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Module 7 > Oral Surgery > Flashcards

Oral Surgery Flashcards

1
Q

“What is the midline of the mandible called?

A

symphysis.

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2
Q

What is the area between the symphysis and the body called?

A

parasymphysis.

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3
Q

What is the pterygoid fovea?

A

muscle attachment for lateral pterygoid muscle.

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4
Q

What attaches to the mental tubercules?

A

Mentalis muscle.

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5
Q

How to differentiate between mandibular body vs angle.

A
  • Body of mandible: where molars sit.
  • angle of mandible: more posteriorly.
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6
Q

Where is the submandibular gland found?

A

Beneath the mylohyoid groove

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7
Q

Define fracture?

A

A break or breach in the continuity of normal anatomical structure of a bone by the application of excessive force resulting in 2 or more fragments of the involved bone.

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8
Q

What percent of facial fractures do mandibular fractures account for? How common are they in the face and body?

A
  • 36-70% of all facial fractures.
  • 2nd commonest facial fracture (after nasal bone).
  • 10th most common of all the bones in the body.
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9
Q

4 causes of mandibular fracture?

A
  • Assault.
  • Sporting injury.
  • Road traffic accident.
  • Pathological (cyst, tumor, osteolytic lesion).
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10
Q

5 types of fractures?

A
  • Simple.
  • Compound.
  • Comminuted.
  • Greenstick.
  • Pathological.
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11
Q

Simple fracture?

A

undisplaced fracture, overlying periosteum intact, Radiograph: crack in cortical bone, two parts of bone have not moved apart.

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12
Q

Compound fracture?

A

Perforated through the overlying periosteum and potentially through the skin.

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13
Q

What kind of fracture is a fracture that involves a tooth socket?

A

COMPOUND FRACTURE.
- Any fracture that involves a tooth socket is a compound fracture and predisposes bone to oral microbiota and increasing infection risk.

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14
Q

Comminuted fracture?

A

multiple fracture lines, tends to be HIGH IMPACT FRACTURES, much more difficult to manage. ex. RTA or bullet wounds.

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15
Q

Greenstick fracture?

A

flexing of the bone so that one of the outer cortices will fracture but the inner will flex so there is no displacement, usually seen in children NOT OFTEN SEEN IN THE MANDIBLE.

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16
Q

2 commonest fractures of the mandible?

A
  • Condylar neck.
  • Angle of mandible.
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17
Q

Ranke the top 3 most common mandibular fractures.

A
  1. Condylar neck.
  2. Angle of mandible.
  3. Parasymphasis.
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18
Q

Why is condylar neck fracture common?

A
  • Point of weakness/ crumple zone.
  • In preference to driving the condylar head back into the base of the skull, the condylar neck will BREAK to try and absorb the impact of the force.
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19
Q

Why is angle of mandible fracture common?

A
  • Erupted/ partially erupted/ completely unerupted mandibular 3rd molar which makes for a point of weakness.
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20
Q

Why is parasymphyseal fracture common?

A

Long rooted canine root.

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21
Q

What is a common finding with coronoid fractures?

A

Displacement of the fracture superiorly because the temporalis muscle contracts and takes the fragment of the coronoid process superiorly into the infratemporal space.

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22
Q

Importance of muscles attached to mandible concerning mandibular fractures?

A

Dependent on the pattern of fracture the muscles can PULL THE FRACTURE TOGETHER or PULL IT APART causing displacement of the fracture.

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23
Q

How are factors influencing displacement classified?

A
  • Horizontally favorable/ unfavorable (upwards direction).
  • Vertically favorable/ unfavorable (lateral direction).
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24
Q

In what direction does the LATERAL pterygoid displace a fractured condyle?

A

Medially and anteriorly.

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25
Q

In what direction do temporalis, masseter and medial pterygoid displace a proximal segment?

A

Medially and superiorly.

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26
Q

In what direction do the digastic, geniohyoid, genioglossus and mylohyoid displace a distal segment?

A

Inferiorly and posteriorly.

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27
Q

What is the biggest factor that determines fracture displacement?

A

Muscle pull.

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28
Q

4 things that determine the amount of displacement?

A
  • Pattern of fracture.
  • Degree of comminution (tend to displace more).
  • Teeth in the fracture line (help keep fracture together).
  • Muscle pull.
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29
Q

Bucket handle fracture?

A

Bilateral parasymphyseal fractures.
seen in EDENTULOUS patients.

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30
Q

What causes fracture displacement of a bucket handle fracture?

A
  • Mylohyoid, geniohyoid, genioglossus and digastric pull ANTERIOR segment DOWNWARDS and BACKWARDS aka POSTERIOR, INFERIOR.
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31
Q

What is a guardsman’s fracture?

A

When someone has been standing for a long time and faint.
- Falls CHIN FIRST –> fracture of SYMPHYSIS.
- Transmits force of impact bilaterally to point of weakness (condylar neck) –> CONDYLAR NECK fracture.

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32
Q

What is the direction of fracture displacement in Guardsman’s fracture?

A

As LATERAL PTERYGOID attaches to pterygoid fovea on medial aspect of mandible, it drags condylar head INWARDS.

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33
Q

What fraction of mandibular fractures tend to be more than one fracture site?

A

Approximately 1/3rd.

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34
Q

What could malocclusion suggest?

A

Displaced fractures.

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35
Q

Important consideration when looking at fractures of the mandible?

A

Always look for multiple fractures when looking at fracture of the mandible.

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36
Q

Patient complains of a numb lip. Where is the fracture?

A

Fracture at some point between the mental foramen and the lingula on the medial aspect of the mandible.

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37
Q

7 extra-oral clinical features of mandibular fracture?

A
  • PAIN.
  • Swelling.
  • bruising.
  • Trismus (due to pain and swelling, or because muscles of mastication are not working properly).
  • Concurrent soft tissue injury (cut lip - dirt, tooth fragment).
  • Otorrhoea EAM tear.
  • Anaesthesia/ paraesthesia of lip.
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38
Q

How can ottorhea due to mandibular fracture occur?

A

Condylar head sits immediately in front of the EAM. If the condylar neck is driven backwards, it can breach the wall of the external auditory meatus. The condylar head can thus be driven into the MIDDLE CRANIAL FOSSA, leading to BLOOD and CSF leaking out of the EXTERNAL AUDITORY MEATUS.

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39
Q

6 intra oral features of a mandibular fracture?

A
  • Hematoma in floor of mouth/ buccal mucosa
  • Malocclusion.
  • Tongue - stable position, swelling.
  • Step deformity.
  • Gingival laceration.
  • Mobility or loss of teeth.
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40
Q

What is a PATHOGNOMIC INTRAORAL sign of mandibular fracture? Why does it occur?

A

COLEMAN’S SIGN - HEMATOMA of FOM considered PATHOGNOMIC of FRACTURE OF MANDIBLE.
- Hematoma occurs as the periosteum overlying the bone has torn and there is a hemorrhage into the adjacent tissues.

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41
Q

coleman’s sign?

A

HEMATOMA of FOM

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42
Q

Why is checking for mobility of segments important?

A
  • Undisplaced fractures without mobility  CAPACITY TO HEAL WITHOUT FURTHER MANAGEMENT.
  • If mobility is present, the fracture margins are constantly moving. This will result in a MALUNION/ NON UNION.
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43
Q

Radiographic way to examine a mandibular fracture?

A

2 views at 90 degrees to each other
- DPT + POSTEROANTERIOR MANDIBLE/ FACIAL - 2 views allow 3D visualisation.

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44
Q

Reverse towne’s view?

A

Specialist view for condylar neck fracture.

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45
Q

3 symptom a patient may present with after a right body of mandible fracture with displacement?

A
  • Pain.
  • Altered sensation (displacement stretched IAN within the canal).
  • Malocclusion (lateral open bite).
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46
Q

Importance of seeking further management if mandibular segment mobility is noted?

A

If mobility is elicited with manual pressure, there will be mobility when the patient functions. As the two fractured ends are not immobilised, the patient could end up with a PERMANENT MALOCCLUSION WITH NON UNION OF THE FRACTURE SITES.

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47
Q

2 indications for management when a patient presents with a mandibular fracture?

A
  • malocclusion.
  • mobility of fragment.
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48
Q

How soon after injury would you ideally refer patient for management?

A

Within a 72 hour window from the point of injury to the point of treatment.

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49
Q

What is wound dehiscence?

A

wound breakdown.

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50
Q

What % of patients experience infection after mandibular fracture?

A

up to 20% of patient.

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51
Q

2 causes for non-union/ fibrous union of a mandibular fracture?

A
  • Delayed presentation for management.
  • Inadequate immobilization (fragments still move independently).
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52
Q

Which facial bone is most prone to infection after fracture? Why?

A
  • Mandible.
  • The line of fracture may involve the socket of the tooth. Commensals from the oral cavity can gain access to fracture sites and cause INFECTION.
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53
Q

4 complications which may result from delay to presentation/ treatment?

A
  • Wound dehiscence.
  • Infection.
  • Exposure of hardware.
  • Non-union/ Fibrous union.
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54
Q

Where do you refer a mandibular fracture? What will they do (3)?

A

Maxillofacial surgery
- Radiographs, management, follow up.

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55
Q

2 types of techniques for managing a mandibular fracture?

A
  • Open vs closed technique.
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56
Q

Which is the preferred management method for managing a mandibular fracture? What is done (3)?

A

OPEN TECHNIQUE
- Open reduction and internal fixation.
- The fracture margins are visualised intra-orally or extra-orally via an incision.
- Fractures are aligned and immobilized using mini plates and screws.

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57
Q

Closed technique for management of mandibular fracture (3)?

A
  • The fracture margins are not directly visualised – no incision​.
  • Intermaxillary fixation (wiring the jaws together).
  • There is often mobility at the fracture site that can have a detrimental effect on healing
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58
Q

How long does it take for bone in ADULTS to heal over a fracture?

A

4-6 weeks.

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59
Q

Is load bearing or load sharing better?

A

Load BEARING (2 large plates) so that 100% of the functional load is supported by the fixation (plates).

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60
Q

What are the 2 principles of treatment for mandibular fracture?

A
  1. Reduction.
  2. Fixation.
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61
Q

What is reduction?

A
  • Aligns the bone ends anatomically​.
  • Recreates the normal anatomy
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62
Q

What is fixation? What are the 2 types?

A
  • Prevents movement of the bone margins whilst healing occurs.
  • Load bearing: 100% of the functional load is supported by the fixation e.g 2 large plates​.
  • Load sharing: load is distributed between the hardware and the bone margins e.g one upper boarder plate and arch bars
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63
Q

What is load bearing?

