BENIGN OR CANCER (MALIGNANT) PAROTID GLAND TUMOR (definition, sign, symptoms, diagnosis, prognosis, and management

Parotid gland

Anatomy of parotid gland

Parotid gland is the salivary glands are paired, numbered 2. Parotid gland is the largest of the salivary glands. Each weighing an average of 25 grams and irregular shape, berlobus, color between green and yellow (Yellowish) located below the external acoustic meatus between the mandible and the muscles sternokleidomastoideus.4

Parotid gland varied shape, when viewed from the lateral triangular 50%, 30% of the top and bottom round. Parotid gland is usually shaped like an inverted pyramid with a surface-surface as follows: superior surface of the small, superficial, anteromedial, and posteromedial. Konkav on the superior surface forms associated with the cartilage of the external acoustic meatus and the posterior part of the temporomandibular joint. Here auriculotemporal nerve supplies the parotid gland. Superficial surface covered by skin and superficial fascia containing a branch of the facial nerve aurikuler, superficial parotid lymph nodes, and the lower limit of platisma.4

The anterior part of the gland adjacent to the posterior edge of mandibular ramus and slightly coat the posterior edge of masseter muscular. Posterior part of the gland is surrounded by the ear, mastoid processus, and the anterior edge of the muscular stemokleidomastoideus. The inside of the medial lobe extends into the cavity parafaring, limited by the processus stilomandibular stiloideus and ligament, muscular digastrikus, and carotid sheath. In the anterior lobe is located adjacent to the medial ptetygoideus. Lateral parts covered only by skin and subcutaneous fat tissue. Connective tissue and fat tissue from the fascia of the neck in this gland wraps. Parotid gland is closely linked to important structures around the internal jugular vein and its branches, the external carotid artery and its branches, lymph glands, auriculotemporalis of nerve branches and nerve trigerninus fasialis.4

Bleeding from the parotid gland and the external carotid artery branches near the parotid gland. Venous blood flow into the external jugular vein through the vein out of the parotid gland. 4

Lime gland nodules found on the skin above the parotid gland (gland preaurikuler) and on the part of the parotid gland itself. There are 10 lymphatic glands found in the parotid glands, mostly found in the superficial part of the gland above the fields related to facial nerve. Lymph nodes from the parotid glands drain their contents into the cervical lymph nodes atas.4

Parotid gland innervation by preganglionic nerve running on the branch of petrosal nerve ganglion glossopharyngeus and bersinaps on otik. Postganglionic fibers reach the gland via nerve auriculotemporal.4

Parotid gland secretions have a channel to remove the Stensen's duct called that will empty into the mouth near the molars 2; location is usually characterized by a small papilla. 4

Physiology of the parotid glands

Every day produced 1 to 2 liters of saliva and swallowed almost everything and direabsorbsi. The process of secretion under the control of the autonomic nerves. Food in the mouth stimulates the nerve fibers which end on the tract nucleus solitaries and ultimately stimulate the salivary nucleus in the midbrain. Salivation is also stimulated by sight, smell through impulses from the cortex of work on the brain stem nuclei of saliva. Ongoing sympathetic activity inhibits the production of such lir anxiety that causes dry mouth. Drugs that inhibit parasympathetic activity also inhibits the production of saliva, such as antidepressants, tranquillizers, and opiate analgesic medications can cause dry mouth (Xerostomia) .7

Saliva consists of water and mucin, forming a gel-like layer on the oral mucosa and wet food (lubrication). Lubrication is important for chewing and food bolus formation, making it easier to swallow. Saliva also contains amylase, which play a role in the digestion of carbohydrates. Lir water containing antibacterial enzymes such as lysozyme and immunoglobulins that help prevent serious infections and bacterial flora mengantur who settled in the mouth. Salivary duct is relatively impermeable to water and secrete potassium, bicarbonate, calcium, magnesium, phosphate ions and water. So the end product of the salivary glands are hypotonic, slightly alkaline fluid that is rich in calcium and phosphate. The composition is important to prevent demineralization of enamel gigi.7

