Mr. X, a 55-year-old male, presented with a gradually enlarging painless swelling in his left parotid region over the past 5 years. Examination revealed a 7 cm x 6 cm firm, non-tender mass that was mobile and had a well-defined margin. Investigations including FNAC, USG, and MRI confirmed a diagnosis of pleomorphic adenoma. The patient underwent a superficial parotidectomy to remove the tumor. Histopathology of the resected specimen confirmed pleomorphic adenoma. The postoperative course was uneventful with intact facial nerve function and no complications.

1. welcome

2. Dr.Md. Sayaduzzaman
Otolaryngology & Head-Neck Surgery Dept.
Dhaka

3. CASE HISTORY
PARTICULARS OF THE PATIENT
Name :X
Age : 55 years
Sex : Male
Address:
Vill : Y
PO : Z
PS : T
Dist : C
Date of admission : 23/08/17

4. CHIEF COMPLAINT
1. Swelling infront of & below the left ear for 5 years.

5. HISTORY OF PRESENT ILLNESS
According to the statement of the patient, He was reasonably
well 5 years back. Then he developed a swelling in front of &
below the left ear for 5 years . It was initially small but
gradually increasing in size. The swelling was painless. He
has no facial paralysis.

6. HISTORY OF PAST ILLNESS
No history of radiation exposure.
PERSONAL HISTORY
Nothing significant.
FAMILY HISTORY
Nothing significant.
HISTORY OF MEDICAL ILLNESS:
No history of DM, HTN, Asthma.
TREATMENT HISTORY
Nothing significant.

7. GENERAL PHYSICAL EXAMINATION
Appearance : Normal
Body build : Average
Cooperation: : Cooperative
Nutrition : Average
Anaemia
Cyanosis
Jaundice
Dehydration Absent
Oedema
Clubbing
Koilonychia
Leukonychia
Heart : S1and S2 audible,
No added sound
Lungs : Clear
Pulse : 82/min, Regular.
BP :130/80mm of Hg
Temperature : 98.4°F
Resp . Rate : 18/min

8. SYSTEMIC EXAMINATION
Cardiovascular System
Respiratory System
Alimentary System NAD
Nervous System
Genitourinary System
Locomotor System

9.  LOCAL EXAMINATION
Inspection:
An oval swelling over the left side of the parotid region.
No scar mark, engorged vein & ulceration over the swelling was present.
Palpation:
 Site : Left parotid region.
 Size : 7 cm x 6 cm .
 Shape : Oval.
 Temperature : Normal.
 Tenderness : Non tender.
 Surface : Bosselated.
 Consistency : Firm.
 Margin : Well defined.
 Fixity : Free from overlying skin & underlying structures.
ENT and Head-Neck EXAM

10.  Relation with masseter : Free from masseter
 Relation with TM joint : Free from TM joint
 Relation with sternomastoid : Free from sternomastoid
 Exam of oral cavity & pharynx : Normal
 Examination of facial nerve : Intact on both side
 Cervical Lymph node : Not palpable

11. PRE OPERATIVE EXAMINATION OF
FACIAL NERVE

13. Ear
Pinna
External auditory canal NAD
Tympanic membrane
mastoid
Nose
External nose
Anterior Rhinoscopy NAD
Posterior Rhinoscopy
Throat And Oral Cavity
 Lip
 Teeth
 Gum
 Tongue
 Floor of the mouth NAD
 Opening of parotid and
submandibular duct
 Soft palate
 Posterior pharyngeal wall
 Tonsils and pillars

14. SALIENT FEATURE
Mr.X, 55 years of age, was admitted in hospital with the
complaint of a gradually increasing swelling on the left parotid
region for 5 years. It was 7 cm x 6 cm in diameter,non tender,
firm in consistency, surface was bosselated, margin was well
defined. It was free from overlying skin and underlying structures.
His facial nerve function was normal.

