PRESENTATION AND OUTCOME OF

PAROTID GLAND TUMOURS

Muhammad Saaiq
 INCIDENCE

Salivary gland tumours are relatively uncommon,

accounting for less than 1% of all reported
malignancies.
¾ In USA parotid tumours claim 650 lives annually.
¾ In UK 40 new cases are reported annually.
Parotid gland is the most common site of neoplasms
among these (75% - 80%) and account for 3-4% of
all head and neck tumours. They display
considerable variation in their biological behaviour
and even histology is not a good prognostic
indicator.
A) EPITHELIAL TUMOURS: CLASSIFICATION
a) BENIGN :
¾ Pleomorphic adenoma (mixed parotid tumour)
¾ Monorphic adenomas
¾ Warthins tumours (Adenolymphoma or Papillary cystadenoma
lymphomatosum)
¾ Benign lymphoepithelial tumour (Goodwin’s tumour)
¾ Oxiphil adenoma (oncocytoma)
¾ Basal cell tumour
¾ Others
b) MALIGNANT
¾ Mucoepidermoid CA
¾ Adenoid cystic CA (Cylindroma)
¾ Acinic cell CA
¾ Adeno CA
¾ CA ex-pleomorphic adenoma
¾ Lympho epithelioma
¾ Rare tumours: Sqamous cell carcinoma, Metastatic tumors, Anaplastic CA
 CLASSIFICATION
(Cont’d)
B)NON EPITHELIAL TUMOURS:
¾ Lymphoma
¾ Hemangioma
¾ Lymphangioma
¾ Neurofibroma
¾ Lipoma
FEATURES OF CA
1) Sudden rapid growth in previously slowly
growing tumour.
2) Mild intermittent pain, tenderness.
3) Nerve involvement/Facial weakness
4) Skin ulceration, tethered skin etc.
5) Symptoms due to surrounding structure
involvement e.g dysphagia
6) Unremarkable mass at the site of origin.
 PAROTID TUMOURS
INCREASING ORDER OF MALIGNANCY

Fast growing CAs

Anaplastic, Adeno CA
Add Your Text
Cylindroma
Add Your Text
Mucoepidermoid tumour
Add Your Text Acinic cell tumour
Pleomorphic adenoma
 RECURRENT MIXED
TUMOUR
y Is characterized by presence of multiple, round, well- circumscribed
nodules growing in salivary gland tissue, in adipose tissue adjacent to
gland or in the scar of previous surgery.
y History of same previous benign tumour.
y Carcinoma may arise in these therefore each nodule should be examined
microscopically.
y Nodules in recurrent mixed tumour do not exhibit the features of cell
anaplasia and invasiveness that characterize malignant mixed tumour.
STAGING (UICC 1987)
T 1 <2 cm. With No extension or extension
T 2 >2-4 cm
T 3 >4-6 cm
T 4 >6 cm
N 1 Ipsilateral single <3 cm
N 2 “ “ >3-6 cm
“ multiple <6 cm
Bilateral contralateral <6 cm
N 3 >6 cm
M* No distant metastasis
M 1 Distant metastasis
MODE OF SPREAD
1) Expansion
2) Local infiltration
3) Peri neural infiltration
4) Recurrence
5) Lymphatic
6) Hematogenous
CLINICAL EXAMINATION
1) LOCAL EXAM. INCLUDING BIMANUAL
EXAMINATION (Compare with the opposite
side).
a) Inspect the gland from outside
b) Palpate the gland from outside:
- main body of gland consistency, tenderness.
- anterior limit
- superior third of the gland
- inferior third of the gland
- postero inferior part of the gland
 Contd:
c) Inspect the Stensen’s duct orifice from inside. Apply
pressure over gland from without.
d) Palpate the duct
e) deep lobe of the gland from inside.
2) TEST THE FACIAL NERVE
3) EXAMINE THE CERVICAL NODES
4) EXAMINE OTHER SALIVARY GLANDS
5) PERFORM SYSTEMIC EXAM.
D/D OF PAROTID
SWELLING
1) Idiopathic hypertrophy of masseter muscle.
2) Pre-auricular lymphadenopathy.
3) TB
4) Reticulosis
5) Calculus(rare)
6) Miscellaneous
Ch. parotitis
Hemangioma
Cysts etc.
 DIAGNOSTIC
INVESTIGATIONS
1) BIOPSY
a) FNAC (90% accuracy)
b) Trucut biopsy
c) Frozen section biopsy
d) Wedge biopsy
e) Histopathology
 Contd.
2) CT scan
3) MRI
4) U/S
5) Sialography
6) CXR
7) Angiography
8) Plain radiography
9) Radio isotope scan
10) Gallium scan
11) Others
TREATMENT
1) SURGERY
a) Superficial parotidectomy
b) Total parotidectomy
c) Radical parotidectomy
d) Functional /Radical neck dissection
GOAL OF SURGERY
y The objective is to eliminate all the tumour with minimum
of deformity and to reconstruct any residual defect.
 SURGICAL OPTIONS

