Salivary glands

bull There are 6 major salivary glandsbull Parotidssubmandibular and sublingualbull About 450minor salivary glandswhich

secretes about 10 of saliva oral cavityoropharynxlarynxPNS

Parotid glands

bull Largestpairedenveloped by investing layer of deep fasciaparotid sheath

bull mainly a serous glandbull Lies between EAC and zygomatic archramus of

mandible anteriorly and ant border of SCM posteriorlyextends anteriorly over masseter muscle

bull First to develop in 4th week IULfrom oral ectodermbull Its duct stensen ductopens opp to second upper

molar

bull Inverted pyramidal bull 3 borders-anteriorposterior and medialbull 4 surfaces-

lateral(superficial)baseanteromedial and posteromedial

bull Facial nerve enters posteromedial surface and divides gland into superficial and deep parts

bull Facial nerve divides into upper zygomatico temporal and lower cervico facial divisions

bull Each division then further subdividesbull to form five branches temporal zygomatic buccal

mandibular and cervical supplying the muscles of facial expression

bull The branching pattern within the parotid gland is also variable and a number of classifications have been described

bull Katz and Catalano described five patterns of

bull 1 Type 1 (25 percent) there is splitting and reunion of the zygomatic and mandibular branches

bull 2 Type 2 (14 percent) The buccal branch subdivides and fuses with the zygomatic branch

bull 3 Type 3 (44 percent) There are major anastamotic links from the buccal branch to other major branches

bull 4 Type 4 (14 percent) There is complex branching and anastamotic links between the two divisions

bull 5 Type 5 (3 percent) The facial nerve trunk divides before leaving the stylomastoid foramen

Submandibular gland

bull Large superficial part and smaller deep partwhich curls around the posterior border of the mylohyoid muscle

bull Superficial part covered by superficial fascia and investing layer of deep cervical fascialies with in submandibular triangle

bull Medially lies the mylohyoid muscle anteriorly and posteriorly lies the hyoglossusstylohoid muscles

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull There are 6 major salivary glandsbull Parotidssubmandibular and sublingualbull About 450minor salivary glandswhich

secretes about 10 of saliva oral cavityoropharynxlarynxPNS

Parotid glands

bull Largestpairedenveloped by investing layer of deep fasciaparotid sheath

bull mainly a serous glandbull Lies between EAC and zygomatic archramus of

mandible anteriorly and ant border of SCM posteriorlyextends anteriorly over masseter muscle

bull First to develop in 4th week IULfrom oral ectodermbull Its duct stensen ductopens opp to second upper

molar

bull Inverted pyramidal bull 3 borders-anteriorposterior and medialbull 4 surfaces-

lateral(superficial)baseanteromedial and posteromedial

bull Facial nerve enters posteromedial surface and divides gland into superficial and deep parts

bull Facial nerve divides into upper zygomatico temporal and lower cervico facial divisions

bull Each division then further subdividesbull to form five branches temporal zygomatic buccal

mandibular and cervical supplying the muscles of facial expression

bull The branching pattern within the parotid gland is also variable and a number of classifications have been described

bull Katz and Catalano described five patterns of

bull 1 Type 1 (25 percent) there is splitting and reunion of the zygomatic and mandibular branches

bull 2 Type 2 (14 percent) The buccal branch subdivides and fuses with the zygomatic branch

bull 3 Type 3 (44 percent) There are major anastamotic links from the buccal branch to other major branches

bull 4 Type 4 (14 percent) There is complex branching and anastamotic links between the two divisions

bull 5 Type 5 (3 percent) The facial nerve trunk divides before leaving the stylomastoid foramen

Submandibular gland

bull Large superficial part and smaller deep partwhich curls around the posterior border of the mylohyoid muscle

bull Superficial part covered by superficial fascia and investing layer of deep cervical fascialies with in submandibular triangle

bull Medially lies the mylohyoid muscle anteriorly and posteriorly lies the hyoglossusstylohoid muscles

