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TUMOURS OF
PAROTID GLAND
DR. HAMZA AHMAD
RESIDENT SURGEON UNIT-1

History:
1.Patient Information:
Name: Muhammad Iqbal Masih
Age: 55 year
Gender: Male
Marital status: Married
Religion: Christian
Known Hypertensive and X-ray operator by profession comes to the Out-patient department with
following complaints:
• Painful swelling in the left cheek-----6 months

History:
2.History of presenting illness:
Mr. Iqbal was in his usual state of health 6 months back when he first noticed a swelling in left parotid region
initially about the size of pea & gradually increase in size to a size of lemon. The swelling is painful. The pain is
intermittent, dull in character worsened by eating, and occasionally radiates to the left ear. He denies any history
of fever, weight loss, or facial weakness. He has no history of dry mouth, altered taste sensations & dysphonia.
He has no other similar swelling elsewhere in the body.
3.Past Medical History: Hypertension (controlled with medication), No history of diabetes or other significant
medical conditions.
4.Past Surgical History: He had history of cholecystectomy few years back.
5.Personal History: Smoker & Occasional alcohol consumption.
6.Family History: No family history of head & neck cancer, salivary gland tumors or other malignancies.

Clinical Examination:
General Examination:
Patient of average build physique & height is conscious, cooperative, and well-oriented to time, place, and
person. Vital signs are within normal limits. No signs of pallor and cyanosis and clubbing etc. Rest of general
physical examination is unremarkable.
Head and Neck Examination:
A firm, non-tender, mobile swelling is palpable in the left parotid region just below the left ear lobule, swelling is
rubbery in consistency with negative translumination.The overlying skin appears normal and have mild
erythema. There is no local rise of temperature. The swelling measures approximately 2x2 cm in size.
Intraoral Examination: No abnormalities detected.
Neck Examination: No cervical lymphadenopathy detected.
Nerve Examination: Facial and trigeminal nerve examination unremarkable.

Differential diagnosis:
▪ Parotid gland tumors
1. Warthin’s Tumor
2. Pleomorphic adenoma
▪ Metastasis tumor from skin, oral cavity etc.
▪ Lipoma

TUMOURS OF parotid gland and salivary glands.pptx

Ultrasound of swelling:
• Ultrasound shows a well-defined homogeneous hypoechoic lesion 2x2 cm in superficial
lobe of left parotid gland.
• The lesion shows multiple cystic spaces with internal septations.
• No evidence of invasion into adjacent structures
• There is no intralesional flow signal.
• The rest of the gland shows normal echo pattern without dilated ducts and stone.
• The right submandibular gland and superficial lobes of both parotid glands show normal
echo pattern, size without focal lesion/ dilated ducts.
• The thyroid gland shows normal echo pattern without focal lesion.
• There is no cervical lymphadenopathy.

CT-SCAN:
▪ Axial scans shows the presence of an ovoid-shape, well-defined,
homogeneous lesion of 2x2cm, with rapid enhancement located in the left
parotid gland.
▪ No invasion of the surrounding structures was noted.
▪ No displacement of the surrounding structured noted.
▪ Rest of the scan appears normal.

Fine needle
aspiration Cytology
(FNAC):
•Aspirate reveals abundant
lymphoid tissue with oncocytic cells.
•Cytology is consistent with a
Warthin tumor (papillary
cystadenoma lymphomatosum).

Warthin’s Tumor of
parotid gland
Definitive Diagnosis

Introduction:
Tumors of the salivary glands are:
• Most heterogeneous group of tumors.
• Greatest diversity of morphologic features.
• uncommon.
• The majority of these neoplasms are benign 80%
▪ and only 20% are malignant.
• The various types of salivary gland tumors are best distinguished by their histologic patterns.

Anatomy:
▪ 3 major salivary glands:
1. The parotid glands
2. The submandibular glands
3. The sublingual glands
▪ Other locations: lateral margin of tongue, palate, lips, buccal mucosa.

