Salivary Gland Important Question And Answers

Salivary Gland

Question.1. Describe surgical anatomy of parotid gland. Describe signs, symptoms and management of pleomorphic adenoma of parotid gland.

Answer. Parotid gland is a major salivary gland.

Surgical anatomy of Parotid Gland

• Parotid gland lies beneath the skin, in front and below the ear.
• Parotid gland is contained in the investing layer of the deep fascia of the neck which is known as parotid fascia.
• Parotid gland is separated from submandibular gland by a fascial thickening known as stylomandibular ligament.
• Parotid space is occupied by the parotid gland.
• From anterolateral edge of the gland, parotid duct or Stensen’s duct passes lateral to the masseter muscle.
• Parotid duct turns medial at the anterior margin of the muscle, where it is related to the buccal fat pad or “boule de Bichat”.
• Location of buccal pad is medial to the parotid duct, between the masseter and buccinator muscles.
• Stenson’s duct pierces the buccinator muscle and enters the oral cavity at the level of the upper second molar tooth.
• At times accessory parotid tissue may extend along the stenson’s duct. A short accessory duct may enter the main duct.

Read And Learn More: General Surgery Question And Answers

Parotid gland Parotid Fascia

• Parotid fascia is mainly the splitting of general investing layer which envelops both parotid and submandibular glands forming the superficial and deep layers.
• Superficial layer is dense and tough while the deep layer is thin and weak.
• Stylomandibular ligament which lies between the styloid process and the angle of the mandible is derived from the deep layer.
• The ligament is tough and separates the parotid from the submandibular gland.
• Communication of parotid space is medial with the lateral pharyngeal space and with the posterior area of the masticator space.
• Posterior area of the masticator space consists of masseter muscle, pterygoid muscles, the small pterygomandibular space and the space of the body of the mandible.
• As many intraparotid anatomic structures radiate from parotid gland, surgeon should be familiar with all those structures, especially those which should not be sacrified.

Bed of the Parotid Gland

Complete removal of the parotid gland reveals the following structures:

• Internal jugular vein, i.e. one vein
• Carotis externa artery and carotid interna artery, i.e. two arteries
• IX, X, XI, and XII cranial nerves, i.e. four nerves

Parotid gland Signs and Symptoms (Clinical Features)

• Middle aged women around 40 years are commonly affected.
• Swelling is painless.
• Parotid swelling has following classical features:

• It present as a swelling in front, below, and behind the ear.
• Raises ear lobule.
• Retromandibular groove is obliterated.

• It is rubbery or fim
• Soft area indicates necrosis
• In long standing cases it can be hard
• Surface can be nodular
• Skin is stretched and becomes shiny
• Being a benign tumor it is neither adherent to the skin nor to masseter.
• After few years pleomorphic adenoma shows features of transformation into malignancy.

Parotid gland Management

• Surgery is the fist line management.
• If only the superficial lobe is involved, then superficial parotidectomy is done wherein parotid superficial to facial nerve is removed.
• Various steps in superficial parotidectomy:

• Give incision, incision should start in front of tragus, vertically descend downwards,curve round the ear lobule till mastoid process and is carried till the neck.
• Facial nerve should be recognized which lies 1cm inferomedial to pointed end of tragal cartilage of external ear.
  • Trace posterior belly of digatric till mastoid process.
  • Facial nerve lies between muscle and tympanic plate.
• Both facial nerve and retromandibular vein divides the parotid gland into deep and superficial lobes. Benign tumors do not invade faciovenous plane of Patey.
• Gentle handling, good suction and nice hemostasis provide visibility to nerve.
• Tumor along with lobe should be removed in Toto to avoid spillage.

• If both the lobes are involved then total conservative parotidectomy is done.
• In this, tumor along with the normal lobe is removed by retaining facial nerve. Avoid rupture of gland.

 

Question.2. Describe in short mixed parotid tumor.
Or
Write short note on mixed parotid tumor.
Or
Write in short about mixed parotid tumor.
Or
Write briefly on clinical features and treatment of pleomorphic salivary adenoma.
Or
Write in short about etiology, clinical features and management of mixed parotid tumor.
Or
Discuss about pleomorphic adenoma.
Or
Write short note on pleomorphic adenoma.
Or
Write short answer on pleomorphic adenoma.

