SURGERY OF THE PAROTID GLAND

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SURGERY OF THE PAROTID GLAND : 

SURGERY OF THE PAROTID GLAND DR SANOOP K ZACHARIAH

SALIVARY GLANDSBROAD CLASSIFICATION : 

SALIVARY GLANDSBROAD CLASSIFICATION Major- PAROTID SUBMANDIBULAR SUBLINGUAL Minor-600-1000 GLANDS BUCCAL, LABIAL, LINGUAL, PALATAL DR SANOOP ZACHARIAH

EMBRYOLOGY-PAROTID : 

EMBRYOLOGY-PAROTID 6-8 weeks of gestation First to develop Last to become encapsulated DR SANOOP ZACHARIAH

PAROTID GLAND : 

PAROTID GLAND Largest salivary gland Paired and pyramidal shaped Covered by 2 capsules Occupies the area known as parotid fascial space Irregular lobulated yellowish DR SANOOP ZACHARIAH

ANATOMY : 

ANATOMY M=MASSETER B=BUCCINATOR D=DIGASTRIC SCM=STERNOMASTOID DUCT DR SANOOP ZACHARIAH

COVERINGS : 

COVERINGS - 2 capsules True capsule-fibrous condensation of gland proper False capsule-part of deep cervical fascia-splits into 2-layers to enclose the gland Superficial layer is thick-attached to the zygoma= PAROTID FASCIA Deeper layer attaches to the styloid process and mandible= STYLOMANDIBULAR LIGAMENT DR SANOOP ZACHARIAH

COMPARTMENTS : 

COMPARTMENTS Neural compartment Facial N, Great Auricular, Auriculotemporal N Venous compartment Retromandibular vein Arterial compartment Superficial Temporal/Transverse Facial DR SANOOP ZACHARIAH

Slide 8: 

EXT CAROTID SUP TEMPORAL MAXILLARY TRANSVERSE CERVICAL POST AURICULAR ARTERIAL COMPARTMENT DR SANOOP ZACHARIAH

VENOUS COMPARTMENT : 

VENOUS COMPARTMENT SUP TEMPORAL MAXILLARY V RETROMANDIBULAR V POST AURICULAR EXT JUGULAR V DR SANOOP ZACHARIAH

Slide 10: 

FN RMV ECA SUPERFICIAL DEEP RELATION OF COMPARTMENTS DR SANOOP ZACHARIAH

FACIO- VENOUS PLANE OF PATEY : 

FACIO- VENOUS PLANE OF PATEY NERVE NERVE SUPERFICIAL LOBE ARTERY VEIN DR SANOOP ZACHARIAH

AURICOTEMPORAL NERVE : 

AURICOTEMPORAL NERVE BR OF TRIGEMINAL N CARRIES SYMP FIBRES TO SWEAT GLANDS ATN DR SANOOP ZACHARIAH

NERVE SUPPLY : 

NERVE SUPPLY SYMPATHETIC-PLEXUS AROUN EXT CAROTID ARTERY PARASYMPATHETIC-AURICOTEMPORAL,GLOSSOPHARYNGEAL N DR SANOOP ZACHARIAH

DISEASES OF THE SALIVARY GLANDS : 

DISEASES OF THE SALIVARY GLANDS DEVELOPMENTAL ANOMALIES INFLAMMATORY DISORDERS OBSTRUCTION AND TRAUMA NEOPLASMS DR SANOOP ZACHARIAH

SALIVARY GLAND NEOPLASMS : 

SALIVARY GLAND NEOPLASMS 1-1.5% of all neoplastic disease Very slow growing DR SANOOP ZACHARIAH

PAROTID GLAND-GOLDEN RULE OF 80 : 

PAROTID GLAND-GOLDEN RULE OF 80 80% of salivary gland tumours occurs in the parotid Of these 80% are benign Of theses 80% are pleomorphic adenomas DR SANOOP ZACHARIAH

SUBMANDIBULAR GLAND NEOPLASMS : 

SUBMANDIBULAR GLAND NEOPLASMS 15% of neoplasms occur in the submandibular gland Of these 60% is benign Of these 90% are pleomorphic adenomas DR SANOOP ZACHARIAH

