Dr .

bharath rajh
Junior resident
Dept of plastic
surgery
Parotid gland – anatomy

 
 The parotid glands are a pair of mainly serous
salivary glands

 Located inferior and anterior to the external acoustic

meatus, between the ramus of mandible and
sternocleidomastoid muscle.

 The gland is roughly wedge-shaped

 
 Gland is divided into two
o
lbes

 Superficial lobe – 80%

 Deep lobe – 20 %
 Parotid duct

 Also called as Stenson’s duct

 It emerges from the anterior border of the gland,

superficial to the masseter muscle, then it pierces the
buccinator muscle & opens into the oral cavity on the
inner surface of the cheek, usually opposite to the
maxillary second molar.

 Parotid capsule

 Investing layer of deep fascia forms the
capsule

 Splits into

 Superficial lamina
 Deep lamina

Structures passing through
parotid gland

Artery:
External carotid enters in the posteromedial surface

Maxillary artery

Superficial temporal artery

Posterior auricular artery



 Nerve supply

 Parasympathetic fibres :- Secretomotor
 Preganglionic fibres arise from the inferior
salivatory
nucleus
 Pass through glossopharyngeal nerve
 Relay in otic ganglion
 Postganglionic fibres reach the gland through
auriculotemporal nerve
 Sympathetic fibres :- Vasomotor
 Sensory nerves :- Auriculotemporal nerve
 Parotid neoplasia

 Benign
 Pleomorphic adenoma
 Warthin’s tumor
 Malignant
 Mucoepidermoid
carcinoma
 Adenoid cystic carcinoma
 Acinic cell carcinoma
 Adenocarcinoma
 Squamous cell carcinoma
 Pleomorphic adenoma

 It is also known as “Mixed salivary tumor”

 It is the most common benign tumor of salivary

glands – 80 %

 Characterized by neoplastic proliferation

of parenchymatous glandular cells along
with myoepithelial components
 
 Distribution:
 Parotid gland: 84%
 Submandibular gland: 8%
 Minor salivary glands: 6.5%
 Widely distributed including the nasal cavity,
pharynx, larynx, trachea
 Sublingual glands: 0.5%
 Clinical features

 Swelling
 Painless
 Raised ear lobule
 Curtain sign positive
 
 Common in females (3:1)
 Common in 4th and 5th decade of life
 Smooth , firm lobulated mobile swelling
wh
ti positive curtain sign
 Ear lobule lifted
 Obliteration of retro mandibular groove
 Deep lobe tumour passes through Patey’s
stylomandibular tunnel pushing tonsil, pharynx,
uvula
 Along with dysphagia
 Features of malignant change

 1.5% in 5 yrs. ; 9.5% in 15
yrs.
 Recent increase in Capsular distension
Obstruction of
zsie
saliva Nerve
 Pain infiltration Tumour
 Nodularity necrosis
 Involvement of skin, LN , Facial nerve,
masseter
 Restriction of jaw movements
 Pathology

 Gross:
 Cartilages
 Cystic
spaces
 Solid
tissues
 Histology

 They contain both epithelial and myoepithelial
(mesenchymal) tissues

 Even though it is capsulated, tumor may come out

as
pseudopods beyond the original extend of the tumor
 Diagnosis

 Fine needle
aspiration

 Core needle
aspiration

 USG

 CT scan

 MRI scan
 
 USG – Hypoechoic with lobulated and distinct
borders
 
 CT scan – Smoothly margined or lobulated
homogeneous small spherical mass

 Small regions of calcification

 When the tumour is small, the enhancement tends

to be prominent
 
 MRI :
 Well-circumscribed and homogeneous
 T1: Usually of low intensity
 T2: Usually of very high intensity (especially myxoid
type)
 T1 C+ (Gd): Usually demonstrates homogeneous
enhancement
 Treatment

 Surgical excision of the
tumour

 Superficial(Patey's operation)
parotidectomy
 Total parotidectomy

 Complications:
 Recurrence of 5 to 50%
 Facial nerve injury
 Warthin’s tumour

 It is also called Adenolymphoma or Papillary
cystadenolymphomatosum

 It is a benign tumour occurs only in parotid, usualy

in the superficial lobe, lower pole.