A

100% of the functional load is supported by the fixation (ex. 2 large plates).

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64
Q

What is load sharing?

A

The load is distributed between the hardware and the bone margins (ex. one upper boarder plate and arch bars).

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65
Q

4 methods of OPEN fixation?

A
  • Mini plates and screws (titanium)
  • Reconstruction plates.
  • Compression plates.
  • Lag screws.
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66
Q

What are miniplates (3)? 2 ways in which they can be placed?

A
  • Made of titanium, Osseointegrate (do not cause reaction in patient).
  • Not removed, stay there for the patient’s life.
  • Directly via: transoral approach,
  • Directly through skin with transbuccal trochar.
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67
Q

What are reconstruction plates? 2 cases when they would be used for mandibular fracture?

A
  • EDENTULOUS mandible.
  • Very COMMINUTED fracture.
  • Much thicker, bigger plates that hold the mandible very rigidly.
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68
Q

What are compression plates?

A
  • Have ASYMMETRIC HOLES, push the bone margins together.
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69
Q

What are lag screws?

A
  • Screws that pierce both through the BUCCAL and LINGUAL cortex and PULL the bone margins together.
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70
Q

7 indications for closed reduction?

A
  • Non-displaced favourable factures
  • Grossly comminuted fractures​
  • Significant loss of overlying soft tissue​
  • Edentulous mandibular fractures​
  • Fractures in children
  • Coranoid process fractures​
  • Undisplaced condylar fractures
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70
Q

What method of fixation is closed technique? 5 things that can be used to achieve this?

A

Intermaxillary fixation.
- Arch bars.
- Eyelet wires.
- Leonard buttons.
- Cast cap splits.
- Gunning splints

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71
Q

IMF for non displaced favorable fractures?

A

Well aligned but very painful, short period of IMF can help support the fracture, make it load sharing. Immobilize the fracture to allow a period of healing.

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71
Q

IMF for grossly comminuted fractures?

A

So many fragments that not able to put them together

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71
Q

IMF for significant loss of overlying tissue?

A

Not enough soft tissue to cover over the plates

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71
Q

IMF for edentulous mandibular fractures?

A
  • Used to wire shut with GUNNING SPLINTS, no longer advocated
  • HOWEVER considered when patient is elderly, frail and not suitable for GA.
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72
Q

IMF for fractures in children?

A
  • Do not want to immobilize mandible as mandibular growth plate is at condylar head and do not want to impede mandibular growth, HOWEVER STILL ON THE LIST FOR INDICATIONS FOR CLOSED TECHNIQUE!!
  • Want to be as conservative as possible in children (avoid open, can make vaccum blow down splint to support mandible)
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73
Q

IMF for undisplaced condylar fractures and coranoid process fractures?

A
  • Unilateral condylar fractures can be managed with analgesia and soft diet
  • If bilateral might use IMF to ensure you do not lose condylar height during healing.
  • Coranoid process fractures can be treated conservatively if not causing significant pain.
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74
Q

3 advantages of closed technique?

A
  • Inexpensive​
  • Simple procedure​ (can be done under LA).
  • No foreign body so reduced risk of infection
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75
Q

5 disadvantages of closed technique?

A
  • Not absolutely stable​ (movement at bone margins can lead to non healing).
  • Prolonged period of IMF up to 6 weeks​
  • Possible TMJ sequelae​ (particularly in young people can impact growth plate and cause asymmetries).
  • Decreased oral intake​
  • Possible pulmonary considerations (reflux of gastric contents causing aspiration pneumonia - stomach contents into lungs).
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76
Q

What are ericht arch bars used for? How do they work? (2) 1 disadvantage?

A

CLOSED REDUCTION.
- Preformed and cut to size.
- Each wire wires arch bar to an individual tooth.
- Impacts gingival health.

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77
Q

What are IMF screws? 4 steps to placing them? What must be avoided?

A
  • MONOCORTICAL screws (only go through labial cortex).
    1. Apply LA to the sit.
    2. make small incision using scalpel.
    3. Use drill to make labial cortex osteotomy.
    4. Screw in the screws.
  • Avoid the root of the CANINE and FIRST PREMOLAR.
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78
Q

3 disadvantages of closed technique using eyelets or leonard buttons?

A
  • Not comfortable for patient.
  • Impacts oral intake.
  • Impacts gingival health.
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79
Q

What are cast cap splints? 2 disadvantages?

A
  • Impressions of teeth taken and cobalt chromium splints made and cemented using black copper cement.
  • Not comfortable.
  • Very difficult to remove.
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80
Q

What are gunning splints used for? What is the process? What is advocated?

A
  • Used for EDENTULOUS mandibular fractures, CLOSED technique.
    1. Anterior teeth from dentures drilled away.
    2. Cleats added to dentures and dentures wired in place under GA and kept in for 6 weeks.
  • Anterior aperture allows oral intake.
  • Nowadays advocate an OPEN TECHNIQUE.
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81
Q

4 indications for the open technique?

A
  • Displaced fractures.
  • Multiple fractures.
  • Edentulous displaced fractures (if not displaced may be able to manage it conservatively).
  • Bilateral displaced condylar fractures (want to do open technique and reduction of at least ONE condyle to render in unilateral fracture).
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82
Q

5 advantages of open reduction?

A
  • Improved alignment and occlusion​
  • Fracture immobilised​
  • Avoid IMF​
  • Low rate of malunion or non-union​
  • Lower rate of infection​
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83
Q

3 disadvantages of open reduction?

A
  • Morbidity of surgical procedure​
  • Expensive hardware​
  • Need for GA
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84
Q

What dictates the number and position of plates?

A

Champy’s principles.

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85
Q

What did champy’s principle say?

A

Placement of a plate along the so- called ideal line of osteosynthesis, thereby counteracting distraction forces that occur along the fracture line thus MAXIMIZING MINIPLATE OSTEOSYNTHESIS.
- Along necks of teeth - LINES OF TENSION.
- Along the border - LINES OF COMPRESSION.

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86
Q

Where should fixation plates be placed in the mandible?

A
  • In the mandibular angle region, this line indicates that a plate may be placed either along or just below the oblique line of the mandible. ​
  • Between the mental foramina 2 plates are recommended below the apices of the teeth​.
  • Along the body, plate above and below the mental foramen.
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87
Q

2 cases when extra-oral open reduction is most appropriate? How is this done?

A
  • Through incision in the neck, called SUBMANDIBULAR APPROACH.
  • Displaced fractures involving the LOWER BORDER OF THE MANDIBLE, most appropriate place to plate mandible is INFERIORLY.
  • Edentulous mandibular fracture, minimize periosteal stripping.
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88
Q

What kind of management is recommended for an edentulous mandible fracture? Why?

A
  • EXTRA-ORAL, OPEN reduction.
  • Edentulous fractures to try and minimize the stripping of the periosteum of the mandible.
  • Atrophic mandibles have very poor vascular supply (derived from overlying periosteum). Extra-oral minimizes stripping ands thus has less of an impact on the vascularity of the bone.
  • Use large reconstruction plates that are load bearing + extra-oral approach to place them as low as possible.
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89
Q

4 reasons why edentulous fractures of the mandible are more challenging?

A
  • Atrophic​
  • Poorly vascularised so ​poor healing capacity​
  • Lack of anatomical landmarks​
  • The less bone height the greater the complication rate​
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90
Q

4 aspects of post-operative care for mandibular fractures?

A
  • Antiobiotics (oral, IV, IM).
  • Steroids (short term to minimize swelling).
  • Fluids.
  • Post-op xrays (to check alignment adequate + medicolegal records).
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91
Q

8 complications following management of mandibular fractures?

A
  • Non-union, fibrous union, mal-union.
  • Altered occlusion.
  • Distracted TMJ.
  • Scars - trauma and iatrogenic.
  • Infection 0.4-32%.
  • Necrosis.
  • Numb lip.
  • Exposed plate.
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92
Q

Why are condylar fractures common?

A
  • Part of the facial crumple zone to prevent the forces from being dissipated into the contents of the cranium.
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93
Q

Two types of condylar fractures?

A
  • Extra capsular (more common).
  • Intra capsular.
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94
Q

Intra capsular condylar fracture?

A
  • Difficult to treat as dealing with small fragments.
  • CLOSED technique using LEONARD BUTTONS and ELASTIC TRACTION (elastic traction so that the fracture is not completely immobilized –> can get ANKYLOSIS of the joint which can lead to TRISMUS and INABILITY TO MOVE THE JOINT ON THE AFFECTED SIDE IN THE LONG TERM).
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95
Q

How are most condylar fractures managed?

A
  • Majority of condylar fractures are not badly displaced thus can be managed CONSERVATIVELY with SOFT DIET and NSAIDs.
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96
Q

TMJ effusion?

A

Direct knock to the chin can cause trauma in the joint CAPSULE. Does not cause any breakages but an effusion aka INFLAMMATION IN JOINT.
- Radiographically no evidence of fracture.
- Would resolve with 2 weeks of NSAIDs.

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97
Q

What happens when a condyle is fractured WITH displacement (4)?

A
  • displacement is ANTERO-MEDIAL.
  • Pt deviates TO the side of the fracture.
  • Premature contact on the side of the fracture.
  • Open bite on contralateral side.
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98
Q

Conservative treatment of a fractured condyle (2)?

A
  • soft diet​.
  • analgesics / anti-inflammatory.
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99
Q

Active treatment of a fractured condyle (2)?

A
  • Open reduction and plating​.
  • Closed - Leonard buttons and elastic traction​ (used for intracapsular fractures).
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100
Q

What is the most common mandibular fracture in children?

A

Condylar fracture. (greenstick - undisplaced or minimally displaced).

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101
Q

How are most mandibular fractures in children managed?

A
  • Most fractures are GREENSTICK fractures - undisplaced/ minimally displaced.
  • Manage with SPLINTS (blow down splint to support the fracture).
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102
Q

What is an important consideration in the management of condylar fractures in children?

A
  • Risk to growth centre​
  • Rarely do open surgery due to the risk of damaging the CONDYLAR GROWTH PLATE. This can lead to asymmetric growth of the mandible with deviation to the affected side.
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103
Q

2 categories of zygomatic fracture treatment GOALS?

A
  1. Restoration of facial symmetry/ projection.
  2. Restoration of orbital volume/ globe position/ shape palpebral fissure.
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104
Q

4 things treatment concepts depend on?

A
  • Timing.
  • Type of injury.
  • Mechanism.
  • Presentation.
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105
Q

Immediate treatment of zygomatic fracture?

