PAROTID SWELLING CASE PROFORMA

2. Skin over Parotid: Any redness, edema, ulceration, sinus,

Name: Age: Sex: Occupation: Address: fistula, discharge, fungation.
HISTORY 3. Stenson Duct: Retract cheek with spatula and inspect the
duct (opposite to 2nd upper molar) Look for any pus, serous
Chief Complaints:
discharge, blood.
Swelling below and in front of Rt/Lt ear since __
4. Fistula: Note position and relation to gland/duct
History of Present Illness:
5. Inspection for other swellings in the neck
Patient was apparently asymptomatic __ days back when he developed
1. Swelling- Onset, duration, size, site, progression (recent increase of PALPITATION:
size), associated with pain/or not/ while eating, any aggravation with Confirm inspection findings
food intake (excessive salivation, size or pain increase), any H/O 1&2. Local rise of Temperature -& Local tenderness
discharge in the mouth (purulent etc) or also fever, any H/O 3. SWELLING: Number, Site size, surface, margins, consistency,
pressure/infiltration on facial nerve ( drooling of saliva, difficulty in fluctuation, matted or not and fixity
closing eyes, deviation of mouth), any H/O significant loss of Curtain sign: Mobility
weight/anorexia/restriction of jay movements, any associated dryness of Clench Masseter muscle- See if swelling is mobile over it or not.
mouth, eyes Bimanual Examination: One finger of one hand inside mouth in
Pain: character (throbbing=abscess, colicky pain during meals= stone) front of tonsil, other hand outside, behind the ramus of
Discharge- for parotid fistula mandible.
Any other swellings in neck 4. Skin over swelling: Induration/Fluctuation/ Pitting on
Other sites of metastasis: pressure (Seen in Parotid abscess)
H/O Cough, haemoptysis, chest pain 5. Duct: Feel for duct by rolling finger over taut masseter,
H/O abdominal pain, jaundice, abdominal distention terminal part bidigitally with index finger inside mouth and
H/O pain in end of long bones, back ache thumb over cheek.
H/O headache, vomitings, convulsions 6. Fistula: Note its position in relation to gland or duct
PAST HISTORY: [masseteric or premasseteric]
H/O similar complaints 7. Examination of FACIAL NERVE
-Any H/O HTN, DM, CAD , Hypo/Hyperthyroidism/ Epilepsy/ 8. Lymph Nodes of the neck. Mostly pre auricular, parotid and
Asthma/COPD/ / Blood transfusions submandibular nodes are involved
H/O irradiation to neck, syphilis, cancer, TB 9.Movements of Jaw: Restricted in malignant.
Drug and Treatment History + Allergic History: + Immunization History [ Sialography: A watery solution of Lipidiol (Neohydriol) is
For Mumps vaccine injected into the orifice of the duct and skiagram is taken. ]
FAMILY HISTORY:
OTHER SYSTEMS:
None of the patient’s parents, siblings or first degree relatives have or have had
similar complaints or any significant co morbidities CVS- Normal S1 S2 heard, No murmurs.
H/O Lymphomas, TB history contact. Respiratory: Normal vesicular breath sounds, No adventitious
PERSONAL HISTORY: sounds, GIT- Per Abdomen
Diet, Appetite, Bowel, Bladder, Sleep, Addictions [Alcohol (for parotitis) CNS- No Facial asymmetry, all reflexes are normal
and Smoking], PROVISIONAL DIAGNOSIS:
This is a case of Rt/Lt sided swelling of superficial lobe of parotid
PHYSICAL EXAMINATION gland most probably neoplastic in origin, mostly a benign tumour
1. GENERAL SURVEY like pleomorphic adenoma with no complications at present.
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky score) NOTES:
-Mental state and intelligence (CCC) Levels of Neck Lymph Nodes:
-Build, state of nutrition [weight loss and cachexia] Level I - Submaxillary and submental
-Decubitus and Attitude, Any facies Level II - Upper jugular
A __ year old patient, supine decubitus who is __ built __ nourished is Level III - Middle jugular
conscious, coherent, cooperative, and comfortably seated/lying on the Level IV - Lower jugular
bed, well oriented to time, place and person. Level V - Posterior triangle
There is No Pallor, Icterus, cyanosis, koilonychias, generalised Level VI - Central neck nodes
lymphadenopathy and no pedal edema. Level VII - Anterior mediastinal
VITALS: Temperature: Pulse, RR, BP.

