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Salivary glands Flashcards

1
Q

Where is the Parotid Gland located?

A
  • Located between the ramus of the mandible and the external auditory canal and mastoid tip, overlies the masseter muscle (anteriorly) and sternocleidomastoid (SCM) muscle (posteriorly)
  • Facial nerve divides the parotid gland artificially into deep and superficial lobes
  • The superficial layer of the deep cervical fascia forms the parotid gland fascia which incompletely surrounds the gland
  • Contains lymphoid tissue within the gland
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2
Q

What are the boundaries of the Parotid Compartment?

A
  • *Superior** – Zygoma
    • *Posterior** – EAC
    • *Inferior** – Styloid, ICA, Jugular Veins
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3
Q

What are the cell types contained in the Parotid?

A

Basophilic, serous cells

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4
Q

What ligament is formed by the fascial envelope between the styloid process and the mandible?

A

Stylomandibular ligament

Separates the parotid gland from the submax gland

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5
Q

What is the Parotid Duct known as?

A

Stenson’s Duct

  • passes over masseter, through buccinator muscle, and opens opposite to the second upper molar (follows along plane from external auditory canal to columella and buccal branch of CN VII)
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6
Q

Does the retromandibular vein pass deep or superficial to the facial nerve?

A

It passs deep to the facial nerve

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7
Q

Describe key features of the Submandibular Gland Anatomy

A

• Within the submandibular triangle (inferior to mylohyoid muscle, superior to the digastrics)
• Superficial layer of the deep cervical fascia envelops the gland and contains the marginal mandibular nerve
• Hypoglossal nerve runs deep to the digastric tendon and medial to the deep layer of the deep cervical fascia
• Facial artery arises from the external carotid artery and courses medial to the posterior digastric muscle then hooks over the muscle to enter the gland and exits into the facial notch of the inferior
mandible
• Lingual artery runs along the lateral aspect of the middle constrictors, deep to the digastrics, and anteriorly and medially to the hyoglossus
• Histological Cell Type: mixed cells (serous and mucinous)

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8
Q

What is the Submandibular duct known as?

A

Wharton’s Duct

opens lateral to frenulum in the anterior portion
of the floor of mouth, behind the incisors

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9
Q

What are the Minor Salivary glands?

A

Sublingual Gland

  • located within the submucosal layer of the floor of mouth

Minor Salivary Glands

  • several hundred glands within the
  • submucosal layer of the oral cavity, oropharynx, nasopharynx, and hypopharynx
  • Histological Cell Type: mucinous
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10
Q

What are the Ducts of Rivinus?

A

drain at the sublingual fold or plica of the floor
of mouth

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11
Q

Describe the embryology of the salivary glands

A
  • Derived from the first pharyngeal pouch
  • 4th week: parotids formed from the posterior stomodeum (ectodermal) forming cords through the mesenchyme which later forms the capsule; parotid encapsulates late allowing entrapment of lymphoid tissue within the parotid fascia
  • 6th week: submandibular glands form as buds in the floor of mouth then grow into the submandibular triangle (endodermal)
  • 9th week: sublingual glands form as multiple buds in the floor of mouth (endodermal)
  • Pathology: aberrant salivary gland tissue, accessory glands (most common in the parotid), diverticuli
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12
Q

Describe the different histology of the salivary glands

A

Parotid: serous

Submandibular gland: mixed (serous and mucinous)

Sublingual and minor: mucinous

Secretory unit = acini cells

Myoepithelial cells surround acini and intercalated ducts

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13
Q

Describe the efferent parasympathetic innvervation of the parotid gland

A
  • inferior salivatory nucleus (medulla)—glossopharyngeal nerve (Jacobson’s nerve) — lesser (superficial) petrosal nerve ➝ otic ganglion—postganglionic parasympathetic fibers—carried by auriculotemporal branch of CNV3 ➝ parotid gland
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14
Q

Describe the efferent parasympathetic innvervation of the submandibular and sublingual glands

A
  • superior salivatory nucleus (pons) — nervus intermedius — chorda tympani—carried on lingual nerve (V3) ➝ submandibular ganglion— postganglionic parasympathetic fibers ➝ submandibular and sublingual glands
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15
Q

Efferent innvervation of the salivary glands versus the lacrimal glands

A

Greater men cry, lesser men spit

Lesser petrosal nerve - salivary glands

Greater petrosal nerve - lacrimal glands

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16
Q

How much saliva is produced per day?

A

.75-1.5 liters of saliva per day

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17
Q

What is the composition of saliva?

