This document discusses the management of tumors of the parotid gland. It outlines the clinical diagnostic process, which involves determining if a bulge is abnormal, the organ of origin, the disorder/disease, and extent. Pattern recognition and prevalence are used to diagnose disorders like inflammatory tumors, malignant tumors, or benign tumors. The paraclinical diagnostic process is also described, including determining the need for tests, selecting appropriate tests based on factors like benefit, risk and cost, and interpreting results. Common tests discussed are biopsy methods, imaging like ultrasound, CT and MRI. The document provides guidance on when each test may be indicated.

1. Tumors of the Parotid Gland
How to Manage
Reynaldo O. Joson, MD, MSc Surg
April 18, 2014

2. Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
Inexactness of medicine as a science
No two patients are the same
No two physicians are the same

3. Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
to
Primary Health Care Physicians
General Surgeons – Head and Neck Surgeons
Other Head and Neck Surgeons and Specialists
Pathologists
Radiologists

4. Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
to
Primary Health Care Physicians
•Know how to recognize tumors and refer to Head and
Neck Specialist
•Know how to recognize mump-parotitis and manage
with analgesics and watchful waiting

5. Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
To
Radiologists
•Know how to detect tumors on imaging procedures and
determine extent or boundary in the head and neck
area
•Know how to describe lesions with utmost clarity
without making more unnecessary comments such as
pathologic diagnosis and need for additional tests and
follow-up

6. Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
To
Pathologists
•Know how to determine the pathology with utmost accuracy –
malignant, nonmalignant, inflammatory disorders and specific
type
•Know how to describe the grading of malignant tumors with
utmost accuracy

7. Tumors of the Parotid Gland
How to Manage
Managing tumors of the parotid gland
will always be a challenge!
to
General Surgeons – Head and Neck Surgeons
Other Head and Neck Surgeons and Specialists
Greatest Challenge
Clinician – Diagnostician – Therapist - Adviser

8. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Presence of an unusual bulge in the periauricular area
- start of suspicion of a parotid tumor
• Determine whether the bulge is normal or abnormal
(whether a swelling or mass). (see more notes)
• Determine the organ or tissue of origin of the swelling
or mass – parotid or other. (see more notes)
• If parotid in origin, determine the disorder and
disease and extent. (see more notes)

9. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Presence of an unusual bulge in the periauricular area
- start of suspicion of a parotid tumor
• Determine whether the bulge is normal or abnormal
(whether a swelling or mass).
• A more prominent ipsilateral part of the jaw,
muscle, or soft tissue in the periauricular area may
be unusual but still considered as normal.
• If bulge is abnormal, is there a dominant mass that
causes the bulge? If none, then consider swelling.

10. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Presence of an unusual abnormal bulge in the
periauricular area - start of suspicion of a parotid
tumor
• Determine the organ or tissue of origin of the swelling
or mass – parotid or other.
• Assess for probability of other organ or tissue
before settling for parotid

11. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Determine the organ or tissue of origin of the swelling
or mass – parotid or other.
• Assess for probability of other organ or tissue
before settling for parotid
• Skin tumor – at skin level
• Bony tumor – bony hard
• Lymph node – presence of inciting source (naso-
oropharynx, mouth, face, scalp, others)
• Soft tissue tumor – more superficial than
parotid with telltale pattern recognition for
common tumors like epidermal cyst and lipoma

12. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease and extent.
• Use pattern recognition and prevalence processes
for diagnosis of disorder and disease
• Use physical signs and symptoms for extent of
disease such as fixation and cervical lymph nodes

13. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• Use pattern recognition and prevalence processes
for diagnosis of disorder and disease
PATTERN RECOGNITION
-realization that the patient’s presentation conforms
to a previously learned picture or pattern of disease
PREVALENCE
- choice of a diagnosis is based on the frequency of
occurrence of the disease in a certain locality, in a
certain age and sex group, and in the affected organ
and system

14. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
Pattern Recognition
Parotitis, acute
Parotitis, chronic
Parotid abscess
Parotid hemangioma / lymphangioma
Parotid cyst
Parotid mass, benign pleomorphic adenoma
Parotid mass, Warthins’ tumor, papillary cystadenoma
lymphomatosum
Parotid cancer
Parotid lymphoma
others

15. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease and extent.
• Use pattern recognition and prevalence processes
for diagnosis of disorder and disease
• Look for pattern for inflammatory tumors –
swelling with no dominant mass, pus,
erythema, severe tenderness (parotitis, parotid
abscess)

16. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease and extent.
• Use pattern recognition and prevalence processes
for diagnosis of disorder and disease
• If no pattern for inflammatory tumors, look for
pattern for malignant tumors – fixation, cervical
lymph nodes, facial nerve paralysis, ill-defined
border of parotid mass, extremely hard in
consistency.

17. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and
disease and extent.
• Use pattern recognition and prevalence processes
for diagnosis of disorder and disease
• If no pattern for malignant tumors, settle for
nonmalignant or benign tumors (especially so if
the tumor feels cystic – parotid cyst)

18. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
• If parotid in origin, determine the disorder and disease
and extent.
• Use pattern recognition and prevalence processes for
diagnosis of disorder and disease
• After determining the most probable disorder,
determine the specific disease if possible.
• Examples:
• Parotitis, right
• Parotid abscess, left
• Parotid cyst, right
• Parotid tumor, left, benign pleomorphic adenoma
• Parotid tumor, left, malignant with neck mets

19. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
primary and secondary clinical diagnoses.
Examples:
Primary: Parotid tumor, right, parotid abscess
Secondary: Parotid tumor, right, malignant
Primary: Parotid tumor, left, benign, pleomorphic adenoma
Secondary: Parotid tumor, left, malignant

20. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
primary and secondary clinical diagnoses.
Examples:
Primary: Parotid tumor, left, benign, pleomorphic adenoma
Secondary: Soft tissue mass, preauricular, left, lipoma
Primary: Parotid tumor, left, benign, pleomorphic adenoma
Secondary: Lymph node, preauricular, left, metastatic from
nasopharyngeal ca

21. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
primary and secondary clinical diagnoses and then
quantitate certainty (certain: ≥ 90%; not certain < 90%)
Examples:
Primary: Parotid tumor, left, benign, pleomorphic adenoma
(90%)
Secondary: Soft tissue mass, preauricular, left, lipoma
(10%)

22. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process, come out with
primary and secondary clinical diagnoses and then
quantitate certainty (certain: ≥ 90%; not certain < 90%)
Examples:
Primary: Parotid tumor, left, benign, pleomorphic adenoma
(90%)
Secondary: Parotid tumor, left, malignant (10%)

23. Tumors of the Parotid Gland
How to Manage
Clinical Diagnosis
After using the clinical diagnostic process and coming with
primary and secondary clinical diagnoses with degree of
certainty,
ADVISE patient and relative on the
clinical diagnoses with bases and degree of certainty.

24. Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
Diagnosis derived after the clinical diagnosis with the use
of paraclinical diagnostic procedures.
Decision-making:
• Indication
• Selection
• Interpretation

25. Paraclinical Diagnostic Process - Indication
PROCESSING OF DATA
CERTAINTY OF CLINICAL Dx
1O
Dx 60% 99%
needed not needed
TREATMENT PLAN FOR 1O
& 2O
Dx
Different Same
needed not needed
Tumors of the Parotid Gland
How to Manage

26. Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
After analyzing on need or no need for paraclinical
diagnostic procedure,
ADVISE patient and relative on recommendation and
bases and
SECURE an informed consent.

27. Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3
Tumors of the Parotid Gland
How to Manage
OBJECTIVES: Increase degree of certainty of diagnosis and extent
OUTPUT EXPECTED
MOST COST-EFFECTIVE DIAGNOSTIC PROCEDURE (with room
for “initial” testing and respect for patient’s concerns)

28. Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1- Watchful monitoring
2- Needle Evaluation + Biopsy
3- Open Biopsy
4- Frozen-section Biopsy
5- Ultrasound
6- X-ray
7-Sialography
8- CT Scan
9- MRI
Tumors of the Parotid Gland
How to Manage

29. Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of certainty of diagnosis.
Parotid Tumor, benign vs malignant
Benefit Risk Cost* Availability**
Type of
exam
Potential Info Info
Yield
Watchful
monitoring
Indirect
exam
Course and
behavior of
mass
99% Time lag (years) Consult fee
P600
RA
Needle
evaluation +
biopsy
Direct
exam
Gross
character and
biopsy
(benign vs
malignant)
90% Pain, infection,
seeding
Procedure
Expense
P6T
RA

30. Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of certainty of diagnosis.
Parotid Tumor, benign vs malignant
Benefit Risk Cost* Availability**
Type of
exam
Potential Info Info
Yield
Needle
evaluation +
biopsy
Direct
exam
Gross
character and
biopsy
(benign vs
malignant)
90% Pain, infection,
seeding
Procedure
Expense
P6T
RA
Open biopsy
(non-frozen)
Direct
exam
Gross
character and
biopsy
(benign vs
malignant)
98% Scar,
pain, infection,
seeding
P15T RA

31. Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of certainty of diagnosis.
Parotid Tumor, benign vs malignant
Benefit Risk Cost* Availability**
Type of
exam
Potential Info Info
Yield
Open biopsy
(non-frozen)
Direct
exam
Gross
character and
biopsy
(benign vs
malignant)
98% Scar,
pain, infection,
seeding
P15T RA
Frozen
biopsy
Direct
exam
Gross
character and
biopsy
(benign vs
malignant)
98% Scar,
pain, infection,
seeding
P30T
(lab,
anesthesia,
operating
room)
RA

32. Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of certainty of diagnosis.
Parotid Tumor, benign vs malignant
Benefit Risk Cost* Availability**
Type of
exam
Potential Info Info
Yield
X-ray Indirect
exam-
Calcification-
stone
1% Radiation P300 RA
Sialography Indirect
exam
Stone;
obstructed
duct
1% Radiation, pain P9T
NRA

33. Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of certainty of diagnosis.
Parotid Tumor, benign vs malignant
Benefit Risk Cost* Availability**
Type of
exam
Potential Info Info
Yield
Ultrasound Indirect
exam
Cystic –
benign
Ill-bordered
solid -
malignant
60% Necrosis P2T RA
CT Scan Indirect
exam
Border and
extent
70% Radiation, dye
reaction, if used
claustrophobia
P10T RA

34. Paraclinical Diagnostic Process - Selection
Tumors of the Parotid Gland
How to Manage
Objective: To increase the degree of certainty of diagnosis.
Parotid Tumor, benign vs malignant
Benefit Risk Cost* Availability**
Type of
exam
Potential Info Info
Yield
CT Scan Indirect
exam
Border and
extent
70% Radiation, dye
reaction, if used
claustrophobia
P10T RA
MRI Indirect
exam
Border and
extent
80% Side effect of
magnet
Dye reaction
P15T RA

35. Paraclinical Diagnostic Process – Selection
Indication Advisory
Watchful monitoring
•If suspicion for malignancy is low – below 10%
•If there is patient’s informed refusal for other diagnostic procedures
Tumors of the Parotid Gland
How to Manage

36. Paraclinical Diagnostic Process – Selection
Indication Advisory
Needle Evaluation + Biopsy
•If a parotid cyst is probable and can be treated with needle aspiration
•If total parotidectomy has to be done if mass turns out to be
malignant
Tumors of the Parotid Gland
How to Manage

37. Paraclinical Diagnostic Process – Selection
Indication Advisory
Open Biopsy
•If there is a need for a definitive histologic diagnosis
Tumors of the Parotid Gland
How to Manage

38. Paraclinical Diagnostic Process – Selection
Indication Advisory
Frozen-section Biopsy
•If there is a need for a definitive intraop histologic diagnosis
•If there is a patient’s informed refusal for a preop needle and open
biopsy (non-frozen) – such as fear of pain of the procedure and willing
to pay higher cost of frozen-biopsy
Tumors of the Parotid Gland
How to Manage

39. Paraclinical Diagnostic Process – Selection
Indication Advisory
X-ray
•If sialolithiasis is suspected
•If there is a need to assess involvement of the adjacent bone
structure by the parotid mass with a procedure of lesser expense
compared to CT Scan and MRI
Tumors of the Parotid Gland
How to Manage

40. Paraclinical Diagnostic Process – Selection
Indication Advisory
Sialography
•If sialolithiasis is suspected
•If there is a need to assess the ductal system of the parotid gland
Tumors of the Parotid Gland
How to Manage

41. Paraclinical Diagnostic Process – Selection
Indication Advisory
Ultrasound
•If the organ or tissue of origin of the periauricular mass is uncertain
•If there is a need to have an imaging evaluation of the parotid mass
to increase degree of certainty of clinical diagnosis without having to
do preop biopsy and also to have an idea of the depth and extent of
the mass
Tumors of the Parotid Gland
How to Manage

