Salivary Gland Tumors Flashcards by Julie Ng

DDX for benign salivary mass

Benign

Pleomorphic adenoma
Adenolymphoma
Myoepithelioma
Oncocytoma

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Ddx for malignant salivary mass

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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Boundaries of the parotid gland

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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80% rule

80% of salivary gland at parotid

80% benign

80% pleomorphic adenoma

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What is the most common benign salivary gland tumor?

Pleomorphic adenoma

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What is the most common malignant salivary gland tumor?

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

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Risk factors for salivary gland tumours

Smoking

Radiation

Viral infections (EBV, HIV, HPV)

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Role of imaging in evaluation of salivary gland

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

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

Temporal

Zygomatic

Buccal

Marginal Mandibular

Cervical

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What muscles do each branch of the facial nerve innervate?

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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Name the other extra-cranial branches of the facial nerve

Posterior auricular

Nerve to posterior belly of digastric

Neve to stylohyoid muscle

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What is chords tympani

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

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Early complications of parotidectomy

Early
- Nerve injury
  - Facial
  - Greater auricular
- Sialocele
- Salivary fistula
- Flap necrosis
- Otitis media

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Late complications of parotidectomy

Late
- Frey’s syndrome

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What is Frey’s syndrome

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

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How to treat Frey’s syndrome?

Anti-perspiratory agent

Botox (repeat 3-6 months)

Surgical landmarks to identify the trunk facial nerve

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

What to do if facial nerve injury during parotidectomy

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

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

Course of the Stensen’s duct

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

Name the important neurovascular structures that pass through the parotid gland

Facial nerve

External Carotid Artery

Retromandibular Vein

Characteristics of pleomorphic adenoma

Young age (40-50)

Slow growing

Rubbery to hard

Risk of malignant transformation 1% per year

Characteristics of Warthin’s tumor

Older (60s)

Soft

Associated with smoking

15% bilateral

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

Transcervical

Transoral

What type of nerve injuries are possible in submandibulectomy?

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

What are the complications of submandibular gland excision

* General * Bleeding * Infection * Specific * Nerve injury * Retained stone in distal stump of Wharton's duct

Where is the incision for transcervical approach

Horizontal incision 2 finger breadths below the ramps of mandible

Why is sub-capsular dissection performed for submandibulectomy?

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

What structure is ligated twice during submandibulectomy?

Facial artery

What is panorex?

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

Options of surgical removal of stones

Stone extraction + marsupialization (if palpable stone) Duct excision (non-palpable stone) Submandibulectomy (non-palpable stone)

What are some minimally invasive options to submandibular stones?

Irrigation, stenting, ductoplasty Basket retrieval Extracorporeal shockwave lithotripsy

Synonyms for Warthin's tumor

Papillary cystadenoma lymphomatosum Monomorphic adenoma Adenolymphoma

What is pes anserinus of the facial nerve?

Main bifurcation of facial nerve into upper and lower branches

How to perform superficial parotidectomy?

* 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

How to perform a submandibulectomy?

* 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

Course of Wharton's duct

* 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

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

* Lingual nerve started lateral to duct * Courses anteromedially * Loops under the duct