NASOPHARYNX, PNS

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NASOPHARYNX, PNS SALIVARY GLANDS

• DR. SRINIVAS RAJKUMAR THIRAVIARAJ

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Why is this subdivisionnecessary?

• The primary tumors in each of these areas have
  different routes of
• spread
• nodal dissemination
• prognosis

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• Cuboidal chamber
• Begins at Posterior Choana
• Continues into Oropharynx via pharyngeal isthmus

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Boundaries

• Anterior
• posterior nasal cavity
• Posterosuperior
• Lower clivus, upper cervical
• spine, and prevertebral
• muscles
• Inferior
• Divided from the oropharynx
• by a horizontal line drawn
• along the hard and soft
• palates

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Neck Lymphatics
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• Level I
• below mylohyoid muscle and above the lower margin
  of the hyoid bone
• anterior to the posterior border of the
  submandibular glands
• level Ia - submental nodes - between the anterior
  bellies of the digastric muscles
• level Ib - submandibular nodes - posterolateral
  to the anterior belly of the digastric muscles

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• Level II
• internal jugular (deep cervical) chain
• base of skull to inferior border of hyoid bone
• anterior to the posterior border of
  sternocleidomastoid (SCM) muscle
• posterior to the posterior border of the
  submandibular glands
• level IIa - anterior, lateral, or medial to the
  vein or posterior to the internal jugular vein
  and inseparable from it
• level IIb - posterior to the internal jugular
  vein and have a fat plane separating the nodes
  and the vein
• between CCAs, below superior aspect of manubrium

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• Level III
• internal jugular (deep cervical) chain
• lower margin of hyoid to lower margin of cricoid
  cartilage
• anterior to the posterior border of SCM
• lateral to the medial margin of the common
  carotid artery (CCA)/internal carotid artery
  (ICA)

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• Level IV
• internal jugular (deep cervical) chain
• lower margin of cricoid cartilage to level of the
  clavicle
• anterior and medial to an oblique line drawn
  through the posterior edge of the
  sternocleidomastoid muscle and the posterolateral
  edge of the anterior scalene muscle 4
• lateral to the medial margin of the CCA

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• Level V
• posterior triangle (spinal accessory) nodes
• level Va - superior half, posterior to levels II
  and III (between base of skull and inferior
  border of cricoid cartilage)
• level Vb - inferior half, posterior to level IV
  (between inferior border of cricoid cartilage and
  the level of clavicles)

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• Level VI
• prelaryngeal/pretracheal/Delphian node
• anterior to visceral space
• from inferior margin of hyoid bone to manubrium
• anterior to of levels III and IV
• Level VII
• superior mediastinal nodes

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Foramen lacerum

• triangular hole between sphenoid, apex of petrous
  temporal and basilar part of occipital.
• The artery of pterygoid canal, the nerve of
  pterygoid canal and some venous drainage pass
  through the foramen lacerum.

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• Foramen Ovale
• Posterior part of the sphenoid bone,
  Posterolateral to the foramen rotundum.
• Otic ganglion,
• V3( Mandibular nerve )
• Accessory meningeal artery,
• Lesser petrosal nerve,
• Emissary veins)

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CA Nasopharynx

• Carcinoma of the nasopharynx frequently arises
  from the lateral wall, with a predilection for
  the fossa of Rosenmuller

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LOCAL SPREAD

• Anteriorly into the nasal fossa,
• Posterolaterally beyond the pharyngobasilar
  fascia to involve the parapharyngeal and the
  carotid spaces
• Laterally to the pterygoid muscles,
• Posteriorly to the prevertebral muscles
• inferiorly to the oropharynx

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• Superiorly, bony erosion of the skull base
  involving
• The floor of the sphenoid sinus,
• Clivus
• Apex of petrous bone
• Basal foramina.