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Parotid glands

bull Largestpairedenveloped by investing layer of deep fasciaparotid sheath

bull mainly a serous glandbull Lies between EAC and zygomatic archramus of

mandible anteriorly and ant border of SCM posteriorlyextends anteriorly over masseter muscle

bull First to develop in 4th week IULfrom oral ectodermbull Its duct stensen ductopens opp to second upper

molar

bull Inverted pyramidal bull 3 borders-anteriorposterior and medialbull 4 surfaces-

lateral(superficial)baseanteromedial and posteromedial

bull Facial nerve enters posteromedial surface and divides gland into superficial and deep parts

bull Facial nerve divides into upper zygomatico temporal and lower cervico facial divisions

bull Each division then further subdividesbull to form five branches temporal zygomatic buccal

mandibular and cervical supplying the muscles of facial expression

bull The branching pattern within the parotid gland is also variable and a number of classifications have been described

bull Katz and Catalano described five patterns of

bull 1 Type 1 (25 percent) there is splitting and reunion of the zygomatic and mandibular branches

bull 2 Type 2 (14 percent) The buccal branch subdivides and fuses with the zygomatic branch

bull 3 Type 3 (44 percent) There are major anastamotic links from the buccal branch to other major branches

bull 4 Type 4 (14 percent) There is complex branching and anastamotic links between the two divisions

bull 5 Type 5 (3 percent) The facial nerve trunk divides before leaving the stylomastoid foramen

Submandibular gland

bull Large superficial part and smaller deep partwhich curls around the posterior border of the mylohyoid muscle

bull Superficial part covered by superficial fascia and investing layer of deep cervical fascialies with in submandibular triangle

bull Medially lies the mylohyoid muscle anteriorly and posteriorly lies the hyoglossusstylohoid muscles

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Inverted pyramidal bull 3 borders-anteriorposterior and medialbull 4 surfaces-

lateral(superficial)baseanteromedial and posteromedial

bull Facial nerve enters posteromedial surface and divides gland into superficial and deep parts

bull Facial nerve divides into upper zygomatico temporal and lower cervico facial divisions

bull Each division then further subdividesbull to form five branches temporal zygomatic buccal

mandibular and cervical supplying the muscles of facial expression

bull The branching pattern within the parotid gland is also variable and a number of classifications have been described

bull Katz and Catalano described five patterns of

bull 1 Type 1 (25 percent) there is splitting and reunion of the zygomatic and mandibular branches

bull 2 Type 2 (14 percent) The buccal branch subdivides and fuses with the zygomatic branch

bull 3 Type 3 (44 percent) There are major anastamotic links from the buccal branch to other major branches

bull 4 Type 4 (14 percent) There is complex branching and anastamotic links between the two divisions

bull 5 Type 5 (3 percent) The facial nerve trunk divides before leaving the stylomastoid foramen

Submandibular gland

bull Large superficial part and smaller deep partwhich curls around the posterior border of the mylohyoid muscle

bull Superficial part covered by superficial fascia and investing layer of deep cervical fascialies with in submandibular triangle

bull Medially lies the mylohyoid muscle anteriorly and posteriorly lies the hyoglossusstylohoid muscles

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Facial nerve divides into upper zygomatico temporal and lower cervico facial divisions

bull Each division then further subdividesbull to form five branches temporal zygomatic buccal

mandibular and cervical supplying the muscles of facial expression

bull The branching pattern within the parotid gland is also variable and a number of classifications have been described

bull Katz and Catalano described five patterns of

bull 1 Type 1 (25 percent) there is splitting and reunion of the zygomatic and mandibular branches

bull 2 Type 2 (14 percent) The buccal branch subdivides and fuses with the zygomatic branch

bull 3 Type 3 (44 percent) There are major anastamotic links from the buccal branch to other major branches

bull 4 Type 4 (14 percent) There is complex branching and anastamotic links between the two divisions

bull 5 Type 5 (3 percent) The facial nerve trunk divides before leaving the stylomastoid foramen

Submandibular gland

bull Large superficial part and smaller deep partwhich curls around the posterior border of the mylohyoid muscle

bull Superficial part covered by superficial fascia and investing layer of deep cervical fascialies with in submandibular triangle

bull Medially lies the mylohyoid muscle anteriorly and posteriorly lies the hyoglossusstylohoid muscles

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull 1 Type 1 (25 percent) there is splitting and reunion of the zygomatic and mandibular branches

bull 2 Type 2 (14 percent) The buccal branch subdivides and fuses with the zygomatic branch

bull 3 Type 3 (44 percent) There are major anastamotic links from the buccal branch to other major branches

bull 4 Type 4 (14 percent) There is complex branching and anastamotic links between the two divisions

bull 5 Type 5 (3 percent) The facial nerve trunk divides before leaving the stylomastoid foramen

