A CASE PRESENTATION OF pleomorphic adenoma

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A CASE PRESENTATION OF LEFT PAROTID SWELLING:

A CASE PRESENTATION OF LEFT PAROTID SWELLING Neeraj Kumar Jain Pg Surgery

Case presentation R.No.78824:

Case presentation R.No.78824 A 50 year old Hindu married female admitted in surgery ward on 01/ sept /2012 with complaints of: Swelling in left side of Face for 6 years.

H/O PRESENTING ILLNESS :

H/O PRESENTING ILLNESS She was alright 6 years back then she noticed swelling on left side of face ,which was intially small, gradually it has increased in size to present size .No aggravating and relieving factors.

Past history : :

Past history : No history of any long illness in the past.

Family history::

Family history: She is married having 8 children, She had Attended Menopause 5 years back. No history of any similar problem in family. No history of any long illness in the family.

Personal history:

Personal history She is vegetarian. No history of any addiction. Post Menstrual history normal. Bowel and bladder habits normal DRUG HISTORY No history of drug allergy.

GENERAL EXAMINATION:

GENERAL EXAMINATION General condition fair Temp not raised Vitals stable Pallor , icterus ,cyanosis absent. Odema , lymphadenopathy absent

Local examination:

Local examination Swelling present on left side of face . Nodular swelling ,nearly 15cm * 10cm in size. Extending from 8 cm away from left nasolabial fold to post auricular region for 5 cm involving pre auricular region (tragus) , zygomatic arch to base of mandible. Nodular ,firm in consistency ,temperature not raised, tenderness present, skin over the swelling normal. Rest of skin is normal.

PROBABLE DIAGNOSIS:

PROBABLE DIAGNOSIS Parotid gland tumour

Haematological investigations:

Haematological investigations Hb - 11.9 g/dl TLC- 7730/ cumm DLC- N-55 L-33 E-05 M-06 B-Positive

Other investigations :

Other investigations Urine examination-NAD RBS-111.0mg/dl CREATININE-0.5mg/dl UREA-22.2mg/dl HIV & HBSAg -NR

USG FINDINGS:

USG FINDINGS There is large heterogeneous hypoechoic lesion 4.5*4.5cm. Mass lesion seen in left parotid area.

FNAC CYTO NO.1115/12:

FNAC CYTO NO.1115/12 Smears are cellular and shows epithelial cell clusters along with fibromyxoid stroma.Cells are plasmacytoid to ovoid in shape with some cells showing anisokaryosis ,scanty cytoplasm , nuclear moulding . Also seen are muciphages and mucious material in the background. IMPRESSION-Overall features are of PLEOMORPHIC ADENOMA

CT SCAN NECK:

CT SCAN NECK

CT SCAN NECK:

CT SCAN NECK OBSERVATION- A large heterogeneous lobulated mass is seen in left parotid region. It is 66*45 mm in size. Medially it is extending to insertion of sternocleidomastoid muscle & carotid sheath. Mass shows large hypodense area in the centre (necrosis) and calcific foci. Mass effect is seen on left submadibular gland , which is pushed medially. IMPRESSION- LARGE NEOPLASTIC MASS IN LEFT PAROTID REGION

OPERATIVE DETAILS:

OPERATIVE DETAILS

SUPERFICIAL PAROTIDECTOMY:

SUPERFICIAL PAROTIDECTOMY Superfecial Parotidectomy was done was performed on 1 OCT 2012, and specimen send for histopathology. Follow up after 10 days.

OPERATIVE DETAILS:

OPERATIVE DETAILS

The skin flap is developed in an anterior direction by cautery:

The skin flap is developed in an anterior direction by cautery

Posterior undermining of the incision in the cervical region facilitates access to the anterior border of the sternomastoid muscle :

Posterior undermining of the incision in the cervical region facilitates access to the anterior border of the sternomastoid muscle

2nd post op day picture:

2 nd post op day picture

Pre op and post op pictures:

Pre op and post op pictures

Postoperative complication:

Postoperative complication Facial nerve weakness. Facial numbness Flap necrosis.

Gross appearance:

Gross appearance

POST OPERATIVE TEMPARARY FACIAL PALASY:

POST OPERATIVE TEMPARARY FACIAL PALASY

Post operative pictures:

Post operative pictures

HISTOPATHOLOGY:

HISTOPATHOLOGY

PowerPoint Presentation:

GROSS

CROSS SECTION:

CROSS SECTION

PowerPoint Presentation:

Low Power view (10X)

PowerPoint Presentation:

Low Power view (10X)

PowerPoint Presentation:

Low power view (10X)

PowerPoint Presentation:

High Power view (40X)

PowerPoint Presentation:

Low Power view (10X)

PowerPoint Presentation:

High Power view (10X)

PowerPoint Presentation:

PLEOMORPHIC ADENOMA

PowerPoint Presentation:

THANKING YOU

Pleomorphic adenoma :

Pleomorphic adenoma Pleomorphic adenoma is a common benign salivary gland neoplasm characterised by neoplastic proliferation of parenchymatous glandular cells along with myoepithelial components, having a malignant potentiality. It is the most common type of salivary gland tumour and the most common tumour of the parotid gland. It derives its name from the architectural pleomorphism (variable appearance) seen by light microscopy. It is also known as "Mixed tumour, salivary gland type", which describes its pleomorphic appearance as opposed to its dual origin from epithelial and myoepithelial elements.