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• ? Intracranially via foramen lacerum
• High frequency of perineural spread along the
  maxillary division (V2) and the mandibular
  division (V3) of the trigeminal nerve with
  subsequent intracranial extension through the
  foramen rotundum and foramen ovale

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Adjacent soft tissue

 
  Nasal cavity 87
  Parapharyngeal space, carotid space 68
  Pterygoid muscle (medial, lateral) 48
  Oropharyngeal wall, soft palate 21
  Prevertebral muscle 19
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Bony erosion/paranasal sinus
   
  Clivus 41
  Sphenoid bone, foramina lacerum, ovale, rotundum 38
  Pterygoid plate(s), pterygomaxillary fissure, pterygopalatine fossa 27
  Petrous bone, petro-occipital fissure 19
  Ethmoid sinus 6
  Maxillary antrum 4
  Jugular foramen, hypoglossal canal 4
  Pituitary fossa/gland 3
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Extensive/intracranial extension
   
  Cavernous sinus 16
  Infratemporal fossa 9
  Orbit, orbital fissure(s) 4
  Cerebrum, meninges, cisterns 4
  Hypopharynx 2
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Nasopharynx Imaging

• Before the era of CT - plain radiography
• The classic 5 views of NPC that Ho described
  consist of lateral, submentovertical,
  occipitosubmental, 25 occipitomental, and
  occipitomaxillary views

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• T1 Attenuation Metastasis

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PARA NASAL SINUSES
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Ethmoid Sinuses

• the Ethmoid air cells
• separated from the orbital cavity by a thin,
  porous bone, the lamina papyracea, and from the
  anterior cranial fossa by a portion of the
  frontal bone, the fovea ethmoidalis.
• They are in close proximity to the optic nerves
  laterally and the optic chiasm posteriorly.

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• The middle ethmoid cells open directly into the
  middle meatus.
• The anterior cells may drain indirectly into the
  middle meatus via the infundibulum.
• The posterior cells open directly into the
  superior meatus.

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• The various radiographic positions used to study
  paranasal sinuses are
• 1. Occipito-mental view (Water's view)
• 2. Occipital-frontal view (Caldwel view)
• 3. Submento-vertical position (Hirtz position)
• 4. Lateral view
• 5. Oblique view 39 Degrees oblique (Rhese
  position)

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Maxillary Sinuses

• The maxillary sinuses are the largest of the
  paranasal sinuses.
• They are pyramid-shaped cavities located in the
  maxillae.
• The lateral walls of the nasal cavity form the
  base and the roofs correspond to the orbital
  floors, which contain the infraorbital canals.

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• The floors of the maxillary sinuses are composed
  of the alveolar processes.
• The apices extend toward and frequently into the
  zygomatic bones.

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• Secretions drain by mucociliary action into the
  middle meatus via the hiatus semilunaris through
  an aperture near the roof of the maxillary sinus.
  
• Ohngren's line is a theoretic plane dividing each
  maxillary sinus into the suprastructure and
  infrastructure it is defined by connecting the
  medial canthus with the angle of the mandible.

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Sphenoid Sinus

• The sphenoid bone forms a midline inner cavity
  that communicates with the nasal cavity through
  an aperture in its anterior wall

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• It is directly apposed superiorly to the
  pituitary gland and optic chiasm, laterally to
  the cavernous sinuses, anteriorly to the ethmoid
  sinuses and nasal cavity, and inferiorly to the
  nasopharynx.

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FRONTAL SINUS

• The paired, typically asymmetric frontal sinuses
  are located between the inner and outer tables of
  the frontal bone.

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• They are anterior to the anterior cranial fossa,
  superior to the sphenoid and ethmoid sinuses, and
  superomedial to the orbits. They usually
  communicate with the middle meatus of the nasal
  cavity.

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NATURAL HISTORY

• Nasal vestibule carcinomas can spread by direct
  invasion of the upper lip, gingivolabial sulcus,
  premaxilla (early events), or nasal cavity (late
  event)
• Vertical invasion may result in septal
  (membranous or cartilaginous) perforation or alar
  cartilage destruction.
• Lymphatic spread from nasal vestibule carcinomas
  is usually to the ipsilateral facial (buccinator
  and mandibular) and submandibular nodes.

