1. A 31-year-old male presented with a swelling in the right parotid region for 1 year. On examination, a 2cmx3cm firm, non-tender swelling was found in the right parotid gland. 2. A provisional diagnosis of pleomorphic adenoma of the right parotid gland was made. 3. The anatomy and clinical features of the parotid gland were discussed, along with differential diagnoses and management of parotid tumors.

1. CLINICAL
MEETING
23.1.20
Department Of Otolaryngology And Head Neck Surgery
Sylhet MAG Osmani Medical College Hospital

2. Presented by:
• Dr. Musanna Nabi Chowdhury
• Dr. Mahesh Acharya
• Dr. Asmita Paudel

3. A 31 year old male presented with
swelling in the right parotid region

4. CASE
Mr. Jahed Ahmed, 31 years old, Muslim,
married, hailing from Golapganj, Sylhet
presented with a swelling in the right side of the
upper part of the neck, just below the right ear
lobule for last 1 year. The size of the swelling is
increasing slowly ever since.
*taken with patient’s permission

5. CASE CONTINUED
There is no pain over the swelling and no history suggestive
of facial nerve paralysis like: any asymmetry of face,
difficulty in closing the eye, chewing the food or any
drooling of saliva from the angle of mouth. On query patient
gives no history of weight loss. On general examination, all
vitals are within the normal limit. Cervical lymph nodes are
not palpable.

6. CASE CONTINUED
On local examination, there is a swelling in the right parotid region
of about 2cm×3cm in size, globular in shape, firm in consistency
and non-tender. The surface of the swelling is smooth, margins are
well defined and rounded. The swelling is free from the skin and
underlying structures. The deep lobe of the parotid gland is not
enlarged. There is no purulent discharge from the ductal opening in
the mouth. There is no any evidence of facial nerve palsy as well.

7. PROVISIONAL
DIAGNOSIS?

8. PLEOMORPHIC ADENOMA
OF RIGHT PAROTID GLAND

9. DIFFERENTIAL DIAGNOSIS
• Adenolymphoma of parotid gland
• Carcinoma of parotid gland
• Lipoma
• Fibroma
• Hemangioma

10. ANATOMY

11. PAROTID GLAND
(Para= Around; Otic = Ear)
Largest salivary gland
Serous in nature
Anteriorly: by the posterior border of the ramus of mandible.
Posteriorly: by the mastoid process.
Superiorly: by the external acoustic meatus and posterior part
of temporomandibular joint.
Medially: by styloid process.

12. 1.False Capsule:
Formed by investing layer of the
deep cervical fascia
• Superficial lamina(thick)
• Deep lamina (thin)
1.True Capsule:
Condensation of fibrous stroma
CLINICAL IMPORTANCE:
The parotid swellings are extremely painful because of unyielding temperament of the parotid capsule, any
inflammation or pressure inside the parotid gland will cause acute pain due to stretching of the capsule.
PAROTID CAPSULE

13. 1.Apex
2.Base
3.3 Surfaces: Superficial (lateral) surface 4. 3 Borders:
Antero-medial surface
Postero-medial surface
Anterior
Posterior
Medial
PRESENTING PARTS

14. 3 chief structures either in part or in whole traverse the gland and branch inside it. From
superficial to deep these are:
•Facial nerve.
•Retromandibular vein.
•External carotid artery.
Some members of the deep parotid lymph nodes and filaments of auriculotemporal
nerve are also found inside the gland
STRUCTURES TRAVERSING PAROTID
GLAND

15. FACIAL NERVE
(queen of the face)
The 5 terminal branches of
the facial nerve radiate like a
goose foot via the anterior
border of the gland and
supply the muscles of facial
expression. Such branching
pattern of the facial nerve is
referred to as pes
anserinus.