Submandibular gland

bull Large superficial part and smaller deep partwhich curls around the posterior border of the mylohyoid muscle

bull Superficial part covered by superficial fascia and investing layer of deep cervical fascialies with in submandibular triangle

bull Medially lies the mylohyoid muscle anteriorly and posteriorly lies the hyoglossusstylohoid muscles

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Submandibular gland

bull Large superficial part and smaller deep partwhich curls around the posterior border of the mylohyoid muscle

bull Superficial part covered by superficial fascia and investing layer of deep cervical fascialies with in submandibular triangle

bull Medially lies the mylohyoid muscle anteriorly and posteriorly lies the hyoglossusstylohoid muscles

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Deep part lies above the mylohyoid musclelateral to hyoglossus and styloglossus

bull Its duct opens in floor of mouth adjacent to lingual frenulum

bull Sublingual glandlie beneath the mucosa of floor of mouthposteriorly contact the deep part of submandibular glandmost of its small excretory ducts open directly on floor of mouthbut some may open into submandibular duct itself

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Micro-anatomy

bull Basic secretory unit acinusarranged in a sphere around a duct

bull Acini are arranged in to a group-lobulebull Lobules along with excretory ductsnerve

fibresvessels and lymphatics form lobesbull Acini has 3 type of cells-bull Serousbull Mucoid bull intermediate

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Salivary secretions

bull Amount and composition of salivary secretionsis entirely dependent on ANS

bull No hormonal controlbull Any drug that interfere in ANSwill alter

salivary secretionsbull Parotids are mainly serouswhile

saubmandibular and sublingual are mixed glands

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Mechanism

bull Produced in response to neurotransmitter stimulation(noradrenalineacetylcholine)which bind to their receptors on acini

bull Receptors are G protein coupledwhich carry the stimulus inside the cells

bull Adrenergic receptorsprovoke amylase and glycoprotein production via a secondary messenger cAMP

bull

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Cholinergic receptors involves a secondary messenger IP3

bull IP3 binds to Endoplasmic reticulumand releases Ca++causing fluid secretion by acinar cells

bull Both PNS and SNSstimulates salivabull PNS makes saliva watery and increases its

amountSNS makes it thick and quantity decreases

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Methods of collecting saliva

bull Collecting mixed salivabull Spitting and drainage-patient inclined forwardssaliva allowed

to collect in mouth and then spitt after 1 min intervalbull Suctionbull Absorbent devices-pre weight cotton is placed under toungue

for 2 minand then taken out and reweight

bull Collecting from individual glandsbull Cannulation of the duct of the particular gland

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Salivary flow rates can be stimulated or unstimulated

bull Common stimulants used are pilocarpine5 citric acidlemon juices

bull Normal rate-03-04ml per minutebull cutt off values of 01mlminfor labeling as

xerostomiabull Stimulated ndashcutt off 05mlmin

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Functions of saliva

bull Lubricationbull Antimicrobial-it has Ig Abull Helps in tastebull Buffering action-phosphatesbicarbonate and

proteinsbull Helps in digestion-

amylaselipaseribonucleaseproteasebull Prevent dental caries and maintain mucosal

integrity

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Non neoplastic disease o salivary glands

bull Infective disordersbull Non specific inflammationbull Sialolithiasisbull Drug induced menifestationsbull Radiotherapy induced changesbull Autoimmune disordersbull Minor salivary gland disorders

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Mumps(epidemic parotitis)

bull Paramyxovirusbull Typicallyinvolves major salivary glandsbull Mode of infection-droplet infectionbull cc-feverchillspyrexiafacial pain which is

more when patient is eatingbull BL enlarged parotidsbull Submandibular and sublingual glands may also

get involved

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Complications-orchitisviral meningitisencephalitispancretitisophritis

bull Diagnosisbull By clinical featuresbull Confirmatory-viral specific IgG and IgAbull Treatment is conservativebull Prevention is by MMR vaccines

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

HIV infection

bull HIV salivary gland disease characterized by recurrent or persistent major salivary gland enlargement usually parotids and xerostomia

bull bull Clinicaily it mimics Sjogren syndrome butbull there are serological and histological differencesThere are no anti-RO or anti-La antibodiesAnd there is infilteration with CD8 cells