A

Avoid to:
- Reduce facial swelling and edema.
- Avoid conjuctival ecchymosis (fluid leakage into conjuctiva).

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106
Q

Early treatment of zygomatic fracture (4)?

A

A few days to a week.
Helps better understand:
- Local anatomy.
- Facial symmetry.
- Extent of fracture (obscured by swelling).
- Improved surgical access.

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107
Q

Delayed treatment of zygomatic fracture (2)?

A
  • Can cause problems if the fracture has healed in an unfavourable position.
  • May require osteotomy cuts and repositioning of the bone into its correct sites.
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108
Q

If fixation of the zygomatic complex is required, where is this usually positioned (3)?

A
  • Frontozygomatic suture.
  • Zygomaticomaxillary buttress.
  • Infraorbital region.
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109
Q

2 most reliable indicator of proper reduction and orientation in 3D?

A

ZYGOMATICOSPHENOIDAL SUTURE/ SPHENOZYGOMATIC SUTURE + ANATOMIC REDUCTION OF ZYGOMATIC ARCH.
- Most reliable indicator of proper reduction & orientation in 3D with restoration of function, symmetry etc is critical.

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110
Q

What does the pattern and degree of open reduction and internal fixation (ORIF) depend on (3)?

A
  1. Degree of comminution.
  2. Stability of the fracture (once it has been reduced).
  3. Presence of other features (orbital content/ volume derangement, facial asymmetry, inf orbital nerve issues, functional issues -jaw opening/masticatory, associated fractures).
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111
Q

5 ‘other features’ which may influence the pattern and degree of open reduction and internal fixation (ORIF)?

A
  • Orbital content/ volume derangement.
  • Facial asymmetry.
  • Inferior orbital nerve issues.
  • Functional issues - jaw opening, masticatory.
  • Associated fractures.
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112
Q

What must you monitor non displaced ZMC fractures for (2)?

A
  • Facial asymmetry.
  • Functional deficit.
  • If either occur, proceed with ORIF.
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112
Q

BEST management of displaced, minimally comminuted fractures?

A

OPEN reduction and INTERNAL fixation at MINIMALLY 2, MAYBE 3 POINTS. Reduction by direct visualisation at the:
1. Frontozygomatic suture.
2. Zygomaticomaxillary buttress.
3. Inferior orbital areas.

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112
Q

Treatment of non-displaced ZMC (5)?

A
  1. Confirmed by CT.
  2. Non surgical management.
  3. Serial observation
  4. Soft diet (+ analgesia)
    - antibiotics and nasal decongestants if there is maxillary sinus involvement.
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112
Q

4 advantages of ORIF?

A
  1. Improved alignment.
  2. Fixation of zygomaticomaxillary buttress provides vertical support.
  3. Orbital rim exposure allows inspection orbital floor.
  4. Inspection of fractures sites prior to closure.
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113
Q

4 causes of poor treatment outcomes for zygomatic fractures?

A
  • Inadequate treatment.
  • Inadequate exposure.
  • Inadequate reduction.
  • Failure to restore orbital volume.
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113
Q

5 indications for orbital floor exploration?

A
  1. Defects larger than 5 mm on CT scan
  2. Severe displacement of ZMC.
  3. Comminution
  4. Soft tissue entrapment with limited upward gaze
  5. Orbital contents herniation into maxillary sinus
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113
Q

Treatment of displaced, minimally comminuted ZMC fractures (2)?

A
  1. Reduction (some fractures will remain stable after reduction alone and require no fixation - RISK OF DISPLACEMENT).
  2. Fixation (one point, two point, three point + orbital floor).
    - some fractures are stabilized with ONE point fixation at the ZYGOMATICOMAXILLARY BUTTRESS.
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114
Q

3 indications for orbital floor reconstruction?

A
  • Enophthalmos (globe sunken in due to a loss of supporting structures).
  • Larger defects (5-10mm)
  • Defects posterior to the axis of the globe
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115
Q

3 indications for 2 point fixation?

A
  1. Minimally displaced fractures
  2. The zygomaticomaxillary complex fracture remains stable after initial reduction with no palpable step deformity at the infraorbital rim.
  3. There are minimal changes on orbital volume and globe displacement is not evident on CT scan.
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116
Q

2 indications for 3 point fixation?

A
  • Instability.
  • Exploration of orbital floor required (with palpable step in infra orbital margin).
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117
Q

What is the aim of fixation?

A

Rigid immobility of fractured segment in correct anatomical position.

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118
Q

5 items used for fixation of ZMC?

A

Kirschner Wires
Lag Screw Fixation
Wire Osteosynthesis
Titanium plates & screws
Resorbable plates & screws

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119
Q

Kirschner wires?

A
  • Fix the mobile fragment to the sound fragment by piercing it with a wire in multiple directions.
  • not commonly used in maxillofacial region.
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120
Q

Lag screw fixation?

A
  • Drill one hole into the SOLID bone and another LARGER hole in the MOBILE fragment.
  • Screw engages sound fragment and pulls fractured fragment into place across the fracture line.
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121
Q

Wire osteosynthesis?

A
  1. Holes drilled SITANT from the fracture site to ensure included bone is of sufficient strength and the wire will not pull through.
  2. Wires are threaded across the fracture site, ideally perpendicularly.
  3. Wire ends are bound together, reducing the fracture. They remain at the site to IMMOBILIZE the fracture.
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122
Q

Titanium plates and screws?

A
  • MOST CURRENTLY USED METHOD.
  • Screw plate directly onto the bone across the fracture site to immobilize it.
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123
Q

Likely sites of potential fracture/ luxation of the ZMC?

A
  • Fronto zygomatic area.
  • Infra orbital margin region.
  • Zygomaticomaxillary buttress.
  • Zygomatic arch
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124
Q

What is the aim of reduction?

A
  • To provide a force in the direction OPPOSITE to that which caused the fracture and to re-approximate the bone to the original position
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125
Q

4 different reduction options?

A
  • ZMC hook extraoral (percutaneous bone hook).
  • ZMC hook intraoral (bone hook).
  • Screw insertion.
  • Carroll-Girard T-bar screw.
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126
Q

2 different approaches to reduction of ZMC?

A
  • Oral.
  • Temporal.
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127
Q

intra-oral approach to reduction of ZMC (2)?

A
  1. Intraoral vestibular incision.
  2. Introduction of instrument under the bone to provide traction.
    - Gillies via different approach/ similar to intra oral hook with different instrument.
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128
Q

Gillies temporal approach steps (7)?

A
  1. Identify incision site.
  2. Skin incision (2mm in length) within the hairline made SUPERIORLY and ANTERIORLY to the helix of the ear (avoid superficial temporal artery).
  3. Dissection through superficial temporalis fascia to DEEP TEMPORALIS FASCIA.
  4. Incise until the SUPERFICIAL layer of the DEEP TEMPORAL FASCIA to a plane immediately superficial to the TEMPORAL FAT PAD.
  5. Introduce instrument (ELEVATOR) and navigate beneath (medial) zygomatic arch.
  6. Apply UPWARD force on elevator to push ZMC outwards.
  7. Close wound using sutures.
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129
Q

What is gillies temporal approach good for treating?

A

Ideal for ISOLATED ZYGOMATIC ARCH ‘W’ FRACTURE which commonly undergo elevation and are stable.

(can still be used as fulcrum to manipulate ZMC fractures as well).

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130
Q

2 instruments used for Gillies temporal approach?

A
  • Bristow.
  • Rowe (elevator with hinge).
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131
Q

Bi-coronal flap?

A

Access to zygomatic arch area in comminuted high energy injuries to allow for FOUR POINT FIXATION.
- Goes across where the coronal suture runs.
- Allows access to frontal regions, superior and lateral part of orbit and zygomatic arch.

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132
Q

Complications of ZMC fracture and treatment (10)?

A
  • Pain​
  • Facial asymmetry​
  • Scarring​
  • Bleeding (epistaxis - if ZMC fracture is displaced and involved the sinus, bleeding into the sinus and subsequent epistaxis).​
  • Hardware failure (exposure, palpability)​
  • Infraorbital nerve paraesthesia​
  • Temperature sensitivity​ (related to the plates).
  • Facial paresis or paralysis​
  • Poor cosmetic result​
  • Trismus
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133
Q

4 basic aspects of an eye examination?

A
  • Visual acuity (how clearly a person can see).
  • Visual fields (check peripheral vision loss).
  • Extraocular movements.
  • Diplopia (double vision).
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134
Q

13 aspects of eye examination performed by opthalmology?

A
  • Ocular motility test.
  • Visual acuity - Snellen chart
  • Pupillary reaction by swinging flash light test
  • Direct light reflex
  • Indirect light reflex
  • Visual field testing
  • Assessment of neuro-sensory disturbances of infraorbital nerve.
  • Retinoscopy
  • Direct and Indirect Fundoscopy
  • Slit lamp examination
  • Fluorescent staining
  • Schiotz tonometer
  • Hertel exopthalmometer
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135
Q

What is a serious orbital complication of ZMC fracture treatment?

A

BLINDESS due to:
- superior orbital fissure syndrome.
- Retrobulbar haemorrhage with compartment syndrome.

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136
Q

What is the superior orbital fissure (5)

A
  • Motor nerves to the eye.
  • Split into superior and inferior.
  • Subject to TRAUMA, SHEAR forces.
  • Especially INFERIOR as contents confined in TENDANOUS RING.
  • very rare (0.3-0.8%)
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137
Q

8 potential complications of superior orbital fissure syndrome?

A
  1. Opthalmoplegia (challenges moving the eye).
  2. Ptosis (drooping of upper eyelid).
  3. Proptosis (protruding eye).
  4. Mydriasis (fixed dilated pupil).
  5. Loss of accomodation.
  6. Anesthesia of forehead/ upper eyelid.
  7. Lacrimal hyposecretion.
  8. Anaesthesia of cornea/ bridge of nose.
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138
Q

Opthalmoplegia? Nerves involved (3)?

A
  • Challenges moving the eye.
  • Occulomotor, trochlear, abduscens. (OAT)
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139
Q

Ptosis? Nerves involved (1)?

A
  • Drooping of upper eyelid due to loss of tension and function of the LEVATOR PALPBRI muscle.
  • Superior branch oculomotor.
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140
Q

Proptosis?

A
  • Decreased tension of the extra ocular muscles which allows for movement of the globe– globe retractors.
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141
Q

Mydriasis? nerves involved (1)?

A
  • Fixed dilated pupil.
  • Disruption of parasympathetic fibres from oculomotor nerve.
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142
Q

Loss of accommodation nerves involved?