15. Provisional Diagnosis
Benign Parotid Neoplasm (Lt)-Pleomorphic Adenoma

16. Differential Diagnosis
 Warthin's tumor
 Carcinoma parotid

17. INVESTIGATION

18. FNAC from left parotid swelling
Finding:
Histopathology reveals biphasic tumour composed of
epithelial element and stromal component arranged singly and
in sheet with large amount of myxoid material in the
background
Diagnosis: Pleomorphic Adenoma

19. USG parotid gland
Finding:
Overall size of left parotid gland is increased.There is
heterogenous hypoehoic area about 7 cm x 6 cm in diameter with
lobulated outline in superficial lobe of left parotid gland.No
calcification is noted.
•Diagnosis: Fairly large lobulated parotid mass lesion(Lt)

20. FINDING:
Fairly large (6.8 cm x 5.9 cm )
lobulated signal intensity
change area is noted in left side
of parotid gland. Anteriorly the
mass is extending up to
masseter muscle.
Right parotid gland is normal
in size. shape & signal intensity
without any focal lesion.
Impression:
Pleomorphic Adenoma(Lt)
MRI OF PAROTID GLAND

21. PRE-OP INVESTIGATIONS
Complete blood count
Hb % : 12.5 gm/dl
ESR : 08 mm in
1st hour
Total count : 9x109/L
Differential count
Neutrophil : 70%
Eosinophil : 2.2%
Basophil : 00%
Lymphocyte : 20%
Monocyte : 05%
Platelet count : 205x109/L
Bleeding time : 02/min
Coagulation time : 08/min
RBS : 4.9 mmol/L
Blood group : B +ve
Urine R/E : NAD
Serum urea : 27 mg/dl
Serum creatinine : 0.7 mg/dl
ECG : NAD

22. CLINICAL DIAGNOSIS
PLEOMORPHIC ADENOMA OF PAROTID GLAND(LT)

23. Surgical Treatment
Superficial Parotidectomy (Lt) was done
under general anesthesia on 29/08/2017

24. Modified Blair Incision
Operative procedure
Marking

25. Anterior flap raising

26. Identification of great auricular nerve

27. Facial nerve identification

28. Identifying facial nerve

29. Removing superficial lobe of parotid gland

30. Tumour removing

33. RMV

34. Facial nerve trunk

35. T
z
UB
LB
MM
C
PD

37. Resected specimen superficial lobe of parotid gland

38. Histopathology report
Finding:
Sections reveals feature of
pleomorphic salivary adenoma. The
tumor is composed of epithelial
component and chondromyxoid
stroma .The epithelial cells are
disposed in sheets and ducts with foci
of squamous metaplasia
Histologic diagnosis: Pleomorphic
Adenoma

39. Final Diagnosis
Pleomorphic Adenoma of Parotid Gland (LT)

40. On 7th POD after removal of stitch

42. POSTOPERAIVE EXAMINATION OF FACIAL NERVE
On 10th POD

43. POST OPERATIVE MANAGEMENT
 Drain was removed on 3rd post operative day.
 Stiches were removed on 8th postoperative day.
 Patient was discharged on 10th postoperative day.

44. Follow up
•Initially monthly for 3 months.
•Then 3 monthly for 1 year.
• 6 monthly for 5 yr.
• Then yearly for life long.
Includes:
• Thorough clinical
examination of parotid
region and neck
• If any suspicious lesion
then USG.
• Contrast MRI.

45. DISCUSSION

46. SURGICAL ANATOMY
Parotid gland
 The paired parotid glands are the
largest of the major salivary
glands
 Weight:on average 15–30 gm.

47. Extention of parotid gland
•Superiorly by zygomatic arch.
•Anteriorly by masseter muscle.
•Posteriorly by sternocleidomastoid
muscle.

48.  Facial nerve and branches
STRUCTURES WITHIN THE PAROTID GLAND

49. Parotid gland is divided by the facial
nerve into
i. Superficial lobe
ii. Deep lobe

50.  BLOOD SUPPLY:
External carotid artery
 VENOUS DRAINAGE :
External jugular vein
 LYMPHATIC
DRAINAGE : Deep
cervical nodes

51. Common benign parotid neoplasm
1. Pleomorphic adenoma (benign mixed
tumour).
2. Warthin’s tumor (papillary cyst adenoma
lypmhomatosum).
3. Monomorphic adenoma
a. Basal cell adenoma
b. Canalicular adenomas
c. Oncocytoma
d. Myoepitheliomas
4. Granular cell tumour
5. Hemangioma
Malignant 20%
Benign 80%

52. Salivary gland
Tumors
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
parotid submandibular minor salivary
gland
benign
malignant
20%
57%
43%
15%
85%
80%

53. Pleomorphic Adenoma
 Mixed tumour
(Pleos – many : morphus – form)
 Commonest benign salivary tumour in adult
 Common in parotid (80%)
 Common in females
 Pseudocapsule, Pseudopodal extensions

54. AETIOLOGY
 Epstein Bar Virus.
 Childhood irradiation.
 Nutritional deficiencies.
 UV exposure.
 Genetic mutation.
 Wood and silica dust exposure.
 Kerosene users.
 Benign lyphoepithelial lesions.