TUMOR PAROTID

Definition
According to Dorland Medical Dictionary 29th edition, the new growth of tumors was defined as a network with the multiplication of cells is uncontrolled and progressive, also called neoplasm. Parotid gland is the largest salivary glands located in front of telinga.8

Epidemiology

Salivary gland tumors are relatively rare, the percentage is less than 3% of all malignancies in the head and neck. Malignancy in tumors associated with exposure to saliva kelenajar radiation, genetic factors, and carcinoma of the breast. Most of the tumors in the salivary glands occur in the parotid gland, where 75% - 85% of all tumors derived from the parotid and 80% of these tumors are benign pleomorphic adenoma (benign pleomorphic adenomas) .8,9,10,11

Inspection
In the anamnesis should be asked about previous radiation to the head-neck area, which had performed surgery on the salivary glands and certain diseases that can cause swelling of the gland (diabetes, cirrhosis, hepatitis, alcoholism). As well as opiate drugs, antihypertensives, phenothiazine derivate, diazepam, and klordiazepoksid can cause swelling, because these drugs reduce the function of the gland ludah.16
By inspection in a resting state and the movement can be determined whether there is abnormal swelling, and where, how the skin and mucous membrane over it, and how the state of the facial nerve function. Sometimes it is obvious on inspection of the fixation to the surrounding tissue, and immediately looked the trismus. Patients should also be checked from behind, to be able to see asimetrisitas that may go unnoticed kita.16
Is done with careful palpation may lead to a proper assessment of tumor localization, size (in cm), shape, consistency, and relationships with their surroundings. If it is possible to do bimanual palpation. Systematic palpation of the neck for lymphadenopathy and Warthin tumor that rarely happens also to be done. The following pathological abnormalities that can occur: 16
1. Disease with metastases to the lymph glands
2. Reactive lymph nodes
3. HIV infection
4. Sarcoidosis
5. Masseteric hypertrophy
6. Prominent cervical transverse process of C1
7. Chronic parotitis
8. Lymphangioma (Paediatric)
9. Haemangioma.

Supplementary examinations

Cytologic examination (biopsy needle is small) is very important in the diagnostic swelling of the salivary gland tumor is suspected. With this method in general can be achieved while working diagnosis. And the majority of clinical and cytologic benign tumor, is no longer required additional examination with imaging. 16

Head and neck X-rays may show any or no bone disorders, tau may be important also for differential diagnostic (salivary gland stones: calcified lymph nodes). CXR is required to find the possibility of hematogenous metastasis. With ekografi or CT, but even better with MRI can provide a general description of the nature of the relationship of space restrictions and the tumor size, localization, located inside or outside the lymph nodes. Pleomorf adenomas can be distinguished from other salivary gland tumors with MRI. This method can not distinguish between benign and malignant tumors. X-ray examination with contrast and glands submandibular glands parotidea (sialografi) is required for further investigation of inflammation (chronic) or calcification and may have significance for the diagnosis diferensial.16

Benign tumors of the salivary glands

A. In Children

Gland benign tumor most often in children is a parotid hemangioma. Mass lies beneath the skin has a bluish discoloration, and there may be fluctuations in the size of the mass when the children cry. This would indicate an increase in tumor size gradually over four to six months of life, but started to resolution at the age of two years. Hemangioma is similar to limfangioma, which also arise in the parotid gland. Pleomorphic adenoma is the third most tumors are found, and the most frequent solid tumor found in children. Other benign tumors include neurofibroma and lipoma. Salivary gland tumors in children most often the parotid gland, submandibular region and are minor salivary glands are rarely terjadi.1

B. In Adults

B.1 pleomorphic adenoma

Benign mixed tumor is causing 75% of the parotid gland, both benign or malignant in adults. The disorder is most often in the parotid region, which appears as a painless swelling that persists for a long time in front of the ear or the parotid gland caudal region. These tumors do not cause pain or facial nerve weakness. In the parotid region, although classified as a benign tumor, the tumor can grow large in size and become the local destructive. Total surgical resection is the only therapy. Care should be taken to prevent injury to the facial nerve and the nerve is protected even if the location is adjacent to tumor.1, 13