Parotid gland:
• The parotid gland - largest of the three major glands and weighs on average between 14 and 30 g.
• Composed almost entirely of serous cells.
• Sebaceous glands may be observed in 10% to 42% of normal parotid glands .
• The parotid glands contain 3 to 32(average: 20) intraglandular lymph nodes.
• Largest salivary gland & roughly wedge shaped.
• Lies b/w Sternomastoid and mandible below the External auditory meatus.
• Coverings :
• True capsule
• False capsule – a layer from the deep cervical fascia.
▪ Parotid glands duct also called as Stenson’s duct
▪ It emerges from the anterior border of the gland, superficial to the masseter muscle, then it pierces the
buccinator muscle & opens into the oral cavity on the inner surface of the cheek, usually opposite to the
maxillary second molar.

Lobes of Parotid gland:
• Parotid divided into:
1. Superficial-------80%
2. Deep lobes-------20%
by the facial nerve.
• Fasciovenous plane of Patey.

Structures within the parotid gland
1. External carotid artery :
Gives terminal branches in the gland
Maxillary artery and superficial temporal artery.
2. Retromandibular vein :
Formed by union of sup. Temporal and maxillary vein
joins post. Auricular vein to form the external jugular vein.
3.The facial nerve:
Enters upper part of posteromedial border and divides into:

Nerve supply of parotid gland:
▪ Parasympathetic fibres :- Secretomotor
▪ Preganglionic fibres arise from the inferior salivatory nucleus
▪ Pass through glossopharyngeal nerve
▪ Relay in ottic ganglion
▪ Postganglionic fibres reach the gland through auriculotemporal nerve
▪ Sympathetic fibres :- Vasomotor
▪ Sensory nerves :- Auriculotemporal nerve

Rule of 80’s:
80% of parotid tumors are benign.
• 80% of parotid tumors are Pleomorphic adenomas.
• 80% of salivary gland Pleomorphic adenomas occur in the parotid .
• 80% of parotid Pleomorphic adenomas occur in the superficial lobe.
• 80% of untreated Pleomorphic adenomas remain benign.

Epidemiology:
• Uncommon neoplasms.
• 2%-3%of all head and neck neoplasms.
• Most salivary gland tumors originate in the parotid glands (64%-80%), malignancy (15%- 32%).
• 7-11% occur in the submandibular glands, malignancy (37% - 45%).
• less than 1% in the sublingual glands,malignancy (70%-90%),
▪ 9%-23% in the minor glands.
• Benign tumors account for 63% to 78% of all salivary gland neoplasms.

Etiology:
• Viruses- EBV, CMV, Polyoma virus
• Ionizing radiation.
• Increased occupational risks- asbestos, nickel compounds or silica dust.
• Employment in the woodworking, rubber industries & beauty saloons.
• Lifestyle- Warthin’s tumors showed a strong association with cigarette smoking.
• Endogenous hormones.

Parotid neoplasms:
▪ Benign
▪ Pleomorphic adenoma ( MC benign )
▪ Warthin’s tumor ( 2nd
MC Benign )
▪ Malignant
▪ Mucoepidermoid carcinoma ( Highest Malignant Potential )
▪ Adenoid cystic carcinoma
▪ Acinic cell carcinoma ( Most Painful )
▪ Adenocarcinoma
▪ Squamous cell carcinoma ( Most Aggressive )

Pleomorphic adenoma:
▪ It is also known as “Mixed salivary tumor”
▪ It is the most common benign tumor of salivary glands – 80 %
▪ Characterized by neoplastic proliferation of parenchymatous glandular cells along with myoepithelial
components
60-70%- Parotid glands ,40-60%- Submandibular glands, 40-70%- Minor salivary glands Seldomly- Sublingual
glands. Age: 30-50 years Sex: female> male – 3:1 – 4:1
1. In Parotid- Presents in the superior lobe as a mass over the angle of the mandible, below and infront of
the ear.
2. Painless, slow growing, firm mass, initially small in size and begins to increase in size.
3. Recurrent tumor- multinodular, fixed on palpation.
4. Palate – intraorally common site.