 Second most common

 
 Usually
10 – 15 %occurs in 6th
bilateral
decade

 More common in males

41:

 Associations:
 Cigarette smoking
 Irradiation
 Morphology

 Slow growing, non tender, smooth, soft, cystic,
fluctuant swelling.
 Often multi-centric and are usually small
(1-4 cm.)
 Typically heterogeneous appearance on
all modalities, often with cystic
components


 Investigations

 Ultrasound :
 A well defined, ovoid, hyper echoic mass.
 In some cases anechoic internal cystic areas may
be present. They are often hyper vascular
 CT scan:
 Can be often well defined , bilateral tumor
 Classic appearance is a cystic lesion posteriorly
within h te
parotid with a focal tumour nodule
 Cystic changes appear as intralesional lower
attenuation
 No calcification

 
 Adenolymphoma produces a “Hot
spot“ in Technetium99-pertechnetate scan
 Diagnostic – due to high mitochondrial
content
 Treatment

 Surgical excision is
curative

 Rate of recurrence is
almost nil

 No malignant change
 Mucoepidermoid tumor

 Commonest type of malignant salivary tumor
in adults

 Commonest malignant tumor of parotid

in childhood

 Common in middle age (35-65 years of

age)

 Female predilection
 
 Parotid is the most common site of tumor

 2nd common is palate minor salivary gland

 Radiation – etiological factor

 t(11;19)(q21;p13) chromosome translocation resulting

in a MECT1-MAML2 fusion gene
 
 Presents as painless, slow-growing mass that is
rm
if or hard.

 Grossly – Un encapsulated mass with cystic

spaces

 Facial nerve involvement in late stages

 Histology

 The tumours are composed of a
mixture of:

 Mucus secreting cells (muco- )

 Squamous cells (-epidermoid)

 Lymphoid infiltrate often also present

 Grade of tumor

 Low grade:
 Well-differentiated cells with little cellular
atypia
 High proportion of mucous cells
 Prominent cyst formation
 Intermediate grade: intermediate features
 High grade:
 Poorly differentiated with cellular
pleomorphism
 High proportion of squamous cells
 Solid with few if any cysts
 
 USG :- well-circumscribed hypo echoic lesion, with
a partial or completely cystic appearance

 CT scan :- Low-grade tumors appear as

we-l circumscribed masses, usually with cystic
components. Calcification may be present

 High-grade tumors are poorly defined margins,

infiltrate locally and appear solid.
 Treatment

 Low grade – wide local excision or superficial
parotidectomy without any adjuvant radiotherapy

 High grade requires complete or radical

parotidectomy, often with sacrifice of the facial
nerve, neck dissection (as nodal metastases are
common) and adjuvant radiotherapy
 Adenoid cystic carcinoma

 It is also called as cylindromatous carcinoma

 Low grade tumor

 Wide distribution and mainly occur in relation to

the airways, salivary glands, lacrimal glands and
breast

 Tendency for perineural extension is high

 
 Common in females 3:1
 Occurs in 5th & 6th decade of life
 Slow growing tumor but highly malignant

 High affinity for perineural transmission

[Anterograde and retrograde]
 Maxillary and mandibular branch of
trigeminal nerve
 Facial nerve
 Reaches Gasserian trigeminal ganglion,
pterygopalantine ganglion & cavernous sinus
 
  Microscopy:-
Cribriform – Swiss cheese pattern
 Tubular
 Solid

 It involves periosteum and bony

medula

 Treatment

 Radical parotidectomy with adjucvant
radiotherapy

 Fast neutron therapy

 Chemotherapy
 
 Recurrence is common
5 years survival rate is 89 %

 15 years survival rate is 40 %

 Positive margin, perineural spread, solid type cary

poor prognosis
 Parotidectomy

 Indications:
 Chronic parotitis
 Salivary calculi
 Parotid abscess
 Parotid tumors
 T1,T2,T3 – Total conservative
parotidectomy
 T4 – Radical parotidectomy
 
  Types: Superficial parotidectomy
 Total conservative
parotidectomy
 Radical parotidectomy
 Suprafacial parotidectomy
 Identification of facial nerve

 Facial nerve is 1cm deep and below the tip of inferior
portion of cartilaginous canal – conley’s point
 By nerve stimulator
 It is inferomedial to the tragal point
 Deep to digastric muscle
 Nerve is just lateral to styloid process
 Tracing branch from distal to proximal (Hamilton
bailey technique)
 Indication for nerve sacrifice

 Preoperative weakness / paralysis of nerve
 Intraoperative evidence of gross invasion
 Tumors transgressing through facial nerve
o
rfm superficial to deep lobe
 Nerve stump is checked for frozen section for
negative margins, if positive, mastoidectomy
& nerve dissection is required






 Complications of
parotidectomy


 Facial nerve injury
 Hemorrhage
Infection – flap necrosis is
c
ommon Salivary fistula
 Frey’s syndrome
 Sialocele
 Injury to greater auricular nerve
