Dr.K.Kuberan M.S Professor of surgery Govt.Royapettah Hospital

Largest salivary glands lying largely below the external acoustic meatus between mandible and sternocleidomastoid muscle and it also projects forwards on the surface of masseter

Ectodermal in origin Each parotid is developed during 5th week from angle of primary oral fissure.

The groove is converted into tube which forms duct and opens into angle of primitive mouth.

With the growth of maxillary and mandibular process the duct opening is shifted to vestibule opposite the upper 2nd molar tooth.

During development the gland lies in between the branches of facial nerve, as development progresses it envelopes the branches.

Superficial part(80%)lies over posterior part of ramus of mandible

Deep part(20%) lies behind mandible and medial pterygoid

Facial nerve lies between them

The gland has a capsule of its own of dense connective tissue but is also provided with a false capsule by investing layer of deep cervical fascia.

Skin Superficial fascia Superficial lamina of investing layer of deep cervical fascia

Great auricular nerve (anterior ramus of C2 and C3)

Mandibular ramus, Masseter and medial pterygoid muscles

• Mastoid process • Styloid process• Carotid sheath with its contained neurovasculature (Common and Internal Carotid artery, Internal Jugular vein, vagus nerve)

Superior pharyngyeal constrictor muscle

From lateral to medial Facial nerve Retromandibular vein (Patey's fascio venous plane)

External Carotid artery

External carotid arteryRetromandibular vein

Superficial and deep group of parotid lymph nodes.

Efferents from these nodes drain into jugulodigastric group of deep cervical nodes

Parasympathetic – stimulates watery secretion

Sympathetic – stimulates mucus rich thick secretion and also vasomotor

Also known as Stensen’s duct Appears at the anterior part of upper border of gland and passes across masseter to traverse buccal fat and buccinator.

Runs obliquely forwards for a short distance between buccinator and the oral mucosa and opens upon a small papilla opposite upper 2nd molar tooth.

Infections – • Very painful due to unyielding nature of capsule.

• Retrograde bacterial infection may occur from mouth via duct.

Viral – mumps, coxsackie A & B, parainfluenza 1 & 3

Bacterial – staphylococcus aureus,streptococcus viridans

Poor oral hygiene HIV Radiotherapy Syphilis Sjogren’s syndrome

Painful diffuse swelling Fever,malaise Warmth, Tender Regional lymph node enlarged

Caused by paramyxovirus Incubation period 2-3 weeks Bilateral 90% Common in children Clinical features:-

Fever Swelling

Pain, tender

OrchitisOophoritisPancreatitisMeningoencephalitis

Ultrasound Calculous Abscess

Meticulous oral hygiene Analgesics Antibiotics Soft diet Parotid abscess-I&D (Hiltons method)

Age 3-6yrs Recurent episode of pain Diffuse swelling Fever Enlarged lymph nodes Spontaneus resolution

In Adults Calculous- Unilateral Auto immune-Bilateral Diffuse swelling Pain Purulant saliva Pressure on sialectic gland may express pus

from the duct.

Xray Plain films are not much useful since

parotid stones are radiolucent. Sialography Punctate

sialectasis(snowstorm)appearance

Extraction of stone through oral cavity

Conservative parotidectomy if multiple calculi

ADENOMA pleomorphic -pleomorphic

adenoma monomorphic-warthin’s tumor Oxyphilic adenoma CARCINOMA (low grade) : acinic cell carcinoma adenoid cystic carcinoma low grade mucoepidermoid

High grade adenocarcinoma squamous cell carcinoma high grade mucoepidermoid carcinomaNon epithelial tumors haemangioma lymphangioma

Lymphomas primary- non-hodgkin’s secondary- lymphoma in sjogren’s Secondary tumors Unclassified tumors Tumor like lesions solid lesions cystic lesions

RULE OF 8080% of salivary neoplasms are of parotid origin

80% of parotid masses are neoplastic

80% of neoplasms in parotid are benign

Intercalated Ducts◦ Pleomorphic adenoma◦ Warthin’s tumor◦ Oncocytoma◦ Acinic cell◦ Adenoid cystic

Excretory Ducts◦ Squamous cell◦ Mucoepidermoid

Striated duct—oncocytic tumors Acinar cells—acinic cell carcinoma Excretory Duct—squamous cell and

mucoepidermoid carcinoma Intercalated duct and myoepithelial

cells—pleomorphic tumors

Most common parotid neoplasm Median age—Fifth decade Common in females Usually unilateral Slow growing mass(80%) Lobular Not well encapsulated Malignant degeneration (2-10%)

Mobile Nontender Firm Solitary mass in parotid region Raised ear lobule Obliteration of retromandibular groove Cannot be moved above zygomatic bone Deviation of uvula & pharyngeal wall

towards midine if deep lobe involved No facial nerve involvement

Greyish white in

color with possible cyst formation and haemorrhage.

Mixture of epithelial, myoepithelial and

stromal componentsEpithelial cells: nests,sheets, ducts,

trabeculaeStroma: myxoid, chrondroid, fibroid, osteoidNo true capsule Tumor pseudopods

Arise from deep lobeSwelling in the lateral wall of pharynxSoft palate displaced to opposite side

Rapid increase in size Pain and nodularity Involvement of skin & ulceration Involvement of masseter Involvement of facial nerve Involvement of neck lymph node

2-4% of all salivary gland neoplasms 4-6% of mixed tumors 6th-8th decades Parotid > submandibular > Minor

salivarygland Risk of malignant degeneration

1.5% in first 5 years 9.5% after 15 years

Presentation Longstanding painless mass that undergoes

sudden enlargement

Histology• Malignant cellular

change adjacent to typical pleomorphic adenoma• Carcinomatous

component: Adenocarcinoma Undifferentiated

Second most common benign parotid tumour (5%)

Most common bilateral benign neoplasm of parotid.