A

Disruption of parasympathetic fibres from oculomotor nerve. ​

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143
Q

Anaesthesia of forehead/ upper eyelid nerves involved (3)

A

Branches of TRIGEMINAL - OPHTALMIC:
- lacrimal (hyposecretion).
- frontal.

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144
Q

Anaesthesia of cornea/ bridge of nose nerves involved (1)?

A

Sensory nasocilliary nerve.

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145
Q

Treatment for superior orbital fissure syndrome?

A
  • Conservative, these often recover spontaneously.
  • Surgery can lead to further hemorrhage or damage to the nerve.
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146
Q

Retrobulbar Haemorrhage with orbital compartment syndrome (5)?

A

​- Very rare complication (1%)​
- Arterial bleed in the orbit​
- Orbit is closed, non-expansile space​. Thus increase in intraorbital pressure​ causes orbital compartment syndrome (globed pushed forward by increase in volume and backward by the eyelids). ​
- Leads to REDUCED PERFUSION ​and thus ISCHAEMIA of the OPTIC NERVE and RETINA.
- Can result in PERMANENT LOSS OF VISION.

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147
Q

Symptoms of retrobulbar haemorrhage with orbital compartment syndome (2)?

A
  • Globe pain (intense)​
  • Diplopia
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148
Q

Signs of retrobulbar haemorrhage with orbital compartment syndrome? (8).

A
  • Proptosis (eye pushed outwards)​
  • Conjunctival chemosis (fluid under conjuctiva)​
  • Subconjunctival haemorrhage​
  • Tense globe to palpation​
  • Reduced visual acuity​
  • Sluggish pupil response​
  • Relative afferent pupillary defect (swing light test). ​
  • Ophthalmoplegia (difficulty in eye movement)
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149
Q

Non surgical management of retrobulbar haemorrhage with orbital compartment syndrome? (4)

A
  • Immediate management to reduce pressure on the eye until surgical management can be implemented.
  • FLUID DEPLETE: Mannitol​, Acetazolamide​, Steroids
150
Q

Surgical management of retrobulbar haemorrhage with orbital compartment syndrome?

A

LATERAL CANTHOTOMY - surgical decompression.
- PRIMARY treatment.

151
Q

5 other ways of saying midface fractures?

A
  • Middle 1/3rd.
  • Panfacial.
  • Complex.
  • Major facial trauma.
  • Le fort types.
152
Q

How do midface fractures typically occur? Name 6 examples of usual coauses.

A
  • Typically HIGH ENERGY, HIGH IMPACT.
  • RTA, Severe assault weapons (ex. bats), falls from height, industrial (large machinery), agriculture (large animals), war injuries.
153
Q

6 potentially serious outcomes and associates of midface fractures?

A
  • Disarticulation of parts of the facial skeleton from the skull base/ cranium.
  • Airway.
  • Haemorrhage.
  • Head injury.
  • Orbital/ eye injury.
  • Other trauma.
154
Q

What are the anterior, posterior, superior and inferior boundaries of the middle third facial skeleton?

A
  • Superiorly: Frontozygomatic, frontomaxillary, frontonasal.
  • Inferiorly: Occlusal plane upper teeth OR alveolar ridge (edentulous).
  • Posteriorly: Pterygoid plates of sphenoid.
  • Anteriorly: The face itself.
155
Q

3 reasons why the maxilla is an important bone in the middle third facial skeleton.

A
  • Largest bone in the middle third facial skeleton.
  • Serves to attach the skull base to the lower part of the face.
  • Maxilla (with its articulations to the rest of the face) helps form once of the significant BUTTRESSES of the face.
156
Q

10 parts that form the middle third facial skeleton (paired bones counted as 1).

A
  • 2 zygomatic bones.
  • 2 maxillae bones.
  • 2 zygomatic process of temporal bones.
  • 2 palatine bones.
  • 2 nasal bones.
  • 2 lacrimal bones.
  • Vomer.
  • Ethmoid (and attached conchae) .
  • Two inferior conchae.
  • Pterygoid plates of sphenoid.
157
Q

How is stability gained in the middle third facial skeleton?

A
  • Consists of AIR CONTAINING SINUSES.
  • Stability via PAIRED BUTTRESSING SYSTEM (vertical, horizontal, sagittal).
158
Q

What is the primary aim of the buttresing system in the middle facial skeleton? What else is it important for?

A
  • Allows them to EASILY RECEIVE MASTICATORY FORCES via the VERTICAL PILLARS of the face.
  • Also allow MID FACE COLLAPSE (depend on size/ direction of force) which is PROTECTIVE of the brain and skull to allow ENERGY ABSORPTION (CUSHION).
159
Q

Name the 3 horizontal buttresses of the middle third of the face?

A
  • Frontal.
  • Zygomatic.
  • Maxillary
160
Q

What does the frontal horizontal buttress of the middle third of the face consist of?

A
  • Superior orbital rim.
161
Q

What does the zygomatic horizontal buttress of the middle third of the face consist of?

A
  • Zygomatic arch.
  • Body of the zygoma extending to the inferior orbital rim.
162
Q

What does the maxillary horizontal buttress of the middle third of the face consist of?

A
  • The palate at the level of the maxillary alveolus.
  • Serrated edges of greater wings of sphenoid.
  • Sagittal buttress of the zygomatic arches.
163
Q

What does the nasomaxillary vertical buttress of the middle third of the face consist of?

A
  • Lateral piriform rim.
  • Frontal process of the maxilla superiorly.
  • Maxillary process of the frontal bone.
164
Q

What does the zygomaticomaxillary vertical buttress of the middle third of the face consist of?

A
  • Frontal bone superioly.
  • Lateral orbital rim.
  • Zygoma and zygomatic processes.
165
Q

What does the pterygomaxillary vertical buttress of the middle third of the face consist of?

A
  • Pterygoid plates of the sphenoid.
  • Maxillary tuberosity.
166
Q

Why is the pterygomaxillary vertical buttress of the middle third of the face important?

A

Establishes the POSTERIOR FACIAL HEIGHT.

167
Q

What is the primary function of the vertical buttresses of the middle face?

A

Primarily TRANSMIT MASTICATORY FORCES to the SKULL BASE.

168
Q

What do the sagittal buttresses of the middle third of the face consist of?

A
  • Zygomatic arches.
  • Palate.
  • Floor of orbit.
169
Q

What is a downside fo the buttress system?

A
  • FRAGILITY.
  • Buttress system READILY DISRUPTED BY TRIVIAL FORCES IN OTHER DIRECTIONS (ex. frontal or lateral).
  • But this CUSHIONS TRAUMA TO THE CRANIUM (midface collapses for protection).
  • (middle third fractures occur at 1/3rd- 1/5th of the forces required to fracture the mandible).
170
Q

What bones in the middle third facial skeleton have the LOWEST TOLERANCE to impact? (rank from 1st to 3rd)?

A
  • Nasal bones least resistance.
  • Zygomatic arch.
  • Maxilla sensitive to horizontal forces.
171
Q
A
  • Frontal bone and body of sphenoid ARTICULATE with a 45 ANGLE sloping down to the OCCLUSAL PLANE of the UPPER TEETH.
172
Q

What displacement occurs when the midface is sheared off from the skull base?

A

When the midface is sheared off the cranial base:
- POSTERIOR displacement MINIMAL due to posterior maxillary teeth meeting posterior mandibular teeth.
- This may produce an ANTERIOR OPEN BITE.

173
Q

What can be a SERIOUS COMPLICATION when the midface is sheared off from the skull base?

A

Downward and backward displacement can cause CHANGE IN ARCHITECTURE of the SOFT PALATE.
- Soft palate pushed onto DORSUM OF THE TONGUE and can LIMIT AIRWAY (+ exacerbated by tissue swelling/bleeding. )

174
Q

Results of middle third skeleton fractures (7)?

A
  • Anterior open bite.
  • Facial lengthening.
  • Extreme - soft palate obstruct airway.
  • Nares blood clot (ok when conscious).
  • Coincident head injury = danger until airway clear.
  • Dish face deformity if severe.
  • Fractures usually MULTIPLE.
175
Q

Le Fort I

A

Maxillary alveolus separated off at the lateral periphorm region headed posteriorly.

176
Q

Le Fort II

A
  • PYRAMIDAL shape.
  • Higher than le fort I, runs through the infraorbital margins and includes nasal bones.
177
Q

What kind of force typically results in a Le Fort I fracture?

A

Force above dentoalveolar segment.

178
Q

What structures are involved in a Left fort I fracture (7).

A
  • lateral nose/ piriform aperture.
  • Anterior/ lateral/ inferior wall of maxillary sinus.
  • Maxillary tuberosity.
  • Palatal process of maxilla.
  • Horizontal plates of palatine bones.
  • Lower parts of pterygoid plate, pterygomaxillary junction.
  • May include nasal septum and septal cartilage.
179
Q

What is le fort 1?

A

HORIZONTAL MAXILLARY FRACTURE which separates the TEETH/ WHOLE ALVEOLAR COMPLEX.

180
Q

What type of force typically results in le fort II?

A

Force (superior) directed at nasal bones.

181
Q

How does le fort II fracture propagate (6)?

A

Fracture line extends from:
- The nasofrontal suture to
- The nasal and lacrimal bones, to
- Zygomaticomaxillary suture
- Along the orbital floor.
- Continues inferiorly towards the maxillary tuberosity
- Through the pterygoid plates at a higher level than le fort 1 injury.

182
Q

What structure are involved in Le Fort II fracture (7)?

A

Separates the whole maxilla with part of the nasal bones and the lower part of the pterygoid plates, the nasal septum, palatine bones, dentoalveolar segment, and medial third of the inferior orbital rim.

183
Q

What is the shape of a le fort II fracture?

A

PYRAMIDAL FRACTURE
- Teeth at the pyramid base.
- Nasofrontal suture remnant apex.

184
Q

What force results in le fort III fracture?

A

At the level of the orbits.

185
Q

Which bones/ structures are involved in le fort III fracture (6)?

A
  • The zygomaticomaxillary complexes
  • Maxilla
  • Palatine bones
  • Nasal bones including the entire septum
  • Most of the pterygoid plate

are separated from the cranial base.

186
Q

What complication is more likely in Le fort III fractures?

A
  • Chance of a tear of the dura and thus a CSF leak (due to proximity to skull base) is greater.
187
Q
A

Due to attachment of medial and lateral pterygoid, increased chance of ANTERIOR OPEN BITE.

188
Q
A
189
Q

6 findings/ conditions that would require referral to oral medicine?

A
  • Red/white/speckled patches.
  • Erosions/ulcers.
  • Vesiculobullous lesions.
  • Burning mouth syndrome.
  • Facial pain.
  • Xerostomia (salivary gland biopsy).
190
Q

What is a biopsy? 3 examples of places you may take biopsy.

