11 Salivary Gland Disorders Flashcards
1
Q
1 During what week of embryogenesis does the parotid gland develop?
A
The 7th embryonic week
2
Q
2 Where does the parotid gland originate during development, and what is its relationship to the facial nerve?
A
The parotid gland originates at the site of the eventual duct orifice and grows in a posterior direction. The facial nerve develops in an anterior direction. The facial nerve eventually becomes surrounded by parotid gland tissue.
3
Q
3 What are the different types of acini in the salivary glands?
A
There are three types: serous acini are found in the parotid, mucous acini in the sublingual and minor salivary glands, and mixed acini, which are found in the submandibular gland.
4
Q
4 Describe the salivary gland duct system. (▶ Fig. 11.1)
A
An acinus is the main secretory component that is composed of a central lumen surrounded by acinar cells that produce saliva. Intercalated ducts form early connections between acini. Both acini and intercalated ducts are lined with myoepithelial cells that help to contract and propel saliva forward. Intercalated ducts feed into larger striated ducts and then into excretory ducts.
5
Q
5 What is the relationship of lymph nodes to the salivary glands?
A
Lymph nodes develop within the pseudocapsule of the parotid gland, leading to intraparotid lymph nodes. No other salivary gland has intraglandular lymph nodes.
6
Q
6 Where are intraparotid lymph nodes typically located?
A
The parotid gland is the only salivary gland with lymph nodes actually within the gland. Most intraparotid lymph nodes lie within the superficial lobe, although they are present in both the superficial and deep lobes.
7
Q
7 Describe the path of the Stenson duct (parotid duct).
A
It originates from superficial portion of parotid gland, travels anteriorly on the masseter muscle and buccinator fat pad, and then travels medially to pierce the buccinator muscle. The duct empties lateral to the second maxillary molar.
8
Q
8 Where does the Wharton duct (submandibular duct) empty into the oral cavity?
A
The submandibular duct empties just lateral to the lingual frenulum.
9
Q
9 What fascial layer forms the parotid fascia?
A
The parotid fascia is continuous with the superficial layer of the deep cervical fascia.
10
Q
10 Describe the fascial connections of the superficial musculosaponeurotic system (SMAS) and its relationship to the parotid gland.
A
The SMAS gives support to the many muscles of facial expression. Over the parotid gland, it is located just superficial to the parotid fascia.
11
Q
11 What is the autonomic nerve supply of the parotid glands?
A
The parasympathetic nervous system supplies the parotid gland via the glossopharyngeal nerve (cranial nerve IX). The sympathetic nervous system supplies the gland via the superior cervical ganglion.
12
Q
12 Describe the path of the parasympathetic inner vation of the parotid gland. (▶ Fig. 11.2)
A
Parasympathetics that are part of the glossopharyngeal nerve (tympanic branch) enter the middle ear through the tympanic canaliculus as the Jacobson nerve. They then exit the middle ear cavity and travel through the middle cranial fossa as the lesser petrosal nerve. The lesser petrosal nerve exits the skull base through the foramen ovale and travels to the otic ganglion. After synapsing in the otic ganglion, postsynaptic fibers are carried via the auriculotemporal nerve to the parotid gland.
13
Q
13 Define accessory parotid gland tissue.
A
Accessory parotid tissue lies anterior to the main parotid gland between the skin and the masseter muscle.
14
Q
14 What are important anatomical landmarks for identification of the facial nerve during parotidectomy?
A
The facial nerve can be located via its relationships to the tragal pointer, tympanomastoid suture line, and the attachment of posterior digastric muscle to digastric groove, or it can be identified distally and dissected in a retrograde fashion or drilled out from the mastoid bone and traced anterograde.
15
Q
15 How does the parotid gland change histologically with age?
A
There is an increase in adipose cells in the parotid parenchyma with age.
16
Q
16 In which anatomical triangle is the submandibular gland located, and what are its boundaries?
A
The submandibular triangle: its boundaries are the anterior and posterior bellies of the digastric muscle and the inferior aspect of the mandible.
17
Q
17 What nerve carries the parasympathetic supply to the submandibular gland?
A
The chorda tympani carries parasympathetic fibers to the submandibular and sublingual glands via the lingual nerve.