SUPERFICIAL PAROTIDECTOMY:

SUPERFICIAL PAROTIDECTOMY Lazy “s” incision given periauricular -mastoid-cervical incision given. The skin flap is developed in an anterior direction by cautery . The plane of dissection is well below the hair follicles, just above the parotid fascia. The skin flap is developed forwards to the anterior border of the gland. Posterior undermining of the incision in the cervical region facilitates access to the anterior border of the sternomastoid muscle

PowerPoint Presentation:

This phase of the dissection aims to free the posterior margin of the gland, allowing identification of the facial nerve. Clips are applied along the fascia overlying the sternomastoid muscle, with the assistant applying traction anteriorly . By sharp dissection along the anterior border of the sternomastoid , an avascular plane is developed , which requires elective transection of the great auricular nerve. At the lower end of the dissection the external jugular vein is often encountered and ligated . The gland is gradually mobilised by sharp dissection up to and on to the anterior aspect of the mastoid process, identifying the posterior belly of the digastric muscle. A second avascular plane is developed along the anterior border of the cartilaginous and bony external auditory meatus immediately anterior to the tragus. The two avascular planes are then connected by blunt and sharp dissection. By developing two broad avascular planes, identification of the facial nerve trunk is facilitated .

PowerPoint Presentation:

A facial nerve stimulator is optional but helpful. Landmarks commonly used to aid identification of the trunk of the facial nerve are: 1 The inferior portion of the cartilaginous canal. This is termed Conley’s pointer and indicates the position of the facial nerve, which lies 1 cm deep and inferior to its tip. 2 The upper border of the posterior belly of the digastric muscle. Identification of this muscle not only mobilises the parotid gland, but also exposes an area immediately superior, in which the facial nerve is usually located.

Location of the facial nerve trunk :

Location of the facial nerve trunk Once the facial nerve trunk is identified, gentle traction anteriorly facilitates further mobilisation. Control of haemorrhage at this stage is vital as bleeding, no matter how minor, significantly impedes visibility for the surgeon. Haemostasis can be achieved with bipolar diathermy, although caution is necessary particularly when the facial nerve is approached. Damage to the stylomastoid artery, which lies immediately lateral to the nerve, can result in troublesome bleeding immediately prior to identification. Pledget swabs soaked in adrenaline are sometimes helpful in reducing the ooze associated with this phase of the dissection.

Dissection of the gland off the facial nerve :

Dissection of the gland off the facial nerve Once the facial nerve trunk is identified, further exposure of the branch of the facial nerve can be achieved by scissors dissectionin the perineural plane immediately above the nerve. The tunnel thus created is then laid open, and divisions and branches of the facial nerve are followed to the periphery in a sequential manner, usually beginning with the upper division. The upper division divides into a temporal and a zygomatic branch, and the lower division into mandibular and cervical branches. In this way, the superficial lobe and its associated tumour are mobilised in a superior to inferior direction The upper division of the nerve is frequently tortuous in its course and can be damaged unless great care is taken during perineural dissection. It is often not necessary to dissect all branches of the facial nerve completely, as adequate tumour clearance can be achieved with a more conservative resection of the superficial lobe. When a branch of the facial nerve is adherent to the tumour or running through the tumour, it may require elective division. With the exception of the buccal branch, the transected nerve should be repaired immediately with a cable graft, harvested from the great auricular nerve

CLOSURE :

CLOSURE The patient is placed into a Trendelenburg position to identify any residual bleeding vessels. A suction drain is applied for a period of 24–48 hours, and the wound closed in layers.

Complications of parotid gland surgery :

Complications of parotid gland surgery Complications of parotid gland surgery include: HAEMATOMA FORMATION; INFECTION; TEMPORARY FACIAL NERVE WEAKNESS; TRANSECTION OF THE FACIAL NERVE AND PERMANENT FACIAL WEAKNESS; SIALOCELE; FACIAL NUMBNESS; PERMANENT NUMBNESS OF THE EAR LOBE ASSOCIATED WITH GREAT AURICULAR NERVE TRANSECTION; FREY’S SYNDROME

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