Salivary Glands

Question 1

What is the 80% rule in salivary gland tumours?

Answer 1

80% of salivary gland tumours are in parotid gland
80% of parotid gland tumours are benign
80% of benign tumours are pleomorphic adenoma

Question 2

The bigger the salivary gland…

Answer 2

The less likely the tumour is malignant

Question 3

Causes of salivary gland tumours

Answer 3

Painful vs painless

Painless
Benign
- Pleomorphic adenoma
- Warthin’s tumour
Malignant
- Mucoepidermoid carcinoma
- Adenoid cystic carcinoma
Systemic
- Alcoholic liver disease (2’ infiltration)
- DM
- Pancreatitis
- Autoimmune: Sjogren’s syndrome

Painful
- Sialolithiasis
- Sialadenitis
- Mumps viral infection

Question 4

Pleomorphic adenoma

Answer 4

• Equal sex ratio, Younger <50
• Firm in consistency
• Nodular
• Unilateral
• Recurrence if not completely excised (2%)
• Risk of malignancy (1-6%) to become SCC
• FNAC: Heterogenous epithelial cells + islands of chondromyxoid, myoepithelial cells
• Perform parotidectomy

Question 5

Warthin’s tumour

Answer 5

• Elderly > 60 y/o, Male
• A/w smoking
• Soft in consistency (doughy)
• Smooth
• Bilateral (10%)
• No recurrence
• No risk of malignancy
• FNAC: Lymphoid cells, multifocal
• Leave tumour alone

Question 6

Most common Ca of the parotid gland

Answer 6

Mucoepidermoid Carcinoma

Question 7

Sialolithiasis

Answer 7

Stones in gland or duct
- P/w pain aggravated by eating or anticipation of eating, esp sour foods
- Intermittent swelling in submandibular triangle or angle of jaw during meal times
- Palpate to see if pus/saliva can be expressed from the parotid duct

Complication
- Sialadenitis: Purulent discharge from duct (Staph aureus, Strep viridans)
- Abscess formation

Question 8

Where is the parotid duct opening located?

Answer 8

Opening of the parotid duct (Stenson’s) is located opposite the 2nd upper molar

Question 9

Investigations to do in salivary gland tumour

Answer 9

• FNAC
• MRI to determine extent of tumour
• X-ray for stones

Question 10

Management of parotid tumour

Answer 10

Tumour involves superficial lobe only: superficial parotidectomy
If benign tumour involves the facial nerve or deep lobe → total parotidectomy, with facial nerve preservation

Tumour involves deep lobe or facial nerve: total parotidectomy with radical lymph node dissection if nodes positive, adjuvant therapy

Question 11

What is the structure that runs between the superficial and deep lobe of parotid gland?

Answer 11

Facial nerve

Question 12

Branches of the facial nerve responsible for closing eyes and smiling?

Answer 12

Closing eyes: Zygomaticus nerve –> Orbicularis oculi
Smiling: Mandibular nerve –> Zygomatic major

Question 13

Complications of parotidectomy

Answer 13

1. Immediate/Intra-operative
2. Early
3. Late

Question 14

Immediate/Intra-operative complications of parotidectomy

Answer 14

Facial nerve (CN VII) lesion –> LMN facial nerve palsy

Question 15

Early complications of parotidectomy

Answer 15

1. Neuropraxia of facial nerve due to traction injury –> Temporary facial weakness
2. Division of great auricular nerve –> Loss of sensation over pinna
3. Infection
4. Hemorrhage/ Hematoma

Question 16

Late complications of parotidectomy

Answer 16

1. Facial synkinesis after facial nerve palsy
   - Eye closure with contraction of mouth muscles
   - Bogorad’s syndrome: hyperlacrimation provoked by eating
2. Frey’s syndrome
   - Flushing/ erythema and sweating on cheek in preauricular area when patient eats or thinks about food
3. Parotid fistula
4. If operation for pleomorphic adenoma → can recur due to incomplete excision as the tumour is not encapsulated

Question 17

Management of parotid stones

Answer 17

Conservative
- Diet: Adequate hydration, soft diet, good oral hygiene
- Local therapy: Massage gland, milk duct, application of moist hot towel
- Analgesia: NSAIDs
- Abx if sialadenitis is present (Strep and Staph coverage)

Surgical
- Transoral removal of stones
- Partial gland resection

Question 18

Purpose of palpating a parotid mass intra-orally

Answer 18

To determine involvement of deep parotid lobe
*whatever that can be felt externally involves superficial parotid lobe

Question 19

What are the borders of the parotid gland?

Answer 19

· Anterior: Masseter
· Posterior: Sternocleidomastoid muscle (SCM)
· Superior: Zygomatic arch
· Inferior: Inferior border of the mandible

Question 20

Besides facial nerve, what other nerve should be checked for?

Answer 20

Greater auricular nerve (sensation to ear lobe and angle of mandible)

Question 21

Sialadenitis

Answer 21

• Painful swelling in submandibular △ / angle of jaw
  I- ntermittent, fluctuant
• Triggered by meals which cause production of secretions

RFs
Dehydration
Malnutrition
Poor oral hygiene
Recent major Sx
Sjogren’s disease
Radioiodine Tx
Direct trauma