Answer. Pleomorphic adenoma is also known as mixed parotid tumor or mixed salivary tumor.

• This is the most common tumor ofthe major salivary gland.
• Pleomorphic adenoma is benign epithelial tumor.
• Epithelial cells proliferate in strands or may be arranged in form of acini or cords.

Pleomorphic adenoma is mixed tumor because of the presence of epithelial cells, myoepithelial cells, mucoid material, pseudocartilage, and lymphoid tissue.

Mixed parotid tumor Etiology

• Dardick’s theory: A neoplastically altered epithelial cell with potential for multidirectional diffrentiation can be responsible for pleomorphic adenoma.
• Differentiation of the ductal reserve cells: Intercalated ductal reserve cells may be differentiated into ductal and myoepithelial cells and later on these cells undergo Mesenchymal metaplasia as they inherently consist of smooth muscle-like properties.

Mixed parotid tumor Clinical Features

• It occurs in middle aged women around 40 years are commonly affected.
• It is usually unilateral, present as single painless, smooth,firm, lobulated mobile swelling in front of parotid with positive Curtain sign, i.e. as the deep fascia is attched above to zygomatic bone, it acts as curtain, not allowing parotid swelling to move above the level of zygomatic bone. This is curtain sign.
• Obliteration of retromandibular groove is common.
• Ear lobule is raised or lifted.
• Swelling is rubbery or fim. Soft area indicates necrosis. In long standing cases it can be hard, surface can be nodular.
  • Skin is stretched and becomes shiny.
• When deep lobe is involved, swelling is located in lateral wall of pharynx, posterior pillar and over soft palate.
  Deep lobe tumor passes through Patey’s submandibular tunnel pushing tonsils, pharynx, soft palate often without any visible swelling or only small swelling when only deep lobe tumor is present.
• Being a benign tumor it is neither adherent to the skin nor to masseter.
• After few years pleomorphic adenoma shows features of transformation into malignancy.

Mixed parotid tumor Investigations

• Fine needle aspiration cytology: It is done to confim diagnosis and rule out the malignancy.
• CT scan: This is to be done when tumor arises from deep lobe.
  It defies the extra glandular spread and extent of parapharyngeal disease as well as cervical lymph nodes.
• FNAC oflymph nodes: Palpable lymph nodes in neck are to be examined for malignancy.
• X-ray of bones: For seeing the bony resorption.
• MRI is the bettr method compared to CT scan. MRI provides bettr soft tissue delineation, i.e. superior perineural invasion.

Mixed parotid tumor Complications

• Recurrence in 5 to 50% of cases.
• Malignancy is seen in 3 to 5% of tumors
• Malignancy is seen in 10% of tumors in long duration.

Mixed parotid tumor Treatment

• Surgery is the fist line treatment.
• If only superficial lobe is involved, then superficial parotidectomy is done wherein parotid superficial to facial nerve is removed.
• Various steps in superficial parotidectomy:

• Give incision, incision should start in front of tragus, vertically descend downwards,curve round the ear lobule till mastoid process and is carried till the neck.
• Facial nerve should be recognized which lies 1cm inferomedial to pointed end of tragal cartilage of external ear. Trace posterior belly of digatric till mastoid process. Facial nerve lies between muscle and tympanic plate.
• Both facial nerve and retromandibular vein divides the parotid gland into deep and superfiial lobes. Benign tumors do not invade faciovenous plane of Patey.
• Gentle handling, good suction and nice hemostasis provide visibility to nerve.
• Tumor along with lobe should be removed In Toto to avoid spillage.

• If both the lobes are involved then total conservative parotidectomy is done. In this, tumor along with the normal lobe is removed by retaining facial nerve. Avoid rupture of gland.

 

Question.3. Write short note on acute parotitis.

Answer. Acute inflammation of parotid can occur due to bacterial or non-bacteria causes. This may be unilateral and bilateral.