42. Paraclinical Diagnostic Process – Selection
Indication Advisory
CT-Scan
•If there is a need for highly refined information compared to those
that will be gotten from ultrasound to assist in assessment of
resectability and extent of resection to be done
•
Tumors of the Parotid Gland
How to Manage

43. Paraclinical Diagnostic Process – Selection
Indication Advisory
MRI
•If there is a need for highly refined information compared to those
that will be gotten from ultrasound and CT Scan to assist in
assessment of resectability and extent of resection to be done
Tumors of the Parotid Gland
How to Manage

44. Paraclinical Diagnostic Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3
Tumors of the Parotid Gland
How to Manage
OBJECTIVES: Increase degree of certainty of diagnosis and extent
OUTPUT EXPECTED
MOST COST-EFFECTIVE DIAGNOSTIC PROCEDURE (with room
for “initial” testing and respect for patient’s concerns)

45. Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
After analyzing the BRCA for the options on paraclinical
diagnostic procedure,
ADVISE patient and relative on recommendation and
bases and
SECURE an informed consent.

46. Paraclinical Diagnostic Process - Interpretation
DATA NEEDED
PRIMARY CLINICAL DIAGNOSIS
SECONDARY CLINICAL DIAGNOSIS
RESULT OF PARACLINICAL DIAGNOSTIC
PROCEDURE
Tumors of the Parotid Gland
How to Manage

47. Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
CORRELATE
RESULT OF PARACLINICAL DIAGNOSTIC PROCEDURE
WITH
PRIMARY AND SECONDARY CLINICAL DIAGNOSIS
CONGRUENT - ACCEPT
INCONGRUENT - MAKE A DECISION!
(Accept or Hold!)
Tumors of the Parotid Gland
How to Manage

48. Paraclinical Diagnostic Process - Interpretation
INTERPRETATION PROCESS
INCONGRUENT - MAKE A DECISION!
(Accept or Hold!)
Tumors of the Parotid Gland
How to Manage
HOLD Advisory:
•Paraclinical diagnosis is a clinical diagnosis least considered.
•Paraclinical diagnosis does not jibe with the clinical picture or
diagnosis.
Possible Actions: Discuss with physician-diagnostician; Discuss with
patient; Repeat test; Go to higher-level test.

49. Tumors of the Parotid Gland
How to Manage
Paraclinical Diagnosis
After interpreting the result of the paraclinical diagnostic
procedure and correlating with clinical diagnoses,
ADVISE patient and relative on
PRETREATMENT DIAGNOSIS (if available already) or
recommendation for another paraclinical diagnostic
procedure and bases and
SECURE an informed consent.

50. Treatment Process - Selection
DATA NEEDED
PRETREATMENT DIAGNOSIS
SEVERITY OR STAGE
GOALS AND OBJECTIVES
TREATMENT OPTIONS
Tumors of the Parotid Gland
How to Manage

51. Treatment Process - Selection
SELECTION PROCESS
Options Benefit Risk Cost Availability
1
2
3
Tumors of the Parotid Gland
How to Manage
OBJECTIVE: To resolve the patient’s health problem
OUTPUT EXPECTED
MOST COST-EFFECTIVE TREATMENT PROCEDURE
ACHIEVEMENT OF GOALS OF PATIENT MANAGEMENT!

52. MANAGEMENT OF A PATIENT
PROBLEM-SOLVING AND DECISION-MAKING
GOALS
RESOLUTION OF HEALTH PROBLEM
LIVE PATIENT
NO COMPLICATION
NO DISABILITY
SATISFIED PATIENT
NO MEDICOLEGAL SUIT

53. Treatment Process - Selection
SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 most effective acceptable 2000 available
2 effectivity <1 >3 acceptable 3000 available
3 least effective acceptable 4000 available
Which is the most cost-effective treatment option?
Option 1
Tumors of the Parotid Gland
How to Manage

54. Treatment Process - Selection
SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 as effective as 2 acceptable 8000 available
2 as effective as 1 acceptable 4000 available
Which is the more cost-effective treatment option?
Option 2
Tumors of the Parotid Gland
How to Manage

