S2 - Salivary Gland Investigation and Surgery

Question 1

Salivary gland investigation

Answer 1

1. clinical examination & palpation
2. SFR
3. plain radiography
4. ultrasound
5. sialography
6. CT/MR scan
7. Scintiscanning
8. Sialadenoscopy

Question 2

What can plain radiographs show

Answer 2

calculi

Question 3

What is this

Answer 3

large submd sialolith

Question 4

What is this

Answer 4

parotid duct calculus

Question 5

What is this

Answer 5

sialolith in submd, impacted in the area where superficial and deep part of gland meet (where hugs mylohyoid muscle) - not uncommon place for it to get stuck

Question 6

What is sialography

Answer 6

injection of duct w radio-opaque dye

shows internal structure and function of gland

Question 7

What is shown in sialograph

Answer 7

small defects along indicate calculi blocking the duct

Question 8

What is shown

Answer 8

deep lobe parotid tumour, extending and pushing towards wall of oropharynx

Question 9

What is MR scan good for

Answer 9

examining soft tissue

Question 10

What is scintiscanning

Answer 10

injection of radiographic isotope (99T-pertechnetate), shows basic imaging and demonstrates uptake and distribution of the isotope

pic 1 - normal uptake
pic 2 - less well uptake w Sjogrens
pic 3 - late stage, hardly any uptake

Question 11

Range of salivary gland surgical procedures (dumb q)

Answer 11

1. removal of calculi
2. ductal dilation/repositioning
3. excision of sublingual gland
4. excision of submandibular gland
5. parotidectomy - superficial or total
6. excision of minor salivary gland lesions/tumours

Question 12

Structures to be aware of during surgical removal of submd duct calculi

Answer 12

• Lingual nerve wraps around duct
• Hypoglossal nerve
• Venus plexus
• Mylohyoid muscle
• Facial artery and vein
• Overlying marginal md branch of facial nerve

revision:
lingual (branch of V3) - sensory to fom, ant 2/3 tongue and taste buds
hypoglossal (XII)- motor supply to tongue muscles
glossopharyngeal (IX) - sensory to posterior tongue, tonsils, pharynx, motor to mm. pharyngeal

Question 13

Can you use sialendoscopy to remove a 6mm calculi?

Answer 13

no
3-4mm = endoscopy (if bigger than this need other techniques aswell)
5-7mm = laser/lithotripsy
>8mm = combined technique

Question 14

What is shown

Answer 14

ranula - sublingual swelling caused by cystic change, usually result of damage to gland and mucous/saliva extravasation

(ranula = frogs belly)

Question 15

Issue with dealing with large sublingual ranula

Answer 15

usually need to remove the salivary gland aswell as well since its damaged, if you just drain it, the cyst can just reform

need to try to preserve submd duct! cannula inserted during surgery

Question 16

What could this be?

Answer 16

not in submd triangle (bound by lower border of md and digastric muscles)

not underneath the skin, it is attached to the skin

has a small depression

-> skin lesion called sebaceous/epidermoid cyst

Question 17

During removal of submd gland, where is incision placed

Answer 17

2cm below lower border of md to avoid marginal mandibular branch of facial nerve

Question 18

Structures in/around the parotid gland to be careful of during surgery

Answer 18

• greater auricular nerve runs over (sensory supply to lobe of ear)
• facial nerve divides superficial and deep part of gland

in deep portion:
- retromandibular vein
- branches of external carotid artery
- auricotemporal nerve (supplies part of skin of ear up to temple and TMJ)
- stylomandibular ligament (seperates parotid gland from submd gland)

Question 19

What is this rare complication of parotid surgery (sweating unilaterally whenever the pt saliva stimulated)

Answer 19

Frey’s syndrome
- facial nerve injured/irritated, noramlly mixture of sympathetic (supplying sweat glands of skin) and parasympathetic (stimulating saliva) - cross-innervation (mixed up) during healing

Question 20

Lump on upper vs lower inner surface of lip. What is it likely to be.

Answer 20

upper lip - more likely malignant
lower - usually mucocele aka benign extravasation cysts (usually caused by trauma)

rmb w latter: cannot just drain, need to remove cyst and damaged saliva gland or else cyst will reform

Question 21

Which of the 2 upper lip swellings is more likely malignant?

Answer 21

1. large rubbery, firm swelling of upper lip
2. smaller, nodular, thickened, more malignant looking swelling

Question 22

Suspected palatal abscess, dentist extracted 1st molar and socket healed but swelling got worse and became ulcerated and painful. What happened?

Answer 22

can see projection of blood vessels into the cyst -> adenoid cystic carcinoma of the palate
(swiss cheese microscopically - cribriform)