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Nasal Cavity and Ethmoid SinusesCa Spread

• The pattern of contiguous spread of carcinomas
  varies with the location of the primary lesion.
• Tumors arising in the upper nasal cavity and
  ethmoid cells can extend to the orbit through the
  thin lamina papyracea and to the anterior cranial
  fossa via the cribriform plate, or they may grow
  through the nasal bone to the subcutaneous tissue
  and skin.

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• Lateral wall primaries invade the maxillary
  antrum, ethmoid cells, orbit, pterygopalatine
  fossa, and nasopharynx.
• Primaries of the floor and lower septum may
  invade the palate and maxillary antrum.

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• Perineural extension (typically involving
  branches of the trigeminal nerve) is seen most
  frequently with adenoid cystic carcinomas.

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• Lymphatic spread of nasal cavity primaries is
  uncommon, although spread to retropharyngeal and
  cervical lymph nodes is possible

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Maxillary Sinuses

• The pattern of spread of maxillary sinus cancers
  varies with the site of origin.
• Suprastructure tumors extend into the nasal
  cavity, ethmoid cells, orbit, pterygopalatine
  fossa, infratemporal fossa, and base of skull.

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• Invasion of these structures gives lesions of the
  suprastructure a poorer prognosis.
• Treatment is associated with greater morbidity as
  a consequence of craniofacial resection or
  radiation of intracranial and ocular structures

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• . Infrastructure tumors often infiltrate the
  palate, alveolar process, gingivobuccal sulcus,
  soft tissue of the cheek, nasal cavity, masseter
  muscle, pterygopalatine space, and pterygoid
  fossa.

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• The maxillary sinuses are have a limited
  lymphatic supply
• Correspondingly low incidence of lymphadenopathy
  at diagnosis (Ipsilateral subdigastric and
  submandibular nodes are involved most frequently.
  
• Hematogenous spread is uncommon.

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CLINICAL PRESENTATION

• Nasal Vestibule
• Asymptomatic plaques or nodules, often with
  crusting and scabbing.
• Advanced lesions - pain, bleeding, or ulceration.

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Nasal Cavity

• Nasal cavity tumors present with symptoms and
  signs of nasal polyps (e.g., chronic unilateral
  discharge, ulcer, obstruction, anterior headache,
  and intermittent epistaxis), hence delaying the
  diagnosis.
• Additional symptoms and signs develop as the
  lesion enlarges medial orbital mass, proptosis,
  expansion of the nasal bridge, diplopia resulting
  from invasion of the orbit, epiphora due to
  obstruction of the nasolacrimal duct, anomaly of
  smell or anosmia from involvement of the
  olfactory region, or frontal headache due to
  extension through the cribriform plate.

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Ethmoid Sinuses

• Central/facial head-aches and referred pain to
  the nasal or retrobulbar region,
• a subcutaneous mass at the inner canthus,
• nasal obstruction and discharge,
• diplopia, and proptosis.

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Maxillary Sinuses

• Diagnsosis mostly made in advanced stages
• facial swelling, pain, or
• paresthesia of the cheek induced by disease
  extension to the premaxillary region,
• epistaxis, nasal discharge and obstruction
  related to tumor spread to the nasal cavity

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SALIVARY GLANDS
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Parotid Gland
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• The gland has four surfaces superficial or
  lateral,superior, anteromedial and posteromedial.
  
• The gland has three borders anterior, medial and
  posterior. The Parotid gland has two ends
  superior end in the form of small superior
  surface and an inferior end (apex).

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• (1) Superficial or lateral relations The gland
  is related superficially to the skin. Superficial
  fascia, superficial lamina of investing layer of
  deep cervical fascia and Great auricular nerve
  (anterior ramus of C2 and C3)

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• (2) Anteromedial relations The gland is related
  anteromedially to the mandibular ramus, masseter
  and medial pterygoid muscles. A part of the gland
  may extend between the ramus and medial pterygoid
  as the pterygoid process. Branches of facial
  nerve and parotid duct emerge through this
  surface.