SUBLINGUAL AND MINOR GLANDS : 

SUBLINGUAL AND MINOR GLANDS 10% of salivary gland tumours 60% are malignant 40% are benign DR SANOOP ZACHARIAH

THEREFORE- : 

THEREFORE- Neoplasm's of sublingual and minor salivary glands are MORE likely to be malignant Neoplasm's of parotid and submandibular gland s are LESS likely to be malignant DR SANOOP ZACHARIAH

INFERENCE : 

INFERENCE “THE LARGER THE GLAND MORE LIKELY THE TUMOUR WILL BE BENIGN” DR SANOOP ZACHARIAH

CLASSIFICATION : 

CLASSIFICATION A) EPITHELIAL TUMOURS BENIGN MALIGNANT B) NON EPITHELIAL(CONNECTIVE TISSUE TUMOURS) BENIGN MALIGNANT C)METASTATIC TUMOURS DR SANOOP ZACHARIAH

EPITHELIAL TUMOURS : 

EPITHELIAL TUMOURS DR SANOOP ZACHARIAH

NON EPITHELIAL TUMOURS : 

NON EPITHELIAL TUMOURS DR SANOOP ZACHARIAH

PLEOMORPHIC ADENOMAS : 

PLEOMORPHIC ADENOMAS COMMONEST TUMOUR OF SALIVARY GLANDS ALSO KNOWN AS “MIXED TUMOUR” M=F MEAN AGE=42 YEARS SLOW GROWING MALIGNANT CHANGE=RARE 2/3 RD OCCURS IN SUPERFICIAL LOBE ETIOLOGY- MOSTLY UNKNOWN RADIATION,SMOKING,HEREDITARY DR SANOOP ZACHARIAH

HISTOLOGY : 

HISTOLOGY HISTOLOGICAL DIVERSITY CYTOMORPHOLICAL AND ARCHITECTURAL DIVERSITY MIXED=2 SUBTYPES OF CELLS CONTAINS MIXED EPITHELIAL AND MESENCHYMAL /STROMAL CELL COMPONENTS IT CONTAINS EPITHELIAL CELLS- MYOEPITHELIAL CELLS- STROMA-HYALINE,CHONDROID,MYXOID OR FIBROUS NOW=BELIEVED TO ORIGINATE FROM DUCTAL MYOEPITHELIAL CELLS DR SANOOP ZACHARIAH

MORPHOLOGY : 

MORPHOLOGY RUBBERY MASS+BOSSELATED SURFACE SURROUNDE BY A FIBROUS CAPSULE CAPSULE VARIES IN THICKNESS CONTAINS PROTUSIONS =PSEUDOPODS EXTENDING BEYOUND CENTRAL MASS THEREFORE FAILURE TO INCLUDE THESE AT SURGERY , CAN LEAD TO RECUURANCE DR SANOOP ZACHARIAH

CLINICAL FEATURES : 

CLINICAL FEATURES PAINLESS SLOW GROWING LUMP SIDE OF THE FACE TYPICAL SITE=BELOW THE LOBULE IN FRONT OF THE TRAGUS NON TENDER,LOBULATED WELL DEFINED MARGINS RUBBERY/FIRM IN CONSISTENCY NO FIXITY TO SKIN/MASSETER PLANE-SUPERFICIAL TO MASSETER BELOW DEEP FASCIA EAR LOBULE RAISED DR SANOOP ZACHARIAH

INVOVELMENT OF FACIAL NERVE : 

INVOVELMENT OF FACIAL NERVE As long as the tumour is benign facial n involvement is uncommon Even large tumors usually do not produce facial n palsy DR SANOOP ZACHARIAH

MALIGNANT TRANSFORMATION : 

MALIGNANT TRANSFORMATION In Pleomorhic Adenoma It Is Called- “Carcinoma –Ex- Pleomorhic Adenoma” Facial Nerve Involevement Is An Indicator Of Malignancy Reported Incidence Is 2-25%, Rationale For Surgery HIGHLY AGGRESSIVE RADICAL TOTAL PAROTIDECTOMY+ POSTOP RT 10 YR SURVIVAL =30% DR SANOOP ZACHARIAH