A

Removal of tissue for histopathological examination (ex. mucosa, bone, curettage of cyst lining or contents).

191
Q

4 Clinical applications of biopsy? (aka when would you take).

A
  • Benign lesions (ex. fibroepithelial polyps, papillomas, denture induced hyperplasia - THERAPEUTIC).
  • Bullous, ulcerative, desquamative lesions.
  • Differential diagnosis of white patches.
  • Suspected malignancy - MANDATORY.
192
Q

What is excisional biopsy?

A

Take the whole lesion away.

193
Q

What is incisional biopsy? 3 sub types?

A

Sample it, establish diagnosis, then organize management.
- Exfoliative cytology.
- Aspirational fine needle
- Labial gland biopsy

194
Q

2 types of biopsy?

A
  • Excisional.
  • Incisional
195
Q

What causes a mucocele?

A

Damage to the duct that would normally discharge saliva into the oral cavity. Instead, damage to the duct causes saliva to collect within the tissues and cause a swelling.

196
Q

What is the treatment for mucocele (3)? What must you warn the patient about (2)?

A
  1. Excise the mucocele in its entirety (cyst/sac of saliva).
  2. Must excise the salivary gland that is damaged at the base or it will reccur.
  3. Closure with STITCHES, leaving a LINEAR scar.
  4. Warn patient that this procedure may result in SCAR and PATCH OF NUMBNESS (bc lower lip is full of very delicate nerve) but will RECOVER.
197
Q

When is excisional biopsy used?

A
  • Small, benign lesions.
  • Normal tissue included.
  • Special investigation = treatment.
198
Q

What may happen if a mucocele bursts? What is the clinical presentation of a mucocele (4)?

A
  • Mucocele may fill up, burst and then recur.
  • When it recurs it tends to be FIBROSED and thus more PERSISTENT.
  • Persistent, fibrosed, fluctuant, painless (unless traumatized).
199
Q

What does epulis mean?

A

Swelling on the gum.

200
Q

What lesions can cause epulis?

A
  • Pyogenic granuloma.
  • Soft tissue inflammatory lesion, often caused by chronic area of irritation (ex. irregular surface of filling).
201
Q

Treatment of epulis (3)?

A
  1. Excise tissue.
  2. Send to histopathology.
  3. Area heals by GRANULATION TISSUE. Do not attempt primary closure in attached gingivae as cannot advance the mucosa.
202
Q

What causes denture induced hyperplasia? Clinical presentation (1)? Treatment?

A
  • Ill-fitting dentures, often worn 24/7.
  • Painless until it becomes traumatized by denture.
  • Excision.
203
Q

What causes leaf fibroma? Clinical presentation? Treatment?

A
  • Ill fitting denture.
  • Benign overgrowth, develops from a small pedunculated stock and continues to grow (flat as it is under the denture).
  • LA at pedunculated stock and cut through stock with a small perimeter of normal tissue.
204
Q

What is a novel/ preferred method of treating denture induced hyperplasia? 2 advantages? 2 steps performed after removing the tissue.

A
  • Cutting diathermy
  • Pass small electric current through tip of an instrument that allows CUTTING and HEMOSTASIS (seal tissue).
  • No bleeding post op and no need for suturing.
  • Put soft lining in denture, place denture in place (also ensure hemostasis).
  • Tissue sent off for histological diagnosis.
205
Q

2 disadvangtages of using a scalpel to treat dentire induced hyperplasia? What can be used instead?

A
  • Bleeding, stitches.
  • Cutting diathermy.
206
Q

4 cases when you may take an incisional biopsy?

A
  • Establish definitive diagnosis when provisional diagnosis is of vesiculobullous disease, lichenoid reaction/ lichen planus, potentially malignant, frankly malignant
207
Q

What is a mapping biopsy? When is it used?

A
  • Multiple specimens may be necessary (mapping biopsies)
  • Heterogenous lesions
208
Q

Why do we need to take a reasonable size of tissue when doing an incisional biopsy?

A

To not macerate the tissue by taking too small samples.

209
Q

What is an incisional biopsy? What is important when taking one?

A
  • Removal of a representative portion of lesion.
  • Need reasonable size of tissue (to not macerate the tissue by taking too small sections).
  • Multiple specimens may be necessary (mapping biopsies)
210
Q

Exophytic?

A

Growing out the way.

211
Q

Endophytic?

A

Growing in the way.

212
Q

What do pathologists like for you to do when biopsy of a suspicious lesion?

A
  • Textbook: Biopsy the periphery of the lesion so that the pathologist has the transition from the normal mucosa into the pathological entity.
  • IDEAL: LARGE PIECE OF THE WORST LOOKING PART OF THE TUMOR.
213
Q

Leukoplakia?

A

White patches that you cannot rub off that are not attributable to other causes.

214
Q

What is a field change? How do you biopsy this?

A
  • Entire area has undergone POTENTIALLY MALIGNANT/ FRANKLY MALIGNANT change.
  • Consent patient for MAPPING BIOPSIES (biopsy each of the areas you are concerned about).
215
Q

Erythroplakia?

A

Red patches that you cannot wipe off that are not attributable to other causes.

216
Q

When cancer is excised, how is it done?

A
  • Remove visible cancer + 1cm in all dimensions (of what appears clinically normal) around to try and ensure you have completely excised the tumor.
217
Q

4 things needed when performing an incisional/ excisional biopsy?

A
  • Something to achieve local anesthesia.
  • Something to handle the soft tissues (tooth-tissue forceps).
  • Cutting tool (ex. scalpel, punch biopsy).
  • Close the wound primarily (ex. sutures).
218
Q

When is diathermy used for biopsies (2)? What is its advantage?

A
  • Used for LARGE biopsies.
  • Must be done in highly vascularized sites of the mouth.
  • Uses electric current through tissue forceps to control haemorrhage, electric current seals arteries, arterioles and veins.
219
Q

When is punch biopsy used? 3 steps to using it .

A
  • Used for SMALL incisional biopsy.
    1. Push the circular blade into the tissue, twist it and it cuts into the tissue.
    2. Lift up with your tooth tissue forceps and cut the inferior surface to release it from the base.
    3. Put into pathological pot for testing.
220
Q

When is CO2 laser used? 2 advantages?

A
  • Used when carrying out EXCISION of large lesions.
  • Used for MANAGEMENT of lesions rather than for BIOPSIES for INVESTIGATIVE REASONS.
    Advantages:
  • Seals BLOOD and LYMPHATIC VESSELS as it cuts thus very little BLEEDING and SWELLING post-op.
  • Little scarring as do not have to effect primary closure.
221
Q

When is cryotherapy used?

A

-Only used in the treatment of vascular lesions such as haemangiomas.

222
Q

6 steps that occur after you take a biopsy?

A
  1. Goes into formal saline (to be fixed - tissues get de-proteinized and tissue sample shrinks)
  2. Sent to pathology.
  3. Imbeded in wax.
  4. Sectioned into 4 micrometer thick sections.
  5. Stained in H and E.
  6. Looked into diagnosis.
223
Q

Why is the fact that the tissue is embedded into saline important?

A
  • Proteins in tissue become de-proteinized and thus TISSUE SHRINKS.
  • Thus do not take less than 6mm punch biopsy.
224
Q

How is closure achieved after excision of lesion with CO2 laser? What is an implication of this?

A
  • DO NOT affect primary closure, LEAVE TONGUE TO GRANULATE.
  • Significant post-op pain, eating is compromised.
225
Q

2 precautions that must be taken when using CO2 laser to ensure pt and operator safety.

A
  • Protect the patient’s vision.
  • Instrumentation should either be covered in something to ensure it does not reflect the laser OR use plastic instruments.
226
Q

7 steps to the biopsy technique?

A
  1. Choose most appropriate site (worst looking part).
  2. LA infiltration (for anaesthesia and haemostasis).
  3. Regular ellipse of tissue of a reasonable size (That can be orientated)
  4. Wedge of tissue (In case the lesion extends underneath to stromal tissue).
  5. Atraumatic technique (Do not want to macerate the tissue).
  6. Haemostasis (electrocautery or diathermy)
  7. Primary closure when possible
227
Q

2 ways to help orientate a biopsy to the pathologist?

A
  • Different coloured sutures.
  • Pin to cardboard board with coloured pins.
228
Q

7 problems that may arise during biopsy?

A
  • Inappropriate specimen (ex. nto from worst area.
  • Specimen too small or macerated.
  • Can’t orientate specimen.
  • Tissues distorted by diathermy, LA, laser.
  • Lab not informed of need for frozen section.
  • Lack of clinical detail on form.
  • Specimen gone up aspirator.
229
Q

4 pieces of clinical detail you should include in a form to histopathology?

A
  • History of presenting complaint.
  • Clinical appearance: size, shape, site, texture, colour, ulcerated, indurated.
  • Sign form and give contact information.
  • Details on risk factors, ex. smoking, alcohol.
230
Q

2 advantages and one disadvantage of frozen sections?

A
  • Allow rapid diagnosis of malignancy.
  • Result within 1 hour.
  • Difficult to assess dysplasia with condidence.
231
Q

2 cases when frozen sections are used?

A
  1. Exclude carcinoma at time of surgery (perioperatively during cancer excision - want to excise the base of the cavity to ensure you have excised all of the tumor).
  2. For direct immunofluorescence (ex. diagnose VESICULOBULLOUS CONDITIONS).
232
Q

What is exfoliative cytology?

A

Removal of surface cells by scraping with a spatula or cytobrush.

233
Q

2 cases where exfoliative cytology is used?

A
  1. Cervical cancer screening.
  2. Research in diagnosis of oral carcinoma (cytokeratins, nuclear and cell area)
234
Q

5 steps to performing FNAC?

A
  1. Use LA.
  2. Insert a wide bore needle.
  3. Aspirate tissue.
  4. Place on slide and fix with spray fixative.
  5. Send to cytopathologist.
235
Q

What does fine needle aspiration (FNAC) do/ what is it used for?

A

Determines whether a lesion is:
- Solid (ex. tumor).
- Fluid filled (ex. cyst).
- Vascular (ex. hemangioma)

236
Q

1 advantage and 1 disadvantage of FNAC?

A
  • Simple to perform.
  • interpretation difficult but experienced cytopatholgists have high success rate
237
Q

What can be used in conjunction with FNAC? Why (2)?

A
  • ULTRASOUND.
  • Ultrasound guidance. Can accurately identify the extent of the tumor. Can see insertion of the needle in ultrasound scan, helps improve accuracy.
238
Q

2 things that can happen to cyst contents after they undergo FNAC?