Acute Non-Suppurative Parotitis (Mumps Parotitis)

It is an acute generalized viral disease with painful enlargement of salivary gland chief parotid.

Acute parotitis Clinical Features

Fever, headache, muscular pain are usually found, both parotids are enlarged with pain and temperature.

Acute parotitis Treatment

Only symptomatic treatments analgesic and anti-inflammatory drugs.

Acute Suppurative Parotitis

It is and acute inflammation of parotid gland caused by Staphylococcus aureus.

Streptococcus viridans and pneumococci may be involved.
Pathogenesis: The bacterium reaches to the salivary gland through the stenson’s duct. This is called as retrograde infection.

Acute Suppurative Parotitis Clinical Features

• Pain and swelling on one side of face
• Browny edematous swelling over the parotid region with all signs of inflammation.
• Cellulitis of overlying skin
• Pus comes out on pressing the parotid gland.

Acute Suppurative Parotitis Investigations

• Ultrasonography of parotid region should be done.
• Pus collected from duct orifie should be sent for culture and sensitivity
• Needle aspiration from the abscess is done to confirm formation of pus.

Acute Suppurative Parotitis Treatment

Conservative line of management:

• It is indicative in stage of cellulitis with no evidence of abscess.
• Maintain good oral hygiene.
• Proper antibiotic mainly cloxacillin 500 mg 6 hourly along with metronidazole 400 mg 8 hourly.

Surgical treatment:

• Incision and drainage should be done under general anesthesia.
• Incise the skin in front of tragus vertically and then parotid sheath is opened horizontally.
  Pus is drained by using the sinus forcep. This is known as blair’s incision. Antibiotics should be continued.
• Proper hydration, mouthwash using povidone iodine or potassium permagnate solutions.

 

Question.4. Discuss clinical features, investigation, and management of submandibular salivary calculus.
Or
Describe etiology, clinical features, investigations and management of submandibular gland stone.

Answer. This is a pathological condition characterized by formation of calcified mass (sialolith) within the salivary gland or its duct.

Submandibular salivary calculus Etiology

The exact cause for sialolith or calculus formation is not clear but factors which contribute to its formation are:

• Stagnation of saliva
• Focus for sialolith formation resulting from ductal epithelial inflmmation and injury.
• Poorly understood biological factors favoring precipitation of calcium salts.

Hilus is the most common site for the formation of sialolith but it can arise anywhere throughout the ductal system.

80% of all salivary duct stones develop in the submandibular or Warthin’s duct.

Predisposition of sialolith formation for the submandibular gland can be due to:

• Composition of secretion of submandibular salivary gland is more alkaline and viscous.
• Submandibular gland consists of higher concentration of calcium and phosphorus ions as compared to other major salivary glands.
• Both submandibular gland and duct are placed in such an anatomically dependent position that the flow of saliva is against gravity which gives more chances for stasis of saliva inside the ducts.
• Stagnation of secretions in Warthin’s duct can also due to angulation ofduct as it courses around the mylohyoid muscle and the vertical orientation of the distal duct segment.

Submandibular salivary calculus Clinical Features

• Patient complains ofperiodic painful swelling when eating,interspersed with periods of remission.
• Occasionally patients report spontaneous extrusion of small calculi from the ducts.
• Most common fiding on examination is point tenderness in the region of the hilum or, near Wharton’s duct of the submandibular gland.
• Salivary secretion may be affected slightly.
• A gelatinous, cloudy, mucopurulent material is seen in basically clear and adequate saliva.
  • This mucopurulent material is derived from the inflmmatory ductal changes caused by calculus blockage and salivary stagnation.
• If treatment is not instituted early pronounced exacerbations are seen, characterized by an acute suppurative process with attndant systemic manifestations.
• Pus may exude from the duct orifie.
• Mucosa around the duct is inflmed, particularly in the flor of the mouth where swelling, redness and tenderness are present along the course of Wharton’s duct.
• Glands are enlarged, tender and tense. Palpation of the gland and the duct causes pain and a flow of pus.