18
Q
18 Secretomotor function of the submandibular and sublingual glands is controlled by which nerve?
A
Parasympathetic contribution of facial nerve (nervus intermedius) via the chorda tympani
19
Q
19 Where is the lingual nerve found during a submandibular gland excision?
A
The lingual nerve is found deep to the submandibular gland. With inferior retraction of the gland and anterior retraction of the mylohyoid muscle, the lingual nerve and the submandibular ganglion can be exposed.
20
Q
20 What is the relationship of the lingual nerve to the submandibular duct in the floor of mouth? (▶ Fig. 11.3)
A
The lingual nerve courses from a posterolateral to anteromedial position, passing below the Wharton duct.
21
Q
21 Where are the facial artery and vein found in relation to the submandibular gland?
A
The facial vein is found on the lateral surface of the submandibular gland; the facial artery is located on the posterior surface of the gland and is often ligated on both the superior and inferior aspect of the gland during submandibular gland excision.
22
Q
22 Name the ducts through which the sublingual gland drains.
A
The sublingual gland drains into the mouth via the smaller duct of Rivinus (which empties into the floor of the mouth or into submandibular duct) and larger duct of Bartholin (empties into submandibular duct).
23
Q
23 What structures border the sublingual gland?
A
The sublingual gland is bordered by the mandible, genioglossus muscle, and mylohyoid muscle.
24
Q
24 What structures are important to be aware of during excision of the sublingual gland?
A
The lingual nerve and Wharton (submandibular) duct run between the sublingual gland and the genioglossus muscle.
25
25 Where are most minor salivary glands located?
The hard palate mucosa harbors most of the mouth's minor salivary glands.
26
26 What are the functions of saliva?
There are many functions of saliva, the most important being lubrication of food, buffering and prevention of caries, mineralization of teeth, antibacterial and bactericidal function, digestion, and taste.
27
27 List the order of salivary gland saliva production from most serous to most viscous.
In order from most serous to most viscous: parotid gland \> submandibular gland \> sublingual gland \> minor salivary glands
28
28 What are the important physical examination findings to assess when evaluating a salivary gland mass?
One should appreciate the size of the mass, invasion of overlying skin, mobility versus fixation, tenderness to palpa tion, facial nerve function, trismus, pharyngeal fullness, and whether there is evidence of a primary skin or scalp lesion.
29
29 Typically, how large must a parapharyngeal mass be to visualize it intraorally?
Usually, a parapharyngeal mass must be at least 3.5 cm to visualize it intraorally.
30
30 Name the key surgical landmarks associated with the location of the facial nerve during parotidectomy?
● The facial nerve lies 1 to 1.5 cm deep and inferior to the tragal pointer. ● The attachment of the posterior belly of the digastric muscle to the digastric ridge identifies the plane of nerve. ● The nerve lies 6 to 8 mm deep to the tympanomastoid suture.
31
31 What is the pathophysiology of Frey syndrome after parotidectomy?
Postganglionic parasympathetic secretomotor fibers carried on the auriculotemporal nerve, which normally innervate the parotid gland tissue, aberrantly reinnervate sweat glands of the overlying skin.
32
32 Name an objective test for Frey syndrome.
The Minor starch-iodine test is an objective measure of gustatory sweating. The preauricular region is coated with iodine, allowed to dry, and then dusted with starch. The patient is then given a sialagogue, and a positive test (indicating Frey syndrome) results in dark blue spots where sweat has dissolved the starch and reacted with iodine.
33
33 What are the treatment options for Frey syndrome?
Treatment options are broad and depend on the patient's discomfort level. Options range from observation and use of antiperspirant, to medications such as glycopyrrolate, or more invasive therapy such as botulinum toxin injection or tympanic neurectomy.
34
34 What techniques can be used to reduce post parotidectomy gustatory sweating?
The most important surgical techniques to prevent Frey syndrome are raising a thick skin flap and doing only a partial superficial parotidectomy.
