Parotid gland tumours Conference Presentation

Parotid gland tumours

1. PRESENTATION AND OUTCOME
OF
PAROTID GLAND TUMOURS
Muhammad
Saaiq
,

2. INTRODUCTION INTRODUCTION

3. INCIDENCE
Salivary gland
t
umours
are relatively uncommon,
accounting for less than 1% of all reported malignancies.
¾
In USA parotid
tumours
c
laim 650 lives annually.
¾
In UK 40 new cases are reported annually. Parotid gland is the most common site of
neoplasms
among these (75% -
80%) and account for 3-4% of
all head and neck
tumours. They display
considerable variation in their biological
b
ehaviour
and even histology is not a good prognostic indicator.

4. CLASSIFICATION

5. A) EPITHELIAL TUMOURS A) EPITHELIAL TUMOURS
a)a)
Benign Benign
b)b)
Malignant Malignant
B) NON B) NON
--
EPITHELIAL TUMOURS EPITHELIAL TUMOURS

6. A)
EPITHELIAL TUMOURS:
a) BENIGN : ¾
Pleomorphic
adenoma (mixed parotid
tumour)
¾
Monorphic
adenomas
¾
Warthins tumours
(
Adenolymphoma
o
r Papillary
cystadenoma
lymphomatosum)
¾
Benign
lymphoepithelial tumour
(Goodwin’s
tumour)
¾
Oxiphil
adenoma (oncocytoma)
¾
Basal cell
t
umour
¾
Others
b) MALIGNANT ¾
Mucoepidermoid
CA
¾
Adenoid cystic CA (Cylindroma)
¾
Acinic
cell CA
¾
Adeno
C
A
¾
CA ex-pleomorphic
adenoma
¾
Lympho epithelioma
¾
Rare
tumours:
Sqamous
cell carcinoma,
Metastatic
tumors,
Anaplastic
CA
CLASSIFICATION

7. B
)NON EPITHELIAL TUMOURS:
¾
Lymphoma
¾
Hemangioma
¾
Lymphangioma
¾
Neurofibroma
¾
Lipoma
CLASSIFICATION
(Cont’d)

8. PAROTID TUMOURS
INCREASING ORDER OF MALIGNANCY
Anaplastic,
A
deno
CA
Cylindroma
Mucoepidermoid tumour
Fast growing
C
As
Add Your Text Add Your Text Add Your Text
Acinic
cell
t
umour
Pleomorphic
a
denoma

9. SO THE INCREASING ORDER OF SO THE INCREASING ORDER OF
MALIGNANCY IS AS FOLLOWS MALIGNANCY IS AS FOLLOWS

10. 1)
Pleomorphic
a
denoma
2)
Acinic
cell
t
umour
3)
Mucoepidermoid tumour
4)
Cylindroma
5)
Fast growing CA
y
Adeno
C
A
y
Anaplastic
CA

11. PLEOMORPHIC ADENOMA

12. y
Most common of all parotid
t
umours
(60 % of all)
y
Patient is usually around 45 years .
y
It is important for three reason:
a.
Close proximity to Facial Nerve that can be damaged during surgery.
b.
May
r
ecurr
i
f
t
umour
i
s damaged at operation
c.
Can become CA ex-pleomorphic
adenoma

13. PRESENTATION OF PRESENTATION OF
PLEOMORPHIC ADENOMA PLEOMORPHIC ADENOMA

14. Usually as a painless slow growing lump on the side of the face in front of the ear. Pleomorphic
adenoma is usually firm to hard, mobile,
well circumscribed lump. Very rarely it arises from deep
lobe and then develop within
parapharyngeal
space.

15. REPRESENTATIVE CASES:
Left sided
p
leomorphic
A
denoma:

16. REPRESENTATIVE CASES:
Pleomorphic
A
denoma

17. REPRESENTATIVE CASES:
Right sided
p
leomorphic
Adenoma:

18. REPRESENTATIVE CASES
Left sided
p
leomorphic
A
denoma:

19. Mucoepidermoid tumour
y
Commonest malignant
tumour.
y
Vary in degree of differentiated.
y
Well
differentiate (low grade), intermediate, poorly
differentiated (high grade), more likely to recur.
y
Mostly slow growing & limited invasion, occasionally metastasize
y
Clinically harder.

20. RECURRENT MIXED TUMOUR

21. y
Is characterized by presence of multiple, round, well- circumscribed nodules growing in salivary gland tissue, in adipose tissue adjacent to
gla
nd or in the scar of previous
surgery.
y
History of same previous benign
tumour.
y
Carcinoma may arise in these therefore each nodule should be examined microscopically.
y
Nodules
in recurrent mixed
t
umour
do not exhibit the
features of cell
a
naplasia
and invasiveness that characterize
malignant mixed
t
umour.

