Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5179_Библиотеки_им_академика_М_И_Перельмана.pdf
374
Manipal Manual of Surgery
MUCOUS CYSTS
• They are examples of retention cyst.
• They occur due to obstruction of the duct of many
mucous secreting glands which cover the inner
surface of the lips and whole of inside of mouth
(Fig. 35.58).
• They are also a type of extravasation cyst.
Clinical Symptoms and Signs
• Painless, slow growing swelling on the inner side of
lip or cheek.
• Most common on the lower lip.
• Typically round, soft, fluctuant, pale pink swelling
or blue domed.
• Transillumination is positive but difficult to
demonstrate as the cysts are small.
• Mucous membrane is free over the swelling.
Differential Diagnosis
• Pyogenic granuloma: It is red in colour, soft and bleeds.
It may be associated with trauma or persistent infection.
• Ectopic salivary gland tumours: They are firm and
non-tender swellings.
Treatment
• Excision can be done under local anaesthesia.
• Once mucous membrane is incised, swelling can be
dissected all around separating it from orbicularis
oris/buccinator muscle and it is removed.
• The mucous membrane is closed with absorbable
sutures.
MISCELLANEOUS
A case of malignant melanoma of the oral cavity
(see the clinical notes)
This 48-year-old man (Figs 35.59 and 35.60) presented
with an innocent looking, painless submandibular lymph
node enlargement. It was firm and nontender. Initially, it
was thought to be due to dental caries. Examination of the
floor of the mouth revealed an interesting melanomatous
lesion. Diagnosis was malignant melanoma with metastasis in nodes. This is just to remind that melanoma can
also occur in the oral cavity (mucosa and firm skin).
Fig. 35.58: Mucous cyst in the floor of the mouth
Section II • General Surgery
Fig. 35.59: This patient presen-
ted with right submandibular
lymph node enlargement
Fig. 35.60: Oral cavity exami-
nation reveals a pigmented
ulcerated lesion
Oral Cavity, Odontomes, Lip and Palate
375
1. Which one of the following has highest chance of
malignancy?
A. Acanthosis B. Dyskeratosis
C. Leukoplakia D. Speckled leukoplakia
2. Drug used to treat leukoplakia is:
A. Vitamin E B. Isonicotinic acid
C
. Isotretinoin D. Niacin
3. Following are true for verrucous carcinoma except:
A. Very slow-growing
B
. Poorly differentiated carcinoma
C. Spread by lymphatics is not common
D. Surgery is the best treatment
4. Carcinoma tongue spreads to following lymph nodes
except:
A. Submandibular B. Submental
C
. Jugulo-omohyoid D. Supraclavicular node
5. Following malignant lesions in the posterior third
of the tongue can occur except:
A. Squamous cell carcinoma
. Adenocarcinoma
B
C. Lymphoepithelioma
D. Sebaceous carcinoma
6. The investigation of choice in oral cancer to find
out the skull base involvement is:
A. CT scan
B
. Angiography
C. MRI
D. Ultrasound
C. Carcinoma floor of the mouth
D. Nasopharyngeal carcinoma
10. Which is the most effective chemotherapeutic drug
for head and neck cancers?
A. Carboplatins B. 5-Fluorouracil
C
. Bleomycin D. Cisplatin
11. Best treatment of carcinoma buccal mucosa—T1 N0
M0 is:
A. Radiotherapy only
. Radiotherapy followed by surgery
B
C. Surgery only
D. Surgery followed by radiotherapy
12. Khaini chewers more susceptible for development
of which carcinoma?
A. Carcinoma lip
B. Cracinoma tongue
C. Carcinoma buccal mucosa
D. Carcinoma floor of the mouth
13. Estlander flap is used to cover:
A. Central defects of lip—lower lip
. Central defects of lip—upper lip
B
C. Lateral defects of more than 50%
D. Lateral defects up to 30%
14. Following are true for precancerous lesions of
lip/oral cavity except:
A. Keratoacanthoma B. Leukoplakia
C. Erythroplakia D. Submucous fibrosis
7. Which cancer in the oral cavity—T1 N0 M0—
requires supraomohyoid block dissection?