35
35 What additional techniques are being used to try to reduce post parotidectomy gustatory sweating?
Rotational sternocleidomastoid flaps, fat transfer, Alloderm implants, and superficial musculoaponeurotic system in terposition are all being used.
36
36 Which salivary gland is most susceptible to acute bacterial sialadenitis?
The parotid gland
37
37 Which population groups are most commonly affected by acute suppurative sialadenitis?
Patients who are medically debilitated, postoperative, and/ or patients with severe dehydration
38
38 Which surgical patients are most commonly affected by acute suppurative sialadenitis?
Patients who have undergone major abdominal surgery and hip replacement/repair, likely a result of poor oral intake attributable to their debilitated state, are most commonly affected.
39
39 Why does the saliva produced by the parotid gland make this gland more prone to sialadenitis compared with the submandibular and sublingual glands?
Parotid saliva is mostly serous compared with the mucinous saliva produced by the submandibular and sublingual glands. Serous saliva lacks antibodies, acid, and enzymes with antimicrobial properties.
40
40 In hospitalized patients, what is the most com monly cultured organism in acute suppurative sialadenitis?
Staphylococcus aureus
41
41 When is imaging of acute suppurative parotitis recommended?
Imaging is indicated after failure to respond to antibiotics or if signs, symptoms, and physical examination raise concern for a parotid abscess.
42
42 What is the best initial treatment of acute suppurative sialadenitis?
Empiric antibiotics with both aerobic and anaerobic cover age, sialagogues, warm compresses, parotid massage, pain medication, and rehydration
43
43 What is the recommended treatment of a parotid abscess?
Surgical drainage through a standard parotidectomy exposure is recommended. When making incisions in the parotid fascia, it should be done parallel to facial nerve branches to minimize risk of damage to the nerve.
44
44 What is the most common symptom that raises concern for sialolithiasis?
Pain and swelling of the salivary glands, especially associated with eating
45
45 Which salivary gland carries the highest risk for salivary calculi formation?
The submandibular gland is the most common location of salivary calculi as a result of increased calcium concen tration, higher pH, more mucinous saliva, and potential anatomical factors (e.g., length, gravity).
46
46 What imaging options are available for diagnosis of sialolithiasis?
There are many choices. Plain X-ray offers little extra information other than the presence of a radiopaque stone. Sialography can give information on strictures, dilations, or filling defects of the ductwork. Ultrasound can be done if a radiolucent stone is suspected. CT often offers the most complete information.
47
47 Which salivary calculi are most often radiopaque and which are radiolucent on standard X-ray?
Submandibular stones. 80% of parotid stones are radiolucent.
48
48 What are the treatment options for sialolithiasis?
Conservative treatment is a valid option. This includes sialagogues, heat, massage, and increased hydration. For larger stones that will not pass with conservative measures, bedside sialotomy, sialendoscopy, or lithotripsy are options. Gland excision is final treatment option for refractory disease.
49
49 What is the number one cause of chronic sialadenitis?
Parotid duct obstruction secondary to sialolithiasis
50
50 What is the best treatment for chronic sialadenitis?
No treatment is consistently successful. Antibiotics, mas sage, warm compresses, and sialagogues may be tried. Ultimately, if conservative measures fail, the affected gland should be surgically resected.
51
51 Patients with chronic sialadenitis should be moni tored for what serious condition?
Patients with chronic sialadenitis are at an increased risk for salivary duct carcinoma.
52
52 When should sialorrhea be managed as an abnormal condition in the pediatric population?
Sialorrhea is associated with the balance of oral control of secretions and swallowing. Up until about 18 months of age, sialorrhea is a normal event because of poor neuro muscular control. If it is still present by 4 years of age, a patient should undergo further workup.
53
53 What other medical conditions are associated with sialorrhea?
Conditions associated with poor neuromuscular control, which cause difficulty swallowing secretions, can be associated with sialorrhea, most commonly in children with cerebral palsy. It is also seen in adults with amyotrophic lateral sclerosis, Parkinson disease, and history of stroke.
54
54 How can sialorrhea be treated medically?
Anticholinergics: **PO glycopyrrolate** and **topical scopolamine**.