Tumors may develop first in the deep lobe and extends into the area retromandibula. In this situation dilindugi facial nerve are carefully and gently retracted so that the tumor can be removed from its location in the space parafaringeal. Sometimes the deep lobe pleomorphic adenomas appear in the mouth. This can be realized with the mole and the arch of the palate deviation tonsilaris to the center line of the lateral mass of the tonsil. Resection should be performed through the neck rather than through the mouth. When the parotid tumor, the entire superficial lobe, or part of the lateral gland facial nerve, was appointed at the same time for purposes of biopsy, cut by maintaining facial nerve. Pathological examination of frozen cuts can not provide the actual origin of the tumor and radical surgery may be needed if the results already obtained permanent cuts. "The release of" pleomorphic adenoma in parotid gland superficial lobe is not recommended because of the possibility of recurrence of tinggi.1, 13

Histologically, pleomorphic adenoma originating from the distal portion of the salivary channels, including channels of intercalated and asini. Mixture of epithelial, myoepithelial and stromal part is represented by its name: benign mixed tumor. Of the three types above can be more dominant than the other types, but all three types must exist to confirm diagnosis.1, 13

At the time of surgery appears encapsulated tumor mass, but the pathological examination showed expansion of the capsule out. If the entire parotid gland tumor with a normal mass surrounding the resected tumor, kekabuhannya incidence of less than 8 percent. Pleomorphic adenoma recurrence Seadandainya, there is the possibility of injury is great at least one of the facial nerve when ulang.1 resected tumors, 13

Although the tumor is considered benign, there are cases of recurrence that many times with excessive growth in which the tumor extends and about the external canal and may extend into the oral cavity and parafaringeal space. Recurrent tumors can undergo malignant degeneration, but the incidence is less than 6 percent. Irradiation therapy for recurrent tumors repeatedly and not given the treatment of unresectable paliatif.1, 13

The differential diagnosis for pleomorphic adenoma is malignant neoplasms: adenoid cystic carcinoma, low-grade polymorphic adenocarcinoma, a neoplasm in the adnexa, and mesenchymal neoplasms. A rare complication of pleomorphic adenoma is a malignant change in the direction of the carcinoma ex-pelomorfik adenoma (carcinoma ex-pleomorphic adenoma) or other name of benign mixed tumors that metastasize (benign mixed tumors metastazing) .19 Prognosis pleomorphic adenoma is perfect, with a cure rate achieved 96% .19

B.2 Limfomatosum Adenokistoma papillary (Warthin tumor)

Other benign tumors of the salivary glands are relatively frequent. These tumors most commonly occur in men aged 50-60 years and are associated with risk factors for smoking. This tumor is a tumor most often occurs bilaterally. These tumors are identified by the presence histologinya papil structure composed of a double layer of granular cells or onkosit eusinofil, cystic changes, and infiltration of matang.19 limfostik

These tumors originate from ectopic ductal epithelium. CT scan may show a mass with clear limits on the postero-inferior part of the superficial lobe of parotid. If the inspection is done then it can be seen radiosialografi increased activity associated with the onkosit and increased content of mitochondria. Diagnosis based on examination histology.19

Therapy consists of surgical resection with facial nerve protection. The tumor is encapsulated and not likely to recur. In general, the handling of parotid tumor biopsy incisions should not be done, because it will change the texture so that when the biopsy scar will damage the anatomical structure of the parotid tumor so that when definitive surgery is performed so that the operation will be difficult for operators to be less good results.

Benign tumors of the salivary glands were: 1.19

1. Oksifil adenoma (cell asidofilik)

2. Serous cell adenoma

3. Onkositoma

Therapy was similar in pleomorphic adenomas.