55. Treatment Process - Selection
SELECTION PROCESS
Treatment Benefit Risk Cost (PhP) Availability
Options
1 as effective as 2 more complication 8000 available
2 as effective as 1 acceptable 4000 available
Which is the more cost-effective treatment option?
Option 2
Tumors of the Parotid Gland
How to Manage

56. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, acute
Parotitis, chronic
Parotid abscess
Parotid hemangioma / lymphangioma
Parotid cyst
Parotid mass, benign pleomorphic adenoma
Parotid mass, Warthins’ tumor, papillary cystadenoma
lymphomatosum
Parotid cancer
Parotid lymphoma
others

57. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, acute
Viral – mumps
NO antibiotics needed
Symptomatic treatment
Non-pharmacologic – warm compress for pain;
sponge bath for fever; etc.
Pharmacologic prn – analgesics; antipyretics
Soft diet if there is pain on chewing
Rest and watchful waiting for spontaneous recovery
from infection

58. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, acute
Bacterial
Antibiotics (BRCA) – Gram (+) and Gram (-) microbes
Investigate and remove cause (example: sialolithiasis)
Symptomatic treatment
Non-pharmacologic – warm compress for pain;
sponge bath for fever; etc.
Pharmacologic prn – analgesics; antipyretics
Soft diet if there is pain on chewing
Rest and watchful waiting for recovery from infection

59. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotitis, chronic, nonspecific
Antibiotics (BRCA) – Gram (+) and Gram (-) microbes, if
needed
Investigate and remove cause (example: sialolithiasis)
Symptomatic treatment
Non-pharmacologic – warm compress for pain;
sponge bath for fever; etc.
Pharmacologic prn – analgesics; antipyretics
Soft diet if there is pain on chewing
Rest and watchful waiting for recovery from infection

60. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid abscess, bacterial
Drain
Antibiotics (BRCA) – Gram (+) and Gram (-) microbes
Investigate and remove cause (example: sialolithiasis)
Symptomatic treatment
Non-pharmacologic – warm compress for pain;
sponge bath for fever; etc.
Pharmacologic prn – analgesics; antipyretics
Soft diet if there is pain on chewing
Rest and watchful waiting for recovery from infection

61. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, benign
Watchful waiting, if chosen
Excision – subtotal parotidectomy; total parotidectomy
if whole gland is involved

62. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, malignant, resectable
Wide Excision – subtotal parotidectomy; total
parotidectomy if whole gland is involved
Neck dissection if metastatic cervical lymph nodes
present or strongly suspected – classical radical neck
dissection for extensive nodes; otherwise modified
radical neck dissection

63. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, malignant, resectable
Wide Excision – subtotal parotidectomy; total
parotidectomy if whole gland is involved
Neck dissection if metastatic cervical lymph nodes
present or strongly suspected – classical radical neck
dissection for extensive nodes; otherwise modified
radical neck dissection
Postop adjuvant treatment – radiotherapy vs
chemotherapy

64. Tumors of the Parotid Gland
How to Manage
Treatment
Guidelines
Parotid tumor, malignant, difficult or non-resectable
Radiotherapy vs chemotherapy
Surgery if lesion becomes resectable

65. Treatment Process - Selection
Tumors of the Parotid Gland
How to Manage
Parotid Cancer, Mucoepidermoid, Superficial Lobe, Resectable
Objective: To resolve the cancer completely with small chance of local recurrence
and with least complication
Benefit Risk Cost Availability
Resolve Survival Rate
Surgery 98% Longest
LLLL
Operation
Anesthesia
Facial nerve
palsy
P100T RA
Radiotherapy 70% LLL Radiation P100T RA
Chemotherapy 30% LL Side effects
drug
P120T RA
Alternative
medicine
1% Shortest
L
Side effects P120T RA

66. Treatment Process - Selection
Tumors of the Parotid Gland
How to Manage
Parotid Cancer, Mucoepidermoid, Superficial Lobe, Resectable
Objective: To extirpative the cancer completely with small chance of
local recurrence and with least complication
Benefit Risk Cost Availability
Recurrence
Rate (local)
Survival
Rate
Subtotal
parotidectomy
(with good
margin)
10% Same Facial nerve
palsy (10%)
Less
expensive
by P10T
RA
Total
parotidectomy
5% Same Facial nerve
palsy (90%)
More
expensive
RA

67. Tumors of the Parotid Gland
How to Manage
Treatment
After the options of the treatment have been analyzed,
ADVISE patient and relative on
Proposed treatment with bases and
SECURE an informed consent.