**Botox** injections (require repeated injections)
55
55 Describe the side effects of anticholinergic med ications.
Urinary retention, increased body temperature/decreased perspiration, tachycardia, xerostomia (increased risk of dental caries), vision changes, confusion, respiratory sup pression, mydriasis, and constipation are all common side effects of anticholinergics.
56
56 What are the surgical options for treatment of sialorrhea?
Removal of salivary tissue can be done via bilateral submandibular gland excision and parotid duct ligation. Transection of the chorda tympani can also decrease salivary output. The submandibular and parotid ducts can be rerouted to decrease output into the oral cavity.
57
57 Define the difference between sialorrhea and ptyalism.
These terms are often used interchangeably. By strict definition, though, sialorrhea means excessive flow of saliva. Usually, it is secondary to administration of medications such as antipsychotics, anticonvulsants, anticholinesterases, or other parasympathomimetic medications. Excessive flow can also be related to medical conditions such as pregnancy, gastroesophageal reflux disease, and oral ulceration/irritation. Ptyalism is the act of drooling and the excessive production of saliva. Historically, it is most commonly used in pregnancy as ptyalism of pregnancy.
58
58 What is the most common cause of xerostomia?
By far, the most common cause is medication side effect.
59
59 What is one of the most important preventative treatments to reduce complications of xerostomia from head and neck radiation?
Topical fluoride and excellent oral hygiene are used to prevent the formation of dental caries because saliva is protective of the teeth.
60
60 What drug is used to treat xerostomia?
Pilocarpine, a parasympathomimetic drug that acts on the M3 acetylcholine muscarinic receptor
61
61 Describe the three stages of radiation-induced sialadenitis.
1. Stage 1: Acute response of salivary glands to lower dose (20 to **30 Gy**). Self-resolution is expected.
2. Stage 2: **Functional loss** of glandular tissue with higher doses (up to **75 Gy**). **Nonrestorative**.
3. Stage 3: **Chronic changes** with high-dose radiation (\> 75 Gy). Cirrhotic changes with **complete glandular atrophy**. **Nonrestorative**.
62
62 Describe Mikulicz syndrome.
Mikulicz syndrome involves bilateral salivary gland swelling that is not associated with another systemic disease. Specifically, it is distinct from salivary swelling associated with Sjögren syndrome.
63
63 What are the clinical signs and symptoms of sialadenosis?
Sialadenosis is characterized by bilateral, recurrent, painless parotid gland swelling, unrelated to food intake.
64
64 What are the histologic findings in sialadenosis?
On histology, one would expect to find enlarged acinar cells (up to three times normal), degenerative neural changes, and myoepithelial atrophy.
65
65 What are the three categories for the develop ment of sialadenosis?
● Endocrine-related sialadenosis (e.g., diabetes mellitus, acromegaly, adrenal disorders, hypothyroidism, preg nancy) ● Dystrophic-metabolic sialadenosis (e.g., pellagra, beri beri, kwashiorkor, anorexia nervosa, bulimia, alcoholism) ● Neurogenic sialadenosis (e.g., anticholinergic medica tions)
66
66 What differentiates a mucous retention cyst?
It is a true cyst with a complete epithelial lining.
67
67 From what salivary gland does a ranula develop?
Ranulas are mucoceles that develop from the sublingual gland.
68
68 What is the common appearance of a ranula on physical examination?
Ranulas often appear as a bluish, translucent mass on the floor of mouth.
69
69 What is the difference between a ranula and a plunging ranula?
A ranula is extravasated mucus that forms a pseudocyst between the mucosa of the floor of mouth (superior border) and mylohyoid muscle (inferior border). A plunging ranula is a ranula that extends inferior to the mylohyoid muscle into the neck.
70
70 What are the routes in which a plunging ranula can pass to reach the neck?
Extravasated mucus from a ranula typically passes around the posterior border of mylohyoid or passes through dehiscent areas of the mylohyoid.
71
71 What are the prevalence and location of mylo hyoid muscle dehiscence?
Studies show that up to 50% of mylohyoid muscles are dehiscent in the anterior two-thirds of the muscle.