16. PATEY’S FACIOVENOUS PLANE
The parotid gland is split into
large superficial and small deep
parts or lobes. The plane
between the superficial and
deep lobes where nerves and
veins are located has been
designated by Patey as
faciovenous plane.
CLINICAL IMPORTANCE
This plane helps the surgeons to eliminate the parotid tumor without damaging the facial nerve.

17. PAROTID DUCT
(STENSON’S DUCT)
Parotid duct, about 5 cm long, appears
from the middle of the anterior border of the
gland and opens into the vestibule of the
mouth opposite the crown of upper second
molar tooth.
The tortuous course of the duct gives a
valve-like mechanism to stop the inflation
of the duct system of parotid gland during
excessive blowing of the mouth as in
trumpet blowing

18. • The probing of the parotid duct is difficult due to its tortuous course.
• The parotid duct and its ramifications can be demonstrated radiologically by
injecting radio-opaque dye via inserted into the mouth of the duct in the
vestibule of the oral cavity (parotid sialogram).
• Sometimes, calculi (stones) may form in the parotid gland and parotid duct.
The calculi lodged in the distal portion of the gland could be taken out by
splitting up the duct from its opening in the mouth
CLINICAL IMPORTANCE

19. Parasympathetic (secretomotor)
Auriculotemporal nerve.
Sympathetic supply:
Sympathetic plexus around external
carotid artery
Sensory Supply:
•Auriculotemporal nerve.
•Great auricular nerve (C2 and C3)
NERVE SUPPLY

20. BLOOD SUPPLY
LYMPHATIC DRAINAGE
Superficial and deep parotid lymph nodes
• The arterial supply - external carotid and superficial temporal
arteries.
• The venous drainage - retromandibular and external jugular veins
Deep cervical lymph nodes

21. DEVELOPMENT
• 4TH WEEK:
The parotid glands arise from ectodermal furrow. The epithelial buds,
near the primitive mouth grow posteriorly toward the otic placodes to
form solid cords with rounded terminal ends
• 10TH WEEK:
The cords are canalized and form ducts. The rounded terminal ends
of the cords form the acini of the glands.
• 18TH WEEK:
Secretion by the parotid glands begins. Supporting connective tissue
develops from the surrounding mesenchyme.

22. DISEASES OF PAROTID GLAND

23. A. Congenital:
1.Aplasia: Absence of the gland,
2.Atresia:Absence of the duct,
3.Aberrancy:Ectopic gland
B. Acquired :
1.Infective: Mumps, Bacterial parotitis
2.Parotid Abscess
3.Parotid tumour( commonly, mixed parotid tumour)
4.Neurological: Frey's syndrome
5.Sialolithiasis

24. • MUMPS: .Viral disease caused by Paramyxovirus
causing painful swelling of the parotid gland .Do not
suppurate
• BACTERIAL PAROTITIS:
1.Acute
2.Chronic
3.Recurrent
May suppurate to form abscess
• PAROTID ABSCESS:
Drained By Hilton’s Method: Small horizontal incision to
avoid injury of facial nerve branches
INFECTIVE

25. • Neurological(Frey's syndrome)
• Sialolithiasis: less commonly in parotid but usually in the
duct of the submandibular gland.

26. TUMOURS OF PAROTID AND OTHER SALIVARY
GLANDS
1.Pleomorphic adenoma
2.Adenolymhoma(Warthin's tumour)
3.Oncocytoma
4.Other adenomas
1.Haemangioma
2.Lymhangioma
3.Lipoma
4.Neurofibroma

27. PLEOMORPHIC ADENOMA
They are called "mixed tumours" because both epithelial and
mesenchymal elements are seen in histology
Clinical feature
• Most common benign tumour of salivary glands usually arises
from superficial lobe
Slight male predilection
• Age 40-50 years
• 85% tumor occur in parotid gland
• Slow growing, mobile(except for those found in hard palate)
• Painless mass