A. Carcinoma buccal mucosa
. Verrucous carcinoma lower lip
B
C. Carcinoma upper lip
D. Carcinoma floor of the mouth
8. Following are true for chronic hyperplastic
candidiasis except:
A. Invasion of Candida albicans
. Antifungal treatment helps
B
C. High malignant potential
D. Floor of the mouth is affected
9. Which one of the following conditions has high
incidence of distant spread?
A. Carcinoma buccal mucosa
. Carcinoma tongue
B
15. Following are features of carcinoma maxillary
antrum except:
A. Can cause asymmetry of face
. Can cause proptosis
B
C. Can cause infraorbital nerve paralysis
D. Can cause buccal branch of facial nerve paralysis
16. Following are the boundaries of nasopharyngeal
space except:
A. Nasal fossae
B. Basilar part of occipital bone
C. Body of sphenoid
D. Cribriform plate of ethmoid bone
17. Following are true for nasopharyngeal carcinoma
except:
A. Presents as high anterior cervical lymphadenopathy
. Can present as trigeminal neuralgia
B
Section II • General Surgery
376
Manipal Manual of Surgery
C. Compression of IX and X cranial nerves
D. Can present as ophthalmoplegia
18. Following are painless ulcers in the tongue except:
A. Gummatous ulcers B. Carcinomatous ulcers
. Systemic diseases D. Tuberculous ulcers
C
19. Following are painful ulcers in the tongue except:
A. Gummatous ulcers B. Tuberculous ulcers
. Aphthous ulcers D. Dental ulcers
C
20. Following are true for syphilitic lesions of the
tongue except:
A. Snail track ulcers B. Gumma
. Hutchinson's wart D. Hunterian chancre
C
21. Following are true for dental cyst except:
A. Upper jaw is commonly involved
. It is a large unilocular cyst
B
C. Cyst contains cholesterol crystals
D. Arises from unerupted tooth
22. Which one of the following swellings does not
contain cholesterol crystals?
A. Branchial cyst B. Sebaceous cyst
. Dental cyst D. Hydrocoele
C
23. Following are true for dentigerous cyst except:
A. Upper jaw is commonly involved
B
. Produces egg shell crackling
C. X-ray shows soap bubble appearance
D. Arises from unerupted tooth
24. Adamantinoma of the jaw has following features except:
A. It is a malignant tumour
. It spreads within medullary bone
B
C. It is treated by wide excision
D. Mandible is the most common site
25. Which of the following is unilocular cyst?
A. Adamantinoma B. Dentigerous cysts
C
. Epididymal cyst D. Dental cyst
Answers
1. D 2. C 3. B 4. D 5. D 6. C 7. D 8. D 9. D 10. D
11. C 12. A 13. D 14. A 15. D 16. D 17. A 18. D 19. A 20. D
21. D 22. B 23. A 24. A 25. D
Section II • General Surgery
36
Salivary Glands
Surgical anatomy of the parotid gland
Acute parotitis
Chronic submandibular sialoadenitis
Salivary gland tumours
Summary of malignant salivary gland tumours
Frey’s syndrome—Gustatory sweating
SU21.1: Describe surgical anatomy of the salivary glands,
pathology and clinical presentation of disorders of
salivary glands.
SU21.2: Enumerate the appropriate investigations and
describe the principles of treatment of disorders of
salivary glands.
INTRODUCTION
There are three pairs of salivary glands—parotid, submandibular and sublingual. In addition to these, there
are many (450) minor salivary glands located in the
cheek, mucosa, lips, palate and base of the tongue.
Parotid, the “big brother of 3”, suffers mainly from three
diseases—infection, enlargement and tumour.
Submandibular salivary gland suffers from mainly two
diseases—sialoadenitis and tumours. Other salivary
glands are of minor importance. However, it should be
remembered that the commonest tumour of minor
salivary glands is malignancy.
SURGICAL ANATOMY OF THE PAROTID GLAND
Parotid gland is present on the lateral aspect of the face,
divided by the facial nerve into superficial lobe and deep
lobe. Superficial lobe overlies the masseter and the
mandible. Deep lobe is wedged between the mastoid
process and the styloid process, ramus of the mandible
and medial pterygoid muscle.