Warthin’s tumor:
• Warthin’s tumour, also known as adenolymphoma or cystadenoma lymphomatosum, is a benign tumour.
• They are the second most common benign salivary gland tumours (5–15%) Mainly seen in older men, after
the 5th
& 6th
decade of life.
• They have been associated with cigarette smoking as well as radiation exposure.
• They are almost exclusively seen in the parotid gland, especially in the inferior pole, and are rarely seen in the
peri-parotid nodes.
• They can occur synchronously or metachronously in the same or bilateral glands. (10-15% Bilateral)
• They are also known to occur with other salivary gland neoplasms such as pleomorphic adenoma and
salivary duct carcinoma.
• Clinically, they present as painless, small slow-growing soft cystic fluctuant swellings. Facial palsy is rare.
Malignant transformation is extremely rare. Recurrences are very rare and may be due to multifocal tumours.

Mucoepidermoid tumor:
▪ Commonest type of malignant salivary tumor in adults
▪ Commonest malignant tumor of parotid in childhood
▪ Common in middle age (35-65 years of age)
▪ Female predilection Blue / Red in color
▪ Parotid is the most common site of tumor
▪ 2nd common is palate minor salivary gland
▪ Radiation – etiological factor
▪ t(11;19)(q21;p13) chromosome translocation resulting in a MECT1-MAML2 fusion gene
▪ Presents as painless, slow-growing mass that is firm or hard.
▪ Grossly – Un encapsulated mass with cystic spaces
▪ Facial nerve involvement in late stages

ADENOID CYSTIC CARCINOMA
• Slow growing, aggressive neoplasm.
• 2nd
MC malignant tumor.
• Common malignant tumor- submandibular, sublingual & minor salivary ,
• 2/3rd
– occurs in minor salivary glands.
• Clinical Features: 1) MC seen in females 5th
-6th
decade. Local recurrence common (30-50%). 2) Parotid,
submaxillary, palate & tongue - MC involved. 3) Early local pain (surface ulceration), FN palsy, local invasion &
fixation to deeper structure. LN metastasis 10%-30%.
• 4) Tendency to spread through perineural spaces (20%-30%)
• Commonly involved nerves- Facial nerve, mandibular & maxillary nerve Pathway for invasion of the skull base.
• More frequent- advanced, recurrent & high grade tumors.

Acinic cell carcinoma
3rd
most comman malignant Ca. of parotid gland.
Low malignancy. M:F=3:2, More common in males
mainly in middle ages (44yrs)
Tumor may be multifocal or B/L.
Clinically – Painless lump, Encapsulated & lobulated. Chiefly occurs Parotid (80%)
• Most common intraoral site Lips & buccal mucosa
• Local recurrence & distal metastasis. Has the best survival rate of any salivary cancer.
• Excision of a facial nerve is not justified unless it is involved.

Squamous cell carcinoma:
• Primary salivary gland SCC is very rare(<1%)
▪ Parotid (80%), submandibular gland(20%)
• Age : 60 to 65years, M:F= 2:1.
• History of previous radiotherapy.

Grade of tumor:
▪ Low grade:
▪ Well-differentiated cells with little cellular atypia
▪ High proportion of mucous cells
▪ Prominent cyst formation
▪ Intermediate grade: intermediate features
▪ High grade:
▪ Poorly differentiated with cellular pleomorphism
▪ High proportion of squamous cells
▪ Solid with few if any cysts

Malignancy should be suspected when:
 Rapid growth
 Facial nerve palsy
 Painful
 Skin infiltration
 Get fixed to massester muscle  Trismus
 Feels stony hard
 Presence of lymph nodes in neck