72
72 What are the treatment options for ranulas, and which is most successful?
Conservative treatment options include injection of scle rosing agents, intraoral marsupialization, or excision of the ranula alone. The most effective treatment, with a recurrence rate of 1 to 2%, is excision of the sublingual gland and ranula together.
73
73 Name the most common cause of nonsuppurative acute parotitis?
The mumps virus is the most common cause of non suppurative acute parotitis.
74
74 The virus that causes mumps is in what family?
Paramyxovirus (RNA)
75
75 What are the most common initial symptoms of mumps?
Children between the ages of 5 and 10 years have nonspecific symptoms of headache, fever, myalgia, and anorexia, followed by bilateral parotid gland swelling.
76
76 Name several viruses that have been associated with viral parotitis.
Influenza, coxsackievirus, echovirus, rabies, mumps, and hepatitis viruses can be associated with viral parotitis.
77
77 How is cat-scratch parotitis diagnosed?
Diagnosis is suggested by a history of exposure to cats and confirmed by elevated titers of Bartonella henselae immu noglobulin (Ig)G and IgM.
78
78 How is actinomycosis of the parotid gland diagnosed?
Diagnosis is achieved using FNA or tissue biopsy.
79
79 What is the pathophysiologic mechanism of Sjögren syndrome?
Autoimmune destruction of exocrine glands
80
80 What are the two broad classifications of Sjögren syndrome?
The two classifications are primary and secondary Sjögren syndrome. Primary cases involve only exocrine glands. Secondary cases involve exocrine glands and any additional connective tissue disease.
81
81 What are the common initial signs and symptoms of Sjögren syndrome?
Xerostomia, keratoconjunctivitis sicca, and parotid gland enlargement
82
82 Patients with Sjögren syndrome are at risk for developing what neoplasm?
Patients with Sjögren syndrome have a 44 times greater risk of lymphoma than do matched controls; 5% of patients with Sjögren syndrome develop lymphoma.
83
83 What autoimmune disease is associated with primary mucosa-associated lymphoid tissue, or MALT, lymphoma of the salivary glands?
Sjögren syndrome
84
84 What are the risk factors for lymphoma develop ment in Sjögren syndrome?
Risk factors include persistent enlargement of parotid glands, splenomegaly, lymphadenopathy, palpable purpura, leg ulcers, or a mixed monoclonal cryoglobulinemia.
85
85 Other than clinical history and laboratory workup, what in-office procedure can be performed to help establish the diagnosis of Sjögren syndrome?
Lower-lip minor salivary gland biopsy
86
86 What laboratory tests are most commonly ordered for suspected Sjögren syndrome?
A rheumatologic workup for Sjögren syndrome includes SS A and SS-B, the most specific tests for Sjögren syndrome. Additional tests including antinuclear antibodies, rheuma toid factor, and sedimentation rates are also frequently obtained.
87
87 True or false. Benign lymphoepithelial lesion of the salivary glands is another name for benign lym phoepithelial cysts of the salivary glands.
False. Although often used incorrectly in the literature, the term benign lymphoepithelial lesions of the salivary glands are clinically and histologically distinct from benign lymphoepi thelial cysts. Benign lymphoepithelial lesions are thought to result from an autoimmune condition related to other disease processes such as Sjögren syndrome, Hashimoto disease, chronic sclerosing sialadenitis, sarcoidosis, and HIV.
88
88 True or false. Patients with benign lymphoepithe lial lesions of the salivary glands are at increased risk for malignancy.
True, unlike benign lymphoepithelial cysts, benign lym phoepithelial lesions are at increased risk for lymphoma transformation.
89
89 A patient with multiple parotid cysts should be tested for what disease? (▶ Fig. 11.4)
HIV
90
90 What are the initial symptoms of Kimura disease?
Diffuse lymphadenopathy, salivary gland swelling (parotid or submandibular), red cutaneous nodules on the head and neck, as well as pigmented, coarse, pruritic skin overlying glandular swelling
91
91 What is the population most commonly affected by Kimura disease?
Young males in their 20s and 30s from Southeast Asia
92
92 What inflammatory cell is most commonly ele vated in Kimura disease?
Eosinophils (both peripheral eosinophilia and intralesional eosinophilia).