Sjögren’s syndrome
Mikulicz disease
Parotid fistula
Surgery for facial nerve palsy
Peripheral nerve repair and transfers
The superficial lobe also receives a duct from the
accessory lobe which is in the region of zygomatic arch/
zygomatic process. The duct of parotid, Stensen’s duct,
2–3 mm in diameter, receives tributaries from
superficial, deep and accessory lobes, passes through
the buccinator muscle and opens in the mucosa of the
cheek opposite the upper 2nd molar tooth. Parotid
gland is covered by a true capsule which is a
condensation of fibrous stroma of the gland and a false
capsule formed by parotid fascia, a part of the deep
cervical fascia.
Facial Nerve
After emerging from stylomastoid foramen, it hooks
around the condyle of mandible, enters the substance
of the parotid and divides into 2 major branches,
zygomaticotemporal
and cervicofacial. Facial
nerve along with retromandibular vein (which
is formed by the union
of superficial temporal
vein and maxillary vein,
formed from branches
of pterygoid plexus
of veins) is present in
this plane. This plane
s called the fascio-
i
venous plane of Patey
(Figs 36.1 and 36.2 and
Fig. 36.1: Two lobes of parotid
gland
377
378
Fig. 36.2: Surgical anatomy of the parotid gland
Manipal Manual of Surgery
Flowchart 36.1). The facial nerve then gives rise to
5 branches which are interconnected like the foot of a
goose, called Pes anserinus. Branches of facial nerve in
the face and the muscles supplied by these nerves are
given in Table 36.1.
Table 36.1 Facial nerve and its branches
Branches of Muscles supplied
facial nerve
1. Temporal → Auricularis anterior and superior portion of
frontalis
2. Zygomatic
Upper → Frontalis and upper half of orbicularis oculi
Lower → Lower half of orbicularis oculi and muscles
below the orbit
3. Buccal → Buccinator, orbicularis oris and a few fibres
of elevators of the lower lip
4. Mandibular → Muscles of the lower lip
5. Cervical → Platysma
Flowchart 36.1: Formation of retromandibular vein and its
branches
ACUTE PAROTITIS
Acute inflammation of the parotid can occur due to
bacterial or nonbacterial causes. It can be unilateral or
bilateral (Key Box 36.1). Three important causes and
their treatment are given below:
Key Box 36.1
Causes of Acute Parotitis
1. Viral : Mumps—commonest
Coxsackie A and B
Parainfluenzae 1 and 3
Echovirus
Lymphocytic choriomeningitis
2. Bacterial : Usually ascending infection
Staphylococcus aureus
3. Recurrent : Recurrent, mistaken for mumps
parotitis of Resolves at puberty
childhood
4. Specific : Mycobacterial, cat-scratch disease,
infections syphilis, toxoplasmosis
5. Allergic : Food and drugs
6. Sexual diseases : HIV-related
7. Postradiation : Reduction in the salivary juice
8. Postoperative : Due to dehydration
Mumps Parotitis
Mumps
1
is an acute generalised viral disease with painful
enlargement of salivary glands, chiefly the parotids. The
virus belongs to Paramyxoviridae family and only one
serotype is known. The disease spreads from a human
reservoir by direct contact, airborne droplets or fomites
contaminated by saliva and possibly by urine.
Clinical Manifestation
• Incubation period is 10–24 days. Fever, headache and
muscular pain are usually found. Both parotids are
enlarged with pain and temperature.
• Swelling starts subsiding by 3–7 days of time.
1
Section II • General Surgery
It causes parotitis, orchitis and pancreatitis.
Treatment
If symptomatic: Maintenance of good oral hygiene and
hydration is useful. Antibiotics may be given to prevent
secondary infection. One episode of infection confers
lifelong immunity.
Acute Bacterial Parotitis
Staphylococcus aureus infection of parotid produces
serious illness with marked engorgement of parotid.
Salivary Glands
379
Typically, it produces parotid abscess. Diabetes, malignancy, malnutrition increase the risk. Decreased salivary
secretion is an important predisposing factor.