A

Further tests:
- Microbiology.
- Protein electrophoresis.

239
Q

When is FNAC particularly useful?

A

With lumps in the parotid glands and neck lumps to determine whether the lump is a tumour.

240
Q

What is true cut biopsy? What is it typically used for?

A
  • Aspirate cells using a fine bore cutting needle. Cores out an area of the tissue for analysis.
  • Generally used for BIOPSIES of NECK LUMPS.
241
Q

2 types of salivary pathology that are often biopsied?

A
  1. Labial gland biopsy for diagnosis of Sjogren’s syndrome (harvest small amount of salivary tissue from minor glands within the substance of the lower lip).
  2. Parotid tumors readily accessible for FNAC which can be ultrasound guided.
242
Q

3 steps to conducting a minor labial gland biopsy.

A
  1. Linear incision in the mucosa (typically horizontal).
  2. Find minor salivary glands 5-6 lobules of minor salivary glands.
  3. Close primarily with sutures to effect primary closure and hemostasis.
243
Q

Why do we biopsy minor salivary glands to assess for diagnosis of Sjogren’s syndrome?

A
  • Pathological changes in minor glands mirror those in major glands.
244
Q

3 types of diagnostic aids?

A
  • Toluidine blue.
  • ViziLite system.
  • VELscope (visually enhance lesion scope).
245
Q

What is toluidine blue?

A
  • Diagnostic aid (helps you determine where you need to biopsy).
  • is a catoionic metachromatic dye that selectively binds in vivo to acidic tissue components of DNA and RNA (binds to abnormal tissues).
246
Q

Why is toluidine blue no longer used?

A

Sensitivity of 56.1% and specificity of 56.9% to detect oral epithelial dysplasia. Nearly all diagnostic aids are not sensitive/ specific enough to be diagnostically useful.

247
Q

What is ViziLite system (2)?

A
  • Used to detect the mucosal tissues undergoing abnormal metabolic or structural changes that by their nature have different absorbance and reflectance profiles when exposed to various forms of light sources – as a result enhancing the identification of oral mucosal abnormalities.
  • Form of CHEMILUMINESCENCE.
248
Q

What is VELscope (visually enhanced lesion scope)?

A
  • AUTOFLUORESCENCE.
  • Light source, if abnormalities appear SLIGHTLY DARKER than normal tissue.
  • The sensitivity and specificity of autofluorescence for the detection of a dysplastic lesion was 84.1% and 15.3% respectively (a lot of false negatives).
249
Q

What sensitivity and sensitivity is necessary for a diagnostic aid to be diagnostically useful?

A

80%

250
Q

What is field cancerization? How may this present clinically?

A
  • All of the mucosa is genetically altered and becomes pre-programmed to undergo malignant change.
  • Patients can have multiple synchronous lesions or go on to develop lesions one after the other.
251
Q

How is dysplasia graded and what is the recommended management for each grade?

A

Dysplasia is split into mild, moderate, severe.
- Mild: low potential for malignant change, MONITOR.
- Moderate and severe: higher potential for malignant change thus ADVOCATE EXCISION.

252
Q

What is the best way to reach a definitive diagnosis of potentially/ frankly malignant lesions?

A

BIOPSY (histopathological examination) remains the GOLD STANDARD for the definitive diagnosis of potentially malignant and frankly malignant lesions.

253
Q

What size of lesion has a greater potential to be malignant?

A

Anything over 2cm has a greater potential to be a malignant lesion.

254
Q

What is the commonest pathology of minor salivary glands? What causes it?

A
  • MUCOUS EXTRAVASATION CYST.
  • Trauma (ex. knock to lip).
  • Disrupts the duct that drains from the gland to the surface, saliva accumulated in the soft tissue producing a cyst- like swelling.
255
Q

How is a mucous extravasation cyst treated? Which site in trickier to treat?

A
  • Under LA, excise overlying mucosa AND gland.
  • FOM trickier bc important vessels, nerves etc,
256
Q

What is the second most common pathology that affects minor salivary glands? Treatment?

A
  • BENIGN/ MALIGNANT tumors.
  • Treatment is SURGICAL EXCISION with a margin of normal tissue.
257
Q

When do major salivary produce saliva?

A

Only when we are eating/ thinking of eating/ smell food.

258
Q

What salivary glands are predisposed to infection?

A
  • MAJOR salivary glands.
  • Period of stasis (not producing saliva) when not eating allows pathogens to travel up duct.
259
Q

When do minor salivary glands produce saliva?

A

Background moisture (all the time).

260
Q

Where do we NOT find minor salivary glands (2)?

A
  • Anterior hard palate.
  • Gingivae.
261
Q

What type of saliva does the parotid gland secrete?

A

Mixed seromucous but mostly serous.

262
Q

How can the parotid be subdivided?

A
  • Superficial parotid lobe: part of parotid that sits above the facial nerve (accounts 4/5ths of the parotid).
  • Deep parotid lobe: sits deep to the facial nerve.
263
Q
A
  • Deep lobe sits curved around the posterior margin of the mylohyoid muscle.
  • One hand on the outside feeling the superficial lobe, one finger on the inside to feel the deep lobe.
264
Q

Where is the submandibular gland located and what is it encapsulated by?

A
  • Submandibular triangles.
  • Encapsulated and covered by cervical fascia and stylohyoid ligament.
265
Q

4 findings of healthy glands on palpation?

A
  • No tenderness.
  • No attachment to overlying skin.
  • Symmetry.
  • Should feel soft, no nodular material.
266
Q

How does the submandibular gland drain? What type of saliva?

A
  • Via Wharton’s duct.
  • Mixed seromucous.
267
Q

What is the submandibular triangle bounded by?

A
  • Anterior and posterior head of digastric.
268
Q

structure sit posterior to submandibular gland (2)? What structures sit superficial to submandibular gland (5)?

A
  • Posterior: Stylohyoid muscle and ligament.
  • Superficial: 2-3 lymph nodes, facial artery, facial vein, marginal mandibular branch of the facial nerve, lingual branch of the trigeminal nerve.
269
Q

What is the smallest of the paired glands? What covers it?

A
  • Sublingual gland.
  • Lies in the FOM, only covered by oral mucosa.
270
Q

How does the sublingual gland drain?

A
  • Drains via tiny ducts Rivini’s ducts on the **plica sublingularis OR
  • A common duct which joing the submandibular duct Bartholin’s duct.
271
Q

Another term for sublingual fold? What ducts are found there?

A
  • Plica sublingularis.
  • Ravini’s ducts.
272
Q

What type of saliva does the sublingual gland secrete?

A

Mucous.

273
Q

Superior and inferior border of sublingual gland? 2 important anatomical structures in the area?

A
  • Superior: oral mucosa.
  • Inferior: mylohyoid muscle.
  • Lingual nerve sits medial.
  • Submandibular duct crosses UNDER lingual nerve and moves superficially.
274
Q

What is the commonest viral infection found in salivary glands? What virus causes it?

A
  • Mumps.
  • Paramixovirus parotitis.
275
Q

What is the commonest pathology seen in salivary glands?

A

Inflammatory disorders.

276
Q

4 commonest pathology found in salivary glands?

A
  • Inflammatory disorders - viral (mumps, coxsackie, CMV, HIV), bacterial, TB, sarcoid, radiation induced xerostomia.
  • Obstruction/trauma
  • Neoplasm.
  • Autoimmune/degenerative - Sjogren’s Syndrome.
277
Q

2 ways a gland can be obstructed?

A
  • Obstruction of duct itself.
  • Obstruction due to growth (ex. tumor) within the gland which obstructs drainage and increases risk of bacterial infection due to stasis of saliva in the duct.
278
Q

What is sialadentitis? 3 viral pathogens that may cause it

A
  • Inflammation of salivary glands.
  • PARAMYXOVIRUS, CMV, HIV.
279
Q

What is the commonest cause of sialadenitis? How does it present (4)?

A
  • Paramyxovirus (mumps).
  • Disease of childhood, bilateral, self-limiting.
  • Significant if in adulthood.
280
Q

CMV as a cause of sialadentitis clinical presentation (3)?

A
  • Most primary infections are asymptomatic.
  • Severe disseminated disease may be seen in neonates and immunocompromised eg transplant and HIV+ve patients.
281
Q

How quick is mumps expected to resolve? How is it treated (2)?

A
  • Expected to resolve within about 2 weeks, SELF LIMITING.
  • Keep WELL HYDRATED.
  • Reasonable anelgesia.
282
Q

In general how are viral infections treated?

A

SELF LIMITING, do not require an antimicrobial

283
Q

How can you tell that a gland is BACTERIALLY infected (not viral). What is the first line treatment for this?

A
  • Pus discharging.
  • Cannot incise and drain as glands are encapsulated. Thus, ANTIBIOTICS are the FIRST LINE for treatment.
284
Q

What are the 2 types of bacterial sialadenitis?

A

Acute and chronic

285
Q

2 causes of bacterial sialadenitis?

A
  • LOCAL CAUSES - Secondary to stasis (ex. patient starving/ fasting, obstruction of duct by mucous plus/stone).
  • SYSTEMIC CAUSES - Immunosuppresion/ immune based/medication/dehydration/ xerostomia/ irradiation.
286
Q

How does a period of statis predispose to sialadenitis?

A

Major salivary gland not producing saliva as it is not asked to. Thus bacteria can ascend up the duct and infect the gland which is normally a STERILE area.

287
Q

What is the management for acute bacterial sialadenitis (4)?

A
  • Antibiotics.
  • Fluids.
  • Sialogogues (ex. chewing gum, citrus based drops) - encourages drainage through the duct.
  • Analgesics.
  • No incision and drainage unless abscess formation.
288
Q

What happens after you manage the acute symptoms following bacterial sialadenitis?

A

No further issues with the gland unless:
- Mucous plug, stone, tumor, Stricture/narrowing of duct due to damage –> will cause PROBLEM TO RECURR.
- Patient will go on to have low grade, CHRONIC SYMPTOMS which WILL NOT RESOLVE with further antibiotic use.

289
Q

What is the management for chronic symptoms following an acute episode of sialadenitis?

A
  • Chronic symptoms merit further investigation (ex. MRI) and discuss benefits of SURGERY.
290
Q

6 steps to differentiate if a facial swelling is due to odontogenic infection or sialadenitis?

