Copyright Â© 2004 Pearson Education, Inc., publishing as Benjamin ...

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings

Case Presentation 

• A **year-old female was admited for elective superficial 

parotidectomy. 

• Patient presented with a history of an painless, slowlygrowing 

left-sided lateral cheek mass. 


Hx 

• PMHx: HTN 

• PSHx: C-section 20y ago 

• Allergies: NKDA 

• Meds: Norvasc 5mg QD 

• Social Hx: denies smoking, alcohol, denies IVDA 


• A&OX3, anicteric 

• Cardiac: S1/S2 RRR 

• Lungs: CTA B/L 

PE 

• Abdominal exam:soft, NT, ND, +BS, no masses 

• Neurological exam: no focal abnormalities, nystagmus, 

abnormal ocular movements, gait disturbance, or 

peripheral neuropathy 


PE 

• 4 cm × 3 cm firm polinodular mass, not adherent to deep 

and superficial tissues in the left parotid area that 

surrounded the left external auditory canal. 

• No eviedence of facial paralysis. 

• Palpation of the neck was unremarkable. 


Fine Needle Aspiration Cytology 

• (FNAC) showed pleomorphic adenoma of the parotid 

gland 


OR 

•The The patient subsequently underwent 

superficial parotidectomy. 

•POD#1: POD#1: D/C home 


Pathology 

• Pleomorphic adenoma 

of the parotid gland, 

myxoid type: 

abundant myxoid 

ground-substance with 

interspersed spindle 

and stellate cells. 


Copyright © 2004 Pearson Education, Inc., publishing as Benjamin Cummings 

Anatomy

Salivary Gland Tumors (SGTs) 

• Arise from either 

• Major salivary glands 

(parotid, 

submandibular, and 

sublingual) 

pleomorphic adenoma of submandibular gland 

• Minor salivary glands 

which are located 

throughout the 

submucosa of the upper 

aerodigestive tract. 



• Parotid gland (70-85%) 

• submandibular gland (8- 

15%) 

• sublingual gland (


• Arise from either 

• Major salivary glands 

(parotid, submandibular, and 

sublingual) 

• Minor salivary glands which 

are located throughout the 

submucosa of the upper 

aerodigestive tract. 

pleomorphic adenoma of 

submandibular gland 


• 15-25% of all parotid tumors 

Malignancy % 

• 37-43 %f submandibular gland tumors 

• >80 % of the minor salivary gland tumors 

• As a general rule, the smaller the 

salivary gland in adults, 

the higher the probability that a 

neoplasm arising in such a 

gland is malignant 

• Spiro RH (Salivary neoplasms: 

overview of a 35-year experience with 

2,807 patients)Head Neck Surg 1986 

;8(3):177-84. 


Figure 11.11




Statistics 

• 3-6% of all head and 

neck neoplasms 

• Incidence of 1-3 per 

100,000 people per 

year 


Age 

• The mean age at 

presentation 

• Ca 55 – 65y 

• benign lesions (a 

decade earlier, 45 y) 


Risk Factors for Carcinogenesis 

• not well understood 

• Radiation exposure 

• EBV 

• Environmental : 

• silica dust 

• Kerosene 


• Genetic (inactivation 

of the tumor 

suppressor gene 

p16INK4A) 

• Dietary:reduced 

intake of fruits and 

vegetables

Risk Factors for Carcinogenesis 

• Incidence of salivary gland 

tumors was studied in a 

cohort of 2945 individuals 

who were irradiated between 

1939 and 1962 (during 

childhood) for tonsillitis, 

acne, or chronic ear disease. 

• 3% developed salivary gland 

neoplasms, 

• 90 % in parotid glands. 

• Mucoepidermoid carcinomas 

MC malignancy 

• Mixed (pleomorphic) 

adenomas MC benign 

neoplasm 


•Schneider AB etal(Salivary gland 

tumors after childhood radiation 

treatment for benign conditions of 

the head and neck: dose-response 

relationships)Radiat Res 1998 

Jun;149(6):625-30.

Smoking & Alcohol 

• In comparison to other head and neck cancers, 

exposure to tobacco smoke and excess alcohol 

intake have not been associated with malignant 

SGTs 

• Muscat JE; Wynder EL, Otolaryngol Head Neck Surg 1998 

Feb;118(2):195-8. 