Common in lower pole Slow-growing, painless mass Marked male predominance Sixth and seventh decade Hot spot in Tc99 scan Malignant transformation rare.

◦ Encapsulated◦ Smooth/lobulated

surface◦ Cystic spaces of

variable size, with viscous fluid, shaggy epithelium

◦ Solid areas with white nodules representing lymphoid follicles

◦Papillary projections into cystic spaces surrounded by lymphoid stroma

◦Epithelium: double cell layer Luminal cells Basal cells

◦Stroma: mature lymphoid follicles with germinal centers

May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes

Rare: 2.3% of benign salivary tumors 6th decade M:F = 1:1 Parotid: 78% Submandibular gland: 9% Presentation

◦ Enlarging, painless mass

Gross◦Encapsulated ◦Homogeneous, smooth◦Orange/rust color

Histology◦Cords of uniform cells and

thin fibrous stroma◦Large polyhedral cells◦Distinct cell membrane◦Granular, eosinophilic

cytoplasm◦Central, round, vesicular

nucleus

Electron microscopy:◦Mitochondrial

hyperplasia◦60% of cell

volume

Basal cell is most common: 1.8% of benign epithelial salivary gland neoplasms

6th decade

M:F = approximately 1:1

Most common in parotid

Trabecular• Cells in

elongated trabecular pattern• Vascular stroma

Tubular◦Multiple duct-

like structures◦Columnar cell

lining◦Vascular stroma

Membranous◦Thick

eosinophilic hyaline membranes surrounding nests of tumor cells

◦“jigsaw-puzzle” appearance

Malignant – 1.Mucoepidermoid carcinoma

2. Adenoid cystic Carcinoma.3. Adenocarcinoma.4. Squamous cell carcinoma.5. Malignant pleomorphic adenoma.

6. Acinic cell tumor 7. Malignant lymphoma 8. Anaplastic carcinoma

Painless asymptomatic mass (80%) Pain=> perineural invasion (30%) Facial nerve palsy or paresis (7-20%) H/o prior parotid tumor indicates

recurrence.

Trismus => advanced disease with extension to masticatory muscles or less commonly invasion into TM joint

Dysphagia => tumour of deep lobe of parotid

Ear pain=>extension into auditary canal

Numbness along Trigeminal nerve =>neural invasion

Hard mass in parotid region Skin ulceration/fixation Fixation to adjacent structures Examination of external auditary canal

for tumor extension Regional lymph adenopathy Blood or pus from stensen’s duct Bulging of lateral pharyngeal wall or

soft palate

Most common salivary gland malignancy

5-9% of salivary neoplasms Parotid 45-70% of cases Palate 18% 3rd-8th decades, peak in 5th decade F>M

Slow growing tumors Limited local invasiveness Low metastatic potential High grade behave like SCC, low grade

behave like benign tumors Sucessfully treated by adequate

radical excision

Presentation◦ Low-grade: slow growing, painless mass◦ High-grade: rapidly enlarging, +/- pain

Gross pathology◦Well-

circumscribed to partially encapsulated to unencapsulated

◦Solid tumor with cystic spaces

Areas of mucous secreting cells Epidermoid and epithelial cells

Poorly encapsulated infiltrating tumors Propensity to spread along nerves Highly invasive but may remain

quiescent for a long time Highest incidence of distant metastasis Lung metastasis are most frequent. Poor prognosis

They can arise within a preexisting benign pleomorphic adenoma (CARCINOMA EX PLEIOMORPHIC ADENOMA)

They may arise denovo (CARCINOSARCOMA)

Intermediate grade malignancy Low malignant potential May be bilateral or multicentric Rarely metastasize May spread along perineural planes

Most commonly in elderly females Usually Non-Hodgkins 5-10% of patients with warthin’s Enlarged parotid with a rubbery

consistency Enlarged regional lymph nodes

Squamous cell carcinoma Sebaceous carcinoma Salivary duct carcinoma Malignant fibrohistiocytoma

Ultrasound FNAC is the diagnostic MRI is superior in demonstrating

benign tumors than CT CT scan/MRI identifies regional lymph

node involvement/ extension into deep lobe / parapharyngeal space

PET may be useful in assessing malignant tumors

Efficacy is well established Safe, well tolerated Accuracy = 84-97% Sensitivity = 54-95% Specificity = 86=100%

First line of management superficial lobe is involved, superficial

conservative parotidectomy If deep lobe(dumb bell) also involved,

total parotidectomy with preservation of facial nerve.

Enucleation should be avoided as recurrence rate is high

Extracapsular enucleation-warthin’s tumor

◦ RADICAL PAROTIDECTOMY Removal of the entire gland,facial nerve and

regional lymph nodes Resection of all involved structures

positive malignancy nodes high grade tumorslocal invasionrecurrent tumors if no h/o previous neck dissectiondeep lobe tumors

Skin grafting Cervicofacial flap Trapezius flap Pectoralis flap Deltopectoral flap Microvascular free flap

Great auricular nerve Hypoglossal nerve Sural nerve

>4 cm in diameter High grade Local invasion Lymphatic/neural/vascular invasion Tumor in/extending to deep lobe Recurrent tumours following re-

resection Positive margins

High grade Neural involvement Locally advanced disease Advanced age Associated pain Regional lymph node metastasis Distant metastasis

Inflammation: whole parotid swollen Neoplasm:A part of the gland is

swollen