93
93 Aside from a CBC, what other blood tests should be ordered in a patient with Kimura disease?
Blood urea nitrogen (BUN), creatinine, and urinary protein to rule out nephrotic syndrome
94
94 What are the treatment options for Kimura disease?
Surgical resection has been considered the treatment of choice. Observation can be offered if the patient is asymptomatic. Medical treatment includes steroids and immunosuppressants.
95
95 What is the most common initial manifestation of necrotizing sialometaplasia?
Ulcer on the posterior hard palate is the most common symptom. The lesions of necrotizing sialometaplasia heal spontaneously in 5 to 9 weeks; thus, the only treatment required is supportive care.
96
96 In a patient with hard palate ulceration, what conditions should be considered in the differential diagnosis?
Aphthous ulcer, trauma, malignancy such as mucoepider moid carcinoma or squamous cell carcinoma, necrotizing sialometaplasia
97
97 What are the initial symptoms of a patient with adenomatoid hyperplasia of a salivary gland?
Painless swelling of the oral mucosa, suggestive of neo plasia, is usually seen; pathology reveals benign salivary tissue.
98
98 Heerfordt syndrome is an extrapulmonary form of what systemic disease?
Sarcoidosis
99
99 What are the characteristics of Heerfordt syndro me?
Heerfordt's syndrome, also know as uveoparotid fever, presents with uveitis, non-suppurative parotitis, and in 50% of the patients, facial palsy.
100
100 How is uveoparotid fever treated?
Heerfordt syndrome, also known as uveoparotid fever, initially manifests with uveitis, nonsuppurative parotitis, and facial palsy. Treatment for Heerfordt syndrome includes systemic steroids and eye care.
101
101 What are the treatment options for benign lymphoepithelial cysts associated with HIV?
Cysts in such cases can be treated with observation, repeated aspiration, and antiretroviral medication such as zidovudine, sclerosing agents, radiation, or surgery.
102
102 True or false. Benign lymphoepithelial cysts associated with HIV have malignant potential if not removed.
False. HIV-positive patients are at increased risk of malignancy, but no reports are documented that show malignant potential of benign lymphoepithelial cysts.
103
103 Rapid growth of a salivary gland in a patient with HIV is most concerning for what pathology?
Malignancy such as Kaposi sarcoma or lymphoma
104
104 When is surgery indicated for management of salivary gland enlargement associated with HIV?
When a gland undergoes rapid growth or other clinical indicators of malignancy, surgery may also be offered if conservative management fails and a patient is worried about cosmesis.
105
105 Apart from Heerfordt syndrome, how often does sarcoidosis affect the salivary glands?
About 5 to 7% of sarcoidosis patients have salivary gland enlargement.
106
106 How should extrapulmonary sarcoidosis with persistent parotid swelling be treated?
Oral steroids
107
107 What is the presentation of salivary gland in volvement with Wegener granulomatosis?
It is a rare association, but patients with Wegener granulomatosis and parotid involvement most often have painful parotid swelling. Biopsy shows necrotizing gran ulomatous changes and microabscesses.
108
108 What is the most common benign parotid tumor in children?
Hemangiomas or pleomorphic adenomas, depending on the series
109
109 What is the most common benign salivary epi thelial tumor in children?
Pleomorphic adenomas
110
110 What is the relative incidence of benign to malignant lesions based on the salivary gland site of origin?
Of all lesions in each salivary gland, 75% of parotid masses are benign, more than 50% of submandibular masses are benign, but more than 80% of minor salivary gland masses are malignant.
111
111 What is the most common benign salivary tumor, and where is it most commonly found?
Pleomorphic adenoma (represents ~75% of benign salivary tumors) is most often found in the parotid gland.
112
112 What is the recommended treatment for pleomorphic adenoma?
Surgical excision along with a cuff of normal salivary tissue is recommended.
113
113 What is the risk of malignant transformation of an unresected pleomorphic adenoma?
Estimates of malignant transformation of a pleomorphic adenoma are 1.5% in the first 5 years and 10% after 15 years.
114
114 What risk factor is unique to Warthin tumor?
Smoking; no other salivary gland tumors are directly associated with a history of smoking.