22. Adenoma Lymphoma
y
Warthin’s tumour, Papillary
c
ystadenoma lymphatosum
i
s
slow growing, soft sometimes fluctuant, bilateral 10%, hot spot on Tc
99
pertechnictate
s
can
y
Treatment excision.

23. Acinic
Cell
Tumour
y
Rare, slow growing, more common in women

24. Adenoid Cystic Carcinoma
y
Elderly, slow growing, hard, fixed painful, areas of anaesthesia
and paralysis of muscles due to
involvement of related nerves.
I
nfilterates
for long
distances in the
p
erineural
tissues of adjacent nerves
and may invade maxillary bone.
y
Metastasis to lymph nodes and
h
ematogenous
to
long
bones may occur.

25. FEATURES SUGGESTIVE OF
PAROTID CA

26. 1) Sudden rapid growth in previously slowly
growing
t
umour.
2) Mild intermittent pain, tenderness. 3) Nerve involvement/Facial weakness 4) Skin ulceration, tethered skin etc. 5) Symptoms due to surrounding structure
involvement e.g
dysphagia
6) Unremarkable mass at the site of origin.

27. DIFFERENTIAL DIAGNOSES OF PAROTID
SWELLING:
1) Idiopathic hypertrophy of
masseter
m
uscle.
2) Pre-auricular
l
ymphadenopathy.
3) TB 4)
Reticulosis
5) Calculus(rare) 6) Miscellaneous
Ch.
p
arotitis
Hemangioma
Cysts etc.

28. CLINICAL EXAMINATION CLINICAL EXAMINATION

29. 1)
LOCAL EXAM. INCLUDING BIMANUAL EXAMINATION (Compare with the opposite side).
a) Inspect the gland from outside b) Palpate the gland from outside:
-
m
ain body of gland consistency, tenderness.
-
a
nterior limit
-
s
uperior third of the gland
-
i
nferior third of the gland
-
postero
inferior part of the gland

30. Contd:
c) Inspect the
S
tensen’s
duct orifice from inside. Apply
pressure over gland from without.
d) Palpate the duct e) deep lobe of the gland from inside. 2) TEST THE FACIAL NERVE 3) EXAMINE THE CERVICAL NODES 4) EXAMINE OTHER SALIVARY GLANDS 5) PERFORM SYSTEMIC EXAM.

31. DIFFERENTIAL DIAGNOSES OF DIFFERENTIAL DIAGNOSES OF
PAROTID SWELLING PAROTID SWELLING

32. 1) Idiopathic hypertrophy of
masseter
m
uscle.
2) Pre-auricular
l
ymphadenopathy.
3) TB 4)
Reticulosis
5) Calculus(rare) 6) Miscellaneous
Ch.
p
arotitis
Hemangioma
Cysts etc.

33. DIAGNOSTIC INVESTIGATIONS DIAGNOSTIC INVESTIGATIONS

34. 1)
BIOPSY
a) FNAC (90% accuracy) b)
Trucut
biopsy
c) Frozen section biopsy d) Wedge biopsy
e)
Histopathology

35. Contd.
2) CT scan 3) MRI 4) U/S 5)
Sialography
6) CXR 7)
Angiography
8) Plain radiography 9) Radio isotope scan 10) Gallium scan 11) Others

36. SURGICAL OPTIONS

37. ¾¾
Superficial Superficial
parotidectomy parotidectomy
¾¾
Total Total
parotidectomy parotidectomy
¾¾
Radical Radical
parotidectomy parotidectomy
¾¾
Functional /Radical neck dissection Functional /Radical neck dissection
¾
enucleation/wide excision
uptill
1950’

38. y
The objective of Surgery is to eliminate all the
t
umour
with minimum of deformity(by preserving the facial nerve) and to reconstruct any residual defect.

39. INCISIONS FOR PAROTIDECTOMY

40. FACIAL NERVE IDENTIFICATION:
1)
Tragal
pointer
of cartilage of external auditory canal--
----1 cm deep, slightly inferior & ant. to
tragal
pointer.
2) 6-8 mm deep to inferior end of
tympanomastoid
suture line.
3) Between the
s
tyloid
process & the attachment
of
diagastric
to
diagastric
ridge of mastoid process.

41. 4)
Follow the posterior facial vein superiorly as it
enters
the
parotid gland & here marginal
mandibular
nerve crosses superficial
to post.
Facial vein which is followed
posteriorly
to main
trunk.
5) “V”Sulcus
b
etween bony external auditory canal
and mastoid process. Identify
b
uccal
branch as it
courses parallel to the parotid duct which is identified
anteriorly
as it crosses the
m
asseter
muscle.
7) Remove the mastoid tip and identify the facial
nerve as it exits to the
styloid
mastoid canal.
8)
Identify Identify
buccal buccal
branch as it courses parallel to the branch as it courses parallel to the
parotid duct which is identified parotid duct which is identified
anteriorly anteriorly
as it as it
crosses the crosses the
masseter masseter
muscle. muscle.