Parafaringeus space is a primary homelands for benign tumors. The most frequent are tumors of the salivary glands arising from the deep lobe of parotid gland and extend into the space parafaringeal. Neurogenic tumors arising as schwanoma may originate in this region of the vagus nerve or the cervical sympathetic pathway. These tumors appear as a soft mass which suppresses lateral pharyngeal wall medial direction. These tumors should be approached through the neck than in the mouth because of the large blood vessels and cranial nerves are important in this space. Not only a preliminary arteriogram showed tumor effect on the location of the internal carotid artery but also useful in detecting tumor kemodektoma or neurogenic tumors in the room ini.1

The most frequent tumor in pleomorphic adenomas is parafaringeal space. The second most common is adenokistik malignant carcinomas. The largest group of other tumors are derived from neurogenic, as schwanoma and neuroma. Some tumors of the room parafaringeal should be addressed, through a trans-cervical approach externally. This action will provide a better control of major blood vessels in this area. Also prevent tumor metastasis, which can occur through a transoral approach. Due to extensive post-operative edema can occur, often required trakeostomi.1

Tabel The mass-mass differences in saliva gland 16

Malignant tumors in Saliva Glands

A. Saliva Gland Malignant Tumors in Children
     A.1 carcinoma mukoepidermoid

Malignant parotid tumors in children are rare. Most frequent tumor in children is mukoepidermoid carcinoma, usually of low rank. This tumor is the largest type of malignancy of the salivary glands caused by radiation. Obtained the highest incidence of events between the ages of 30-40 decade. Nearly 75% of patients had an asymptomatic swelling symptoms, 13% with pain, and a few others with facial nerve paralysis. These tumors originate from epithelial cells of salivary duct interlobar and intralobar. These tumors are not encapsulated, and lymph node metastasis was found as much as 30-40%. Determination of the degree of malignancy based on clinical pathology consists of a low-grade, medium, and tinggi.1, 22

Low-grade tumors resembling pleomorphic adenoma (oval-shaped, well defined, and the presence of mucoid fluid). Intermediate-grade tumors and is characterized by a high degree of infiltrative process. Young patients are usually degree rendah.22

In certain circumstances, even after adequate resection, if there is evidence of metastatic disease, postoperative radiation therapy is recommended. Should be considered carefully to deliver radiation to the child to get an idea of ​​the potential complications that would come. In certain circumstances such as if there is invasive to the nerves or blood vessels, or metastatic disease should be done radiasi.22

     A.2 Adenocarcinoma

Parotid is the second most frequent malignancy in children. These tumors present in 4% of all parotid tumors and 20% of minor salivary tumors. Most of the patients tanapa symptoms (80%), 40% of the tumor was found fixed to the tissues above or below, 30% of patients develop metastases to cervical nodes, 20% had facial nerve paralysis, and 15% felt pain on his face. 22,23,24

These tumors originate from the terminal tubules and intercalated duct cells or strained. Another type of species is a type of undifferentiated malignancy as a whole has a poor life expectancy. And squamous cell cancer asini adenokistik at first almost had a benign disease course, with a long life expectancy, only the last show on local recurrence of the first or distal arising from the area or lung metastasis. Therapy remains inadequate resection, total, regional. 22,23,24

B. Malignant tumors of the salivary glands in Adults

With increasing age, the possibility that the mass in malignant salivary gland getting bigger, in general, which often occurs in people with age 40 years was 25% of parotid tumors, 50% of submandibular tumors, and one-half to two-thirds of minor salivary gland tumors are ganas.1

Based on the degree of ferocity, salivary gland tumors can be divided into degrees high, medium, and rendah.1

