parotid gland tumour literature review

2.  40 years /M/married/shopkeeper/R/O RWP
presented to OPD with c/o
 swelling infront of right ear: 7 years

3.  Patient was in usual state of health 7 years back
when he noticed swelling in front of right ear while
washing his face, which is painless and gradually
increased in size over 7 years.
 Initially it was pea sized that slowly grew to the
size of a lemon but never disappeared.
 There is no h/o pain, discharge or change in size of
swelling after eating.
 No h/o dry eyes or mouth, inability to close eyes,
drooling of saliva, chewing difficulty.
 No h/o swelling in any other part of the body.

4.  No h/o earache, discharge from ear, hearing
difficulty , fever, sore throat, oral ulcers ,appetite
loss, weight loss, night sweats
 No h/o headaches, any visual distubances, poor
balance.
 No c/o numbness or tingling sensation of any
part of face or neck.
 No h/o any recent illness, any radiation exposure,
previous surgery for any head or neck lesion.

5.  GIT:h/o heartburn,epigastric fullness
 CVS:unremarkable
 Respiratoy: b/l clear normal vesicular
breathing
 CNS:grossly intact

6.  Co-morbids:
no h/o HTN,DM,IHD,TB,HCV,HBV
 Past History:
No h/o any previous hospital
admission or surgical intervention.
 Drug history:
H/O medications intake for heart
burn and epigastric pain off and on over the last two
years
 Family history:
negative for all kinds of malignancy

7.  GPE:
 Patient average built, sitting comfortably, well
oriented in time place and person
 Pulse:78/min, regular
 BP:120/70mmHg
 RR:12/min
 Temp:98.6F
 Weight:70kg

8.  There is no hand sweating, palmer erythema,
skin, nails or joints changes, tremors.
 There is no edema , pallor, dark skin and
sclera, raised JVP, skin pigmentation, skin
freckling at armpits and groin,
lymphadenopathy.
 No visible bone deformities

9.  There is a swelling infront of right ear, extending
from just infront of tragus to lateral to angle of
mouth , below and behind the right ear lobule.It
has normal overlying skin with no visible
punctum and discharge.It becomes prominent on
clenching the teeth.
 Rest of the face is symmetrical, B/L normal
frowning, B/L normal eye opening and clousure,
normal angle of mouth, no drooling of saliva
 Jaw movements are normal

10.  Ear examination
normal pinna and mastoid, no obvious
deformities, no skin changes , no discharge from
ear , normal tympanic membrane, no
perforations or redness of tympanic membrane,
rinne and weber test are normal.

11.  Oral cavity:
 Poor oral hygiene,no ulcers
 No discharge from stenson’s duct orifice
 Tonsillar area normal
 Normal soft palate

12.  The swelling extends from just infront of the
right ear to below and behind it obliterating right
ear hollow, about 6x5cm in size, normal
temperature, non tender, round, firm, regular
surface and well defined margins and slightly
mobile in all planes.
 It is not attached to overlying skin.
 The deep part of the gland is not palpable on
bimanual examination.
 There are no palpable cervial lymph nodes

13.  40 years old male with painless slowly
growing swelling infront of right ear for the
last 7 years that is firm, round,6x5cm,non
tender,mobile,not fixed to skin or underlying
structures

14.  Benign parotid tumor
 Lipoma
 Sebaceous cyst
 Neurofibromatosis

15.  Parotid is the only salivary gland tumor with
intra parenchymal lymph nodes
 Masses with aggressive growth can be
secondary to cutaneous squamous cell
carcinomas or melanomas,lymphomas

16.  80% of total salivary gland tumors
 80-90% benign parotid tumors
 10-20% malignant parotid tumors
 Tumor more in female than males
 Mostly unilateral except warthin tumor(B/L)

17. adenoma
monomorphic
Warthin
tumor
pleomorphic
Pleomorphic
adenoma

18. carcinoma
Low grade
Acinic cell
carcinoma
Adenoid cystic
carcinoma
Low grade
mucoepidermoid
carcinoma
High grade
Adenocarcinoma
High grade
mucoepidermoid
carcinoma

19. T –staging
 T0 …………no evidence of primary tumor
 Tis…………. Carcinoma in situ
 T1 ………….<2cm
 T2…………..>2cm- <4cm
 T3…………..>4cm with extra parenchymal
extension
 T4…………..moderately / very advanced disease
(extra parenchymal extension means
clinical or macroscopic invasion of soft tissues)

20.  N- staging
 N0……….. No lymph nodes
 N1……….. Mets in single ipsilateral L/N <3cm
 N2……….. Mets in single ipsilateral L/N >3cm
multiple ipsilateral L/N 0>6cm
bilateral / contralateral 0>6
 M staging
 M0………….no distant mets
 M1………….distant mets

21. stage T N M PROGNOSIS
0 TIS 0 0
1 T1 0 0 97%
2 T2 0 0 81%
3 T3 N0-N1 0 56%
4 T4 N0-N1 M0-M1 15%

22.  Baselins
 FNAC….ultrasound guided
 Open biopsy
 CT scan
 Frozen section

23.  Highly specific
 When patient is unfit for surgery,can be used
to make diagnosis
 Incase of lymphoma dignosis,surgery can be
avoided
 Sensitivity 90%

24.  Can distinguish benign from malignant in 80%
of cases

31.  Surgical treatment of benign tumors is aimed
at complete removal of the mass with facial
nerve preservation.

32.  A third of malignant tumours have an indolent
nature and may be clinically indistinguishable
from benign lesions.

33.  Ultimate diagnosis of malignancy, and
definition of histiotype, always rely on final
histological findings on the surgical sample

34.  At present, neither clinical and surgical
feeling, nor frozen section, or FNAC can
provide reliable and legally acceptable
indications for VIIth nerve sacrifice.

