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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
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
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
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
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
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
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
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
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 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
bull
bull Thank you