A. High degree of malignant tumors

Which include a high degree are: 1

1. Carcinoma mukoepidermoid

2. Squamous cell carcinoma

3. Undifferentiated adenocarcinoma

4. Adenokistik carcinoma (silindroma)

Adenokistik carcinoma (silindroma) is a salivary gland tumor include tumor specific with a high degree of malignant potential. The tumor is in the can in 3% of all parotid tumors, 15% of submandibular tumors, and 30% of minor salivary gland tumors. Majority of patients felt asymptomatic, although most of the tumor fixed to the structure above or below it. Involvement of bone found in 1.5 cases, 25% have pain in the face, 20% have involvement of the facial nerve, and lymphatic metastasis rate of approximately 15%. These tumors are characterized by early perineural spread. Tumor origin is thought of myoepithelial cells. There are three patterns of growth, namely: cribriform, solid, and tubular. These tumors differ from previous tumors because it has a long course of the disease characterized by frequent local recurrence, and relapse can occur after 15 years. Patients with carcinoma adenokistik have high life expectancy of up to five years, the life expectancy of ten years whole found less than 20 persen.1, 22

High degree of malignant tumor therapy include radical surgical resection of primary tumor, if necessary, adjacent vital structures such as the mandibular, maxillary, and even the temporal bone. So that a perfect excision of the tumors are malignant, the facial nerve adjacent to the tumor should be excised. Nerve grafting to restore nerve continuity can be considered beneficial because it can restore the function of the facial nerve. If the facial nerve paralysis has been demonstrated, the poor prognosis.1

Tabel Tumor Malignant Tumor-gland saliva in Adult1

2. Malignant tumors moderate and low

Which include the degree of tumor type is squamous cell carcinoma mukoepidermoid and asini. If these tumors occur in the parotid gland, performed parotidektomi dilindingi total and facial nerve was not dangerous if perlindingan total resection of the malignancy. Direct invasion of the nerves will impede the protection of the nerve. Frozen section should be performed to rule out the presence of nerve invasion, and invasion was always occurs in the cranial. If possible do nerve grafts at the time of resection bedah.1

Radical neck dissection is not a routine part of the initial resection for malignant parotid but necessary if the palpable presence of cervical metastasis or if there is a recurrence of malignant tumor of the parotid region. Radical neck dissection combined with radical resection of the parotid area. If at the time of surgery was found that one of them associated with malignant parotid tumors, the preferred procedure is parotidektomi total removal of the surrounding premises, adjacent soft tissue. Facial nerve is protected if it does not harm the tumor resection. Facial nerve graft is performed if possible, especially if the nerve pathway should be resected. If possible, part of the eye is protected, as this will cause a major problem post-surgery. Digastrikus upper nodes and lymph-nodes in the parotid gland removed at the time of the initial surgical procedure. If the lymph-nodes showed keganasa, complete radical neck dissection is recommended, or post-operative radiation treatment. 1

High degree mukoepidermoid carcinoma and squamous cell carcinoma is a tumor that is likely to cause cervical metastasis. There is a 40% incidence of metastasis for squamous cell carcinoma and 16% for high-grade carcinomas mukoepidermoid. Adenokistik carcinoma, adenocarcinoma, and carcinoma can metastasize asini directly to the neck but most likely because it spreads by direct extension. These tumors are also likely to cause hematogenous metastasis to the lung. Resection for parotid tumors and lymph subdigastrikus. If at that time found to have metastasis, neck dissection can be done total.1

Facial nerve paralysis is a sign of poor prognosis, it is also an indication of the greatest likelihood of metastasis is an indication for cervical and neck surgery radikal.1

For the treatment of post-operative radiation therapy is recommended for most malignant parotid tumors. Additional radiation therapy may lower recurrence rate total. Radiation therapy is not a replacement therapy for surgical resection is adequate and does not reduce the number of positive tumor recurrence if the limit. 1

The prognosis for adults with malignant parotid tumors depend on tumor stage and size at the time found, the presence or absence of facial nerve paralysis, and showed cervical metastasis. Specific pathology of the tumor is important in ensuring the survival and extensive surgical procedures required. Initial complaint of pain in some studies menunukkan marks a poor prognosis. 1,15,16,19

Tabel TNM classification of tumors of the salivary glands1

(*)Local expansion of the means described as a tumor involving the skin, soft tissue, bone, or the lingual or facial nerve 1