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull If severe cosmetic problem or severe xerostomiaRadiations at 8-10 Gy is indicacted

bull Patient may gets prone to acute bacterial infectionskaposi sarcomaNHL

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Acute Suppurative parotitis

bull Painful enlarged glandssudden in onsetbull Feverdysguesiapain increases on opening

mouthbull Stensenrsquos duct is swollen and redwith

purulent discharge

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull More commonly seen in dehydrated personsImmunocompromised and concurrent illnessXerostomia patients-due to any causepoor

hygieneTPNductal obstructionCausative organism-staph aureusInvestigations-CBCpus culture

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

complications

bull Abscess formationbull Parapharyngeal space infectionbull Ludwig anginabull TREATMENTbull Antibiotics hydrationpain killersbull If disease progresses-surgical drainage

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Granulomatous Diseases

bull Tuberculosis sarcoidosis and actinomycosis may involve the salivary glands

bull Tubercular infection may involve parenchyma or lymph nodes of the parotid and present as a non-tender mass

bull overlying skin undergoes necrosis leading to a fistula formationbull Surgical excision of the involved tissue and antitubercular treatment bull sarcoidosis of the parotidis characterised by fever enlargement of the

parotid and lacrimal glands chorioretinitis and cranial nerve palsiesbull Actinomycosis present as an acute abscess with sinus formation

discharging sulphur-like granules or as an indolent swelling in the parotidbull Treatment is surgical drainage and large doses of penicillin or tetracycline

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Chronic non specific sialadenitisbull Chronic non-specific sialadenitis is Characterised by

recurrent or persistent enlargement of usually one major salivary gland

parotidsgtsubmandibular glands HO recurrent parotitis of childhood or sialolithiasisMostlycause is some ductal abnormality like any pressure on

the ductlike from denturesor due to small strictures or sialoliths

Treat acute attack like acute parotitis50 patients have spontaneous resolutionrest require surgical

excision

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Sialolithiasis

bull Formation of calculuswith in ductal system bull Common in submandibular glandsfemales

and adultsbull Presents with pain and swelling with

eatingwhich resolves after few hoursbull Calcium phosphate are predominant saltbull Cause remains unknown- calcification of

mucus plugs

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull On examination by bimanual palpationtender and enlarged submandibular glandand stone may be felt in the duct

bull Xray as mostly stones are radio-opaquebull USGsialographybull When small and accesiblemanual expression of the

stone is feasiblebull Surgically ndashwhen present in anterior segment of the ductbull Surgical exicion of gland if stone is in posterior segment

of the duct or with in the gland

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Lithotripsy and basket retrieval of fragments(lt7mm)

bull Sialoendoscopy

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Drug induced menifestations

bull Salivary gland swellingbull occasional side effect of phenylbutazone clozapinesulphadiazine

cytosine arabinoside or chlorhexidinedozapine bull Mild acute sialadenitis (sometimes termed iodide mumps) can arise in

response to iodine-based contrast media bull Radioactive iodine used for the treatment of thyroid cancer can cause

transient sialadenitis manifests itself as transient xerostomia and unilateral or bilateral salivary gland enlargement the parotid being particularly affected

bull The clinical features develop within 24 hours of iodine therapy and resolve in a week

bull Add lemon confectionarieswhile undergoing radioactive iodine exposure

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

xerostomia

bull Due to anticholinergic or sympathomimetic action

bull TCAanti histaminicsbeta blockersatropine

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Xerostomia due to radiotherapy

bull Radiotherapy of head and neck malignancies can cause profound xerostomia and salivary gland acinar destruction when the radiotherapy is directed through the major salivary glands

bull bull The degree of xerostomia reflects the duration and dose of radiotherapy

bull bull The xerostomia is irreversible and patients have oral symptoms like those of Sjogrens syndrome