A
  1. Establish whether this is an odontogenic infection or sialadenitis.
  2. Take a history, find out if there way PRANDIAL SYMPTOMS (pain and swelling associated with mealtimes which resolves within a few hours).
  3. Did they have DENTAL PAIN prior to the facial swelling.
  4. Determine the status of their teeth. If teeth are healthy, more likely to be a salivary gland problem.
  5. Investigate with a RADIOGRAPH (if teeth suggest it might be odontogenic).
  6. If identified in sialadenitis, NO ROLE IN TREATING - REFER to MAX FAX for IV antibiotics and potentially INCISION & DRAINAGE.
291
Q

How would you investigate whether a swelling in the submandibular triangle is due to odontogenic cause of the gland itself?

A
  1. Bimanual palpate the submandibular gland to see if it is the gland.
292
Q

What does it indicate when a patient presents with a swollen submandibular gland where the overlying skin is not red/ inflamed?

A

Likely a CHRONIC problem, surgery to remove submandibular gland is appropriate.

293
Q

Patient presents with a submandibular gland swelling. What are 2 investigations that may be undertaken in hospital?

A
  • FNA under ultrasound guidance (allows you to give histopathological diagnosis).
  • MRI scan.
294
Q

What is the most common cause of inflammatory obstruction of the salivary glands? How does this cause inflammation?

A
  • Sialolithiasis
  • An organic nidus (ex. area of mucus) where calcium and phosphate ions come out of solution from the saliva and become deposited onto the nidus.
  • This occurs consequently - LAMINATIONS/ CONSECUTIVE LAYERS of calcium-phosphate ions deposited so that it ENLARGES OVER TIME.
  • Stasis of saliva allows ASCENDING INFECTION.
295
Q

Who does sialolithiasis often affect? Which glands are most often affected?

A
  • Commonest condition affecting > 20 years.
  • Submandibular 80%.
  • Parotid 19%.
296
Q

3 causes of inflammatory obstruction or trauma?

A
  • Sialolithiasis.
  • Mucus plug.
  • Duct stricture (caused by trauma).
297
Q

How does obstructive sialadenitis present? (4 stages)

A
  1. Starts as RECURRENT EPISODES of TRANSIENT, PRANDIAL salivary gland swelling (stone small enough to allow some saliva through yet back pressure of saliva causes swelling and pain of the gland. Resolves after 1 hour of eating as rest of saliva escapes).
  2. NO SYMPTOMS between attacks as saliva escaped from gland, symptoms ALWAYS ASSOCIATED WITH MEALTIMES.
  3. The bigger the stone becomes, the MORE SEVERE THE SYMPTOMS.
  4. Once the stone becomes large enough it causes COMPLETE OBSTRUCTION, STASIS of saliva and thus SWELLING does NOT go down. Thus commensals from the oral cavity enter the gland and cause INFECTION.
298
Q

How does acute sialadenitis secondary to obstruction (sialolithiasis) present (3)?

A
  • Stasis allows ascending infection.
    1. Increasing, painful swelling of 24-72 hours duration.
    2. Oral discharge of pus.
    3. Systemic manifestations (ex. malaise, fever, high respiratory rate, high pulse rate, lymphadenopathy).
299
Q

How is a small intraductal salivary stone treated? A large one?

A
  • Small: Use of sialogogues to encourage gland to produce saliva and pass the stone.
  • Meidum/Large: If about 1/3rd larger than duct diameter or more, will fully obstruct the duct leading to a persistent swelling. Management involves SURGICAL REMOVAL of INTRADUCTAL STONE.
  • Advise pt that whatever has caused these stones to form predisposes them to getting more stones in the future.
300
Q

If a stone is in the floor of the mouth, what is the best radiographic view to see it?

A

Occlusal

301
Q

If a salivary stone is in the submandibular gland, what is the best view to show it?

A

DPT

302
Q

How are stones classified?

A
  • Intraductal.
  • Intraglandular.
303
Q

Why is the submandibular gland most commonly affected by sialoliths (2)?

A
  • Long tortuous duct.
  • More alkaline pH (makes calcium and phosphate ions to come out of solution and be deposited on an organic nidus as saliva is supersaturated).
304
Q

Treatment for intraglandular submandibular gland stone?

A
  • If the patient has chronic sialadenitis, the only treatment they can be offered is REMOVAL OF THE GLAND.
305
Q

What must we caution patients after the removal of a major salivary gland?

A

The removal of one1-2major salivary glands does NOT lead to XEROSTOMIA (large physiological reserve of saliva).

306
Q

What must you do when removing an intraductular sialolith located very far back in the duct?

A

Place a suture BEHIND the stone to prevent it from moving BACKWARDS into the gland when you are trying to retrieve it.

307
Q

How is an intraglandular sialolith treated in the submandibular gland? In the parotid gland?

A
  • Submandibular gland: surgical removal of entire gland.
  • Parotid gland: surgical removal of SUPERFICIAL PORTION of the gland (sits above facial nerve).
308
Q

What is a problem often associated with people who develop salivary stones? What do you have to do?

A
  • CALCULUS FORMATION.
  • Ensure you eliminate any calculus on the lingual aspect of the lower incisors traumatizing the DUCT ORIFICE. This causes INFLAMMATION OF THE SOFT TISSUE AROUND THE DUCT and NARROWS THE DUCT APERTURE aka ELIMINATE TRAUMA.
309
Q

What is basket retrieval of stones?

A
  • Instead of surgical technique, an ENDOSCOPIC TECHNIQUE into the duct itself.
  • Open a basket which retrieves the stones, LESS INVASIVE FORM OF ELIMINATING INTRADUCTAL STONES.
  • Only works on relatively SMALLER stones.
310
Q

7 steps to removing an intraductular submandibular sialolith?

A
  1. LA to freeze up the area all around the stone.
  2. Pass a suture behind the stone to immobilize it in the duct and in front of the stone (also helps emphasize the duct)
  3. Incise down through the firm swelling. Cuts through the roof of the mucosa and the duct.
  4. Can see the stone (yellow/ cream color).
  5. Take out stone, flush with sterile saline and ensure there are no further stones distal to it.
  6. Remove traction sutures.
  7. Either leave it like that WITHOUT sutures (suturing can cause stricture formation and partial obstruction and more problems of obsturctive sialadenitis) OR put in non-dissolvable sutures to stitch the duct lining to the overlying mucosa to make the duct orifice LARGER. As it heals it will decrease in size to approximately its original size - AKA EITHER LEAVE OPEN or STITCH OPEN.
311
Q

What is lithotrypsy?

A
  • Machine that produces ULTRASONIC WAVES which BREAK DOWN THE STONE INTO SMALL COMPONENTS that can be spontaneously shed.
  • Typically used as a replacement to gland removal for LARGE INTRAGLANDULAR STONES rather than having the gland removed.
312
Q

What type of pathology is common in the sublingual gland?

A

MUCOUS RETENTION PHENOMENON - MUCUS RETENTION CYST/ RANULA.

313
Q

What do mucus retention phenomena most commonly affect (2)?

A
  • Sublingual gland.
  • Minor salivary glands.
314
Q

What is a mucocele? What are the 2 types?

A

Mucocele is a cyst.
- Mucous retention cyst: seen in the sublingual gland.
- Mucous extravasation cyst: seen in the lip after trauma.

315
Q

What is a mucous retention cyst of the sublingual gland?

A

Cystic enlargement of the floor of the mouth due to cystic formation within the duct itself rather than the saliva leaking out into the adjacent tissue.

316
Q

What is a plunging ranula?

A
  • Mucous retention cyst in the floor of mouth plunges between the fibres of the FOM (formed by the mylohyoid muscle) and thus presents as a SWELLING OF FOM + SWELLING OF SUBMANDIBULAR TRIANGLE.
317
Q

What is a ranula?

A

A large mucous retention cyst in the FOM.

318
Q

What does the treatment of a ranula depend on (3)? 2 treatment options for ranulas is sublingual gland?

A
  • Its size, site and whether or not there is a chance of recurrence.
    1. Marsupialization.
    2. Remove the cyst and the entire sublingual gland.
319
Q

Why is surgical removal of the sublingual gland tricky? (4)

A

Close to:
- Submandibular duct.
- Lingual artery, vein and nerve

320
Q

What is marsupialization?

A

Create an opening in the ranula which allows the gland to discharge.

321
Q

Clinical appearance of a sublingual gland ranula?

A
  • Bluish hue.
  • Very superficial.
  • If large can affect function (speech, swallowing).
322
Q

What is an uncommon pathology in the sublingual gland?

A

Uncommon to get ascending infections. Unusual to present with acute bacterial ascending sublingual sialadenitis.

323
Q

Why does necrotizing sialometaplasia occur?

A

Trauma has caused damage to the ducts of the minor salivary glands, causing NECROSIS & INFLAMMATION.

324
Q

What structures does necrotizing sialometaplasia affect?

A

The minor salivary glands of the palate.

325
Q

Clinical appearance of necrotizing sialometaplasia (7)?

A
  • Sloughy, ulcerated, indurated ulcer.
  • Periphery of ulcer is VERY KERATOTIC.
  • Red spots are INFLAMED MINOR SALIVARY DUCT ORIFICES.
  • Patients present with PAIN.
  • Should resolve within 2-3 weeks, if not requires biopsy.
326
Q

What is a tumor of the salivary gland?

A

A LOCALIZED enlargement of tissue (localized salivary gland enlargement).

327
Q

How to differentiate between the presentation of salivary gland tumors vs sialadenitis?

A
  • Tumors cause LOCALIZED, DISCRETE salivary gland swelling.
  • Bacterial sialadenitis causes DIFFUSE ENLARGEMENT OF GLANDS.
328
Q

What % of head and neck tumors to salivary gland tumors account for?

A

Less than 3%

329
Q

Are salivary gland tumors more common in major or minor salivary glands? Give %.

A
  • MAJOR GLANDS more COMMON.
  • Minor glands account for only 15-20% of all salivary tumors.
330
Q

Which salivary gland is most often affected by salivary tumors? What % is benign?

A
  • 90% occur in PAROTID GLAND.
  • 80% are BENIGN.
331
Q

What % of submandibular gland tumors are benign?

A

50%

332
Q

What percent of sublingual gland tumors are benign?

A

25%

333
Q

What are the 2 most common sites (with %) that minor salivary gland tumors arise in?

A
  • 55% hard palate.
  • 20% upper lip.
334
Q

A patient presents with a swelling in the UPPER LIP. Give 2 differential diagnoses.

A
  • Mucocele.
  • Minor salivary gland tumor.
335
Q

A patient presents with a swelling in the LOWER LIP. Give 2 differential diagnoses.

A
  • MUCOCELE.
  • Minor SG tumors of the lower lip are RARE!
336
Q

What proportion of MINOR salivary gland tumors are malignant?