Suppuration occurs due to involvement of intraparotid lymph nodes, peri-parotid lymph nodes or due
to involvement of parenchyma of the gland.
Reduction in Salivary Juice
It can occur due to various factors mentioned in the
box. Postoperative parotitis can be prevented by good
mouth care and good oral hygiene. Due to poor oral
hygiene, ascending infection occurs from the oral cavity
resulting in parotitis (Key Box 36.2).
Key Box 36.2
Causes of Salivary Flow
Postoperative
Poor oral hygiene
Dehydration
Enteric fever, septicaemia
Postradiotherapy, for oral cancer
Clinical Features
• A patient who is recovering in the postoperative
period may complain of pain and swelling in the
parotid region. Presence of severe pain with a very
sick, toxic look and high grade fever, chills and rigors
indicates parotid abscess. Diffuse brawny swelling
is characteristic.
• The swelling is due to inflammation of parotid and
since it is enclosed by parotid fascia, the swelling
takes the shape of parotid gland. However, it is not
common for a parotid abscess to raise the ear lobule.
For the reason mentioned above, fluctuation is a
late feature. If the abscess is not drained, it is likely
to rupture into the external auditory canal (Key
Box 36.3).
• The opening of the parotid duct may be inflamed
and on gentle compression of the parotid gland, pus
can be seen coming out of the parotid duct.
Investigations
Complete blood picture: Total count and neutrophils
are elevated.
Blood sugars: Fasting and post-prandial sugar are done
to rule out diabetes.
Ultrasound: It is the investigation of choice. It can
differentiate parotid abscess from cellulitis with brawny
induration. Abscess appear as hypo-anechoic lesions,
with irregular margins.
Treatment
. Conservative line of management
I
• Indicated in a stage of cellulitis with no abscess.
• Maintaining good hydration of the patient in the post-
operative period.
• Improvement in the oral hygiene—mouthwashes
with potassium permanganate (KMnO
) solution.
4
• Appropriate antibiotics against staphylococci, such
as cloxacillin, are administered in the dose of 500 mg,
6th hourly along with metronidazole 400 mg,
8th hourly to treat anaerobic infections.
• It takes about 3–5 days for the inflammation to settle
down.
II. Surgical treatment when there is pus
• Under general anaesthesia, an adequate vertical
incision is made in front of the tragus of the ear up to
deep fascia. Open the deep fascia in two or three
places and drain with blunt haemostat so as to avoid
damage to facial nerve. This is described as Blair’s
method of drainage of parotid abscess. A drainage
tube has to be kept which can be removed after
–4 days (Key Box 36.4).
3
Key Box 36.4
Drainage of Parotid Abscess
Should not wait for fluctuation
High grade fever, and toxicity are indications
Vertical incision
Hilton’s method is preferred to break multiple loculi
Key Box 36.3
Swellings wherein One should not
Wait for Fluctuation
Parotid abscess
Breast abscess
Ischiorectal abscess
Pulp space infection
Any deep-seated abscess
RECURRENT PAROTITIS OF CHILDHOOD
• Children between ages of 3 and 6 years are commonly
affected.
• Aetiology is unknown, may be due to sialectasis
(dilatation of branches of salivary duct).
• Recurrent pain and swelling of one or both parotids
is common.
• Each attack may last for 3 to 7 days.
• It is self-limiting (if the attack is minor).
Section II • General Surgery
380
Manipal Manual of Surgery
• Sialography shows punctate sialectasis, called
snowstorm appearance.
• A short course of antibiotics has to be given to cover
Streptococcus viridans.
• Rarely, superficial parotidectomy may be necessary.
SURGICAL ANATOMY OF THE SUBMANDIBULAR
SALIVARY GLAND (Fig. 36.3)
• Submandibular salivary gland is located in the sub-
mandibular triangle. It lies partly below and partly
above the mandible.
• It is in very close contact with the belly of the digastric
muscle. At surgery, once the deep fascia is opened,
the intermediate tendon of digastric is located and
when it is retracted downwards, mobilisation of the
gland becomes easy.