Submandibular salivary calculus Investigations

• Occlusal radiograph
• Intraoral periapical radiograph: Submandibular stones are mostly radioopaque.
• Ultrasound (Excellent non-invasive method)
• Sialography: A retrograde injection of a radiopaque dye as neohydriole into the duct of salivary gland.
  (Occluded submandibular salivary duct can be best observed by simple palpitation.

Submandibular salivary calculus Treatment

Stone in the submandibular duct:

• Small stone in the distal part of the duct is removed manually.
• Stone in deeper parts require operation. This can be removed by incising the mucosa over the flor of the mouth, after stabilizing the stone.

If the stone is present inside the gland:

• This requires excision of submandibular salivary gland.
  Three steps of dissection of gland includes incision, mobilization and excision
• Incision: It should be a skin crease incision over the lower pole of the gland.
• Mobilization of the gland: Division of the facial artery twice, once in deeper plane on the posterolateral aspect and another at the superolateral aspect close to the lower border of the mandible which gives mobilization of the gland.
• Excision of the gland: It is done by ligating and dividing the submandibular duct.

 

Question.5.Describe the etiology, clinical features, and treatment of submandibular sialolithiasis. 

Answer. Sialolithiasis is the formation of hardened intraluminal deposits in ductal system of salivary gland which obstructs the normal flow of saliva.

Submandibular Sialolithiasis Etiology

The exact cause for sialolith or calculus formation is not clear but factors which contribute to its formation are:

• Stagnation of saliva
• Focus for sialolith formation resulting from ductal epithelial inflmmation and injury.
• Poorly understood biological factors favoring precipitation of calcium salts.

Hilus is the most common site for the formation of sialolith but it can arise anywhere throughout the ductal system.

80% of all salivary duct stones develop in the submandibular or Warthin’s duct.

Predisposition of sialolith formation for the submandibular gland can be due to:

• Composition of secretion of sub mandibular salivary gland is more alkaline and viscous.
• Submandibular gland consists of higher concentration of calcium and phosphorus ions as compared to other major salivary glands.
• Both submandibular gland and duct are placed in such an anatomically dependent position that the flow of saliva is against gravity which gives more chances for stasis of saliva inside the ducts.
• Stagnation of secretions in Warthin’s duct can also due to angulation of duct as it courses around the mylohyoid muscle and the vertical orientation of the distal duct segment.

Submandibular Sialolithiasis Clinical Features

• It is usually seen in patients in the 5th to 8th decade of life.
• Recurrent swelling of the gland region is seen at the meal time.
• Recurrent episodes of acute, subacute or suppurative sialadenitis are present.
• Swelling is sometimes seen as hard lump present in the flor of the mouth or cheek.
• Submandibular salivary gland becomes tense and tender.
• Swelling and tenderness subside only to recur again during meal time.
• Large submandibular calculi can be seen as a swelling in the flor of the mouth.
• Stone may be palpable during bimanual palpation and may be movable up and down the duct.
• As in chronic infection and obstruction, the gland undergoes atrophy rarely, becomes indurated and when operated it is seen to be adherent to adjacent structures.

Submandibular Sialolithiasis Treatment

Treatment is surgical.

Removal Of Submandibular Calculi (transoral sialolithotomy)

• Place the patient in sittng position and give local anesthesia.
• Locate the stone accurately by using radiographs and palpation.
• Pass a suture behind the stone as well as below the duct to prevent stone from sliding backwards during removal.
• Retract the tongue for proper visualization.
• Palpate submandibular gland extraorally in submandibular region and is pushed upwards toward floor of mouth
  to fi intraoral tissues under tension. During this take care of lingual nerve and sublingual gland.
• If the sialolith is present posteriorly, incision should be placed slightly medially to avoid injury to the lingual nerve.
• Place a superfiial incision through mucosa alone and give blunt dissection to reach the duct for preventing injury to
  the lingual nerve.
• If stone is more anteriorly placed, incision is given medial to plica sublingualis or else there are chances of injury to
  sublingual gland.
• Duct should be located at place where stone is lodged. As duct is located, a longitudinal incision is given directly
  over the duct where stone is located.
• Transverse incision should not be given as it retracts and gets divided completely and a salivary fitula may be formed.
• Incision given should reveal the stone and is of suffient length to be removed easily. Stone can usually be removed easily with a forceps or a larger stone may need to be crushed into smaller pieces and removed.
• A probe is then passed from the caruncle to the region of stone to ensure patency of the duct in the anterior region.
• Incision on the duct need not be sutured. Incision in the flor of the mouth should be sutured with interrupted sutures.