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• (3) Posteromedial relations The gland is related
  posteromedially to mastoid process of temporal
  bone with its attached Sternocleidomastoid and
  digastric muscles, styloid process of temporal
  bone with its three attached muscles (Stylohyoid,
  Stylopharyngeus and Styloglossus) and carotid
  sheath with its contained neurovasculature
  (Internal Carotid artery, Internal Jugular vein,
  9th, 10th, 11th and 12th cranial nerves)
• .

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• (4) Medial relations The parotid gland comes
  into contact with the superior pharyngyeal
  constrictor muscle at the medial border where the
  anteromedial and posteromedial surfaces meet.
  Hence there is a need to examine the fauces in
  parotitis

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Parotid Gland Anatomy Summary

• Superficial to and partly behind the ramus of the
  mandible and covers the masseter muscle.
• Superficially, it overlaps the posterior part of
  the muscle and largely fills the space between
  the ramus of the mandible and the anterior border
  of the sternocleidomastoid muscle.

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• One or more isthmi that wrap around the branches
  of the facial nerve connect the superficial and
  deep lobes of the gland.
• The nerve enters the deep surface of the gland as
  a single trunk, passing posterolateral to the
  styloid process.

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• It usually leaves the gland as five or more
  branches, emerging at the anterior, upper, and
  lower borders of the gland.
• The facial nerve runs superficial to the main
  blood vessels that traverse the gland but is
  interwoven within the glandular tissue and its
  ducts.

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• The parotid gland contains an extensive lymphatic
  capillary plexus, many aggregates of lymphocytic
  cells, and numerous intraglandular lymph nodes in
  the superficial lobe

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• Lymphatics drain from more lateral areas on the
  face, including parts of the eyelids, diagonally
  downward and posteriorly toward the parotid
  gland, as do the lymphatics from the frontal
  region of the scalp.

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• Superficially and more deeply, are parotid nodes.
  
• Drain downward along the retromandibular vein to
  empty in part into the superficial lymphatics and
  nodes along the outer surface of the
  sternocleidomastoid muscle and in part into upper
  nodes of the deep cervical chain.
• Lymphatics from the parietal region of the scalp
  drain partly to the parotid nodes in front of the
  ear and partly to the retroauricular nodes in
  back of the ear, which, in turn, drain into upper
  deep cervical nodes

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Innervation

• Entirely autonomic.
• Postganglionic sympathetic fibers from superior
  cervical sympathetic ganglion reach the gland as
  periarterial nerve plexuses around the external
  carotid artery and their function is mainly
  vasoconstriction.
• The cell bodies of the preganglionic sympathetics
  usually lie in the lateral horns of upper
  thoracic spinal segments.

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• Preganglionic parasympathetic fibers leave the
  brain stem from inferior salivatory nucleus in
  the glossopharyngeal nerve (cranial nerve IX) and
  then through its tympanic and then the lesser
  petrosal branch pass into the otic ganglion.
  There, they synapse with postganglionic fibers
  which reach the gland by hitch-hiking via the
  auriculotemporal nerve, a branch of the
  mandibular nerve.
• Parotid gland salivation is ultimately caused by
  the glossopharyngeal nerve

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Submandibular Gland

• The paired submandibular glands or submaxillary
  glands are major salivary glands located beneath
  the floor of the mouth.
• They weigh about 15 grams and produce around
  60-67 of the total volume of saliva.

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• Fills the triangle between the two bellies of the
  digastric and the lower border of the mandible
  and extends upward deep to the mandible.
• It lies partly on the lower surface of the
  mylohyoid and partly behind the muscle against
  the lateral surface of the muscle of the tongue,
  the hypoglossus.
• The submandibular gland has a larger superficial
  part, or body, and a smaller deep process.