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Oral and topical pilocarpineenhance function of minor salivary glandswhich generally get escaped due to virtue of their location

bull Radio protector like amifostine may lessen the radiotherapy ill effects

bull IMRT

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Sjogren syndrome

bull Autoimmune connective tissue diseaseinvolving lacrimal and salivary glands

bull Cx as Primary or secondary diseasebull Primary disease-involves the lacrimal and salivary

glandsbull M=Fbull Secondary disease ndashin addition to

above autoimmune connective tissue disorder(RA)bull more common in females

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Clinical features-

bull Dry eyes(xero ophthalmia)bull xerostomia-bull dysphagiadysarthriabull cariesgingivitis candida infections median rhomboid glossitis

bull abnormal taste sensation(dysguesia)bull Intermittent swelling of the glands

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Complications

bull Acute suppurative parotitisbull Chronic sialadenitisbull Salivary calculibull Lymphoma(NHL)

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

investigations

bull ESRbull RA positive factorbull ANA positivebull Anti ndashro and Anti ndashLabull biopsybull Rule out-lymphomaAIDSGraft versus host

diseasesarcoidosis

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

treatment

bull Local agentsbull Chewing gumsbull sialogogues

bull Systemic agentsbull Pilocarpinebull Cevimelinebull Bethanacholbull Pyridostigminebull Bromhexinebull Interferon alphabull Corticosteroidsbull Hydroxychloroquinbull Azathioprinbull Cyclophosphamidebull Sulfasalazinebull Dietary supplementsbull Electric stimulation

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Dosage of pilocarpine for sjogren syndrome

bull Dosage for pilocarpine 5mg four times a day for 12 weeks

bull Pilomax(brand name)

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Ocular symptoms a positive response to at least one of the following questions

bull Have you had daily persistent troublesome dry eyes for more than three months

bull Do you have a recurrent sensation of sand or gravel in the eyesbull Do you use tear substitutes more than three times a daybull II Oral symptoms a positive response to at least one of the following

questionsbull Have you had a daily feeling of dry mouth for more than three monthsbull Have you had recurrently or persistently swollen salivary glands as an adultbull Do you frequently drink liquids to aid in swallowing dry foodbull III Ocular signs - t a positive result for at least one of the following two testsbull (1) Schirmers I test performed without anaesthesia 1048644 5 mm in five

minutes)bull (2) Rose bengal score or other ocular dye score (10486444 according to van

Bijstervelds scoring system)

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull IV Histopathology In minor salivary glands (obtained through normal-appearing mucosa) focal lymphocytic sialoadenitis

bull V Salivary gland involvement defined by a positive result for at least one of the following-

bull Unstimulated whole salivary flow 1048644 15 rnL in 15 minutes)bull Parotid sialography showing the presence of diffuse sialectasias (punctate

cavitary or destructivebull Salivary scintigraphy showing delayed uptake reduced concentration

andor delayed excretion of pattern) without evidence ofobstruction in the major ducts tracer

bull VI Autoantibodies presence in the serum of the following autoantibodiesbull Antibodies to Ro(SSA) or La(SSB) antigens

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

mucocoelesbull typically presenting as single blue or translucent sessile swellings on the

lower lipbull both genders and all age groups the peak age of incidence being

between 10 and 29 years bull The lateral aspect of the lower lip is the most common site of occurrence

but other common sites include the floor of the mouth and the ventral surface of the tongue

Occasionally can be multiple or develop suddenly at mealtimesbull extravasation type in which duct damage causes pooling of mucus in the

adjacent connective tissue or retention cysts may resolve spontaneously but large recurrent or unsightly mucocoeles

often need to be surgically excised or removed by laser or cryotherapybull Other therapies include intralesional corticosteroid injections and

gamma-linolenic acid (oil of evening primrose)

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Neoplastic disorders

bull 75 benign 25 malignantbull Pleomorphic adenoma being commonestbull Commonest malignant is mucoepidermoid

cancer

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Benign tumours

bull 75 of all salivary neoplasia

bull Female preponderance

bull Pleomorphic adenoma is commonenst

bull Radiation exposure is a risk factor(similar to thyroid neoplasia)

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Pleomorphic adenoma

bull Most common tumour of the salivary glandsbull Female preponderance seen in all ages most

commonly in 4th or 5th decade of lifebull It can arise from parotidsubmandibular or other

minor salivary glandsvery rare in sublingual glands

bull More common in parotidsbull 80 of parotid pleomorphic adenomas arises

from superficial lobe

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull If arises from minor salivary glandsMC site is-bull Hard palatebull Cheek and lips(2nd common)

occasionally these tumours may be seen to arise anywhere from nasal cavity to bronchi

They may be multicentric or bilateral(but not as common as warthin tumour)

