KMCT DENTAL COLLEGE

MANASSERY P.O MUKKAM

DEPARTMENT OF ORAL AND MAXILLOFACIAL

SURGERY

SEMINAR ON:

PLEOMORPHIC ADENOMA

SUBMITTED BY

SHIBINI P

FINAL YEAR PART II

REG NO :190020913

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 CERTIFICATE

This is to certify that SHIBINI P. REG NO: 190020913 has satisfactorily

completed the seminar in DEPARTMENT OF ORAL AND MAXILLO FACIAL
SURGERY for Final year part II BDS course during the year 2024.

DATE :

LECTURE IN CHARGE :

INTERNAL EXAMINER :

EXTERNAL EXAMINER :

HEAD OF DEPARTMENT

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 CONTENTS

SL TOPIC PAGE
NO NO
1. Introduction 4
2. Parotid Neoplasia 5
3. Pathology 7
4. Microscopic Appearance 8
5. Clinical Features 9
6. Carcinoma Ex Pleomorphic Adenoma 10
7. Investigation 11
8. Management 12

9. Conclusion 16
10. Reference 17

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 INTRODUCTION

• Pleomorphic adenoma, the most common salivary gland tumor, is also known as benign
mixed tumors (BMT's),
• because of its dual origin from epithelial and myoepithelial elements. It is the commonest
of all salivary gland tumors constituting up to two-thirds of all salivary gland tumors.

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 PAROTID NEOPLASIA

BENIGN TUMOUR

• Pleomorphic adenoma
• Warthin's tumour

MALIGNANT TUMOUR

• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Acinic cell carcinoma
• Adenocarcinoma
• Squamous cell carcinoma

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 PLEOMORPHIC ADENOMA

• MIXED TUMOUR
• SITE: PAROTID GLAND (90%)
• Submandibular gland (7%)
• Minor salivary glands: Palate
• Occurs more commonly in females (3:1)
• AGE: any age : 40-50yrs
• Usually unilateral

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 PATHOLOGY

• BENIGN TUMOR
• Tumor capsule-well formed, but incomplete
• Tiny excrescences (pseudopods) project outside.
• Give rise to recurrences

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 MICROSCOPIC APPEARANCE

Two groups of cells:

• Well differentiated epithelial cells-acini/cords/sheets

• Spindle/stellate cells
• Abundant intercellular mucoid material-resemble:
• cartilage
• Pleomorphic stroma
• No necrosis
• Rarity of mitotic figures

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 CLINICAL FEATURES

• Painless slow growing swelling

• In the parotid both lobes involved. If only deep lobe involved - DUMB BELL TUMOUR
• Dysphagia if deep lobe is involved
• Deviation of uvula pharyngeal wall towards midline-deep
• Deep lobe swelling passes through
• PATEY'S STYLOMANDIBULAR TUNNEL
• Raised ear lobule
• Cannot be moved abv zygomatic bone-CURTAIN SIGN
• FACIAL NERVE NOT INVOLVED

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 CARCINOMA EX PLEOMORPHIC ADENOMA

• Long standing pleomorphic adenoma-malignant transformation

• Recent increase in size
• Pain, nodularity
• Involvement of skin, ulceration
• Involvement of masseter
• Involvement of facial nerve
• Neck lymph node
• Restriction of jaw movements

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 INVESTIGATIONS

1. Fine needle aspiration cytology (FNAC)

• Done to confirm the diagnosis and rule out malignancy.

2. CT scan
• Done when the tumour is arising from the deep lobe. It helps to define the extra glandular
spread, the extent of parapharyngeal disease, cervical lymph nodes and bony infiltration.
• Indications for CT scan.
• Suspected bone destruction at skull base.
• Suspected involvement of mandible.
• To assess neck nodes

3. FNAC of the lymph nodes

• That are palpable in the neck in cases of malignancy of the parotid gland.

4. X-ray of the bones (mandible and mastoid process)

• To look for bony resorption, if malignancy is suspected.

5. MRI
• Better investigation.
• However, it is expen-sive-CT scan and MRI lack specificity for differentiating between
benign and malignant lesions.

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 MANAGEMENT

• Tumor is RADIO RESISTANT

• SURGERY
• ENUCLEATION avoided, High recurrence
• SUPERFICIAL PAROTIDECTOMY -PATEY'S OPERATIONif supf lobe alone
involved)
• TOTAL CONSERVATIVE PAROTIDECTOMY (IF both lobes involved)
• FACIAL NERVE IS PRESERVED

TREATMENT OF PLEOMORPHIC ADENOMA

Conservative superficial parotidectomy

• It is the standard surgery done for benign pleomorphic adenoma.

• It means removal of the entire lobe containing the tumour which is superficial to the
facial nerve.
• Facial nerve should always be preserved.
• Enucleation should never be done as it causes recurrence and can injure facial nerve.
• It is difficult to remove a recurrent tumour.

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 STEPS OF SUPERFICIAL PAROTIDECTOMY

1. Adequate exposure

• Iincision which starts in front of tragus of ear, vertically descends down-wards, curves
round the ear lobule up to the mastoid process and is carried downwards in the neck
(Lazy S incision).

2. Recognizing the facial nerve at surgery

• Facial nerve lies 1 cm inferomedial to the bony cartilaginous junction of external auditory
canal.
• In very difficult cases, identify styloid process and nerve is superficial to it.
• Trace the posterior belly of digastric up to the mastoid process. Facial nerve is in between
the muscle and tympanic plate (immediately above the muscle).
• A nerve stimulator may be used

3. Developing a plane

• Facial nerve and retro-mandibular vein divide the parotid gland into superficial and deep
lobes.

4. Gentle handling

• Good suction and perfect haemostasis help in clear recognition of the nerve.

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 COMPLICATION OF PAROTIDECTOMY

• FLAP NECROSIS avoid acute bending of the incision and to use gentle retraction
• FACIAL NERVE PALSY careful identification
• FLUID COLLECTION Blood or seroma-perfect haemostasis and drain should be used
• FISTULA SALIVARY duct should be ligated
• FREY SYNDROME occurs in 10% of the cases

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 TOTAL CONSERVATIVE PAROTIDECTOMY

• Excision of superficial and deep lobe of parotid gland while preserving the facial nerve.

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 CONCLUSION

• Pleomorphic adenoma is exceptional in the nasal cavity, with only a few cases reported in
the literature.
• Although benign, the risk of local recurrence, malignant transformation and metastasis
requires close long-term follow-up.

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 REFERENCE

• Textbook of oral and maxillofacial surgery - Neelima Anil Malik (Fifth edition)
• Textbook of oral and maxillofacial surgery - SM Balaji (Fourth Edition)

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