True, the facial nerve divides the parotid gland into the superficial (80%) and deep (20%) lobes.

2.  Mid-17th century – Anatomy of the parotid
gland and the role of the main ducts.
 Greeks called "para-auricular swellings" -
described findings associated with calculi and
inflammation.
 1650-1750 , salivary gland surgery was limited to
the treatment of ranulas and oral calculi.

3.  Bertrandi in 1802 - The concept of surgical
excision of a parotid tumor
 Initial surgeries - serious disfiguration and disability
 By1850, the focus shifted toward
dissection and the intimate relationship
between the FN and the parotid gland

5.  Codreanu (1892) - First total parotidectomy with
facial nerve preservation.
 Early 1950s - Grafting of the facial nerve after
resection.
 Beahrs and Adson (1958) - Surgical technique of
current parotid gland surgery.
*They stressed surgical landmarks for avoiding injury FN
*Advocated complete removal of the superficial portion for
benign lesions confined to that portion of the gland

9.  Largest salivary gland. (wt. 15gms)
 Enclosed by investing layer of deep cervical
fascia.
 FN divides the gland into the superficial (80 %)
and deep lobe (20%)
 Parotid duct (Stensons) is 5 cm long and opens
opposite the upper second molar.
 Lymphatic drainage – periparotid/intraparotid
 Accessory parotid lobe – Present in 20% of
patients

10.  Branches of the facial nerve
 Terminal branch of the external carotid
artery that divides into the maxillary
artery and the superficial temporal artery
 Retromandibular vein
 Intraparotid lymph nodes

11. Parotid glands
 Superficial lobe – 80% of the glandular mass
 80% of all salivary tumors occur in the parotid
gland.
 80% arise in the superficial lobe.
 80% are benign
 80% are pleomorphic adenomas.

12.  Paired salivary glands -
lie below the mandible
 Larger superficial and a
smaller deep lobe -
around the posterior
border of the mylohyoid
 The deep part lies on
the hyoglossus muscle

13.  Deep cervical fascia
which splits to enclose
it.
 Wharton’s duct(5 cm)
emerges from deep
surface
 It drains into the
anterior floor of the
mouth at the
sublingual papilla

15.  Paired set of salivary glands
 Anterior part of the floor of mouth between
the mucous membrane, the mylohyoid
muscle and the body of the mandible
close to the mental symphysis
 Numerous excretory ducts - open either
directly into the oral cavity or indirectly via
ducts that drain into the submandibular
duct

18.  pleomorphic adenomas
originate from the
intercalated duct cells
and myoepithelial cells
 oncocytic tumors
originate from the
striated duct cells
 acinous cell tumors
originate from the acinar
cells
 Mucoepidermoid
tumors and squamous
cell carcinomas develop
in the excretory duct
cells.

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

23.  Epithelial ,mesenchymal and
myoepithelial components,
 Abundant matrix mucoid,myxoid or
chondroid supporting tissue
 Contains cartilages, cystic spaces, solid
tissues.

25.  Dumb bell tumor –
if deep lobe is
involved

26.  Lobulated , painless swelling, Long duration
 Neither adherent to skin/ masseter muscle
 Generally firm / variable consistency
 Raised ear lobule
 Curtain sign – swelling cannot be moved
above zygomatic bone

27. Curtain sign deflected ear lobule

30.  FNAC
 CT Scan
 MRI Scan
 Incisional biopsy is contraindicated !!!!

31.  Surgery is the TOC
 Superficial parotidectomy- if only
superficial lobe is involved
 Total conservative parotidectomy- if
both lobes are involved.

32. Adenolymphoma (misnomer)
Second most common tumor in the salivary glands.
Warthin in 1929
Slow growing , painless cystic neoplasm –
exclusively in the parotid gland.
Typically- lower pole
Proliferation of lymphoid tissues of intra/peri parotid LN
Predisposing factor – smoking, radiation exp and EBV

33.  Round to oval Swelling , well
circumscribed encapsulated
masses
 Multicentric or multifocal disease
 Soft ,fluctuant
 Fifth to seventh decades of life
 Male : female :: 10:1
 Elderly males , smokers
 Bilateral 10%
 No Malignant potential

34. Investigations
 FNAC
 Tc99 scan – hot spot
(due to high mitochondrial content)
Treatment
 Superficial parotidectmy with preservation
of facial nerve
 Enucleation
 Observation

35.  <1% of salivary tmrs
 More common in females
 Exclusively in parotid
 Composed of oncocytes ,arranged in
chords or sheets
 Descrete well encapsulated
 Hot spot on Tc 99 scan

36.  Rare
 Females > males
 Composed of columnar cells arranged in
double layer
 Slow growing ,well circumscribed firm
nodule with cystic spaces

37.  MC parotid tmr in children
 Present at birth
 Soft, compressible, fluctuant with typical
bluish hue
 Usually spontaneous resolution (5-6 yrs)
 Oral prednisolone
 Surgery only in complicated cases

41.  MC malignant tumor of salivary gland
 MC malignant tumor to occur in parotid
 F > M
 Slow growing
 Pain , facial palsy
 Arises from excretory ducts of glands
 Presence of mucin prosucing cells,
squamous cells of ducts or acini.