2.1 asini cell carcinoma

Occurs in approximately 3% of parotid tumors. These tumors invade more women than men. The peak incidence between ages 5 and 6 decades. There is a cervical lymph node metastases in 15% of cases. Typical pathological signs is the presence of amyloid. The origin of the component cells are thought serous acinar and duct cells intercalated.24

2.2 Squamous cell carcinoma

Generally occurs in older men and is characterized by rapid growth. Incidents of metastasis to lymph nodes by 47%. These tumors are usually found in the parotid gland. Tumor cells is thought to originate from duct ekskretorius.24

2.3 Salivary duct carcinoma 

These tumors are rare, resembling mammary ductal cancer. Stensen duct is more commonly affected than the duct of Wharton. These tumors have a tendency to recur at the same place (35%) and can progress to distant metastases (62%), with only 23% of patients can live for 3 years. 22.24

2.4 myoepithelial carcinoma

These tumors are rare. These tumors are unique because there is myoepithelial differentiation by immunohisto-chemical structure and ultra structure unique. Treated with postoperative radiation and chemotherapy if diindikasikan.24

2.5 Onkositoma malignant

Similar to benign except for marked variation in the presence of distant metastasis, metastasis to cervical lymph and blood vessels, nerves, or the invasion of limfatik.24

2.6 Malignant Lesions limfoepitel

These tumors are rare, characterized by the presence of benign and malignant areas in the tumor. Section represent malignant anaplastic cancer originating from the ductal. Metastasis to lymph nodes has repeatedly ditemukan.24

2.7 Malignant Lymphoma

Primary malignant lymphoma of the salivary glands are rare, generally in old age can be the man. It is also observed in approximately 5-10% of patients with parotid gland Warthin tumor. Optimal therapy is radiation therapy to biopsy the area. Better prognosis for salivary gland lymphoma than nodal lymphomas with a similar histologic appearance. 23.24

2.8 Metastasis to the parotid glands from elsewhere

Parotid gland can be a metastasis of the malignancy derived from the skin, kidney, lung, breast, prostate, and gastrointestinal pencernaan.24

Complication after parotidektomi

A. Frey's syndrome

Gustatory sweating when parotidektomi present in 50% of patients. Cross re-innervation occurs in the nervous system autonomic parotid gland occurring after parotidektomi. Parasympathetic fibers, which is stimulated by the smell and taste of food is now menginervasi sweat glands and blood vessels by acetylcholine, and lead to sweating and redness of the skin over the area tersebut.22

B. Paralysis / paresis of the facial nerve

 paralysis / paresis nerve paresis after surgery of benign salivary tumors are usually small (<5%).> 22:24

Additional therapy

Since the number of histologic subtypes of malignant parotid, a general statement relating to the use of additional therapy can not be made. If it can be in surgery, surgery is the primary modality of treatment for most malignant parotid gland tumors. Common indication for postoperative radiation therapy as follows: 24

A. The largest tumor diameter> 4 cm

2. High-grade tumors

3. Tumor invasion into local structures, lymphatics, nerves and blood vessels

4. The tumor is very close to the nerve

5. Tumors originate from within or outside the lobe in

6. Tumors arising after resection re-

7. Positive limit of the final inspection of pathology

8. The involvement of regional lymph nodes

There is no proven effective chemotherapy as single modality therapy. For some histologic subtypes, some experts recommend a combination of chemotherapy and radiation. Currently, the use of immunotherapies currently in the experimental stage. 24

Prognosis

After adequate therapy in benign tumors occur locally residif less than 1% of cases. However, if a benign tumor is not removed widely, often resulting local residif. This can especially happen if just doing a simple enucleation. On re-operation there is a greater chance of nerve damage is important as the facial nerve and in some cases such residif is malignant. 16,19,22,23,24

Prognosis in malignant tumors is highly dependent on the histology, tumor size and local extension and number of metastatic neck gland. If a malignant tumor before treatment had no loss of nerve function, then the prognosis is worse. 5-year survival is approximately 5%, but it still remains dependent on histologinya. 16.24

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