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PAROTID GLANDAPPLIED
ANATOMY AND SURGICAL
CONSIDERATIONS
DR FAHAD QIAM
FCPS II RESIDENT (ORAL AND MAXILLOFACIALSURGERY)
SURGICAL E WARD
KHYBER TEACHING HOSPITAL
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CONTENTS
What is the parotid gland
Anatomy of the parotid gland
Applied anatomy of the parotid gland
Overview of parotid gland disorders
Surgical exposure of the parotid gland & case
presentation
Complications of parotid gland surgery
Self assessment exercise
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PAROTID??
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Starts to develop
at 35thday in
utero
Largest of all
salivary glands
Secretes serous
saliva andsalivary amylase
Contributes 25%
of total saliva
production
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RELATIONS
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IMPORTANT RELATIONSHIPS
External carotid artery and its branches
Retromandibular vein and its tributaries
Facial nerve
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EXTERNAL CAROTID ARTERY AND ITS
BRANCHES
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RETROMANDIBULAR VEINS AND ITS
TRIBUTARIES
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FACIAL NERVE
Arises at the pons
Exits via internal acoustic meatus
Goes into facial canal of temporal bone
Exits skull at stylomastoid foramen
Large motor and smallsensory root
Geniculate ganglionGreater petrosal nerve, nerve tostapedius and chorda tympani
Motor supply to the muscles of facial expression
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NERVE TESTING
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DA JALIL
KEBABS!!
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FACIAL NERVE
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NERVE SUPPLY
Auriculotemporal nerve provides sensory supply
Auriculotemporal nerve Otic Ganglion Glossopharyngeal nerve
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WHO????
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APPLIEDANATOMY
Bi-lobed structure
Facial nerve passesaround the isthmus
connecting the two lobes
Contains lymph nodesthat are both intra-
glandular and extra-
glandular
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ANATOMICAL VARIATIONS
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FACIALNERVEGIVESTWOBRANCHESINTHE
GLAND, TEMPOROFACIALANDCERVICOFACIAL
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CASENO.1 A 56 year old man
reported to theDepartment of Oral andMaxillofacial Surgery witha painless swelling in theright pre-auricular region
for the past 3 years. Theswelling was firm,indurated, well localizied,measuring 4x5cm ingreatest diameter. Therewere no associatedsymptoms. No dentalcause for the swelling wasfound. OPG wasunremarkable. Facialnerve was intact.
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HOW TO DIAGNOSE?
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SURGICAL EXPOSURE OF THE
PAROTID GLAND
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HEADPOSITIONINGANDDRAPING
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THEINCISION
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FACIALNERVEMARKERS
Tragal pointer (nerve is inferior and 1cm deep to thislandmark)
Tympanic ring
Anterior aspect of mastoid bone
Tympanomastoid suture line (leads directly tostylomastoid foramen)
Posterior belly of digastric muscle (Facial nerve at samedepth, just above muscle)
Styloid process (facial nerve in angle between styloid anddigastric, and crosses styloid more anteriorly)
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CASENO.2 A 6 year old male
reported with a 2 monthhistory of a tenderswelling in the left pre-auricular region. It was
associated withoccasional pusdischarge and bleedingduring spitting.
Bilateral submandibularlymph nodes werepalpable
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NEED FOR DEEP PAROTIDECTOMY?
Rare as deep lobe is only affected in 20% of parotid
tumors
Undergoes atrophy after superficial parotidectomy
More cumbersome as it usually requires a ramus
osteotomy for full exposure
Requires ligation of external carotid artery,
retromandibular vein, superficial temporal veins
and division of facial nerve trunk
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COMPLICATIONS
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FREYS SYNDROME
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BELLS PALSY
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FOLLOWUP
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SIALOCELE
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PARASTHESIA OF THE EAR LOBE
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KEYPOINTS No or short muscle relaxant
Excellent lighting
Correctly applied traction and
counter traction
Adequate exposure (SMAS)
Clear definition of regionalanatomy
Always take a cuff of normalparotid tissue
Use of EMG based facial nerve
testing
Use of bipolar current
Raw gland surface should not besutured to the skin
Pressure dressing
Use of close suction drain
Sacrifice versus preservation
Patient counselling
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ANYQUESTIONS?