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• The inferior surface is adjacent to the
  submandibular lymph nodes, and the deep process
  of the submandibular gland lies between the
  mylohyoid laterally and the hyoglossus medially,
  and between the lingual nerve above and the
  hypoglossal nerve below .

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• Rich lymphatic capillary network lies in the
  interstitial spaces of the gland.
• From the lateral and superior portions of the
  gland, lymph flows to the prevascular or
  preglandular submandibular lymph nodes.

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• The posterior portion of the gland gives rise to
  one or two lymphatic trunks, which follow the
  facial artery and go directly to the anterior
  subdigastric nodes of the internal jugular chain
  .

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• Arterial Supply - facial and lingual arteries.
• Venous Drainage - lingual and facial veins.
• Lymphatics - The submandibular nodes lie in
  close proximity to the gland, or within its
  structure. Lymph flows from this region to the
  upper deep cervical nodes (level II).

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Lymphatic Spread

• Lymph will usually travel to upper deep cervical
  nodes, including the jugulo-omohyoid node.

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Innervation

• The submandibular ganglion is the source of
  neural supply to the submandibular gland. This
  small ganglion is associated with the lingual
  nerve as it passes anteriorly along the floor the
  mouth. Parasympathetic fibres arrive via the
  chorda tympani, a branch of the facial nerve VII.
  Sympathetic fibres are derived from the facial
  artery plexus.
• General sensory nerves arrive from the lingual
  nerve (V3).

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Sublingual Gland

• This smallest of the three major salivary glands
• Lies between the mucous membrane of the floor of
  the mouth above and the mylohyoid muscle below,
  the mandible laterally, and the genioglossus
  muscles of the tongue medially .

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• The sublingual gland drains either to the
  submandibular lymph nodes or more posteriorly
  into the deep internal jugular chain between the
  digastric and omohyoid muscles. Rarely, the
  lymphatics of the sublingual gland drain into a
  submental node or supraomohyoid jugular node

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• Arterial Supply
• The sublingual branch of the lingual artery and
  submental branch of the facial artery contribute
  to the supply of the sublingual gland.
• Venous Drainage
• Either accompanying sublingual veins to the
  common facial vein or passing laterally to the
  facial vein.
• Lymphatics
• The sublingual gland drains primarily to
  submental nodes.

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Innervation

• via the submandibular ganglion,
• Nerves passing to the sublingual gland leave the
  ganglion and region the lingual nerve, before
  departing again to supply their target organ

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• Sub lingual , Y-Mylohyoid, T - Hyoglossus

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NATURAL HISTORY

• Local invasion is the initial route of spread of
  malignant tumors of the salivary glands,
  depending on location and histologic type. For
  parotid tumors, this may result in fixation to
  structures in around 20 of cases . Skin invasion
  is more often seen in parotid tumors (10),
  compared with submandibular tumors (3) .

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• Approximately 25 of patients with a malignant
  parotid salivary gland tumor present with facial
  palsy from cranial nerve invasion

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Clinical Presentation

• Three of four parotid masses are benign .
• Patients most often have a painless, rapidly
  enlarging mass, often present for years before a
  sudden change in its indolent growth pattern
  prompts the patient to seek medical attention

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• Duration of clinical symptoms before diagnosis
  may last more than 10 years . For malignant
  tumors, the median duration of clinical symptoms
  generally is shorter (3 to 6 months) compared to
  that of benign tumors, although for some minor
  salivary gland tumors, median periods of 2 year
  have been reported .

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• Pain is more frequently associated with malignant
  disease.
• Although as many as one third of parotid cancers
  may have facial nerve involvement, only 10 to
  20 of patients complain of pain .

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• Pain may appear with involvement of deeper
  structures (masseter, temporal, and pterygoid
  muscles).
• Rarely, tumors of the parotid may involve the
  base of skull and cause intractable pain and
  paralysis of various cranial nerves.