42.  High grade(predominantly squamous
cells)
 Intermediate grade,
 low grade (predominantly mucous cells)

43.  Low grade can be managed similar to that
of pleomorphic adenoma
 Positive margin- post op RT
 Intermediate grade- total conservative
parotidectomy
 High grade- more aggressive treatment
 Total parotidectomy with resection of
involved facial N br. And nerve grafting
 Neck dissection,full course of post op RT

44.  2nd MC malignant tmr of parotid
 MC malignant tmr of SM & SL gland
 Cystic or Cribriform arrange ment- “Swiss
Cheese pattern”
 Perineural invasion
 Tubular , cribriform, solid
(prgnosis best to worst)

45.  Treatment – Aggressive resection of the
gland
 Any nerve in the path of tmr should be
resected.
 Recurrences – skull base ,cranial nerves as
the tmr spreds into CNS
 Resistant to RT, recurrence cannot be
cured with RT

46.  Malignant tmr of acinic cells
 Slow growing, almost always in parotid
 Finger like extension into adjacent tissues
 LN involvement is common.
 Trtmnt – aggressive resection with TP ,
resection of FN, nerve grafts, complete ND
if nodes are palpable.

47. Hard infiltrating mass often associated with
 FN involvement
 Cervical node mets
 Systemic organ mets
 Treamment – surgery f/b post op RT
 Poor prognosis

48.  Parotid is common site
 High grade tmr
 M> F
 High propensity for regional nodal
spread
 Poor prognosis

49.  Almost always in parotid (only SG which
contain LN or lymphatic tissue)
 Primary (NHL) or secondary
 Local manifestation of syst disease
 Often found in pts with AIDS

50.  MC involved SG – parotid (rich lymphoid
tissue)
 Arise from malignant neoplasm of head
and neck area
 Melanoma > Sq cell ca >others
 Hematogenous spread– parotid is MC
site– MC from Ca of thyroid

53.  Superficial Parotidectomy
 Total parotidectomy with or with out FN
conservation

54.  ‘Lazy S’ pre auricular mastoid-cervical
incision

55.  Development of skin
flap
 Mobilisation of gland
 Development of
avascular plane

56.  Identification of facial
nerve
* 1cm deep and
inferior to Conley’s
pointer
* Immediately superior
to upper border of
post belly of digastric
muscle

57.  Dissection of the
gland off the FN (in
the perineural plane
with scissors)

58.  Closure with a suction drain

64. 1) Tmr with peri neural invasion
 Adenoid cystic Ca
2) MC SG tmr in adults
 Pleomorphic adenoma
3) MC parotid tmr in children
 Hemangioma
4) Male smoker with Tc 99 hot spot
 warthins

65. 5) MC malignant tmr of parotid
 Mucoepidermoid Ca
6) MC malignant tmr of SM/SL
 Adenoid cystic Ca
7)MC parotid tmr
 Pleomorphic adenoma
8)Mets MC from
 Head and neck tmr (MC- Ca Thyroid)

66.  Adenolymphoma of parotid gland is
primarily NHL
 False
 Adenoid cystic ca recurrence can be
easily treated by post operative RT
 false

67. 3) TOC for hemangioma of parotid is
superficial parotidectomy
 False
4) Salivary gland lymphoma almost always
involves parotid as it is the only SG that
contain lymphoid tissue
 True

68.  The most common parotid tumor is
› A. Pleomorphic adenoma
› B. Mucoepidermoid carcinoma
› C. Adenoid cystic carcinoma
› D. Detroit tigers

69.  Most parotid tumors are ___________
› A. Benign 60%
› B. Benign 80%
› C. Malignant 60%
› D. Malignant 80%

70.  All of the following are true regarding
adenoid cystic carcinoma except?
› A. It rarely spreads to Lymph nodes
› B. It is a common minor salivary tumor
› C. It typically does not involve nerves
› D. 40% develop pulmonary metastasis

71.  What is the most common tumor of
minor salivary glands
› A. Pleiomorphic Adenoma
› B. Adenoid cystic carcinoma
› C. Mucoepidermoid carcinoma
› D. Squamous cell carcinoma

72.  What seperates the superficial parotid
from the deep lobe?
› Facial Nerve