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Head and Neck + Plastic > Salivary Gland Tumors > Flashcards

Salivary Gland Tumors Flashcards

1
Q

DDX for benign salivary mass

A

Benign

  • Pleomorphic adenoma
  • Adenolymphoma
  • Myoepithelioma
  • Oncocytoma
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2
Q

Ddx for malignant salivary mass

A
  • Muco-epidermoid cancer
  • Adenoid cystic carcinoma
  • Salivary gland ductal carcinoma
  • Polymorphous adenocarcinoma
  • Carcinoma ex pleomorphic adenoma
  • Less common: SCC, acinic cell, mammary analog secretory
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3
Q

Boundaries of the parotid gland

A

Superior: below zygomatic arch

Inferior: posterior bell of digastric

Anterior: lateral surface of masseter

Posterior: mastoid and anterior border of SCM

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4
Q

80% rule

A

80% of salivary gland at parotid

80% benign

80% pleomorphic adenoma

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5
Q

What is the most common benign salivary gland tumor?

A

Pleomorphic adenoma

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6
Q

What is the most common malignant salivary gland tumor?

A

Mucoepidermoid and adenoid cystic carcinoma (half of all malignant tumors)

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7
Q

Risk factors for salivary gland tumours

A

Smoking

Radiation

Viral infections (EBV, HIV, HPV)

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8
Q

Role of imaging in evaluation of salivary gland

A
  • differentiate neoplastic from benign
  • define intra- versus extraglandular
  • assess local extension vs invasion
  • detect nodal and systemic metastases
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9
Q

Name the extra-cranial branches of the facial nerve within the parotid gland.

A

Temporal

Zygomatic

Buccal

Marginal Mandibular

Cervical

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10
Q

What muscles do each branch of the facial nerve innervate?

A

Temporal -frontalis, orbicularis oculi, corrugated supercollider

Zygomatic - orbicularis oculi

Buccal - buccinator, zygomaticus, orbicularis oculi

M.M - depressor labii inferioris, depressor anguli oris, mentalis

Cervical- platysma

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11
Q

Name the other extra-cranial branches of the facial nerve

A

Posterior auricular

Nerve to posterior belly of digastric

Neve to stylohyoid muscle

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12
Q

What is chords tympani

A

Sensory branch of facial nerve that innervated anterior ⅔ of the tongue

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13
Q

Early complications of parotidectomy

A
  • Early
    • Nerve injury
      • Facial
      • Greater auricular
    • Sialocele
    • Salivary fistula
    • Flap necrosis
    • Otitis media
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14
Q

Late complications of parotidectomy

A
  • Late
    • Frey’s syndrome
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15
Q

What is Frey’s syndrome

A

Gustatory sweating due to regrowth of parasympathetic nerve into the sweat glands of the skin

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16
Q

How to treat Frey’s syndrome?

A

Anti-perspiratory agent

Botox (repeat 3-6 months)

17
Q

S

Surgical landmarks to identify the trunk facial nerve

A
  • Tragal pointer: nerve is 1 cm deep and inferior
  • Tympanomastoid suture, leads directly to stylomastoid foramen
  • Posterior belly of digastric, FN at same depth, just above ms
  • Mastoid process
  • Stylomastoid foramen hard to identify surgically
  • Styloid process: FN located in angle between styloid process and posterior belly
  • Retrograde dissection from peripheral branches from buccal branch
18
Q

What to do if facial nerve injury during parotidectomy

A

No shortening: Repair with 8/0 or 9/0 Ethilon or

Loss of length: Repair with nerve graft (greater auricular, sural)

19
Q

Course of the Stensen’s duct

A

Anterior surface of the gland

Traverses the Masseter

Pierces the buccopharyngeal fascia and buccinator moving medially

Opens into oral cavity next to 2nd upper molar

20
Q

Name the important neurovascular structures that pass through the parotid gland

A

Facial nerve

External Carotid Artery

Retromandibular Vein

21
Q

Characteristics of pleomorphic adenoma

A

Young age (40-50)

Slow growing

Rubbery to hard

Risk of malignant transformation 1% per year

22
Q

Characteristics of Warthin’s tumor

A

Older (60s)

Soft

Associated with smoking

15% bilateral

23
Q

What types of surgical approaches to submandibular gland excision are there?