28. .
Demonstrate pleomorphic patterns of various ratios of
epithelial and mesenchymal elements and are enclosed in a
connective tissue pseudocapsule.
• The lack of true capsule, the deficiencies of the
pseudocapsule, and the tumor extensions through these
defects are thought to contribute to recurrences
HISTOLOGY

29. WARTHIN TUMOUR: (Adenolymphoma or papillary
cystadinoma lymphomatosum)
• Male: female=5:1 .
• Commonly seen in elderly people
• Doughy painless mass often found in the tail of the parotid

30. Mucoepidermoid carcinoma: In minor salivary glands is more
aggressive but in major salivary glands, they behave like pleomorphic
adenoma.
Adenoid cystic carcinoma(Cylindroma): slowly growing but
infiltrates widely into tissue planes and muscles, also invades perineural
spaces and lymphatics causing pain and 7th nerve Palsy.
Squamus cell carcinoma: rapidly growing that infiltrates and
causes pain and ulcerates through skin

31. INVESTIGATION
S

32. 1. Fine Needle Aspiration Cytology:
Allows pre-operative assessment of nature of tumour
Open biopsy is contraindicated due to
1. Chance of injury to facial nerve
2. Chance of parotid fistula formation
3. Seeding of tumour cells
4. High chance of recurrence
#Indicated only if:
• Minor salivary gland tumour
• Ulcerated lesion
• Where FNAC suggests lymphoma
• In cases of diffuse enlargement

33. 2.CT/MRI:
Anatomical localization
Local, regional, distant invasion
#MRI is better because of
Excellent assessment of margin
Deep extension and infiltration
Bone marrow invasion
Perineural spread

34. 3. USG:
• Distinguish intrinsic from extrinsic tumours
• It can be used to differentiate solid from cystic mases in the salivary
glands
• USG guided FNAC
4.FROZEN SECTION BIOPSY:
• When FNAC findings/diagnosis is at odds with clinical and/or
intraoperative findings
• When preoperative FNAC is non-diagnostic
5.Sialography:
• In evaluation of functional integrity of salivary gland
• In case of obstructions
• To evaluate, the ductal patterns

35. MANAGEMENT

36. TREATMENTS OPTIONS
A. Surgery
B. Surgery + Radiotherapy
FACTORS THAT INFLUENCE TREATMENT
• Age
• Metastatic spread
• Facial nerve involvement
• Site of tumour
• Size, extent, grade and stage of tumour

37. A. SURGERY
1. Superficial Parotidectomy: Removal of
superficial lobe
2. Total Conservative Parotidectomy:
3. Radical Parotidectomy: Removal of both
lobes and facial nerve
4. Extended Radical Parotidectomy
I. For deep lobe tumours
II. Facial nerve preserved
‘Lazy S’ incision

38. B. Radiotherapy
Primary treatment limited to unresectable tumours
Post-operative indicated for:
1. Tumour more than 4 cm
2. Presence of positive surgical margins
3. Facial nerve preserved despite being adherent to tumour
4. Lymph node metastasis
5. High grade tumour
6. Perineural invasion
7. Recurrent pleomorphic adenoma
8. Spillage after surgery of pleomorphic adenoma

39. COMPLICATIONS OF PAROTID SURGERY
1. Hematoma formation
2. Infection
3. Temporary facial nerve palsy and permanent facial weakness
4. Sialocele
5. Facial numbness
6. Permanent numbness of ear lobe associated with greater auricular
nerve transection
7. Frey’s syndrome

40. FREY’S SYNDROME (GUSTATORY SWEATING)
Commonly occurs after parotid surgery or trauma.
Characterized by o Sweating
o Warmth
o Redness
of the face as a result of salivary stimulation by the
smell or taste of food
There is no effective treatment, but various options
are:-
• Injection of Botulinum Toxin A.
• Surgical transection of the nerve fibers (only a
temporary treatment).
• Application of an ointment containing an
anticholinergic drug such as scopolamine.