“Carcinoma –Ex- Pleomorhic Adenoma” : 

“Carcinoma –Ex- Pleomorhic Adenoma” The epithelial component undergoes malignant transformation The risk for malignant transformation is 1.5% within the first 5 years increases to 9.5% in 15 years DR SANOOP ZACHARIAH

DIAGNOSIS : 

DIAGNOSIS MAINLY CLINICAL IMAGING FNAC? DR SANOOP ZACHARIAH

IMAGING : 

IMAGING USG- GOOD-CONFIRMS A PAROTID,RULE OUT A VASCULAR NEOPLASM CT MRI EXACT ANATOMIC DETAILS AND RELATION TO ADJACENT STRUCTRES-CT/MRI DR SANOOP ZACHARIAH

TISSUE DIAGNOSIS : 

TISSUE DIAGNOSIS OPEN SURGICAL BIOPSY SHOULD NEVER BE PERFORMED OPEN BIOPSY =ABSOLUTELY CONTRAINDICATED WHY ? TENSE TUMOUR WITHIN A THIN COVER INCISION WILL CAUSE TUMOUR TO BURST MICROSCOPIC SEEDING OF BENIGN CELLS -CAUSE MULTIPLE LOCAL RECURRANCE “THIS CAN BE TREATED ONLY THEN BY RADICAL POST OP RADIOTHERAPY” DR SANOOP ZACHARIAH

WHAT ABOUT FNAC? : 

WHAT ABOUT FNAC? FNAC CAN BE SAFELY PERFORMED- 95% SENSITIVE STUDIES SHOW THAT NEEDLES SMALLER THAN 18 G DO NOT CAUSE TUMOUR SEEDING RISK OF FACIAL NERVE INJURY? DR SANOOP ZACHARIAH

TREATMENT : 

TREATMENT “THIS TUMOUR IS RADIORESISTANT” THEREFORE=SURGERY IS RX OF CHOICE WHICH SURGERY? ENUCLEATION? WIDE EXCISION? SUPERFICIAL PAROTIDECTOMY? TOTAL PAROTIDECTOMY? DR SANOOP ZACHARIAH

ENUCLEATION/WIDE EXCISION : 

ENUCLEATION/WIDE EXCISION NOT RECOMMENDED AS IT DOES NOT COMPLETELY REMOVE TUMOUR EXTENSIONS BEOUND THE CAPSULE RECURRENCE RATE=30-50%=UNACCEPTABLE DR SANOOP ZACHARIAH

TREATMENT OF CHOICE : 

TREATMENT OF CHOICE ADENOMA IN SUPERFICIAL LOBE=SUPERFICIAL PAROTIDECTOMY ADENOMA IN DEEP LOBE =TOTAL PAROTIDECTOMY DR SANOOP ZACHARIAH

MALIGNANT PAROTID TUMOURS : 

MALIGNANT PAROTID TUMOURS RISK FACTORS RADIATION EXPOSURE RADIOACTIVE SUBSTANCE EXPOSURE HEREDITARY SMOKING CHEMICAL CARCINOGENS-NICKEL ALLOYS INDUSTRIAL-SAW DUST DR SANOOP ZACHARIAH

Slide 39: 

MUCOEPIDERMOID CARCINOMA MOST COMMON MALIGNANT PAROTID TUMOUR LOW GRADE TUMOURS BEHAVE LIKE BENIGN TUMOURS HIGH GRADE HAVE POOR PROGNOSIS. LOCAL INVASION METASTASIS DR SANOOP ZACHARIAH

ADENOID CYSTIC CARCINOMA : 

ADENOID CYSTIC CARCINOMA POORLY ENCAPSULTED TUMOUR AKA=“CYLINDROMA” HIGH AFFINITY FOR PERINEURAL INVASION AND CAN SPREAD TO BRAIN PRODUCES “CANON BALL METS” IN THE LUNGS DR SANOOP ZACHARIAH

SUPERFICIAL PAROTIDECTOMY : 