Arise from intercalated duct and myoepithelial cells

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Histology of tumourbull Glandular(ductal myoepithelial cells)bull cellular(epithelial cells)bull chondromyxomatous tissue-bull Hence called -MIXED TUMOURS

bull Chondromyxoid tissue ndashbull (this cartilagenous tissue is not of mesodermal origin)

characteristic featurethis is not seen in any other salivary gland tumour

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Classified into 3 typeson histological basisbull Myxoid(stroma rich80myxoid20cellular)bull Cellular composed of glandular and epithelial cells(80

cellular20 myxoid)bull Mixed(classical)bull Tumour is encapsultedcapsule may thin or absent

focally bull sends its processes into surrounding normal

tissueso while doing surgery surrounding normal tissue should be removed

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Clinical featuresbull Patient with parotid pleomorphic adenoma presents with

a very slow growing massbehind angle of jaw or front of tragus

bull painless and firm massbosselated bull bimanually palpable if arising from submandibular

glandtypically presents with a swelling in submandibular triangle

bull If deep lobe parotid involved-bull medial displacement of tonsillbull Altered quality of voicebull Obstructive sleep apnoea

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Assessment

bull IMAGING-not required in all casesbull Involvement of deep lobe or masses confined to deep lobe

onlybull Parotid masses with facial weakness(suggestive of malignancy)bull When examination is difficult

bull MRIgtCTbull CT-higher attenuation than normal tissuebull enhancing well defined masses with in parotid on CECTbull MRI-T1-low signal intensityT2-high signal intensity

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull MRI-may tell parapharyngeal mass is from parotid deep lobe(occupies prestyloid space)

bull FNAC-on cytology differentiation between benign and malignant tumours very difficult

bull It does not has risk of tumour seedingbull Most Common confused diagnosis-pleomorphic

adenomaadenoid cysticlow grade adenocarcinomabull Warthinlymphomalymph nodes of parotid

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Open biopsy-should be avoidedbull whenever FNAC doubtfulsuperficial

parotidectomy should be donebull Howevercan be donebull very extensive tumoursbull where cytology is positive for malignancy allows

categoriesation of the tumourbull Diffuse enlargement

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rapid increase in size

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

treatmentbull Superficial parotidectomybull Those involving deep loberequire total parotid removelwith

conservation of facial nervebull Other indications of total parotidectomybull Spillage of tumour into deep lobe intraop-occurs in myxoid

variant

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins Tumour)

bull fifth and seventh decade with preponderance in males (101) bull Second MC benign tumourof parotidsbull Seen only in parotidsas lymphoid tissue absent in other

salivary glandsbull mostly involve the tail of the parotid can be bilateral (10)

multiple bull A synchronous tumour may be presentbull Adenolymphoma is a rounded encapsulated tumour at times

cystic with mucoid or brownish fluidbull Histologically oncocytic epithelial and lymphoid elements are

seen

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Older smoker malebull Usually slow growingbull Rapid expansiondue to cystic or degenerative

changes associated with pain(can be mistaken with malignancy)

bull Aspiration of brownish fluid-characteristicbull Tc99 scan-hot nodule(as it has oncocytic epithelium)bull Treatment is superficial parotidectomy bull Malignant changeexceedingly rare

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Oncocytoma (Oxyphil Adenoma)

bull arise from acidophilic cells called oncocytesrich in mitochondria

bull comprise less than 1 of all salivary gland tumoursbull Mostly seen in the elderly(7th or 8Th) bull involve the superficial lobe of parotidbull bull Oncocytomas show increased uptake of

technetium-99bull superficial parotidectomy

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Haemangiomas

bull Haemangiomas are the most common benign tumours of the parotid in children predominantly affecting females Most of them are discovered at birth grow rapidly in the neonatal period and then involutes spontaneously

bull Cutaneous haemangioma may co-exist in 50 of the patients They are soft and painless and increase in size with crying or straining

bull Surgical excision is indicated if they do not regress spontaneously

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Lymphangiomas

bull They are less common and may involve parotid and submandibular glands On palpation they feel soft and cystic They do not regress spontaneously and are surgically excised

bull Rare tumours-Lipoma and neurofibroma

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Malignant tumours

bull Very rarebull 03 of all cancers(swedish study 1960 to

1989)

bull Very resistant to treatmentbull Cure rate is very poorbull Diverse histopathology