• However, the benign Warthin's tumor occurs in 

smokers > nonsmokers 

• Yoo GH; etal(Warthin's tumor: a 40-year experience at The 

Johns Hopkins Hospital)Laryngoscope 1994 Jul;104(7):799- 

803. 


Relation to Breast Ca 

• Women who developed SGTs before age 35 had 

a elevation in breast cancer risk compared to 

women without a history of SGT (relative risk 

3.30); (not statistically significant) 

• Possible hormonal contribution to SGT risk 

• Early menarche (odds ratio [OR] = 4.1) and 

nulliparity (OR = 2.6) were associated with 

increased risk of SGT 

• Sun EC; etal(Salivary gland cancer in the United 

States_Cancer Epidemiol Biomarkers Prev 1999 

Dec;8(12):1095-100 


CLINICAL MANIFESTATIONS 

• Most present with a 

solitary, discrete, slowly 

growing, and 

asymptomatic mass. 

• With deep lobe tumors, 

the mass may be poorly 

defined 

• Inspection of the scalp, 

neck, and skin may 

reveal cutaneous 

malignancies that can 

metastasize to Parotid 



• A careful H&P 

• Thorough oral 

examination is an 

essential first step 



• Inspection of the 

parapharyngeal 

area and tonsillar 

fossae is 

necessary to 

determine 

possible 

extension or 

tumor origin in 

the deep lobe of 

the parotid gland 


Facial nerve 

• Facial nerve paralysis or paresis 

associated with a parotid mass is 

almost always associated with 

malignant tumors. 

• Two notable exceptions : 

• sarcoid infiltration of the 

parotid gland with facial 

paralysis(Heerfordt's 

syndrome) 

• Intraparotid facial nerve 

schwannoma 



Location of facial nerve schwannomas (n = 29) 

•Most facial nerve schwannomas 

present in the intratemporal 

rather than the intraparotid 

portion of the nerve. 

IC, Intracranial; IT, intratemporal; IP, intraparotid 



Axial and coronal CT demonstrating extension of tumor into 


temporal bone.

Hematoma of Parotid 

• This elderly patient who was on 

anticoagulants fell down and hit 

his left face on the edge of a 

table. 

• The ecchymotic spot behind the 

ear mimicked Battle's sign, 

however there was no evidence 

of temporal bone fracture by 

otoscopy. The ear canals and 

tympanic membranes were 

normal. 

There were no fractures on CT, 

but a heterogenous swelling of 

the left parotid gland was evident 



Hematoma of Parotid

Tumors of the Accessory Lobe of the Parotid Gland 

• The evaluation of a 

midcheek mass can be 

extremely challenging. 

• Accessory parotid gland 

tissue has been described 

as salivary tissue adjacent 

to Stenson’s duct that is 

distinctly separate from 

the main body of the 

parotid gland 

•Lin, Derrick T. etal(Tumors of the Accessory Lobe of the Parotid Gland: 

A 10-Year Experience) Laryngoscope. 114(9):1652-1655, 1655, September 2004 


Tumors of the Accessory Lobe of the Parotid Gland 


Mumps 

• Mumps virus 

• Enters through 

respiratory tract 

• Infects parotid 

glands 

• Prevented with 

MMR vaccine 


Figure 25.14

• Hemangiomas 

represent one of the 

most common 

childhood neoplasms. 

• Often managed 

conservatively, 

requiring numerous 

years for spontaneous 

involution. 

Parotid Hemangioma 



• No effective medical 

treatment has been 

reported for children 

with large, deforming 

hemangiomas of the 

parotid gland and 

overlying cheek. 


(Steroids??) 

• Accelerated regression 

with corticosteroid 

therapy. 

• 3M old male patient 

before treatment. Then 

at age 9 months, 

during final month of 

corticosteroid taper. 




(Interferone) 

• Accelerated regression of with 

interferon therapy. 

• 3M old female patient, 

corticosteroid given for bilateral 

cervicofacial hemangioma failed, 

causing congestive heart failure, 

auricular destruction, and 

respiratory compromise 

requiring tracheostomy. (Right) 

• Then at age 11 months, after 

completion of 7 months of drug 

treatment. 


