Copyright © 2004 Pearson Education, Inc., publishing as ... · Title: Microsoft PowerPoint - Parotidpre.ppt Author: sasha Created Date: 2/23/2005 11:25:00 PM

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


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

• Patient presented with a history of an painless, slowly-growing left-sided lateral cheek mass.

Case Presentation


Hx

• PMHx: HTN• PSHx: C-section 20y ago• Allergies: NKDA• Meds: Norvasc 5mg QD• Social Hx: denies smoking, alcohol, denies IVDA


PE

• A&OX3, anicteric

• Cardiac: S1/S2 RRR

• Lungs: CTA B/L

• 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 patient subsequently underwent The patient subsequently underwent superficial superficial parotidectomyparotidectomy..

POD#1: D/C homePOD#1: D/C home


Pathology

• Pleomorphic adenoma of the parotid gland, myxoid type: abundant myxoidground-substance with interspersed spindle and stellate cells.


Anatomy


Salivary Gland Tumors (SGTs)• 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


Salivary Gland Tumors (SGTs)

• Parotid gland (70-85%)• submandibular gland (8-

15%) • sublingual gland (<1%)• Minor salivary glands,

which are most densely concentrated in the hard palate (5-8 %)


Salivary Gland Tumors (SGTs)

• 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


Malignancy %

Figure 11.11

• 15-25% of all parotid tumors • 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.





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 Schneider AB etal(Salivaryetal(Salivary gland gland tumors after childhood radiation tumors after childhood radiation treatment for benign conditions of treatment for benign conditions of the head and neck: dosethe head and neck: dose--response response relationships)Radiatrelationships)Radiat ResRes 1998 1998 Jun;149(6):625Jun;149(6):625--30. 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 parapharyngealarea and tonsillarfossae 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'ssyndrome)

• Intraparotid facial nerve schwannoma



Location of facial nerve schwannomas (n = 29)

Most facial nerve Most facial nerve schwannomasschwannomaspresent in the present in the intratemporalintratemporalrather than the rather than the intraparotidintraparotidportion of the nerveportion 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. Lin, Derrick T. etal(Tumorsetal(Tumors of the Accessory Lobe of the Parotid Gland: of the Accessory Lobe of the Parotid Gland: A 10A 10--Year Experience) Year Experience) Laryngoscope. 114(9):1652Laryngoscope. 114(9):1652--1655, September 20041655, September 2004


Tumors of the Accessory Lobe of the Parotid Gland


Mumps

Figure 25.14

• Mumps virus• Enters through

respiratory tract• Infects parotid

glands• Prevented with

MMR vaccine


Parotid Hemangioma

• Hemangiomasrepresent 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.


Parotid Hemangioma

• Accelerated regression with corticosteroid therapy.

• 3M old male patient before treatment. Then at age 9 months, during final month of corticosteroid taper.

(Steroids??)(Steroids??)


Parotid Hemangioma

(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.


Parotid Hemangioma

• 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.


Parotid Hemangioma

• Surgical resection of parotid hemangiomasprovides 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 nonneoplasticcauses 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).



10092Stewart et al.(1999)

8682Al-Khafaji et al. (1998)

9691Cajulis et al. (1997)

9898Cristallini et al. (1997)

9270Atula et al. (1996)

10091Roland et al. (1993) Specificity%Sensitivity%(%)

Stewart CJ; etal(FNA cytology of salivary gland: a review of 341 cases)Diagn Cytopathol 2000


Radiologic imaging• 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




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


Surgical Options

Benign Tumors

• 68 year-old woman presented with a painless, slowly-growing, 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.


Surgical Options

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.


Surgical Options

Malignant Tumors

• 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


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


Parotidectomy

• The standard Blair incision or the cosmetically superior face lift incision can be used.


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 tragalpointer


The nerve is then dissected anteriorly, separating it from the substance of the parotid.



Tumor Location in relation to branches of the facial nerve

3Branches of n. VII in close proximity with tumour capsule

17Proximity to both the upper and lower divisions of n. VII

39Proximity to the lowr division of n. VIIe

3Proximity to the upper division of n. VII

Papadogeorgakis N, J Craniomaxillofac Surg. 2004 Dec;32(6):350-3.


Types of surgical technique

Papadogeorgakis N, J CraniomaxillofacSurg. 2004 Dec;32(6):350-3.

3‘Enforced’enucleation

42Partial superficial parotidectomy

17Superficial parotidectomy

No. of patients

Surgical technique


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 scarPost Operative scar

24 Hour, 5, 9 & 14 Day Post24 Hour, 5, 9 & 14 Day Post--Op Photo's Op Photo's

swelling at 14 days postswelling at 14 days post--op. op.

Scar at 1 Year PostScar at 1 Year Post--op. op.


Wound Closure

• After total parotidectomy, the resulting retromandibulardepression is improved by using the rotation advancement falp., incorporating a vicrylmesh to augment the parotid bed.

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


Locoregional control for patients with microscopic positive margins treated with surgery alone versus surgery with postoperative RTXSilverman: Laryngoscope, Volume 114(7).July 2004.1194-1199



Copyright © 2004 Pearson Education, Inc., publishing as Benjamin CummingsCopyright restrictions may apply.

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

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

Copyright © 2004 Pearson Education, Inc., publishing as Benjamin CummingsCopyright restrictions may apply.

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

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


• (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

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Copyright © 2004 Pearson Education, Inc., publishing as ... · Title: Microsoft PowerPoint - Parotidpre.ppt Author: sasha Created Date: 2/23/2005 11:25:00 PM