A

Proportion of carcinomas is MUCH HIGHER in minor SGs.

337
Q

What diagnosis does intermittent, persistent, unilateral and bilateral salivary gland swelling suggest?

A
  • Intermittent swelling: transient obstruction. ​
  • Persistent swelling: complete obstruction (would also get associated pain).​
  • Unilateral and diffuse: obstructive sialadenitis OR viral sialadenitis. ​
  • Unilateral but localized: could be tumor. ​
  • Bilateral and localized: WARTON’s TUMOR (only bilateral tumor we deal with in the salivary glands. ​
  • Bilateral and diffuse: Sjogren’s syndrome, sialadenosis.
338
Q

What diagnoses do prandial vs persistent pain suggest?

A
  • Prandial: obstructive phenomenon.​
  • Persistent: Sjogren’s, neoplastic pain (malignant neoplasms can grow along nerves).
339
Q

What could facial balsy suggest?

A

Alarm bell regarding malignant neoplasm in the salivary gland (altered function of the facial nerve due to malignant neoplasm growing along it).

340
Q

What diagnoses do xerostomia and sialorrhea siggest?

A
  • Xerostomia: NOT a good diagnostic tool as can occur due to multiple reasons (ex. polypharmacy). Sjogren’s syndrome. ​
  • Sialorrhea: not usually associated with salivary gland disease but rather neuromuscular condition that affects ability to swallow/ clear saliva.
341
Q

What diagnoses do localized, diffuse, soft and nodular consistencies of salivary glands suggest?

A
  • Localized: usually tumors (malignant or benign). ​
  • Diffuse: inflammatory - can be bacterial, viral, autoimmune. ​
  • SOFT Consistency: Enlarged glands should be UNIFORMLY SOFT to touch.​
  • NODULAR/ HETEROGENOUS consistency: Tumors (usually cannot palpate for stones unless very large).
342
Q

2 types of neurologic pain associated with salivary gland disease?

A
  • Facial nerve: palsy, pain.​
  • Lingual nerve: pain (associated with affected side of tongue).

MALIGNANCY - neoplastic growth along the nerve.

343
Q

What salivary gland diagnosis does viscous saliva suggest?

A
  • Not common when dealing with bacterial inflammatory conditions or tumors.
  • More common in AUTOIMMUNE CONDITIONS.
344
Q

You see a swelling on the hard palate. On palpation, how can you tell if is likely odontogenic infection or a tumor?

A
  • Odontogenic infection: FLUCTUANT swelling.
  • Tumor: FIRM swelling.
345
Q

What % of minor salivary gland tumors are benign? Malignant?

A
  • 25% benign.
  • 75% malignant.
346
Q

How is a tumor of a minor salivary gland investigated (2)?

A
  • Incisional biopsy.
  • CBCT (to see if there has been erosion through bone).
347
Q

What is the lower part of the parotid called? Where does it usually sit?

A

The TAIL of the parotid. Sits behind the ANGLE OF THE MANDIBLE.

348
Q

What is a CLINICAL sign of a parotid tail lobe tumor?

A

Elevation of the earlobe.

349
Q

What is the most common tumor affecting the parotid gland?

A

Pleomorphic adenoma (benign tumor).

350
Q

Would you excise a benign parotid gland tumor?

A

YES because can become large and unsightly/ limit function.

351
Q

What can you do to investigate a parotid tumor (1)? What can you NOT do and WHY?

A
  • CAN do: FNA cytology with ultrasound guidance.
  • CANNOT do: Would not do incisional biopsy as opening of the gland can cause SEEDING of the TUMOR CELLS into the surrounding tissues and thus cause RECURRENCES.
352
Q
A
353
Q

In which glands can incisional biopsy be undertaken?

A

Minor, SUBMUCOSAL glands (ex. palate, lip).

354
Q

7 investigations used for salivary gland pathology?

A
  • radiographs/ sialography (therapeutic?)​
  • FNA - 90% accuracy ​
  • ultrasound​
  • CT/MRI​
  • scintigraphy​
  • labial gland biopsy​
  • blood tests, microbiology, sialochemistry
355
Q

What radiographs can be used for investigation of salivary gland pathology?

A
  • Occlusal if stone in the floor of mouth.​
  • DPT if stone for parotid/ submandibular glands.
356
Q

What is sialography?

A
  • Injection of the dye into the duct to outline the ductal structure. Thought that it opened the duct and offered therapeutic effect – now outdated. ​
357
Q

3 things we can learn from ultrasound of salivary pathology?

A
  • SIZE
  • POSITION
  • CONSISTENCY (ex. cystic, solid, vascular).
358
Q

When are CT and MRI used for investigation of salivary pathology?

A
  • MRI: soft tissue contrast.​
  • CT: if worried about bone invasion by tumor.
359
Q

What is scintigraphy?

A

Checks the function of the gland using RADIOISOTOPES (rarely used).

360
Q

When is labial gland biopsy used? Why?

A
  • Advocated for the investigation of SJOGREN’S.​
  • By sampling minor glands in the lip, you can get the same histological changes in the minor glands which are mirrored in the major glands - helps confirms the diagnosis.
361
Q

When is microbiology used for the investigation of salivary pathology?

A

To ensure you are giving the correct antimicrobials.

362
Q

3 indications for surgery in terms of salivary gland pathology?

A
  • Chronic pain post acute episodes.
  • Repeated acute or chronic sialadenitis.
  • Benign/ malignant tumors +/- nerve reconstruction.
363
Q

What would you do if patient presented with chronic pain following an acute episode of saliadenitis? (3)

A

Investigate for: duct stenosis, tumor, undiagnosed Sjogren’s.

364
Q

3 surgical management options for patients presenting with repeated acute or chronic sialadenitis?

A
  • Excise sialolith from submandibular duct.
  • Remove gland .
  • Ranula - marsupialise or complete removal of cyst and associated sublingual gland.
365
Q

benign and malignant salivary gland tumor surgical excision?

A
  • Benign: remove only the tumor. ​
  • Malignant: tumor removed with margin of normality which may sacrifice the nerve thus may have to recoHonstruct them.
366
Q

Through what approach is the submandibular gland excised? What must be done? 2 important structures in the area?

A
  • EXTRAORAL approach - lift skin and platysma muscle to acces submandibular gland.
  • Tie off submandibular duct to prevent ingress of bacteria into the submandibular space.
  • Two important anatomical structures: Marginal mandibular branch of facial nerve, lingual nerve.
367
Q

What can damage to the marginal mandibular branch of the facial nerve cause?

A

Drooping of the corner of the mouth.

368
Q

What can damage to the lingual nerve cause?

A

Located on the deep aspect of the submandibular gland, Can cause NUMBNESS of the LATERAL SIDE of the TONGUE.

369
Q

5 potential complications following removal of submandibular gland (5 things you must consent patient for).

A
  • Pain, swelling, bruising​
  • Scar​
  • Numbness of the tongue​ (due to damage to the LINGUAL nerve. Can be transient or permanent.) ​
  • Weakness of the lower lip​ (due to damage to the marginal mandibular branch of the FACIAL nerve. Can be transient or permanent.​).
  • Weakness of tongue movement​ (due to damage to the HYPOGLOSSAL nerve. Can be transient or permanent.)
370
Q

2 cases when parotid surgery may be advocated?

A
  • Painful Sjogren’s syndrome (superficial parotidectomy - generally parotid is causing the pain).
  • Tumors.
371
Q

4 different types of parotid surgery?

A
  • Extracapsular dissection.
  • Lobar resection.
  • Superficial parotidectomy.
  • Total parotidectomy.
372
Q

What is extracapsular dissection? What is a benefit?

A
  • Dissect to the outer capsule of the tumor and remove just the tumor.
  • Thus very conservative of the salivary tissue/ not sacrificing any healthy tissue.
373
Q

What is lobar resection?

A
  • Take some normal tissue along with the tumor.
  • Slightly more involved that extracapsular dissection.
374
Q

What is superficial parotidectomy?

A
  • Regardless of the size/ how deep the tumor was, you would dissect the 4/5ths of the parotid gland that sat superficial to the facial nerve.
375
Q

What is the surgery of choice for painful Sjogren’s?

A

Superficial parotidectomy.

376
Q

What is total parotidectomy? When is it advocated? What is a potential complication?

A

Only advocated when there is a DEEP LOBE TUMOR (5th of the lobe beneath the facial nerve). If malignant nerve involves th efacial nerve, it must also be ressected and the patient will be left with a PALSY. Reconstructive surgery may be offered to improve the situation.

377
Q

How do you determine if a parotid gland tumor is benign or malignant?

A

FNA cytology under ultrasound guidance.

378
Q

Which nerve divides into the 5 branches of the facial nerve? Name them.

A

Trunk of parotid nerve exits the stylohyoid foramen and branches into branches of facial nerve:
- Temporal.
- Zygomatic.
- Buccal
- Marginal mandibular
- Cervical

379
Q

What happens to the facial nerve after a superficial parotidectomy?

A
  • As it is exposed it becomes DEHYDRATED and thus results in TRANSIENT FACIAL PALSY.
  • Function tends to recover unless there has been irreversible damage during resection.
380
Q

What is Frey’s Syndrome? What causes it?

A
  • Gustatory sweating.
  • Parasympathetic innervation of the salivary gland cross-reacts with the sympathetic innervation of the vascular components in the area.
  • Thus when you sit down to eat, the parasympathetics cross over to the sympathetics and cause SWEATING and FLUSHING (vascular dilation).​
381
Q

7 potential post operative complications of parotid gland surgery?

A
  • Pain, swelling, bruising​
  • Facial nerve injury – weakness of muscles of facial expression​
  • Gustatory sweating (Frey’s Syndrome)​
  • Numbness around ear lobe​
  • Salivary fistula​
  • Infection​
  • Recurrence of tumour
382
Q

How can numbness of the earlobe occur after parotid gland surgery?

A

If auriculotemporal nerve is damaged. generally permanent as it means nerve has been severed.

383
Q

How can salivary fistula occur after parotid gland surgery?

A
  • In superficial parotidectomy, you leave the deep lobe of the gland behind.
  • This does not have a discharging duct and can continue to produce saliva because the parasympathetics still simulate it.
  • Saliva can collect under the skin, track down the scar line and produce a SALIVARY FISTULA.
  • Saliva may drain through the hole and down their neck. Requires surgical correction.
384
Q

When may recurrence of tumor occur after parotid gland surgery (2)?

A
  • Particularly for MALIGNANT tumors
  • Especially when doing EXTRACAPSULAR technique and rupture the capsule thus SEEDING the tumor.

Module 7 (7 decks)

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