• Submandibular salivary gland is divided into a
superficial part and a deep part by the mylohyoid
muscle which forms the oral diaphragm. During
excision of the gland, a few fibres of mylohyoid are
also removed. When submandibular salivary gland
enlarges, it is bidigitally palpable because the deep
portion is deep to mylohyoid and it is in the floor of
the mouth.
• Facial artery enters the gland from its posterolateral
surface and deeply grooves the gland. It is ligated at
this place first during excision of the gland. After
grooving the gland, it ascends laterally and curls
around the lower border of mandible to enter the face.
It is ligated at this place also.
• Main duct of submandibular gland, Wharton’s duct
arises from deep part of gland and opens on a papilla
beside the frenulum of the tongue in the oral cavity.
• In a deeper plane, the gland is related to two nerves—
lingual and hypoglossal.
CHRONIC SUBMANDIBULAR SIALOADENITIS
• Obstruction is the most important cause of
submandibular sialoadenitis. Trauma to the floor of
the mouth is another cause.
• Obstruction can be due to stone, disease, stricture of
the duct, or fibrosis of the papilla (calculus—most
common).
• The causative organism is Staphylococcus.
SIALOADENITIS DUE TO CALCULI
• The disease starts with acute bacterial sialoadenitis
which occurs secondary to obstruction. The
submandibular gland has a poor capacity for
recovery following infection. Despite control of
acute symptoms with antibiotics, the gland becomes
chronically inflamed.
• Calculi (80% of them occur in the submandibular
salivary gland) commonly occur in the duct and also
within the gland and produce recurrent sialoadenitis.
Calculi are more common in the submandibular
salivary gland than in the parotid gland because of
the following reasons:
1. Higher mucin content in the submandibular
salivary gland secretions.
2. Calcium and phosphate
content in the secretion
is high. Hence, 80% of
them are radiopaque
and are detected by
X-ray (Fig. 36.4).
plain
3. Nondependent drainage
of the secretions. Gland is
in the neck and opening
of the duct in the oral
cavity.
4. Kinking or hooking of
submandibular duct by
lingual nerve.
Fig. 36.4: Submandibular
calculi in the duct—removed
(intraoral approach)
Section II • General Surgery
Fig. 36.3: Anatomy of the submandibular salivary gland
Clinical Features (Key Box 36.5)
Key Box 36.5
Submandibular Salivary Gland Enlargement
Location—submandibular region
Lobular, firm swelling
Bidigitally palpable
Stone may be palpable within the duct, intraorally
Salivary Glands
• Salivary colic: It is a severe pricking type of pain
which is exaggerated at the time of meals. Salivary
secretions are induced by a meal or lemon (lemon
juice test). As a result of blockage due to a stone, the
tension within the gland increases, resulting in pain.
• Lingual colic: If a calculus is situated within the sub-
mandibular duct where it is hooked by lingual nerve,
the pain can radiate to the tongue as a result of
irritation to the lingual nerve.
• Enlargement of salivary gland during meals is the
characteristic feature of salivary calculus. Classically
submandibular salivary gland swelling is located in
the submandibular region. It is firm in consistency
with a lobular surface. It is tender and both lobes are
enlarged. It is bidigitally palpable (submandibular
lymph node is palpable only in the neck) both inside
the oral cavity and in the neck. The swelling reduces
in size once the stimuli are withdrawn (after meals).
• The stone may be palpable within the gland (in the
neck), within the duct (intraorally), or sometimes it
may be seen at the orifice of the submandibular duct
on the side of lingual frenulum.
• It is not uncommon to get a severe septic sialoadenitis
with gross swelling of the gland and inflammatory
oedema almost like Ludwig’s angina (Fig. 36.5).
Investigations
Ultrasound can easily detect the stone as hypoechoic
areas, enlargement of gland and location of the stone.
More common is stones are located in the distal part of
the duct.
Treatment
• An oblique lateral or posterior oblique occlusal
radiography may demonstrate a stone.
1. Stone in the submandibular duct: This can be
removed by incising the mucosa over the floor of
the mouth, after stabilising the stone. Removal of
the stone is followed by gush of old dirty contents
of the submandibular gland (Fig. 36.6).
