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Presentation on theme: "EVALUATION OF PAROTID SWELLING"— Presentation transcript:

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

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

3 DEVELOPMENT Ectodermal in origin
Each parotid is developed during 5th week from angle of primary oral fissure. The groove is converted into tube which forms duct and opens into angle of primitive mouth.

4 DEVELOPMENT (contd.) With the growth of maxillary and mandibular process the duct opening is shifted to vestibule opposite the upper 2nd molar tooth. During development the gland lies in between the branches of facial nerve, as development progresses it envelopes the branches.

5 PAROTID GLAND Superficial part(80%)lies over posterior part of ramus of mandible Deep part(20%) lies behind mandible and medial pterygoid Facial nerve lies between them

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

7 Superficial or lateral relations:
Skin Superficial fascia Superficial lamina of investing layer of deep cervical fascia Great auricular nerve (anterior ramus of C2 and C3)

8 Anteromedial relations:
Mandibular ramus, Masseter and medial pterygoid muscles

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

10 Medial relations: Superior pharyngyeal constrictor muscle

11 Structures: From lateral to medial Facial nerve
Retromandibular vein (Patey's fascio venous plane) External Carotid artery

12 Blood Supply External carotid artery Retromandibular vein

13 Lymphatic drainage Superficial and deep group of parotid lymph nodes.
Efferents from these nodes drain into jugulodigastric group of deep cervical nodes

14 Nerve supply Parasympathetic – stimulates watery secretion
Sympathetic – stimulates mucus rich thick secretion and also vasomotor

15 Facial nerve (pes anserinus)

16 Parotid duct Also known as Stensen’s duct
Appears at the anterior part of upper border of gland and passes across masseter to traverse buccal fat and buccinator. Runs obliquely forwards for a short distance between buccinator and the oral mucosa and opens upon a small papilla opposite upper 2nd molar tooth.

17 Applied anatomy Infections –
Very painful due to unyielding nature of capsule. Retrograde bacterial infection may occur from mouth via duct.


19 Causes of acute parotitis
Viral – mumps, coxsackie A & B, parainfluenza 1 & 3 Bacterial – staphylococcus aureus,streptococcus viridans Poor oral hygiene HIV Radiotherapy Syphilis Sjogren’s syndrome

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

21 Mumps (epidemic parotitis)
Caused by paramyxovirus Incubation period 2-3 weeks Bilateral 90% Common in children Clinical features:- Fever Swelling Pain, tender

22 Complications of mumps:
Orchitis Oophoritis Pancreatitis Meningoencephalitis

23 Investigations Ultrasound Calculous Abscess

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

25 RECURRENT PAROTITIS (sialectasis)
Age 3-6yrs Recurent episode of pain Diffuse swelling Fever Enlarged lymph nodes Spontaneus resolution

26 RECURRENT PAROTITIS (Chronic interstitial parotitis)
In Adults Calculous- Unilateral Auto immune-Bilateral Diffuse swelling Pain Purulant saliva Pressure on sialectic gland may express pus from the duct.

27 Investigation Xray Plain films are not much useful since parotid stones are radiolucent. Sialography Punctate sialectasis(snowstorm)appearance

28 Treatment of parotid calculi
Extraction of stone through oral cavity Conservative parotidectomy if multiple calculi

29 Classification of parotid tumors
ADENOMA pleomorphic -pleomorphic adenoma monomorphic-warthin’s tumor Oxyphilic adenoma CARCINOMA (low grade) : acinic cell carcinoma adenoid cystic carcinoma low grade mucoepidermoid

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

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

80% of salivary neoplasms are of parotid origin 80% of parotid masses are neoplastic 80% of neoplasms in parotid are benign

33 Bicellular Theory Intercalated Ducts Excretory Ducts
Pleomorphic adenoma Warthin’s tumor Oncocytoma Acinic cell Adenoid cystic Excretory Ducts Squamous cell Mucoepidermoid

34 Multicellular Theory Striated duct—oncocytic tumors
Acinar cells—acinic cell carcinoma Excretory Duct—squamous cell and mucoepidermoid carcinoma Intercalated duct and myoepithelial cells—pleomorphic tumors

35 Pleomophic Adenoma

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

37 Physical examination Mobile Nontender Firm
Solitary mass in parotid region Raised ear lobule Obliteration of retromandibular groove Cannot be moved above zygomatic bone Deviation of uvula & pharyngeal wall towards midine if deep lobe involved No facial nerve involvement

38 Macroscopy Greyish white in color with possible cyst formation and haemorrhage.

39 Histology Mixture of epithelial, myoepithelial and stromal components
Epithelial cells: nests,sheets, ducts, trabeculae Stroma: myxoid, chrondroid, fibroid, osteoid No true capsule Tumor pseudopods

40 Dumb-bell tumor Arise from deep lobe
Swelling in the lateral wall of pharynx Soft palate displaced to opposite side

41 Carcinoma ex pleomorphic adenoma
Rapid increase in size Pain and nodularity Involvement of skin & ulceration Involvement of masseter Involvement of facial nerve Involvement of neck lymph node

42 Carcinoma Ex-Pleomorphic Adenoma
2-4% of all salivary gland neoplasms 4-6% of mixed tumors 6th-8th decades Parotid > submandibular > Minor salivarygland Risk of malignant degeneration 1.5% in first 5 years 9.5% after 15 years Presentation Longstanding painless mass that undergoes sudden enlargement

43 Carcinoma Ex-Pleomorphic Adenoma
Histology Malignant cellular change adjacent to typical pleomorphic adenoma Carcinomatous component: Adenocarcinoma Undifferentiated

44 Warthin’s tumour (papillary cystadeno lymphomatosum)
Second most common benign parotid tumour (5%) Most common bilateral benign neoplasm of parotid. Common in lower pole Slow-growing, painless mass Marked male predominance Sixth and seventh decade Hot spot in Tc99 scan Malignant transformation rare.