A

Transcervical

Transoral

24
Q

What type of nerve injuries are possible in submandibulectomy?

A

Marginal mandibular nerve - difficulty controlling saliva, biting mucosal surfaces when chewing

Hypoglossal nerve- deviation of tongue to affected side, fasiculation and wasting

Lingual nerve- paraesthesia / loss of taste in anterior 2 / 3 of affected side

25
Q

What are the complications of submandibular gland excision

A
  • General
    • Bleeding
    • Infection
  • Specific
    • Nerve injury
    • Retained stone in distal stump of Wharton’s duct
26
Q

Where is the incision for transcervical approach

A

Horizontal incision 2 finger breadths below the ramps of mandible

27
Q

Why is sub-capsular dissection performed for submandibulectomy?

A

To avoid damage to marginal mandibular nerve (not for oncological resection reasons)

28
Q

What structure is ligated twice during submandibulectomy?

A

Facial artery

29
Q

What is panorex?

A

Plain Xray with full view of upper and lower jaw, teeth, TMJs and sinuses

30
Q

Options of surgical removal of stones

A

Stone extraction + marsupialization (if palpable stone)

Duct excision (non-palpable stone)

Submandibulectomy (non-palpable stone)

31
Q

What are some minimally invasive options to submandibular stones?

A

Irrigation, stenting, ductoplasty

Basket retrieval

Extracorporeal shockwave lithotripsy

32
Q

Synonyms for Warthin’s tumor

A

Papillary cystadenoma lymphomatosum

Monomorphic adenoma

Adenolymphoma

33
Q

What is pes anserinus of the facial nerve?

A

Main bifurcation of facial nerve into upper and lower branches

34
Q

How to perform superficial parotidectomy?

A
  • GA
  • Neck extension with head ring, head turned to contralateral side
  • Modified Blaire or Face lift incision and elevation of cervico-fascial flap until anterior border of parotid gland
  • Identify greater auricular nerve and external jugular vein. Preserve posterior branch of GAN
  • Separate parotid gland from SCM
  • Identify landmarks for facial nerve
  • Identify pes anserinus and trace upper and lower branches
  • Dissect facial nerve from parotid gland with fine curved blunt tip scissors
  • Divide parotid fascia and tissue superiorly and inferiorly for anterior mobilisation of gland
  • Identify retromandibular vein as it crosses FN
  • Removed superficial parotid lobe
35
Q

How to perform a submandibulectomy?

A
  • GA
  • Neck extended with head ring, head turned to contralateral side
  • Incision 2 FB from ramus of mandible
  • Elevation of subplatysmal flap to inferior border of mandible
  • Identify and ligate facial vessels
  • Sling up facial vessels, and retract away marginal mandibular nerve
  • Retract free edge of mylohyoid muscle anteriorly to expose deep lobe
  • Retract gland downward to show V-shaped course of lingual nerve and ligate attachment
  • Dissect out gland and Wharton’s duct
  • Identify hypoglossal nerve before ligation of Wharton’s duct
  • Divide facial artery 2nd time at lower border of posterior pole
36
Q

Course of Wharton’s duct

A
  • starts at medial aspect of superficial submandibular gland
  • continues upward and posterior, curves around free edge of mylohyoid
  • continues anteriorly between hyoglossus and mylohyoid, then between genioglossus and sublingual
  • emerges in sublingual papilla at the base of lingual frenulum
  • **crossed twice by lingual nerve
37
Q

What is the relationship between Wharton’s duct and the lingual nerve?

A
  • Lingual nerve started lateral to duct
  • Courses anteromedially
  • Loops under the duct

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