35.  Ultrasound guided fine needle aspiration
cytology is recommended for all salivary
tumours.
 For benign parotid tumours complete excision
of the tumour should be performed.

36.  If the facial nerve function is normal pre-
operatively then every attempt to preserve
facial nerve function.
 If the facial nerve is divided intra-operatively
then immediate microsurgical repair

37.  Neck dissection is recommended in all cases
of malignant parotid tumours except for low-
grade small tumours.
 Where malignant parotid tumours lie in close
proximity to the facial nerve there should be a
low threshold for adjuvant RT

38.  Most important prognostic parameters are
 Clinical Facial nerve involvement
 Positive margins after resection
 Facial nerve involvement 10-20%
 Facial pain 10/15%
 Deep lobe tumors are more malignant 35%
 Size > 4 cm
 Arising from deep lobe

39.  Facial nerve weakness.
 Rapid increase in the size of the lump.
 Ulceration or induration (or both) of the
mucosa or skin overlying fixed skin.
 Paraesthesia or anaesthesia of neighbouring
sensory nerves.
 Intermittent pain, increasing relentlessly.
 History of previous skin cancer, Sjögren's
syndrome or previous radiation to the head
and neck

40.  There is no evidence that liberal facial nerve
sacrifice improves prognosis

41.  At present, the worst problems concerning the
nerve may be encountered in the eventual
resection of recurrences of pleomorphic
adenomas in these cases, adequate informed
consent of the patients is mandatory.

42.  Surgery in recurrant pleomorphic adenoma has
higher incidence of permanent facial nerve
dysfunction 8%, than in surgery with nerve
preservation in malignancy 3.7%

43.  Surgical treatment of benign tumors is aimed
at complete removal of the mass with facial
nerve preservation.

44.  Superficial parotidectomy
 Extracapsular dissection
 Extended/radical parotidectomy

45.  Dissection of all facial nerve branches and
removal of entire superficial lobe

46.  Dissection of only facial nerve branches which
is required to safely remove the tumor with the
cuff of normal parotid tissue surrounding it

47.  Reserved for neoplasms in an advanced stage,
involves the removal of the entire parotid
gland, with sacrifice of the facial
nerve(resected at level of extra cranial
emergence)and the resection en bloc of the
adjacent structures affected by neoplastic
infiltration, such as the temporal bone, the
mandibular bone, the skin, blood vessels and
nerves.

48.  Total extended radical parotidectomy
combined with post-operative radiotherapy,
represents the best therapeutic approach with
regard both to quality of life and life
expectancy, in patients with an advanced stage
of malignant neoplasm of the parotid gland.

49.  Extended parotidectomy can be extended to
partial or complete mastoidectomy and
petrosectomy

50.  Modified blair incision
 Face lift incision
 Modified face lift incision/rhytidectomy
 Retroauricular hairline incision
 Cervicomastoidofacial incision
 Preauricular broken/postauricular trichophytic
skin incision

55.  Skin flaps are raised to expose the parotid
tissue in the plane just superficial to the
parotid fascia and in the subplatysmal plane in
the neck portion of the incision.

56.  The inferior portion of the gland is mobilized
from its inferior, posterior, and medial
attachment

57.  Identification of facial nerve

59. 1. Tragal “pointer” (of Conley)
2. Tendon of posterior belly of digastric muscle
3. Tympanomastoid suture/fissure:
4. Styloid process
5.Posterior facial vein
6.Tracing of branches,marginal
mandibular/buccal

62.  Elevate the parotid tissue off of the nerve
branches
 Acellular dermal matrix graft can be placed in
the wound to cover the main trunk and major
divisions prevents scarring and freys
syndrome

63.  Freys syndrome
 Facial nerve paralysis
 Salivary fistulas

64.  Eyelid gold weight implants.
 Static facial slings.
 Aesthetic surgery
 Nerve grafting when possible
 Anterior free faciocutaneous flap
ALT(anterior-lateral thig) with vascularized
lateral femoral cutaneous nerve

65.  Intermediate, high grade or adenoid cystic
tumours,
 with close or positive margins
 neural/perineural invasion
 lymph node metastases
 lymphatic/vascular invasion
 Stage IV disease
 Deep lobe salivary malignancies

66.  The mean five-year survival for advanced
high-grade parotid cancer is 35%.[14] Where
there is facial nerve involvement, this falls to
9%
 ten-year survival for stage 1 parotid tumours
(tumour <2 cm with no local or metastatic
spread) is 83%.

67.  Salivary glands tumor are 2-3% of all
malignant tumors
 80% parotid massess,70-80% are benign,80%
are pleomorphic adenomas
 Ultimate diagnosis of mallignancy depends on
histological diagnosis
 Most important prognostic markers for
malignancy are clinical features

68.  One third of malignant tumors have indolent
course
 Surgical options are
superficial,extracapsular,deep and extended
parotidectomy
 Facial nerve sacrifice does not improve the
prognosis

69.  All attempts should be made to preserve nerve
 When there are malignant features then
adjuvant radiotherapy should be considered.

70.  Snell clinical anatomy
 KLM Clinical anatomy
 Bailey and love surgery
 Medscape
 AJCC
 NCBI

71.  Thank you