115
115 Which benign salivary tumor is most often bilateral?
Warthin tumor of the parotid gland
116
116 The cells of a true oncocytoma contain an abundance of what organelle?
The cells of an oncocytoma contain a very large number of mitochondria.
117
117 Where are salivary monomorphic adenomas most commonly located?
The most common presentation is of minor salivary glands on the upper lip.
118
118 What are some of the histologic types of mono morphic adenomas?
Monomorphic adenoma is a term that refers to a set of rare salivary gland tumors. They include basal cell adenoma, canalicular adenoma, clear cell adenoma, glycogen-rich adenoma, and myoepithelioma.
119
119 What is the most common location of a benign salivary canalicular adenoma?
Salivary canalicular adenomas are most commonly found in minor salivary glands of the upper lip.
120
120 What is the most common salivary gland malig nancy in children?
Mucoepidermoid carcinoma
121
121 True or False. A history of radiation therapy to the head and neck is a risk factor for future develop ment of salivary gland tumors.
True. A history of radiation therapy at any age and any dose increases the risk for development of salivary gland tumors.
122
122 List the risk factors associated with salivary gland cancer.
Previous radiation exposure, history of head and neck skin cancer, Epstein-Barr virus, HIV infection, Hodgkin disease, industrial exposure to rubber manufacturing or nickel compound, or employment in a beauty salon are risk factors.
123
123 What are clinical signs and symptoms of salivary gland malignancy?
Pain, fixed lesion, invasion of overlying skin, rapidly growing mass, facial nerve palsy, and cervical lymphadenopathy
124
124 True or false. In general, the best radiologic study to evaluate a malignant salivary gland mass is CT with contrast.
False. Although CT provides useful information, MRI is the preferred imaging modality for parotid gland lesions. MRI provides superior detail regarding invasion of surrounding structures and type of pathology.
125
125 True or False. FNA biopsy of salivary gland malignancies has high sensitivity but low specificity.
False. The sensitivity is fairly low, whereas the specificity is quoted to be greater than 90% in most studies.
126
126 Define the T stages for the Tumor, Node, Metas tasis (TNM) classification for major salivary gland malignancies.
(▶ Table 11.1)
127
127 Define the N stages for the TNM classification for major salivary gland malignancies.
● Nx: Regional lymph nodes cannot be assessed. ● N0: No regional lymph nodes ● N1: Single ipsilateral node, 3 cm or smaller ● N2a: Single ipsilateral node 3 to 6 cm in diameter ● N2b: Multiple ipsilateral nodes; none larger than 6 cm ● N2c: Bilateral or contralateral nodes, none larger than 6 cm ● N3: Any lymph node larger than 6 cm in diameter
128
128 Define the overall staging (I through IV) for major salivary gland malignancies.
● Stage I: T1N0M0 ● Stage II: T2N0M0 ● Stage III: T3N0M0 or T1–3N1M0 ● Stage IVA: T1–3N2M0 or T4aN0–2M0 ● Stage IVB: T4bN1–3M0 or T1–4N3M0 ● Stage IVC: M1
129
129 What is the incidence of malignancy in tumors of the major salivary glands?
About 15 to 32% of parotid tumors are malignant, 41 to 45% of submandibular tumors are malignant, and 70 to 90% of sublingual gland tumors are malignant.
130
130 What is the incidence of cervical lymph node metastasis in a primary submandibular neoplasm?
30%
131
131 What is the most common histologic subtype of malignant salivary gland tumors?
Mucoepidermoid carcinoma is the most common malig nant salivary gland tumor, followed by adenoid cystic carcinoma, and then adenocarcinoma.
132
132 Grading of mucoepidermoid carcinoma is critical to prognosis and management. What is the histologic appearance of low-grade mucoepider moid carcinoma?
Low-grade mucoepidermoid carcinoma is more cystic with little atypia and low mitotic activity. High grade is more solid.
133
133 What is the prognosis of mucoepidermoid carci noma?
Patients with low-grade and intermediate-grade carcinoma with no regional or distant metastases have an excellent prognosis, with 5-year survival greater than 90%. High grade tumors have a lower 5-year survival of around 50%.