68. Referral - When to Refer?
All physicians, both certified and not yet certified,
must know their limitations.
Only they themselves can determine their own
limitations.
They must realize their limitations so that they do
not cause undue harm to their patients and so that
they know when to refer to colleagues.
Tumors of the Parotid Gland
How to Manage

69. Referral - To Whom to Refer?
Referral must be made to somebody
who may or can solve the patient’s
health problem
rationally, effectively, efficiently, and
humanely, and
who has a good track record of
handling the kind of problem on
hand.
Tumors of the Parotid Gland
How to Manage

70. Tumors of the Parotid Gland
How to Manage
Referral
After the options of referral have been analyzed,
ADVISE patient and relative on
need of referral if needed and with bases and
SECURE an informed consent.

71. Tumors of the Parotid Gland
How to Manage
Surgical Treatment
Assuming a surgical treatment will be done.
How to manage it!

72. Surgical Treatment
Process
PREOP PREPARATION
Tumors of the Parotid Gland
How to Manage

73. Surgical Treatment Process - Preop
Preparation
• INFORMED CONSENT
• PSYCHOSOCIAL SUPPORT
• OPTIMIZATION
• SCREENING
• OPERATIVE MATERIALS
Tumors of the Parotid Gland
How to Manage
See Preoperative and Preanesthetic Evaluation or Risk Assessment and
Management
PCS Guidelines (Non-cardiac surgery)
ASA Practice Advisory for Preanesthetic Evaluation (2011) – No
routine!

74. Surgical Treatment Process - Preop
Preparation
• INFORMED CONSENT
• PSYCHOSOCIAL SUPPORT
Tumors of the Parotid Gland
How to Manage
Risk Information - parotidectomy
Facial nerve palsy (temporary or permanent)
Frey’s Syndrome
Numbness of ear (great auricular nerve transection)
Bleeding
Infection
Anesthestic
Risk Information – neck dissection
Numbness

75. Management of a Surgical Patient [Process]
Surgical Treatment
Process
INTRAOP
MANAGEMENT

76. Surgical Treatment Process - Intraop Mgt
PHASES
• INCISION
• EXPOSURE
• INTRAOP EVALUATION
• OPERATIVE PROCEDURE PROPER
• HEMOSTASIS CHECK
• CORRECT COUNT
• WOUND CLOSURE
Tumors of the Parotid Gland
How to Manage

77. Surgical Treatment Process - Intraop Mgt
Quality Standards:
GENTLE
METICULOUS and PRECISE
NO IATROGENIC INJURIES
NO UNNECESSARY MOVES
EVERY MOVE HAS A REASON!
Tumors of the Parotid Gland
How to Manage

78. Surgical Treatment
Process
POSTOP CARE
Tumors of the Parotid Gland
How to Manage

79. Surgical Treatment Process - Postop Care
•SUPPLY BASIC NEEDS OF PATIENT
• COMFORT
• ANALGESICS
• FLUID AND ELECTROLYTES
• NUTRITION
•SUPPORT ORGAN FUNCTION
•WOUND CARE
•MONITORING FOR COMPLICATIONS
•ADVICE ON
• HOME CARE
• FOLLOW-UP PLAN
Tumors of the Parotid Gland
How to Manage

80. Surgical Treatment
Process
POSTOP FOLLOW-UP
PLAN
Tumors of the Parotid Gland
How to Manage

81. Surgical Treatment Process - Postop Follow-
up Plan
OBJECTIVES:
• EVALUATE TREATMENT OUTCOME
• PROVIDE PSYCHOSOCIAL SUPPORT
MONITORING GUIDELINE:
PHYSICAL EXAMINATION
SYMPTOM-DIRECTED
INVESTIGATION
Tumors of the Parotid Gland
How to Manage

82. Surgical Treatment Process - Postop Follow-
up Plan
FF-UP FREQUENCY GUIDELINES: CONSIDER
• USUAL COURSE OF DISEASE
• PERSONALITY OF PATIENT
• PATIENT’S CONVENIENCE
Tumors of the Parotid Gland
How to Manage

83. Tumors of the Parotid Gland
How to Manage
Reynaldo O. Joson, MD, MSc Surg
0918-804-03-04