A
  • >99% water
  • salts (calcium phosphate, calcium carbonate)
  • organic compounds and enzymes (amylase, albumin, lysozyme, immunoglobulin A, ptyalin initiates the first phase of starch digestion, others)
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18
Q

List the functions of saliva

A
  • Moistens oral mucosa
  • Moistens & cools food
  • Medium for dissolved food
  • Buffer (HCO3)
  • Digestion (Amylase, Lipase)
  • Antibacterial (Lysozyme, IgA, Peroxidase, FLOW)
  • Mineralization
  • Protective Pellicle
  • Modulation of taste
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19
Q

Evaluation of the Parotid Gland Mass

A
  • Character of Parotid Mass: onset and duration, rapid (inflammatory) versus slow growing (neoplastic), diffuse versus discrete mass (tumor), unilateral versus bilateral involvement (sialadenosis, mumps), associated pain, association with food ingestion (sialadenitis)
  • Contributing Factors: history of smoking or alcohol abuse; exposure to radiation or toxins (lead or mercury); history of sarcoidosis, Sjögren’s disease, tuberculosis, gout, amyloidosis; recent facial trauma or surgery
  • Associated Symptoms: xerostomia, sialorrhea, weight loss, fever, trismus, otalgia* (auriculotemporal nerve)
  • Physical Exam: palpation (mobility, size, consistency), bimanual palpation with duct inspection and saliva expression (or purulence), tenderness (inflammatory process), facial nerve function (malignancy), parapharyngeal space involvement (examine intraorally), cervical lymphadenopathy, complete head and neck history and physical exam
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20
Q

Imaging and Ancillary Tests for Parotid Masses

A
  • Fine Needle Aspirate (FNA): indicated for discrete nodules of the parotid gland, widely practiced although controversial (may not change management), differentiates cysts, inflammatory processes, lymphoma, and other neoplasms
  • CT/MRI: indicated if suspect a tumor or for preoperative evaluation (see Table 2–1), ultrasound (U/S) differentiates cystic lesions
  • Superficial Parotidectomy: diagnostically indicated for discrete nodules which require biopsy; incisional biopsy (enucleation) risks tumor seeding, recurrence, facial nerve injury, and violation of tumor margins
  • Technetium-99m Isotope Scan: rarely utilized, may differentiate a Warthin’s tumor or oncocytoma from other salivary gland neoplasms
  • Sialography: visualizes ductal anatomy, indicated for ductal calculi, trauma, fistulas, Sjögren’s disease, contraindicated in acute infections
  • Lab Work: may consider mumps titers, complete blood count, autoimmune and Sjögren’s Profile (SS-A, SS-B, ANA, ESR)
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21
Q

What is Ptyalism?

A

Drooling

  • neurological (Parkinson’s disease, epilepsy), sialorrhea, swallowing disorders (relative ptyalism)
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22
Q

What is Xerostomia?

A

Dry Mouth

  • central (rare)
  • primary salivary disorders (Sjögren’s
    disease, radiation sialadenosis),
  • dehydration
  • medications
    (psychotropics, general anesthesia, B-blockers, amphetamines),
  • mouth breathing
    from nasal obstruction
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23
Q

What is Sialorrhea?

A

excessive saliva production

  • central
  • psychogenic,
  • parasympathicomimetic medications (pilocarpine)
  • diseased gland (tumor, inflammation)
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24
Q

Management of Sialorrhea and Xerostoma?

A

Ptyalism/Sialorrhea:

  • chorda tympani transection (Jacobson’s nerve neurectomy), ductal rerouting procedure to the posterior cavity, ligation of Stenson’s duct, submandibular gland excision

Xerostomia:

  • artificial saliva, frequent small drinks, pilocarpine hydrochlorate drops, aggressive dental care
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25
Q

Describe the features of Acute Suppurative Sialadenitis

A

Pathogen

S. aureus (most common)

Pathophysiology

salivary stasis or obstruction, retrograde migration of bacteria, postoperative parotiditis

Risks

dehydration, postsurgical (GI procedures), radiation and chemotherapy, Sjögren’s syndrome

Symptoms

sudden onset of erythema, tenderness, warmth, and purulence at ductal orifice, auricle may protrude, trismus

Diagnosis

clinical history and exam, cultures

Treatment

rehydration, warm compresses, antimicrobial therapy (may require parenteral antibiotics for severe cases), sialogogues, parotid massage, oral irrigations, if no resolution after 2–3 days then consider CT or U/S to evaluate for abscess (may require I&D)

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26
Q

Describe the features of Mumps and Viral Infections

A

Presents in pediatric population (4-6 years old)

Pathogen

paramyxoviruses

Symptoms

75% bilateral, painful parotid swelling (may involve
submandibular and sublingual glands), malaise, fever, trismus

Diagnosis

mumps titers; hemoagglutination antigens; virus may be cultured from saliva, urine, or CSF

Complications

sudden sensorineural hearing loss (SNHL) (CN
VIII involvement), infertility (with orchitis), encephalitis,
pancreatitis, and nephritis

Treatment

self limiting: requires only supportive care (hydration,
analgesics), audiological evaluation, vaccine is available