134
134 What is the recommended treatment for low grade and high-grade mucoepidermoid carcino ma?
Low-grade carcinoma requires removal of the salivary gland with a margin of healthy tissue, but elective neck dissection is not necessarily required. High-grade carcinoma requires total excision and elective or therapeutic neck dissection and often adjuvant radiation.
135
135 Describe the natural history of adenoid cystic carcinoma.
Adenoid cystic carcinoma is difficult to cure. Its course is slow and prolonged; it commonly has perineural invasion at manifestation; and despite excision, it frequently recurs.
136
136 Which salivary gland malignancy has the highest rate of distant metastasis?
Adenoid cystic carcinoma. About 30% to 50% of patients develop metastasis, most commonly to the lungs.
137
137 What are the 5- and 10-year survival rates for patients with acinic cell carcinoma?
Acinic cell carcinoma is a relatively low-grade cancer with a 5-year survival rate ranging from 75 to \> 90% and a 10-year survival rate ranging from 60 to 75%.
138
138 What are the two main subtypes of malignant mixed tumor?
Carcinoma ex-pleomorphic adenoma and carcinosarcoma (rare)
139
139 True or False. With complete surgical excision, patients with salivary gland carcinosarcoma have good long-term survival.
False. Death from disease often occurs within 3 years of diagnosis even with complete surgical excision.
140
140 What is the most common presentation of carcinoma ex-pleomorphic adenoma?
A male patient in his 60s to 70s with a long-standing parotid mass that suddenly increases in size over several months
141
141 What is the most common manifestation of a polymorphous low-grade adenocarcinoma?
The most common initial manifestation is an asymptomatic mass of the hard palate present for months to years.
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142 Describe the clinicopathologic features of poly morphous low-grade adenocarcinoma.
Slow growth, indolent behavior, and almost exclusively involves minor salivary glands with an infiltrative growth pattern and perineural invasion
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143 What other cancer does salivary duct carcinoma histologically resemble?
High-grade ductal carcinoma of the breast
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144 What is the most important diagnosis to rule out when squamous cell carcinoma is found in the parotid gland?
Other primary (e.g., skin) carcinomas with metastasis to the parotid must be ruled out. This situation is much more common than primary parotid squamous cell carcinoma.
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145 Which cancer most commonly metastasizes to the parotid lymph nodes?
Skin cancer of the head and neck
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146 Although this topic is debated, what are the general indications for total parotidectomy in a patient with parotid malignancy?
● Benign tumors in the deep lobe ● Malignant tumors in the deep lobe ● High-grade parotid tumors, even if in superficial lobe ● Parotid malignancy with cervical lymph node metastasis ● Any tumor that metastasizes to parotid gland
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147 In general, what is the management of salivary gland malignancy with cervical lymph node metastasis?
If a parotid gland malignancy has cervical metastases, an ipsilateral modified radical or select neck dissection is recommended.
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148 True or False. Patients with node-negative (N0) necks and parotid malignancies \< 4 cm should undergo prophylactic neck dissection.
False. Although the topic is debated, most of the literature shows that tumors with larger than 4-cm extraparotid tumor extension and higher-risk histologic types (undifferentiated carcinoma, squamous cell carcinoma, high-grade mucoepidermoid, adenocarcinoma not otherwise specified, carcinoma ex-pleomorphic adenoma, and salivary duct carcinoma) are the only parotid tumors that warrant prophylactic neck dissection.
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149 What type of neck dissection should a patient with a node-negative (N0) neck and high-grade salivary gland malignancy have?
In general, selective neck dissection: levels I through IV for a parotid primary and levels I through III for submandibular primaries
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150 What are the indications for adjuvant radiation therapy for salivary gland malignancies?
Adjuvant radiation is indicated in cases of advanced stage, positive margins after resection, high-grade tumor, peri neural invasion, or bony invasion.
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151 What is the most common tumor type of the minor salivary glands?
When combining all tumor types, malignant tumors are more common than benign tumors in the minor salivary glands, with mucoepidermoid carcinoma the most com mon malignant tumor.
