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