381
Fig. 36.5: Submandibular
sialoadenitis
Fig. 36.6: Inflamed opening of
submandibular duct
2. Chronic sialoadenitis: This requires excision of
submandibular salivary gland. Three steps of dissection of the gland include incision, mobilisation
and excision (Manipal Rule of 2—Table 36.2).
• Incision: It should be a skin crease incision over the
lower pole of the gland, the posterior limit of the
incision should be at least 2 cm away from the angle
of the mandible, to avoid damage to the cervical
branch of facial nerve. The incision is deepened till
the deep fascia is opened.
• Mobilisation of the gland: Division of the facial
artery twice, once in a deeper plane on the posterolateral aspect and another at the superolateral aspect
close to the lower border of the mandible is an important step which permits mobilisation of the gland.
Separation of the gland from fibres of mylohyoid
muscle by dividing small arteries completes the
mobilisation (Fig. 36.7).
• Excision of the gland: It is done by ligating and
dividing submandibular duct.
Complications
• Damage to lingual nerve, marginal mandibular nerve
or even to hypoglossal nerve. Seroma and infection
are the other complications.
• Transection of the nerve to mylohyoid muscle
produces anaesthesia of the submental skin.
Table 36.2 Submandibular salivary gland excision—Shenoy’s Manipal rule of 2
• 2 common indications → Stone and as a part of radical neck dissection
• 2" long incision → Curved incision over the swelling
• Protect 2 superficial nerves → Cervical and marginal mandibular branches of facial nerve
• Protect 2 deep nerves → Lingual and hypoglossal nerves
• Ligate facial artery 2 times → First at deeper plane and then at superficial plane
• Divide 2 muscles → Superficial—platysma; Deep—fibres of mylohyoid
• Remove 2 lobes → Superficial and deep lobe
• Incision is 2 cm medial to mandible, 2 cm anterior to angle of → T
the mandible
o protect 2 superficial nerves
Section II • General Surgery
382
Fig. 36.7: Submandibular stone and gland
Manipal Manual of Surgery
SALIVARY GLAND TUMOURS
INTERNATIONAL CLASSIFICATION
I. Epithelial tumours
II.
Nonepithelial tumours.
I. Epithelial Tumours
A.Adenoma
. Pleomorphic adenoma
1
2. Monomorphic adenomas
• Adenolymphoma (Warthin’s tumour)
• Oxyphilic adenoma (oncocytoma)
• Other types
. Mucoepidermoid tumours
B
C. Acinic cell tumour
D.Carcinoma
1. Carcinoma in pleomorphic adenoma
2. Adenoid cystic carcinoma
3. Undifferentiated carcinoma
4. Adenocarcinoma
5. Epidermoid carcinoma
6. Acinic cell tumour
7. Mucoepidermoid carcinoma
8. Malignant mixed tumour
II. Nonepithelial Tumours
1. Lipoma
. Lymphoma
2
3. Neurofibroma
4. Lymphangioma
5. Sarcoma
Salivary gland tumours are not uncommon. There
are dozens of histological types of salivary gland
tumours. However, pleomorphic adenoma and adenolymphoma are the common benign types. Carcinoma
arising in pleomorphic adenoma, mucoepidermoid
tumours and adenoid cystic carcinoma are important
Section II • General Surgery
malignant tumours.
Incidence: 80% of salivary gland tumours are found in
the parotid gland. Out of these, 80% are benign, of which
80% are pleomorphic adenomas.
In the submandibular salivary gland, 50% are benign
and 50% are malignant.
In the minor salivary glands, 90% are malignant.
Thus, the incidence of malignancy increases from major
to minor salivary glands.
PLEOMORPHIC ADENOMA OF PAROTID GLAND
(MIXED TUMOUR)
It is the most common benign salivary gland neoplasm.
Pathology
• Epithelial cells proliferate in strands, or may be
arranged in the form of acini or cords.
• There are also myoepithelial cells which proliferate
in sheets. They are called spindle-shaped cells.
• The tumour produces mucoid material, which
displaces and separates the cells resembling cartilage
in histological section.