45 Gross pathology Encapsulated Smooth/lobulated surface
Cystic spaces of variable size, with viscous fluid, shaggy epithelium Solid areas with white nodules representing lymphoid follicles

46 Histology Papillary projections into cystic spaces surrounded by lymphoid stroma Epithelium: double cell layer Luminal cells Basal cells Stroma: mature lymphoid follicles with germinal centers

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

48 Oxyphilic adenoma (Oncocytoma)
Rare: 2.3% of benign salivary tumors 6th decade M:F = 1:1 Parotid: 78% Submandibular gland: 9% Presentation Enlarging, painless mass

49 Pathology Gross Encapsulated Homogeneous, smooth Orange/rust color
Histology Cords of uniform cells and thin fibrous stroma Large polyhedral cells Distinct cell membrane Granular, eosinophilic cytoplasm Central, round, vesicular nucleus

50 Oxyphilic adenoma Electron microscopy: Mitochondrial hyperplasia
60% of cell volume

51 Monomorphic Adenomas Basal cell is most common: 1.8% of benign epithelial salivary gland neoplasms 6th decade M:F = approximately 1:1 Most common in parotid

52 Basal Cell Adenoma Trabecular Cells in elongated trabecular pattern
Vascular stroma

53 Basal Cell Adenoma Tubular Multiple duct-like structures
Columnar cell lining Vascular stroma

54 Basal Cell Adenoma Membranous
Thick eosinophilic hyaline membranes surrounding nests of tumor cells “jigsaw-puzzle” appearance

55 Malignant tumours Malignant – 1.Mucoepidermoid carcinoma
2. Adenoid cystic Carcinoma. 3. Adenocarcinoma. 4. Squamous cell carcinoma. 5. Malignant pleomorphic adenoma. 6. Acinic cell tumor 7. Malignant lymphoma 8. Anaplastic carcinoma

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

57 Clinical features (contd.)
Trismus => advanced disease with extension to masticatory muscles or less commonly invasion into TM joint Dysphagia => tumour of deep lobe of parotid Ear pain=>extension into auditary canal Numbness along Trigeminal nerve =>neural invasion

58 Clinical features Hard mass in parotid region Skin ulceration/fixation
Fixation to adjacent structures Examination of external auditary canal for tumor extension Regional lymph adenopathy Blood or pus from stensen’s duct Bulging of lateral pharyngeal wall or soft palate


60 Mucoepidermoid Carcinoma
Most common salivary gland malignancy 5-9% of salivary neoplasms Parotid 45-70% of cases Palate 18% 3rd-8th decades, peak in 5th decade F>M

61 Mucoepidermoid carcinoma
Slow growing tumors Limited local invasiveness Low metastatic potential High grade behave like SCC, low grade behave like benign tumors Sucessfully treated by adequate radical excision

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

63 Mucoepidermoid Carcinoma
Gross pathology Well-circumscribed to partially encapsulated to unencapsulated Solid tumor with cystic spaces

64 Histopathology Areas of mucous secreting cells
Epidermoid and epithelial cells

65 Adenoid cystic carcinoma (cylindroma)
Poorly encapsulated infiltrating tumors Propensity to spread along nerves Highly invasive but may remain quiescent for a long time Highest incidence of distant metastasis Lung metastasis are most frequent. Poor prognosis

66 Malignant mixed tumors
They can arise within a preexisting benign pleomorphic adenoma (CARCINOMA EX PLEIOMORPHIC ADENOMA) They may arise denovo (CARCINOSARCOMA)

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

68 Lymphoma Most commonly in elderly females Usually Non-Hodgkins
5-10% of patients with warthin’s Enlarged parotid with a rubbery consistency Enlarged regional lymph nodes

69 Rare tumours of parotid
Squamous cell carcinoma Sebaceous carcinoma Salivary duct carcinoma Malignant fibrohistiocytoma

70 Investigations Ultrasound FNAC is the diagnostic
MRI is superior in demonstrating benign tumors than CT CT scan/MRI identifies regional lymph node involvement/ extension into deep lobe / parapharyngeal space PET may be useful in assessing malignant tumors

71 Fine-Needle Aspiration Biopsy
Efficacy is well established Safe, well tolerated Accuracy = 84-97% Sensitivity = 54-95% Specificity = 86=100%


73 Surgery (benign tumors)
First line of management superficial lobe is involved, superficial conservative parotidectomy If deep lobe(dumb bell) also involved, total parotidectomy with preservation of facial nerve. Enucleation should be avoided as recurrence rate is high Extracapsular enucleation-warthin’s tumor

Removal of the entire gland,facial nerve and regional lymph nodes Resection of all involved structures


76 Functional neck dissection
positive malignancy nodes high grade tumors local invasion recurrent tumors if no h/o previous neck dissection deep lobe tumors

77 Reconstruction for wound closure
Skin grafting Cervicofacial flap Trapezius flap Pectoralis flap Deltopectoral flap Microvascular free flap

78 Reconstruction of facial nerve
Great auricular nerve Hypoglossal nerve Sural nerve

79 Indications for RT >4 cm in diameter High grade Local invasion
Lymphatic/neural/vascular invasion Tumor in/extending to deep lobe Recurrent tumours following re-resection Positive margins

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

81 Hobsley’s dictum Inflammation: whole parotid swollen
Neoplasm:A part of the gland is swollen



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