 

Question.6. Write short note on Sialolithiasis.

Answer. Sialolithiasis is the formation of hardened intraluminal deposits in ductal system of salivary gland which obstructs the normal flow of saliva.

Sialolith Composition

Sialolith is made up of:

• Inorganic materials: Calcium phosphate, calcium carbonate,combined with other salts such as Mg, Zn, etc.
• Organic materials, i.e. glycoproteins, mucopolysaccharides and cellular debris.
• Aggregations of bacteria, clumps of epithelial cells, mucus,blood clots following trauma, are all suggested to form foci.

 

Question.7. Write short note on Warthin’s tumor.

Answer.

• Warthin’s tumor is also called adenolymphoma.
• It is a benign parotid tumor, it constitute about 10% of parotid tumors.
• Origin of adenolymphoma during development some parotid tissue gets included within lymph nodes which are present within the parotid sheath.
• It involves only superfial lobe of parotid gland.

Warthin’s tumor Etiology

Smoking and radiation exposure can be the cause.

Warthin’s tumor Clinical Features

• Middle-aged or elderly males are commonly affcted usually they are smokers.
• Can be bilateral, in some cases.
• It has smooth surface, round border with soft, cystic flctuant swelling in lower pole often bilateral and is non-tender.
• Classically, situated at the lower pole of parotid elevating the ear lobule.
• May be multicentric.
• This tumor affects only parotid gland.

Warthin’s tumor Investigations

• Adenolymphoma produces “hot spot” in 99 Technetium pertechnetate scan which is diagnostic.
• FNAC can be done
• Biopsy is done and histology reveals:

• Cyst is lined by a bilayered oncocytic epithelium, the inner cells of which are tall columnar with fine granular and eosinophilic cytoplasm and slightly hyperchromatic nuclei.
  The outer layer consists of basaloid cells.
• An eosinophilic coagulum is present within the cystic spaces.
• The numerous lymphocytic components may represent normal lymphoid tissue within which tumor is developed.

Warthin’s tumor Treatment

It is best treated by superficial parotidectomy which spares the facial nerve

 

Question.8. Write short note on parotid fitula.

Answer. It is an uncommon condition, which occurs after the surgery on the parotid gland.

It may arise from parotid duct or gland.

Fitula Types

• Duct fibula forms after superfiial parotidectomy. It is profuse and often persisting.
  So duct should be ligated using non-absorbable suture as far as possible, anteriorly to allow normal saliva drainage from deep lobe.
  If common duct is ligated deep lobe atrophies without causing any fitula.
• Gland fitula occurs from the raw surface after superficial parotidectomy. It is mild and symptom subsides in a month with anticholinergic drugs. Jacobsom tympanic neurectomy completely stops the secretion from the fistula in this type.

Fitula Etiology

• Rupture or bursting of parotid abscess.
• Inadvertent incision for drainage of parotid gland
• Penetrating injury to parotid gland
• As a complication after the superfiial parotidectomy.

Fitula Clinical Features

• The chief complaint is an opening on the cheek, which discharges during meal.
• *Excoriation of adjacent structure takes place.
• Tenderness and induration
• Trismus.