Because of the presence of epithelial cells, myoepithelial cells,
mucoid material, pseudocartilage and lymphoid tissue, the
tumour is called pleomorphic adenoma.
• As the tumour grows, it compresses the normal
parotid tissue and the branches of the tumour
penetrate the thin capsule and enter the substance of
the parotid. Simple enucleation will result in a
recurrence. Hence, superficial parotidectomy has to
be done.
Clinical Features
1. Middle-aged women, around 40 years, are commonly
affected (Fig. 36.8A) (female, fifth decade and fullness
near ear lobule).
. Typically, a history of a very slow-growing swelling
2
(for a few years) is usually present.
Fig. 36.8A: Pleomorphic
adenoma—classical signs
Fig. 36.8B: Gross enlargement
of parotid gland of 30 years
duration
Salivary Glands
383
3. The swelling is painless. Any painless swelling near
the ear is best assumed to be parotid gland neoplasm unless proved otherwise (Fig. 36.8B).
Signs (Key Box 36.6)
Key Box 36.6
Clinical Examination of Parotid Tumours
Benign Malignant
Firm Firm/hard
Nodular Irregular/nodular
Not fixed Restricted mobility
(fixity to masseter)
No lymph nodes Lymph nodes palpable
Facial nerve is not Facial nerve paralysis
involved
. Parotid swelling has the following classical features:
1
• It presents as a swelling in front, below and behind
ear.
• Raises ear lobule
(Fig. 36.9)
• Retromandibular
groove is obliterated.
• However, big is the
parotid swelling, the
upper border is confined (limited) to lower
border of zygomatic
process because of the
attachment of parotid
fascia. This is called
curtain sign (Fig. 3
6.9).
Fig. 36.9: Curtain sign.
(Courtesy: Dr Haribabu, Dr
Ramanayya, Dr G.V. Prakash,
SVMC, Tirupathi)
2. It is rubbery or firm. Soft areas indicate necrosis. In
long-standing cases, it can be hard. Surface can be
nodular or sometimes bosselated. Skin is stretched
and shiny. However, being a benign tumour, it is
neither adherent to the skin nor to the masseter
(Fig. 36.10).
3. After a few years, pleomorphic adenoma may
show features of transformation into malignancy
(carcinoma expleomorphic adenoma).
It should be suspected when
• It starts growing rapidly
• Skin infiltration occurs
• Facial nerve paralysis occurs
• Gets fixed to masseter muscle
• Red, dilated veins over the surface
• Presence of lymph nodes in the neck
• Tumour feels stony hard.
Carcinoma ex Pleomorphic Adenoma (Ca ex PA)
• Presents as a firm mass
• Features of infiltration of facial nerve, masseter muscle,
skin or bone may be present
• It occurs due to progressive change: Loss of hetero-
zygosity (LoH) at chromosomal arms 8q, then 12Q and
17Q.
• Mutation of p53—a tumour suppressor gene is also
implicated in the malignant transformations of Ca ex PA.
• In high grade Ca ex PAs, epidermal growth factor
receptor (EGFR) is overexpressed. Thus, it may have a
role in ‘invasive’ Ca ex PAs.
INTRAORAL EXAMINATION (Fig. 36.11)
• Approximately 10% of the parotid tumours are
behind the facial nerve in the deep lobe.
• This is appreciated by intraoral examination wherein
the tumour presents with a parapharyngeal mass
which displaces the tonsil or soft palate medially.
• Deep lobe tumours present as dysphagia. Such
tumours may not show gross swelling on the outer
aspect but as they grow, they pass through the stylo-
Fig. 36.10A: Lateral view. Note
the upper extent limited up to
zygomatic process, described
as curtain sign positive.
Fig. 36.11: Deep lobe tumour.
Importance of intraoral examination
(Courtesy: Dr Sreejayan, Professor,
Department of Surgery, Calicut
Medical College, Calicut, Kerala)
Fig. 36.10B: Lateral view showing
nodular surface
Fig. 36.12: Parotid cyst in a
young boy—It was fluctuant
and transillumination negative. It was a haemangioma
Section II • General Surgery