• 17 children underwent 

surgical resection of 

parotid hemangiomas at 

Childrens Hospital Los 

Angeles from 1997-2003. 

• All 17 patients had 

improvements in facial 

asymmetry and 

deformity. 


• There were no major 

complications. 

Reinisch, John F. etal(Surgical Management of Parotid Hemangioma. 

Plastic & Reconstructive Surgery. 113(7):1940-1948, June 2004. 



• Surgical resection of 

parotid hemangiomas 

provides an aesthetic 

benefit to young children 

with low associated 

morbidity. 

• Early resection by an 

experienced surgeon 

should be considered as a 

treatment option for these 

disfiguring lesions. 

Reinisch, John F. etal(Surgical Management of Parotid Hemangioma. 

Plastic & Reconstructive Surgery. 113(7):1940-1948, June 2004. 


Fine Needle Aspiration (FNA) 

• simple procedure 

• identify nonneoplastic 

causes of parotid 

enlargement and, if 

malignancy is confirmed, 

help prepare the surgeon 

for a potentially more 

radical operation 

• Depends on operator 

experience and the 

interpretative skills of the 

cytopathologist 

• overall sensitivity 87-94% 

• overall specificity 75- 

100% 



Figure 1: Direct smear of the left 

parotid tumor aspirate showing 

neoplastic myoepithelial cells 

with abundant clear cytoplasm 

(H&E, x200). 

Figure 2: Direct smear of the left 

parotid tumor aspirate showing 

anastomosing tubules amongst a 

background of clear 

myoepithelial cells (H&E, x200). 



Roland et al. (1993) 

Atula et al. (1996) 

Cristallini et al. (1997) 

Sensitivity%(%) 

91 

70 

98 

Specificity% 

100 

92 

98 

Cajulis et al. (1997) 

Al-Khafaji et al. (1998) 

91 

82 

96 

86 

Stewart et al.(1999) 

92 

100 

Stewart CJ; etal 

(FNA cytology of salivary gland: a review of 341 cases)Diagn Cytopathol 2000 


• Imaging of a superficial, 

mobile parotid is unlikely to 

change the overall surgical 

approach. 

• situations that may warrant 

special therapeutic 

consideration: 

• Tumors of the deep 

parotid lobe 

• Tumors which extend into 

the parapharyngeal space 

• Recurrent tumors 

• Direct facial nerve 

invasion, skin 

involvement, or bone 

extension 

• Presence of cervical 

lymphadenopathy 


Radiologic imaging



Sensitivity and specificity of CT & MRI according 

to surgery 




Surgical Options 


Benign Tumors 

• Superficial or total parotidectomy, 

depending upon the location and 

extent of the tumor 

• Although wide resection margins 

are not usually necessary when 

dealing with benign lesions, simple 

enucleation is not recommended 

because of a high incidence of local 

recurrence 

• a complete superficial 

parotidectomy may not be 

necessary if a small tumor can be 

resected with a limited cuff of 

normal tissue. 

• Facial nerve should never be 

sacrificed during parotidectomy for 

benign lesions


• 68 year-old woman presented 

with a painless, slowlygrowing, 

cystic mass in the 

tail of her left parotid. 

• Histologic examination 

revealed a benign cyst. 

• Cysts of the parotid gland are 

not uncommon. 

• 2 to 5 % of all parotid gland 

lesions and can appear at any 

age. 

Benign Tumors 



Malignant Tumors 

• Surgical excision is the 

primary treatment 

modality in almost every 

case. 

• Wide surgical margins of 

normal, uninvolved tissue 

are required and may 

include skin , muscle, and 

mandibular or temporal 

bone. 



• Low-grade T1 and T2 tumors: 

superficial or total 

parotidectomy with 

conservation of the facial 

nerve 

• High-grade lesions are treated 

with total parotidectomy with 

preservation of the facial 

nerve if a plane between the 

tumor and the nerve can be 

identified and if the nerve was 

functionally intact prior to 

surgery 

Malignant Tumors 


Facial nerve 

• If intact preoperatively, it 

should be spared even in 

cases involving high 

grade malignancy 

• If involved 

preoperatively, it should 

be resected and 

immediate reconstruction. 


