Salivary Gland Tumors

Question 1

What is the innervation to the parotid gland

Answer 1

Parasympathetic: CN 9

Sympathetic: superior cervical ganglion

Question 2

What and where is stensen’s duct

Answer 2

Parotid duct

• located 1/2 b/w Zarch and angle of mouth
• • courses anterior to masseter, pierces buccinator and enters oral cavity at 2nd maxillary molar

Question 3

Where are the submandibular and sublingual glands located and their ducts

Answer 3

Submandibular: occupies space between two digastric bellies and inferior to mandible border

• mainly lies superficial to mylohyoid but also has deep lobe that lies between mylohyoid and hyoglossus muscles
• Warthins duct, 5cm in length, courses from posterior (deep lobe) along FOM, crossign CN 12 and lingual n to exit at frenulum

Sublingual gland

• lies immediately deep to FOM mucosa at anterior tongue, above genioglossus, behind mandible
• Rivinus and bartholins duct open direct into FOM or into warthins duct

Question 4

What is the innervation to the sunlingual and submandibular glands

Answer 4

• Parasympathetic: Cn 7
• Sympathetic: superior cervical ganglion

Question 5

What is the epidemiology of SGT?

Answer 5

• 80% of SGT are in the parotid, 15% submandibular, 5% minor
• 80% are benign
• of the malignant tumors, the majority are in minor salivary glands = the samller the gland, the more likely its malignant
• Most common parotid tumor: Pleomorphic adenoma
• most common submandibularminor tumor: Adenoid cystic Ca
• most common malingnat parotid tumor Mucoepidermoid Ca

Question 6

What are RFS for developing SGT

Answer 6

Radiation exposure (10-30yr delay)

Also potentially smoking (warthins) EBV

Question 7

What is your differential Dx for a mass in a Salivary gland

Answer 7

NEOPLASTIC

Benign

• Pleomorphic Adenoma
• Warthins
• oncocytoma

Malignant

• Mucoepidermoid Ca (can be low grade)
• Adenoid Cystic Ca (low grade)
• Adenocarcinoma
• Acinic cell Ca
• Carcinoma Ex-Pleomorphic adenoma
• SCC

INFLAMMATORY

• inflammation, acute, chronic
• sialocele
• sialodenosis
• granulomatous disease (sarcoid)

INFECTIOUS

• TB, cat scratch

Question 8

What is your DDX for infiltrative process of Salivary gland

Answer 8

• Sarcoid
• Sjogrens
• Sialodenosis
• inflmmation
• Sialolithiasis

Question 9

What is your managmeent

Answer 9

History

• MASS - growth pattern, tenderness,
• nasal/sinus obstruction (minor glands)
• constitutional
• CN7 involvement

Physical

• MASS - mobility, invasion to adjcent structures
• lymphadenopathy
• bimanual palpation of each SG
• CN 7 exam

Investigation

• U/S
• CT
• FNA/core biopsy
• CXR - lung mets

Question 10

What i syour treatment of benign vs malignant lesions

Answer 10

Benign

• Parotid - superficial parotidectomy - no scarifice of CN7, no ND
• Submand/sublingual/minor - simple excision

Malignant

• depends on tumor grade, size, type
• Total parotidectomy +/- CN7 resection (only is preop paralysis or intraop gross disease)+ nerve graft/static sling +/- ND +/- Rtx
• ND if + clinical/radiologic
• If node negative, ND elective for T3/4, high grade adenoCa, salivary duct CA, SCC
• Rtx if T3/4

Question 11

What is a pleomorphic adenoma

Answer 11

Benign mixed tumor - epithelial and myoepithelial

• usually in tail of parotid
• 7% risk of degeneration into Carcinoma Ex-plemorphic adenoma

Tx - superficial parotidectomy

Question 12

What is warthins tumor

Answer 12

Papillary cystadenoma Lymphomatosum

• 10% bilateral, in tail, ass. w smoking
• 2nd most common parotid tumor

Question 13

What is mucoepidermoid carcinoma

Answer 13

Most common malignant parotid tumor

• Low grade or high grade
• high grade high risk of LN mets
• 2nd most common submandibular/minor gland tumor behind adenoid cystic ca

Question 14

What is adenoid cystic ca

Answer 14

Most common malignant tumor of submandibular/minor glands

• high risk of perineural/vascular invasion
• high risk of lung mets
• Tx - WLE + post op Rtx

Question 15

What tumors metastasize to the parotid

Answer 15

• Melanoma of the H&N, Trunk
• SCC of the H&N
• lung
• breast
• renal
• prostate
• GI

Question 16

What are methods of identifying the main trunk of the facial nerve

Answer 16

• Via Tragal pointer
  
  • in preauricular portion of incision, seperatio of parotid fascia and ECA reveals tragal pinter. 1-1.5cm deep and inferior is located manin trunk
• Via tympanomastoid suture
  
  • • 6-8mm lateral to stylomastoid foramen is located TM suture. From suture, main trunk is located 6-8mm deep to suture
• Retrograde tracing
  
  • identification of terminal facial branches and tracing branches to main trunk
    *

Question 17

Describe steps for parotidectomy

Answer 17

• Modified Blair incision - preauric from root of helix, to lobuel, posterior to mastoid, then traced along anterior border of SCM til 2 fingerbreadth below mandible
• lift preauric skin flap superficial to parotid fascia and neck flap in subplatysmal plane
• ID GAN EJV along SCM and liekly needed to be divided
• once reached patorid, identify main trunk and trace out. Resect all gland above CN7 (superficial parotidectomy)

Question 18

Describe excision of a submandibular gland

Answer 18

• Incision 3-4fingerbreadth below mandible, at inferior edge of submandibular gland
• incise though platysma, identify facial vein and ligate, lift superioly, and this will protect marginal br
• ligate facial artery to free superior attachment of gland
• mylohyoid vessels divided and muscle retracted anteriorly and submandibular gland pulled posteriorly to expose deep portion of gland
• Submandibular duct, submandibular ganglion, lingual n, CN12 nerves identified lying on top of hyoglossus
• longual n br to gland trasnected and facial art dvided second time

Question 19

What is frey syndrome and treatment

Answer 19

Aberrant reinnervation of ATN - parasympathetics to parotid gland and sympathtics to scalp sweat glands cross innervate and results in gustatory sweating

Tx

Non-op

• scopolamine topical/oral
• glycopyrrolate
• botox

Operative

• skin excision, dermal/fat interposition graft/ADM, TPF