42. OTHER METHODS: y
Staining method (injection of
Methylene
b
lue in
salivary duct).
y
Nerve stimulator.
y
Anatomical identification with mechanical stimulation.

43. FACIAL NERVE:

44. TRAGAL POINTER

45. FACIAL NERVE POSITION

46. DEEP LOBE TUMOUR

47. NERVE DISSECTION

48. FACIAL NERVE BRANCHES

49. RETROMANDIBULAR VEIN

50. FACIOVENOUS PLANE

51. RETROMANDIBULAR PARAPHARYNGEAL
SPACE

52. REPRESENTATIVE CASE:
Right sided
p
leomorphic
Adenoma:

53. REPRESENTATIVE CASE:
Right sided
p
leomorphic
Adenoma:

54. REPRESENTATIVE CASE:
Right sided
p
leomorphic
Adenoma:

55. SUMM
ARY:
PRINCIPLES OF PAROTID CA MANAGEMENT:
1)
T
1
&
T 2 low grade
M
ucoepidermoid
C
A &Acinic
cell CA -----
Superficial or total
p
arotidectomy
with Facial N.
presevation
2) T 1
&
T2
high grade
A
deno
CA, malignant
pleumorphic
a
denoma,
undifferentited
C
a, Sq-Cell CA----
Total
p
arotidectomy
w
ith resection of

first echelon of lymph nodes

56. Contd.
3) T 3 N* or N+ Any recurrent
tumour
not
in
group
IV.-----Radical
parotidectomy, sacrifice
of
Fascial
N
. with immediat
e
reconstruction, neck dissection for N+ neck + post op radiotherapy
4) T4-----Radical
p
arotidectomy
with resection of skin,
m
adible
muscles
as
indicated.
Sacrifice of Facial N. with immediate

recons
truction, neck dissection, post op irradiation.

57. POSTOP RADIOTHERAPY:
Radiotherapy may be used as an ad
junct to surgery or as palliation in
inoper
able cases.
y
In benign mixed
tumours:
-
p
resence of residual disease
-
f
ollowing excision of recurrent
tumour.
b) In malignancy for:
-
r
ecurrent
tumour
-
p
ositive margins after surgery
-
n
arrow margin on facial nerve
-
m
ultiple nodal metastasis
-
p
er
ineur
a
l
i
nvasion

58. PAROTID GLAND TUMOURS,
Our Experience at PIMS

59. Objective:
To document the presentation and outcome of
parotid gland tumours in our set up.
Study Design:
Descriptive study.
Place of the Study :
This study was carried out in the
Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad.
Duration of the Study:
Jan 01, 2003 to Dec 31, 2007.
Subjects and Methods: All patients with parotid gland tumours. Convenience sampling technique. Initial assessment and diagnosis was made by history,
physical examination and fine needle aspiration cytology (FNAC). Local extent of tumour was assessed with CT scan in selected patients with FNAC proven malignancy..
Data Collection Instrument and Processing:

60. INTERVENTIONS UNDERTAKEN INTERVENTIONS UNDERTAKEN
(n=63) (n=63)
SURGERY SURGERY
N
o. of
PATIENTS/ %
1
Superficial
Parotidectomy 60
(95.23%)
2
T
otal
Parotidectomy 3
(4.77%)
3
P
ostoperative Radiotherapy.
6
(9.54%)

61. COMPLICATIONS OBSERVED (n=9) COMPLICATIONS OBSERVED (n=9)
COMPLICATION
No. of PATIENTS/ %
1
Transient facial nerve weakness
2 (3.17%)
2
Permanent facial nerve palsy
2 (3.17%)
3
Symptomatic Numbness of Great auricular nerve area
2 (3.17%)
4
Frey's syndrome
2 (3.17%)
5
Flap tip necrosis
1 (1.58%)

62. Parotid gland tumours constitute a significant source of
morbidity
and
hospitalization
i
n our relati
vely y
ounger
population. In
our
set up,
pleomorphic
a
denoma constitutes the l
eading
type. Painless lump in the
parotid
region, of a relati
vely longe
r duration is the usual
p
resenting

feature. Superficial
parotidectomy
with
preservation of facial nerve is the
most frequently instituted definitive treatment. y
Parotid gland
t
umour
t
hough less comm
on are encountered in our count
r
y.
y
Problems in their management are larg
ely related to the facial nerve. A
proper consent should therefore be
taken from the patient preoperatively
and such patients should perfectly be
managed wh
ere expertise to
handle
compli
cations of surgery can be ta
ckled in a proper and judicious
way.
Conclusions

63. Thank You Thank You