupture.
The tumour is removed ,leaving a parted but
essentially intact parotid gland .
Depending on the depth of the tumour, a suction drain
can be used at the surgeon’s discretion.
92. (f) The tumour is mobilized with preservation of the facial nerve branch
(arrows).
93. (g) Excision of the tumour.
The picture shows the remaining parotid bed with the facial nerve branch
intact (arrows).
94. Extracapsular dissection
The cruciate incision is re-approximated and the skin
incision closed.
It is advised that a mastoid-type pressure dressing is
always applied at the end of the procedure otherwise
sialoceles can occur.
The pressure dressing is kept for about 48 hours.
95. (h) The parotid fascia leaves are replaced and sutured together in a watertight fashion.
This restores the parotid capsule integrity and prevents development of Frey’s
syndrome.
96. Radical parotidectomy
Radical parotidectomy is performed for patients in
whom there is clear histological evidence of a high-
grade malignant tumour (e.g. squamous cell
carcinoma) with invasion of facial nerve.
Low-grade and low stage malignant tumors can
usually be managed by standard superficial
parotidectomy.
Radical parotidectomy involves removal of all parotid
gland tissue and elective division of the facial nerve,
usually through themain trunk .
101. (e) Appearance after left radical neck dissection and left radical parotidectomy.
Posterior mandible (upper arrow) and great vessels of the neck (lower arrow) are
visible.
102. Radical parotidectomy
The surgery inevitably removes the ipsilateral masseter
muscle and may also require simultaneous neck
dissection, particularly where there is clinical,
radiological and cytological evidence of lymph node
metastases in the ipsilateral neck.
When indicated, facial nerve can be repaired using
cable grafts (interpositional greater auricular or sural
nerve grafts).