LOCAL EXAMINATION-Parotid Gland

After taking informed consent, patient is examined by exposure of the

face in sitting position with arms by the side of the body.
INSPECTION:
1. Swelling:
A. Superficial Lobe: Number, Position, raised ear lobule or not,
depression below ear lobule obliterated or not, size, shape, surface,
margins and extent
B. Deep Lobe: Inspect oral cavity (bulge in tonsil, lateral wall of pharynx)
VIRCHOW’S NODE: The left supraclavicular lymph node lying between Facial Nerve Branches:
the two heads of sternocleidomastoid is called the Virchow’s lymph The facial nerve emerges from the stylomastoid foramen and
node. This lymph node may be involved by metastasis from carcinoma enters the posteromedial surface of the parotid gland. It
stomach, testicular tumour, carcinoma oesophagus and bronchogenic initially divides into an upper division (zygomaticofacial) and
carcinoma a lower division (cervicofacial). Within the gland the nerve
branches and rejoins to form a plexus within the parotid
Palpation of Parotid Duct: gland (known as pes anserinus).
The parotid duct is palpated as it lies on the masseter muscle by a finger The nerve branches then emerges from the upper pole,
rolling across the masseter muscle as the patient clinches his teeth to anterior border and the lower pole of the parotid gland.
make the muscle taut. The terminal part of the duct is palpated These branches are
bidigitally between the index finger inside the mouth and the thumb Temporal
over the cheek. Zygomatic
To palpate deep part of parotid duct: By bidigital palpation with one Upper buccal
finger inside the mouth against the tonsillar fossa and the other finger Lower buccal
outside in the parotid region Mandibular
Parotid gland is divided into superficial and deep parts by the Cervical
faciovenous plane (parotid plexus)
Surgery: Superficial Parotidectomy
Differential Diagnosis: Removal of superficial part of the parotid gland along with
Adenolymphoma of the parotid gland, Chronic sialadenitis, Carcinoma of the tumour is called superficial parotidectomy.
parotid gland, Cervical lymphadenopathy due to tuberculous lesion or The incision starts below the zygomatic process just in front
metastasis of lymphoma, Lipoma, Fibroma Rhabdomyosarcoma. of the tragus then curves round the ear lobule and the
descend downwards along the anterior border of the upper
Frey’s syndrome: third of the sternocleidomastoid muscle.
This is a condition of gustatory sweating and flushing in the parotid
region following parotidectomy and may occur in more than 50% of
patients.
This follows injury to auriculotemporal nerve during surgery of parotid
gland or temporomandibular joint, or may follow accidental injury to the
parotid gland or temporomandibular joint. Following injury to
auriculotemporal nerve, the postganglionic parasympathetic fibre from
the otic ganglion reroutes to the sympathetic nerve from the superior
cervical ganglion destined to supply the cutaneous vessels and sweat
gland of the skin in the parotid region.
The parotid region is bounded by:
Anteriorly—by the posterior border of mandible
Posteriorly—by the mastoid process and the attached
sternocleidomastoid muscle
Below—by the posterior belly of digastric
Above—by the zygomatic arch.

The international classification of salivary tumours are:

1. Epithelial tumours
• Adenomas:
−− Pleomorphic adenomas
−− Adenolymphoma—Warthin tumour
−− Oxyphilic adenoma
−− Monomorphic adenomas
• Carcinomas:
−− Acinic cell carcinoma
−− Mucoepidermoid carcinomas
−− Adenoid cystic carcinoma
−− Adenocarcinoma
−− Squamous cell carcinoma
−− Undifferentiated carcinoma
−− Carcinoma superimposed on a pleomorphic adenoma
2. Non-epithelial tumours
• Haemangioma:
• Lymphangioma
• Neurofibroma
• Neurilemmoma
3. Malignant lymphoma
4. Unclassified and allied condition