PAROTID GLAND APPLIED ANATOMY AND SURGICAL CONSIDERATIONS

DR FAHAD QIAM FCPS II RESIDENT (ORAL AND MAXILLOFACIAL SURGERY) SURGICAL E WARD KHYBER TEACHING HOSPITAL

CONTENTS

What is the parotid gland Anatomy of the parotid gland Applied anatomy of the parotid gland Overview of parotid gland disorders Surgical exposure of the parotid gland & case presentation Complications of parotid gland surgery Self assessment exercise

PAROTID??

Starts to develop at 35th day in utero Largest of all salivary glands Secretes serous saliva and salivary amylase Contributes 25% of total saliva production

RELATIONS

IMPORTANT RELATIONSHIPS

External carotid artery and its branches

Retromandibular vein and its tributaries

Facial nerve

EXTERNAL CAROTID ARTERY AND ITS BRANCHES

RETROMANDIBULAR VEINS AND ITS TRIBUTARIES

FACIAL NERVE

Arises at the pons

Large motor and small sensory root

Exits via internal acoustic meatus

Goes into facial canal of temporal bone

Geniculate ganglion

Greater petrosal nerve, nerve to stapedius and chorda tympani

Exits skull at stylomastoid foramen

Motor supply to the muscles of facial expression

NERVE TESTING

DA JALIL KEBABS!!

FACIAL NERVE

NERVE SUPPLY

Auriculotemporal nerve provides sensory supply

Auriculotemporal nerve Otic Ganglion Glossopharyngeal nerve

WHO????

APPLIED ANATOMY

Bi-lobed structure

Facial nerve passes around the isthmus connecting the two lobes Contains lymph nodes that are both intraglandular and extraglandular

ANATOMICAL VARIATIONS

FACIAL NERVE GIVES TWO BRANCHES IN THE GLAND, TEMPOROFACIAL AND CERVICOFACIAL

CASE NO.1

A 56 year old man reported to the Department of Oral and Maxillofacial Surgery with a painless swelling in the right pre-auricular region for the past 3 years. The swelling was firm, indurated, well localizied, measuring 4x5cm in greatest diameter. There were no associated symptoms. No dental cause for the swelling was found. OPG was unremarkable. Facial nerve was intact.

HOW TO DIAGNOSE?

SURGICAL EXPOSURE OF THE PAROTID GLAND

HEAD POSITIONING AND DRAPING

THE INCISION

FACIAL NERVE MARKERS

Tragal pointer (nerve is inferior and 1cm deep to this landmark) Tympanic ring Anterior aspect of mastoid bone Tympanomastoid suture line (leads directly to stylomastoid foramen)

Posterior belly of digastric muscle (Facial nerve at same depth, just above muscle)
Styloid process (facial nerve in angle between styloid and digastric, and crosses styloid more anteriorly)

CASE NO.2

A 6 year old male reported with a 2 month history of a tender swelling in the left preauricular region. It was associated with occasional pus discharge and bleeding during spitting. Bilateral submandibular lymph nodes were palpable

NEED FOR DEEP PAROTIDECTOMY?

Rare as deep lobe is only affected in 20% of parotid tumors Undergoes atrophy after superficial parotidectomy More cumbersome as it usually requires a ramus osteotomy for full exposure

Requires ligation of external carotid artery, retromandibular vein, superficial temporal veins and division of facial nerve trunk

COMPLICATIONS

FREYS SYNDROME

BELLS PALSY

FOLLOW UP

SIALOCELE

PARASTHESIA OF THE EAR LOBE

KEY POINTS

No or short muscle relaxant Excellent lighting Correctly applied traction and counter traction Adequate exposure (SMAS) Clear definition of regional anatomy Always take a cuff of normal parotid tissue Use of EMG based facial nerve testing

Use of bipolar current Raw gland surface should not be sutured to the skin Pressure dressing Use of close suction drain

Sacrifice versus preservation

Patient counselling

ANY QUESTIONS?