Fitula Diagnosis

• Sialography is done to fid out origin of fitula whether from parotid gland or duct or ductules.
• Fistulogram or CT fitulogram should be done.
• Discharge study
• MRI

Fitula Treatment

• Anticholinergics: Hyoscine bromide (probanthine).
• Radiotherapy.
• Often exploration of fitula is required.
• Repair or reinsertion of the duct into the mucosa.
• Newman Seabrook operation—A probe is passed into the parotid duct through the opening in mouth.
  Another probe is passed through the fitula.
  Duct and fitula are dissected over the probe.
  After removal of the fitula tract severed duct ends are identified; and ends are trimmed.
  Probes are removed.
  A tantalum wire is passed into the duct across the severed ends and duct is sutured over it using 4 zero vicryl.
  Tantalum stent is removed after 3 weeks.
• If still persists, auriculotemporal nerve which supplies secretomotor component of parotid is cut.
• If there is stenosis at the orifie of the Stenson’s duct, papillotomy at the orifie may help.
• Total conservative parotidectomy is done in failed cases.

 

Question.9. Write short note on acute parotid abscess.

Answer. It is a result of an acute bacterial sialadenitis of the parotid gland.

• It is an ascending bacterial parotitis, due to reduced salivary flw, dehydration, starvation, sepsis, after major surgery, radiotherapy for oral malignancies and poor oral hygiene.
• Parotid fascia is densely thick and tough and so parotid abscess does not show any fluctuation until very late stage.
• Causative organisms are Staphylococcus aureus (commonest), Streptococcus viridans and often others like gram-negative and anaerobic organisms.

Acute parotid abscess Clinical Features

• Pyrexia. malaise, pain and trismus.
• Red, tender, warm, well-localized, fim swelling is seen in the parotid region (brawny induration).
• Tender lymph nodes are palpable in the neck.
• Features of bacteremia are present in severe cases.
• Pus or cloudy turbid saliva may be expressed from the parotid duct opening.

Acute parotid abscess Investigations

• Ultrasonography of parotid region should be done.
• Pus collected from duct orifie should be sent forculture and sensitivity
• Needle aspiration from the abscess is done to confim formation of pus.

Acute parotid abscess Treatment

• Antibiotics are started depending on culture report.
• When it is severely tender and localized, incision and drainage is done under general anesthesia.
  Skin is incised in front of tragus vertically and then parotid sheath is opened horizontally.
  Pus is drained using sinus forceps and is sent for culture.
  Antibiotics should be continued.
• Proper hydration, mouth wash using povidone-iodine;potaium permanganate solutions, nutrition.
  Often patient with parotid infection needs admission and treatment.

 

Question.10. Write short note on sialadenitis.

Answer. Sialadenitis is defined as the inflammation of the salivary gland.

Sialadenitis Types

• Acute bacterial sialadenitis
• Chronic bacterial sialadenitis
• Chronic sclerosing sialadenitis/ Kutter’s disease
• Allergic sialadenitis.

Sialadenitis Etiology

• Microorganisms, i.e. S. aureus, S. viridans
• Predisposing factor, i.e. dehydration, malnutrition, cancer and surgical infections
• Poor oral hygiene
• Drugs: Anti-Parkinson, diuretics and antihistaminics.

Sialadenitis Symptoms

• Fever
• Sudden onset of pain at the angle of jaw.

Sialadenitis Sign

• Unilateral involvement of parotid gland is common
• Parotid gland is tender, enlarged and the overlying skin is warm and red
• Swelling causes elevation of the ear lobule.
• Intraorally, parotid papilla may be inflmed
• Cervical lymphadenopathy

Sialadenitis Management

• Meticulous oral hygiene should be practiced
• Soft diet should be given
• High dose of parentral antibiotic
• IV saline is given.

Sialadenitis Surgical treatment

If improvement does not occur surgical drainage of the affcted gland should be performed.

 

Question.11. Name the treatment modalities and diffrentiating features of parotid abscess and periodontal abscess.

Answer.

 

Question.12. Write in brief on Sjögren’s syndrome.
Or
Write short note on Sjögren’s syndrome.

Answer. It is a chronic inflammatory autoimmune disorder that affcts salivary, lacrimal and another exocrine gland.

Sjögren’s syndrome Types

• Primary Sjögren’s syndrome: It is also known as Sicca syndrome. It consists of dry eyes, i.e. xerophthalmia and dry mouth, i.e. Xerostomia.
• Secondary Sjögren’s syndrome:It consists of dry eyes, i.e. xerophthalmia, drymouth, i.e. xerostomia and collagendiso-rders, i.e.rheumatoid arthritis or systemic lupus erythematous.