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Risk factors

bull Smoking + alcoholismbull Exposure to ionising radiationsbull PUFA is beneficiaryprotective rolebull Livestock processing professionalare exposed

to aflatoxins B1bull EBV

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Mucoepidermoid cancersbull Most common salivary gland malignancy

bull Parotids commonly involved

bull Most common malignancy of parotids

bull may also be seen in minor salivary glands

bull More common in femalesany age group may be affected

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Microscopic appearance

histological appearance

+

bull mixture of mucin producing cells and epithelial cells

bull depending upon which component is more- divided into

bull High grade(30 5 yr survival) (more solid component)

bull low grade(90 5 year survival)(more mucin component

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Clinical features

bull Low grade ndashpresent as a pain less massjust like benign masses

bull High grade-behave more aggressivelybull painfacial palsy and lymph node metastasis

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull For Low Grade tumours-superficial parotidectomywith nerve preservation

bull High grade-poor prognosisbull Total parotidectomy + facial nerve sacrifice +

neck dissectionbull Supra Omohyoid ND for N0 neckbull Post Op RT

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Adenoid cystic carcinoma

bull Slow growing but locally invasive tumourbull Mostly arise from minor glandsbull also most common malignancy of

submandibular glandbull Equal in male and femalebull generally in age group 40 to 60 yearsbull

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull 100 recurrence at primary site after 30 yearseven after negative margins surgically

bull Distant metastasis characteristicmost commonly to lungs

bull Lymph node metastasis is rarebull Perineural invasionbull severe pain due to peripheral nerve invasion

facial palsy bull Skip metastasis may also be seen along the nerves

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull 3 histological patternsbull Solid pattern-adverse prognosisbull cribriform-most common patternswiss

cheese patternbull tubular pattern

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Prognostic factors

bull Those arising from minor glands(particularly from hard palate)

bull Distant metastasisbull Perineural invasionbull Solid histological pattern

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

treatment

bull For local tumourswhich have not eroded near by bonesno nerve involvement-wide local excision

bull For larger tumours-extensive surgery with post op radiotherapy

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Acinic cell carcinoma

bull Most benign of all salivary gland cancersbull Presents as painless lump usually in parotidsbull Most common cancer to present with bilateral

disease(most common benign is warthin tumour)bull Best prognosis among all salivary cancersbull Conservative approach with nerve sparing is

usually requiredunless there is gross invasion of the nerve

bull Post op RT

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Carcinoma ex Pleomorphic adenoma

bull bull develop within pre-existing pleomorphic adenomas (3 percent)

bull risk of malignancy may increase up to 10 percent by 15 years

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Risk of malignant change(carcinoma ex pleomorphic adenoma

bull Occurrence in submandibular glandbull Older patientsbull Tumour gt45 cm bull Long duration-risk increases by 10after 15 years

bull Signs of malignant changebull Facial nerve palsybull Fixity to skinbull Cervical lymphadenopathybull Painbull Rpid increase in size

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Squamous cell carcinoma

bull bull True primary SCC of the salivary glands is rare but SCC involving the

bull gland is much more commonbull bull Poor prognostic factors include bull advanced agebull tumour fixationbull lymph node metastases

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

lymphoma

bull Nearly all NHLbull Almost always arise in parotids bull Sjogren syndrome are at 40 time higher risk to develop

lymphomabull Criteria(batsakis)bull Histological proofthat there is no involvement of intraglandular LNbull Presence of lymphoma markersbull Extraglandular lymphoma must not be present

bull Chlorambucil(for low grade lymphoma)bull VAPEC-B regimen (high grade lymphoma)bull surgery or radiotherapy

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Metastasis to parotids

bull Mostly occurs to intra parotid lymph nodes from SCC of skin

bull May also occur from malignant melanoma(but very rare)

bull Enbloc parotidectomy with neck dissection in continuity with primary lesion

bull Distant mets may also be seen in parotids from lungbreast and kidney primaries