55. RULE OF 8O’s
 80% of all salivary tumors occur in the parotid gland.
 80% occurs in superficial lobe.
 80% are benign tumor.
 80% are pleomorphic adenoma.

56. Evaluation of Patients
1. History
Important points in the history:
- Parotid mass (duration, rate of the growth,
presence of pain)
- Facial paralysis
- Cervical lymphadenopathies
- Eyes and joints symptoms
- History of exposure to radiation

57. PRESENTATION
 The tumors spherical or oval
 Slow growing
 Painless mass
 Mobile
 Foreign body sensation,dysphagia
 Firm single nodular mass

58. Examination
• Site,
• Size,
• Shape,
• Temperature,
• Tenderness of the mass,
• Margin,surface
• Fixity-skin & underlying structures
• Relation with masseter

59. EXAM CONT…
Relation with TM joint & EAC
Relation with sternocleidomastoid
Examination of the oral cavity and
tonsillar fossa with special attention to
parotid duct.
 Facial nerve functions
 Cervical lymphadenopathies

60. INVESTIGATION
 FNAC – important and diagnostic
 USG –parotid gland
 MRI with contrast
 CT SCAN- in suspected bone involvement.
 OPEN BIOPSY – contraindicated
 Chance of injury to facial nerve.
 Seedling & high chance of recurrence.
 Parotid fistula formation.

61. Treatment
Surgery is the Treatment of choice
Minimum standard surgery is superficial parotidectomy.
Superficial parotidectomy- if only superficial lobe is
involved
Total conservative parotidectomy- if both lobes are
involved.

62. Landmark of facial nerve in parotid surgery
 Tragal pointer
 Tympanomastoid suture
 Styloid process
 Posterior belly of digastric
 Retrograde identification

63. The post-operative complications:
 Hematoma
 Facial nerve paralysis – which could be:
 Temporarily: 5 – 10% of the patients.
 Permanent: less than 2% of the cases
 Salivary fistula– it presents as an opening in the suture line
below the lobule of the ear
 Frey’s syndrome .
 Recurrence
 Numbness of the ear due to injury of great auricular nerve.
 Flap necrosis

64. RECURRENCE AFTER SURGERY
 Inadequate excision of tumour
 Spillage
 Extracapsular extension
 Retained pseudopods

65. CARCINOMA IN EX PLEOMORPHIC
ADENOMA
Long standing Pleomorphic adenoma-malignant
transformation
 Recent increase in size
 Pain , nodularity
 Involvement of skin, ulceration
 Involvement of masseter
 Involvement of facial nerve
 Neck lymph node
 Restriction of jaw movements due to bone involvement

66. Malignant transformation may occur commonly after 20
yrs. This is due to radiation and genetic instability within the
tumor.
Different pattern of malignant change occur in
pleomorphic adenoma, of which carcinoma ex pleomorphic
adenoma is most commonly encountered.
Other two forms are Carcinosarcoma and metastasizing
pleomorphic adenoma.

67. PAROTID SURGERIES
0
2
4
6
8
10
12
14
16
2015 2016 2017
parotid surgery
superficial
parotidectomy
•No permanent facial
paralysis
•1 x recurrent case
developed mild temp
neuroprexia &
corrected.
(n=12)
(n=34)

68. Pleomorphic adenoma is most common benign tumor of
parotid gland. Minimum surgery is superficial parotidectomy .
Complete removal of tumor without spillage as well as
preservation of all branches of facial nerve is mandatory. As
facial expression and function is the prime concern of human
nature, identification & preservation of facial nerve, meticulous
surgery with bloodless field by skilled hand is needed to prevent
recurrence & morbidity.
CONCLUSION