Sjögren’s syndrome Clinical Features

• Xerostomia is present with unpleasant taste, soreness and diffilty in eating dry fruits.
• Patient also complains of xerophthalmia and arthralgia
• Severe tiredness is present.
• There is cobble stone appearance of tongue.
• There is often secondary acute bacterial sialadenitis and rapid progressive dental caries.
• Burning sensation present in the eyes.
• Parotid gland is predominantly affcted, sometimes sub mandibular and minor glands can also be affcted.

Sjögren’s syndrome Investigations

• Sialography: Presence of snowstorm and branchless fruit laden tree appearance.
• Rose bengal staining test: Keratoconjunctivitis sicca is characterized by corneal keratotic lesion which stain pink when‘rose bengal’ dye is used.
• Schirmer test: Lacrimal flw rate is measured by this test.
  In this test a strip of fiter paper is placed in between eye and eyelid for determining degree oftears which is measured in millimeter.
  When flow is reduced to 5 mm in 5 minute sample, patient is considered positive for Sjögren’s syndrome.
• Sialometry: In this salivary flw rate estimation is carried out. Stimulated flw rate in symptomatic primary and secondary sjögren’s syndrome is below 0.5 to 1 mL/min.
• Sialochemistry: In Sjögren’s syndrome saliva of parotid gland is has twice total lipid content and high phospholipids and glycolipids.
• Blood investigations should be done.

Sjögren’s syndrome Treatment

• Ocular lubricants, i.e. artifiial tears should be used and provide relief.
• Xerostomia is managed by saliva substitutes.
• Frequent drinking of water is mandatory.
• Maintenance of oral hygiene is mandatory.
• Fluoride application should be done.
• Various saliva stimulants, i.e. pilocarpine, bromhexine and cevimeline are used.
• If salivary gland is enlarged to the extent that it is giving discomfort to the patient, then surgery is carried out.

 

Question.13. Classify tumors of parotid gland. Discuss clinical features and management of malignant parotid tumors.

Answer.Classification of tumors of parotid gland
International Classification of Parotid Tumors

Parotid Gland Epithelial

Adenomas

Pleomorphic adenoma

Monomorphic adenoma

• Adenolymphoma
• Oxiphilic
• Other type

• Mucoepidermoid—low grade malignancy
• Acinic cell tumor
• Carcinoma

• Adenoid cystic carcinoma
• Adenocarcinoma
• Epidermoid carcinoma
• Undifferentiated carcinoma
• Carcinoma Ex pleomorphic adenoma

Parotid Gland Non-Epithelial

• Hemangioma
• Lymphangioma
• Neurofiroma

Parotid Gland Metastatic

• Epidermoid carcinoma
• Malignant melanoma

Parotid Gland Malignant Parotid tumor

It is also known as carcinoma ex pleomorphic adenoma

Clinical Features of Malignant Parotid tumor

• It occurs from 2nd to 9th decade of life.But is common between 5th to 6th decades.
• Pain is very commonly present.
• Size of the tumor is very large and tumor can be associated with ulceration.
• These tumors can also lead to facial nerve palsy.
• Tumor gets fied to underlying structures as well as to overlying mucosa or skin.

Management of Malignant Parotid tumor

Radical Parotidectomy

• It is the removal of both the lobes of parotid, facial nerve,parotid duct, fier of masseter, buccinators, pterygoids and radical block dissection of the neck.
• If there is no involvement of the facial nerve, it should be preserved. But, if facial nerve is removed it should be reconstructed by the greater auricular nerve or sural nerve
• Advanced tumor with the fied nodes in neck may require radiotherapy but the response rate is poor.

Postoperative Radiotherapy

• This is useful to reduce the chances of relapse.
• Mainly external radiotherapy should be given.

Chemotherapy

• It is also given.
• Drugs given here depend on the tumor type.
• Intra arterial chemotherapy is benefiial
• Overall efficy of chemotherapy is less as compared to radiotherapy.
• 5FU, Cisplatin, Doxorubicin, epirubicin, cetuximab are used.