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Diagnosis and investigations

bull Following signs and symptoms are omnious-bull Painnerve palsyskin invasionneck nodesbull Fiberoptic upper airway endoscopy should be

carried out in all patientsbull FNACbull Open biopsy carries risk of seeding the tumourbull Chest XRAYMRI and CT scan to see extent of

tumour

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

staging

bull T1=lt 2 cm without extraparenchymal extensionbull T2=gt 2-4 cm without parenchymal extensionbull T3=gt 4-6 cm andor extraparenchymal

extensionbull T4=gt 6 cm andor base of skull or seventh

nerve involvement

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull N1=Single psilateral node lt3 cmbull N2a=Single ipsilateral node gt 3-6 cmbull N2b=Multiple ipsilateral nodes lt6 cmbull N2c=ipsilateral or contralateral nodes lt 6 cmbull N3=Nodes gt 6 cm

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Complications and informed consent

bull Facial nerve injury-more commonly occurs in large tumousmalignancyinexperienced surgeon and revision cases

bull mostly temporary(neuropraxia)which recovers in few weeksbull Permanent injury is very rarebull direct injuryheat injurytraction injurybull more common in marginal mandibular nerve

bull Facial anesthesiabull Cosmetic defectbull Salivary fistula

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Freyrsquos syndrome

bull Gustatory sweatingmost common complication

bull Topical anticholinergicsbotulinum toxin injection

bull Raising a thick skin flapbull muscle rotational flaps based on sup

temporal arterybull Can be detected by starch iodine test

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

Superficial parotidectomybull GAsupine with shoulder elevatedhead turned to other side Incision-lazy S incision

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Flap raised superficial to parotid fascia(in the face)till anterior border of parotid mass

bull In neckflap raised subplatysmalbull Parotid is mobilized from EACSCM and the

digastric musclesbull Greater auricular nerve is then sectionedbull Facial nerve is the identifiedusing landmarks

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Inferior portion of cartilagenous EAC(tragal pointer)nerve lies 1cm deep to it

bull Groove between cartilagenous and bony EACfacial nerve is immediately deep and inferior to it

bull Anterior border of posterior belly of digastric

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull Parotid superficial lobe is then dissected off from facial branches

bull USE of facial nerve monitoring has helped in identification in nerve

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92

bull

bull Thank you

• Salivary glands
• Slide 2
• Parotid glands
• Slide 4
• Slide 5
• Slide 6
• Submandibular gland
• Slide 8
• Slide 9
• Micro-anatomy
• Salivary secretions
• Mechanism
• Slide 13
• Methods of collecting saliva
• Slide 15
• Functions of saliva
• Non neoplastic disease o salivary glands
• Mumps(epidemic parotitis)
• Slide 19
• HIV infection
• Slide 21
• Acute Suppurative parotitis
• Slide 23
• complications
• Granulomatous Diseases
• Chronic non specific sialadenitis
• Sialolithiasis
• Slide 28
• Slide 29
• Drug induced menifestations
• xerostomia
• Xerostomia due to radiotherapy
• Slide 33
• Sjogren syndrome
• Clinical features-
• Complications
• investigations
• treatment
• Dosage of pilocarpine for sjogren syndrome
• Slide 40
• Slide 41
• mucocoeles
• Neoplastic disorders
• Benign tumours
• Pleomorphic adenoma
• Slide 46
• Histology of tumour
• Slide 48
• Clinical features
• Slide 50
• Slide 51
• Slide 52
• Assessment
• Slide 54
• Slide 55
• Slide 56
• Slide 57
• Risk of malignant change(carcinoma ex pleomorphic adenoma
• treatment (2)
• Adenolymphoma (Papillary Cystadenoma Lymphomatosum Warthins T
• Slide 61
• Oncocytoma (Oxyphil Adenoma)
• Haemangiomas
• Lymphangiomas
• Malignant tumours
• Risk factors
• Slide 67
• Mucoepidermoid cancers
• Microscopic appearance histological appear
• Clinical features (2)
• Slide 71
• Adenoid cystic carcinoma
• Slide 73
• Slide 74
• Prognostic factors
• treatment (3)
• Acinic cell carcinoma
• Carcinoma ex Pleomorphic adenoma
• Risk of malignant change(carcinoma ex pleomorphic adenoma (2)
• Squamous cell carcinoma
• lymphoma
• Metastasis to parotids
• Diagnosis and investigations
• staging
• Slide 85
• Complications and informed consent
• Freyrsquos syndrome
• Superficial parotidectomy
• Slide 89
• Slide 90
• Slide 91
• Slide 92