SSI from 2.3% to 1.7% (-27%)
y Risk stratification of patients according to National nosocomial infection surveillance system (NNISS) include wound type (contaminated/dirty), ASA grade (3,4,5) and duration of operation (>75th percentile of normal) to give risk of SSI in a particular patient.
y Bowel preparation lowers the patient’s risk of infection from that of a contaminated case (25%) to a clean contaminated case (5%).
y Unicentric origin
y Reccurrences are multicentric y Usually encapsulated
y Has finger like projections into surrounding.
Clinical features of benign adenoma
y Females of middle age group present with a painless slowly enlarging swelling behind the ear lobule in the parotid region and raising the ear lobule present since many years y It is a mobile, nontender, rounded swelling with well defined margins and smooth surface
and firm to hard consistency
y Facial nerve is not involved and overlying skin is free y No lymphadenopathy
y A pleomorphic adenoma of deep lobe may push tonsil medially and be palpable intraorally.
Clinical features suggestive of malignancy y Rapid increase in size
y Pain and tenderness y Lymphadenopathy
y Fixity to skin or deeper structures y Facial nerve involvement
y Multicentric tumors suggest recurrence.
Investigations
y FNAC is enough for diagnoses
y CT head and neck or MRI in case of malignancy y Preoperative workup for anesthetic fitness.
Treatment
y Superficial parotidectomy (Patey’s operation)
y Total parotidectomy without facial nerve preservation for malignancy.
Q63. Write a note on Warthin tumor.
Write a note on adenolymphoma.
Ans. Introduction
y It is the second most common neoplasm of the salivary gland
y It is found only in the superficial lobe at lower pertion of parotid gland y Commonly affects males in old age group
y It is always benign.
Pathology
y Smoking is a risk factor
y Contains both epithelial and lymphoid components and therefore is called adenolymphoma
y Unicentric origin
y Usually well encapsulated
y Also contains cystic areas and papillary epithelial projections with double layer of lining epithelium and therefore is also called papillary cystadenoma lymphomatosum.
Clinical features
y Males of old age group present with a painless slowly enlarging swelling behind the ear lobule in the parotid region and raising the ear lobule present since many years y It is a mobile, nontender, rounded swelling with well defined margins and smooth surface
and soft to cystic consistency
y Facial nerve is not involved and overlying skin is free y No lymphadenopathy.
Investigations
y FNAC is enough for diagnoses
y Shows hot spot on technetium pertechnetate scan y Preoperative workup for anesthetic fitness.
Treatment
y Superficial parotidectomy (Patey’s operation).
Q64. Write a note on superficial parotidectomy and enumerate its complications.
Ans. Superficial parotidectomy is the removal of the superficial lobe of parotid gland and is indicated in all the benign tumors of the superficial lobe of the parotid gland.
y Incision – Blair incision
– Modified Blair incision – Sistrunk incision
Fig. 2: Incision for parotid surgery
y The marking starts from the preauricular region, goes upto mastoid tip from below the ear, then comes anteriorly to merge with normally present neck line below mandible y When the angle at mastoid tip between horizontal and vertical limbs of the incision is
pointed, it is called as Blair incision. This pointed tip is associated more with chances of necrosis and therefore modified blair incision is used now which has made that angle curved
y After the incision, the anterior flap is raised superficial or deep to platysma to expose the anterior parotid surface covered by deep fascia, posterior flap raised upto sternomastoid and superiorly upto the junction of cartilaginous and bony auditory tube
y During raising the anterior flap, care should be taken to avoid injury to facial nerve branches as they emerge from the parotid gland anteriorly
y Next, the deep fascia is incised along the mastoid tip and posterior belly of digastrics identified to begin the dissection at the posteroinferior border of the parotid gland and proceed anterosuperiorly
y The dissection is done in the patey’s fasciovenous plane with the nerve and vein lying in it and the arteries deeper to this plane
y The tragal pointer cartilage is 1 cm above and superficial to the posterior belly of digastric and aids in identification of the facial nerve trunk. The facial nerve lies 1 cm medial and inferior to the tragal pointer
y The retromandibular vein, styloid process and tympanomastoid sutures are also useful landmarks to identify the facial nerve in this region. The nerve is superficial to retromandibular vein, lateral to styloid process and just inferior to the tympanomastoid suture line
y The nerve enters the parotid at its posteromedial surface
y The technique of parotid dissection involves inserting the blade of instrument along the direction of nerve, lift, spread and then cut in that order
y The superficial lobe of the parotid gland is resected keeping the deep lobe, parotid duct and all the facial nerve branches in situ
y The incision is closed with sutures and drain palced which is kept for around 2 days. The sutures are removed on 5th day usually to decrease scarring.
Complications Wound complications y Seroma
y Hematoma
y Infection and stitch line abscess y Flap necrosis
Facial nerve paresis or paralysis Parotid fistula
Sensation loss at an angle of mandible due to greater auricular nerve damage.
Frey syndrome
y Causes damage to auriculotemporal nerve during surgery followed by cross connection between parasympathetic fibres of auriculotemporal nerve and sympathetic fibers of the sweat glands supplying the angle of jaw
y This leads to sweating at parotid region and angle of jaw when the patient eats instead of salivary secretion
y Minor’s starch iodine test is confirmatory y Management
– Prevention by taking a segment of auriculotemporal nerve during surgery to prevent
– Treatment
- Local aluminium chloride application
- Tympanic neurectomy (surgical division of the cross connected fibers) - Botulinium toxin injection.