Lymph node sampling 

• Routinely performed 

from level II of the 

jugular chain 

• Positive sampling on 

frozen section should 

then be followed by a 

MRND 

• Tumors with extension 

to bone may require 

lateral or subtotal 

temporal bone 

resection or 

mandibulectomy 


• The standard Blair 

incision or the 

cosmetically superior 

face lift incision can be 

used. 

Parotidectomy 


Parotidectomy 

• Branches of the facial nerve 

course between the 

superficial and deep lobes of 

the parotid. 

• The main trunk of the facial 

nerve Controversial: 

• 8 mm deep to the 

tympanomastoid suture 

line and at the same level 

as the digastric muscle. 

• > 1 cm deep to end slightly 

inferior to the tragal 

pointer 


The nerve is then dissected 

anteriorly, separating it from 

the substance of the parotid. 



Tumor Location in relation to branches of the facial nerve 

Proximity to the upper division of n. VII 

Proximity to the lowr division of n. VIIe 

Proximity to both the upper and lower divisions of n. VII 

Branches of n. VII in close proximity with tumour capsule 

3 

39 

17 

3 

Papadogeorgakis N, J 

Craniomaxillofac Surg. 

2004 Dec;32(6):350-3. 


Types of surgical technique 

Papadogeorgakis N, 

J Craniomaxillofac 

Surg. 2004 

Dec;32(6):350-3. 

Surgical technique 

Superficial 

parotidectomy 

Partial superficial 

parotidectomy 

‘Enforced’ 

enucleation 

No. of 

patient 

s 

17 

42 

3 


Frey L. Le syndrome 

-Frey L. Le syndrome du nerf auriculo-temporal. 

Rev Neurol 1923;II:97–104 

-Injury to auriculotemporal N. 

-Post op gustatory sweating 

-Cross reinnervation with branches of 

symp supply to skin 



Post Operative scar 

• 24 Hour, 5, 9 & 14 Day Post-Op Photo's 

• swelling at 14 days post-op. 

op. 

• Scar at 1 Year Post-op. 

op. 


• After total 

parotidectomy, the 

resulting 

retromandibular 

depression is 

improved by using 

the rotation 

advancement falp., 

incorporating a vicryl 

mesh to augment 

the parotid bed. 

Wound Closure 

Honig JF. 

J Craniofac Surg. 2004 Sep;15(5):797-803. 


Wound Closure 

Honig JF. 

J Craniofac Surg. 2004 Sep;15(5):797-803. 


RTX 

• Postoperative RTX for malignant 

neoplasms in the following 

circumstances: 

• Deep lobe parotid tumors 

• Gross or microscopic 

residual disease 

• Close or positive histologic 

surgical margins 

• High-grade malignancy 

• Recurrent malignancy 

• Bone or connective tissue 

involvement 

• Metastatic regional cervical 

lymph nodes 

• Perineural involvement 

• Intraoperative tumor spillage 


Adjuvant RTX 

• M. Therkildsen, etal( Salivary gland carcinomas—Prognostic 

factors) Acta Oncol 37 (1998) 


Locoregional control for patients with microscopic positive margins treated with 

surgery alone versus surgery with postoperative RTX 

Silverman: Laryngoscope, Volume 114(7).July 2004.1194-1199 


Locoregional control for patients with microscopic positive margins treated with 

surgery alone versus surgery with postoperative RTX 

Silverman: Laryngoscope, Volume 114(7).July 2004.1194-1199 




Disease-specific survival rates in patients with (+) and without (-) distant metastasis (DM) 

Sung, M.-W. et al. Arch Otolaryngol Head Neck Surg 2003;129:1193-1197. 

Copyright restrictions may apply. 


Survival rates after the appearance of distant metastasis (DM) according to the metastatic 

sites 

Sung, M.-W. et al. Arch Otolaryngol Head Neck Surg 2003;129:1193-1197. 

Copyright restrictions may apply. 


• (A good surgeon must have the eyes of an eagle, a 

lion's heart and the hands of a lady) 

D r L. Willoughby, 1935

Copyright Â© 2004 Pearson Education, Inc., publishing as Benjamin ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?