¾ Superficial parotidectomy
¾ Total parotidectomy
¾ Radical parotidectomy
¾ Functional /Radical neck dissection
¾enucleation/wide excision uptill
1950’
y The objective is to eliminate all the tumour with
minimum of deformity and to reconstruct any residual
defect.
INCISION
 Facial Nerve identification
1) Tragal pointer of cartilage of external auditory canal--
----1 cm deep, slightly inferior & ant. to tragal
pointer.
2) 6-8 mm deep to inferior end of tympanomastoid
suture line.
3) Between the styloid process & the attachment of
diagastric to diagastric ridge of mastoid process.
4) Follow the posterior facial vein superiorly as it enters
the parotid gland & here marginal mandibular nerve
crosses superficial to post. Facial vein which is
followed posteriorly to main trunk.
5) “V”Sulcus between bony external auditory canal and
mastoid process. Identify buccal branch as it courses
parallel to the parotid duct which is identified
anteriorly as it crosses the masseter muscle.
6) Remove the mastoid tip and identify the facial nerve as
it exits to the styloid mastoid canal.
7)Identify buccal branch as it courses parallel to the
parotid duct which is identified anteriorly as it crosses
the masseter muscle.
OTHER METHODS
y Staining method (injection of Methylene blue in
salivary duct).
y Nerve stimulator.
y Anatomical identification with mechanical stimulation.
NERVE DISSECTION
TRAGAL POINTER
FACIAL NERVE
POSITION
 PRINCIPLES OF PAROTID
CA MANAGEMENT:
1) T 1 & T 2 low grade Mucoepidermoid CA &Acinic cell CA -----
Superficial or total parotidectomy with Facial N. presevation

2) T 1 & T2 high grade Adeno CA, malignant pleumorphic adenoma,

undifferentited Ca, Sq-Cell CA----
Total parotidectomy with resection of first echelon of lymph nodes
3) T 3 N* or N+ Any recurrent tumour not in group IV.-----Radical
parotidectomy, sacrifice of Fascial N. with immediate
reconstruction, neck dissection for N+ neck + post op
radiotherapy
4) T4-----Radical parotidectomy with resection of skin, madible
muscles as indicated. Sacrifice of Facial N. with immediate
reconstruction, neck dissection, post op irradiation.
POSTOP
COMPLICATIONS:
Specific to parotid surgery:
1) Facial N. damage ------ permanent or transient
2) Frey’s syndrome
3) Salivary Fistula
4) Recurrence
OTHERS:
Hematoma, Infection, Flap necrosis
Numbness of ear due to Gr. Auricular N. injury,
Cosmatic deformity, Keloid etc.
 POSTOP RADIOTHERAPY:
Radiotherapy may be used as an adjunct to surgery or as palliation in
inoperable cases.
yIn benign mixed tumours:
- presence of residual disease
- following excision of recurrent tumour.
b) In malignancy for:
- recurrent tumour
- positive margins after surgery
- narrow margin on facial nerve
- multiple nodal metastasis
- perineural invasion
DEEP LOBE TUMOUR
FACIAL NERVE
BRANCHES
RETROMANDIBULAR
VEIN
FACIOVENOUS PLANE
RETROMANDIBULAR
PARAPHARYNGEAL
SPACE
PAROTID GLAND TUMOURS,
PIMS Experience
Objective: To document the presentation and outcome of
parotid gland tumours in our set up.
Study Design: Descriptive study.
Place of the Study : This study was carried out in the
Department of Surgery, Pakistan Institute of Medical
Sciences (PIMS), Islamabad.
Duration of the Study: Jan 01, 2003 to Dec 31, 2007.
Subjects and Methods:
All patients with parotid gland tumours.
Convenience sampling technique.
Initial assessment and diagnosis was made by history,
physical examination and fine needle aspiration
cytology (FNAC). Local extent of tumour was assessed
with CT scan in selected patients with FNAC proven
malignancy..
Data Collection Instrument and Processing:
 CONCLUSION

Parotid gland tumours constitute a significant source of morbidity and

hospitalization in our relatively younger population. In our set up,
pleomorphic adenoma constitutes the leading type. Painless lump in the
parotid region, of a relatively longer duration is the usual presenting
feature. Superficial parotidectomy with preservation of facial nerve is the
most frequently instituted definitive treatment.
yParotid gland tumour though less common are encountered in our country.
yProblems in their management are largely related to the facial nerve. A
proper consent should therefore be taken from the patient preoperatively and
such patients should perfectly be managed where expertise to handle
complications of surgery can be tackled in a proper and judicious way.
Thank You