SUPERFICIAL PAROTIDECTOMY HYPOTENSIVE ANAESTHESIA HEAD UP POSITION INFILTRATION WITH LIGNOCAINE /ADRENALINE 1:80,000 LONG-TERM PARALYTIC AGENTS SHOULD BE AVOIDED TO ALLOW FOR CN VII MONITORING WHEN INDICATED DR SANOOP ZACHARIAH

IDENTIFYING THE FACIAL NERVE : 

IDENTIFYING THE FACIAL NERVE First expose important landmarks Posterior belly of digastric Mastoid process Tympanic bone External auditory canal cartilage DR SANOOP ZACHARIAH

Identifying the facial nerve : 

Identifying the facial nerve Tragal pointer-1.0–1.5 cm deep and slightly anterior and inferior to the tip of the external canal cartilage (also called ‘pointer’) The nerve bisects the angle made by the digastric and tympanic plate 1.0 cm deep to attachment of the posterior belly of the digastric muscle to the digastric groove of the mastoid bone The CN VII lies 6–8 mm distal to the end point of the tympano mastoid fissure Nerve stimulators Magnifying loops DR SANOOP ZACHARIAH

TOTAL PAROTIDECTOMY : 

TOTAL PAROTIDECTOMY NERVE PRESERVING TOTAL PAROTIDECTOMY NERVE SACRFICING TOTAL PPAROTIDECTOMY(RADICAL) DR SANOOP ZACHARIAH

COMPLICATIONS : 

COMPLICATIONS HAEMORRHAGE- RETROMANDIBULAR VEIN NERVE INJURIES GLAND RUPTURE-TUMOR SEEDING INFECTION DR SANOOP ZACHARIAH

FACIAL NERVE INJURY : 

FACIAL NERVE INJURY Temporary paralysis(NEUROPRAXIA) occurs in 10-30% Permanent paralysis occurs in 1% Facial nerve injury occurs in 10% of S.Parotidectomies Common injury occurs to mandibular branches DR SANOOP ZACHARIAH

NEUROPRAXIA : 

NEUROPRAXIA TEMPRORARY DUE TO TRACTION RECOVERS IN 6 -8 WEEKS NO ACTIVE TREATMENT IS REQUIRED DR SANOOP ZACHARIAH

TRANSECTION OF FACIAL N : 

TRANSECTION OF FACIAL N WITHOUT NERVE TISSUE LOSS IF IDENTIFIED AT SURGERY IMMEDIATE SUTURING WITH 10-0 SILK UNDER MICROSCOPE WITH NERVE TISSUE LOSS OR NERVE DELIBERATLEY RESECTED WITH TUMOUR CABLE GRAFT-USING GREATER AURICULAR NERVE BIO ARTIFICIAL NERVE GRAFTS DR SANOOP ZACHARIAH

SURGERIES FOR ESTABLISHED FACIAL N INJURY : 

SURGERIES FOR ESTABLISHED FACIAL N INJURY REINERVATION OF FACIAL MUSCLES BY “HYPOGLOSSAL N TRANSFER” CROSS FACIAL N GRAFTING VIA “SURAL N AUTOGRAFT” REGIONAL MUSCLE TRANSFER TEMPORALIS MUSCLE TRANSFER UNILATERAL BROW LIFT-TO LIFT THE EYELID EYELID WEIGHTS IMPLANTS DR SANOOP ZACHARIAH

MALIGNANT LYMPHOMA : 

MALIGNANT LYMPHOMA TRUE EXTRANODAL LYMPHOMA= VERY VERY RARE LYMPHOMA USUALLY NODAL=FROM LN WITHIN/AROUND THE GLAND PREDISPOSING FACTORS HIV SJOGRENS SYNDROME BELL=BENIGN LYMPHOEPITHELIAL LESION TYPE NON HODGKINS-(MONOCYTOID B CELL) RX MENT TOTAL PAROTIDECTOMY +/- RT+/- APPROPRIATE CHEMO BASED ON TYPE DR SANOOP ZACHARIAH

Thank you : 

Thank you DR SANOOP ZACHARIAH

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