Prognostic factors
 Histopathological diagnosis
 Facial nerve paralysis
 Skin involvement
 Stage
 Location
 Incidence of recurrence
 Distant metastasis
 Radiotherapeutic sensitivity
 Chemotherapeutic sensitivity

TNM classification of carcinomas of the major salivary glands

Main investigations: ( USG,FNAC & CT Scan )
▪ FNAC:-
1) Accuracy95-98%
2) Diff benign from malignant
disease.
3) The key to successful FNAC is
immediate
evaluation of the specimen for
adequacy.
Ultrasound:
1) Ideal tool for the initial assessment of
superficially located tumors of the parotid and
submandibular gland Distinguish intrinsic from
extrinsic neoplasm.
2) USG f/o malignant tumors include
ill-defined margins,
heterogeneous architecture,
subcutaneous invasion,
& the presence of LN metastases.

CT & MRI:
1) Effective modalities for imaging the size, the local, and the regional extension of the
primary tumor and the neck metastasis & to differentiate intra from extra glandular mass.
2) CT IOC for subtle cortical involvement & bone destruction.
3) MRI IOC for bone marrow invasion.
4) MRIIOC for detecting perineural spread.
5) Contrast-enhanced MRI IOC for intracranial invasion
Disadvantage Of MRI :-
1) Less sensitive in cystic lesions.
2) Inability to detect calcification.

Investigations:
1 )Plain X ray
2) X ray chest To R/O secondaries.
3) OPG To R/O mandibular involvement.
4) Open biopsy Rarely used due to risk of recurrence & FN damage Useful HP guidance for use of
palliative CTRT, poor surgical candidate, obvious malignancy.
5) Sialography:-
a) C/I:-Acute infection, Iodine allergy, Multiple myeloma.
b) Limitation:- Mass < 2mm, Deep lobe pathology.
6) Radiosialography Tc99 To detect mass lesion & parenchyma function No use in ductal system study.
7) Colour doppler sonography Non invasive  Evaluates vascular anatomy.
8) PET Differentiate benign from malignant lesions.

Treatment: ( Parotidectomy )
▪ Indications:
▪ Chronic parotitis
▪ Salivary calculi
▪ Parotid tumors
▪ T1,T2,T3 – Total conservative parotidectomy
▪ T4 – Radical parotidectomy
▪ Types:
▪ Superficial parotidectomy
▪ Total conservative parotidectomy
▪ Radical parotidectomy

Indications of facial nerve sacrifice:
▪ Preoperative weakness / paralysis of nerve
▪ Intraoperative evidence of gross invasion
▪ Tumors transgressing through facial nerve from superficial to deep lobe
▪ Nerve stump is checked for frozen section for negative margins, if positive,
mastoidectomy & nerve dissection is required

Indications of PORT:
▪ 1) High-grade tumor
▪ 2) Deep lobe cancers
▪ 3) All T3 and T4 cancers
▪ 4) Recurrent disease
▪ 5) Documented LN metastasis
▪ 6) Extraparotid extension
▪ 7) Gross/microscopic residual disease
▪ 8) Tumor involving or close to the facial
nerve.
1) Clinically cervical Lympadenopathies
(15%).
2) Parotid tumor bigger than 4cm Occult
metastasis risk >20%.
3) High grade malignancy Occult
metastasis risk >25%.
Indications of neck dissection:

Treatment plan of parotid gland tumors:

Chemotherapy useful in pallation
& in inoperable cases.
Combination regimen have not
proven better results
2 groups
Epidermoid like tumor
i.e.
Sq. cell CA
Mucoepidermoid Ca.
Adeno Ca like tumors i.e.
Adenoid cystic Ca,
Acinic cell Ca,
Ca. ex polymorphic Ca
Methotrexate
Cisplatin
Adriamycin
Cisplatin
5-flurouracil
COMPLICATIONS
OF PAROTID
SURGERY

THANK YOU
TILL NEXT �ձ��ѷ�…�Ħ�Ħ�Ħ

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