Other Viral Infections

CMV (higher mortality in neonates),
Coxsackievirus, influenza A

27
Q

Describe the features of Chronic Inflammation of the salivary glands

A

Types

  1. Granulomatous: tuberculosis, atypical mycobacterium, actinomycosis (poor oral hygiene, dental caries), cat scratch fever, sarcoidosis
  2. Secondary: progression from acute sialadenitis

Symptoms

xerostomia, slow painless enlargement, may be recurrent

Diagnosis

sialography (“tree-leaf ” appearance), CT, PPD, serum markers, VDRL, FTA-ABS, cat-scratch antigen test, etc

Complications

abscess, fistula, ductal destruction

Treatment

  1. Medical: sialogogues, antibiotics, warm compress, massage
  2. Conservative Surgical Management: ductal dilatation
  3. Destructive Surgical Management: gland excision, ductal ligation, gland irradiation, or neuronectomy

NOTE: incisional biopsy should be avoided because of high risk of fistula formation (especially with mycobacterial infections)

28
Q

What is Uveoparotid Fever?

A

AKA Heerfordt’s Syndrome

more common in women

Pathophysiology

extrapulmonary form of sarcoidosis

Symptoms

self-limited uveitis, parotid enlargement, SNHL, facial palsy, malaise, fever

Diagnosis

based on clinical history and exam and evidence of sarcoidosis in salivary gland tissue

Treatment

corticosteroids

29
Q

What is Kuettner’s Tumor?

A

AKA Chronic Sclerosing Sialadenitis of the
Submandibular Gland

Pathophysiology

may be autoimmune mediated

Symptoms

firm, enlargement of submandibular gland (similar to tumor)

Diagnosis

biopsy

Histopathology

chronic inflammation with destruction of acinar
cells, sclerosis, “cirrhotic” changes

Treatment

submandibular excision for diagnosis and treatment

30
Q

Describe features of Radiation Sialadenitis

A

often permanent if exposed to >40–50 Gy

Symptoms

xerostomia, hypogeusia, ageusia

Diagnosis

clinical exam and history of radiation exposure

Histopathology

interstitial fibrosis

Treatment

symptomatic (pilocarpine drops, artificial saliva, frequent drinks), dental care (fluoride rinses)

31
Q

Describe the features of Sialolithiasis

A

AKA Salivary Calculi

  • most common in submandibular gland
  • associated with gout (uric acid calculi)

Pathophysiology

change in the viscosity of the saliva may cause
mucous obstruction, calcium phosphate and calcium carbonate form around this center causing obstruction

Symptoms

recurrent pain, swelling, worse with meals (salivary colic)

Diagnosis

stone may be palpable, sialography (90% of submandibular calculi are radiopaque, 90% of parotid calculi are radiolucent, may be multiple), CT, U/S

Complications

fistulas, acute suppurative sialioadenitis, ductal
strictures

Treatment

gland massage, bimanual expression, transoral incision, sialodochoplasty (reconstruct duct), gland excision if recurrent or if stone is lodged within substance of the gland, extracorporeal
lithotripsy

32
Q

Describe the features of Sjogren’s Syndrome

A

Myoepithelial Sialadenitis, or Benign Lymphepithelial Lesion

most common in middle-aged women’

Pathophysiology

systemic autoimmune destruction of exocrine
glands, B-cell hyperactivity associated with Non-Hodgkin’s Lymphoma

Types

  1. Primary: exocrine gland involvement only
  2. Secondary: associated with other connective tissue disorder (most commonly rheumatoid arthritis)

Other Sicca-like Causes: aging, medications (diuretics, anticholenergics, antihistamines, antidepressants), dehydration, hepatitis, other autoimmune disease

Symptoms

keratoconjunctiva sicca (filamentary keratitis, sandy sensations in eyes), xerostomia (dental caries, dry mucosa), intermittent bilateral parotid swelling (atrophy at end-stage of disease), achlorhydria, Raynaud’s phenomenon, pancreatitis, myositis,
anemia, glomerulonephritis, hepatosplenomegaly

Treatment

artificial saliva, frequent small drinks, artificial tears, consider pilocarpine hydrochlorate drops and oral corticosteroids for severe
acute exacerbation

33
Q

How do you diagnose Sjogren’s Syndrome?

A
  • Clinical History (must have 2 of 3): keratoconjunctiva sicca, xerostomia, or other connective tissue disease
  • Biopsy: lip biopsy or minor salivary glands reveals lymphocytic infiltration with glandular atrophy
  • Serology: ANA, RF, ESR, SS-A and SS-B (antibodies specific for primary Sjögren’s syndrome), decreased IgM (suggest higher risk of progression to malignancy)
  • Sialography: globular, multiple contrast collections throughout gland (“pine tree” appearance)
  • Schirmer test: evaluates tear production
34
Q

What is Mikulicz’s Disease?

A

Mikulicz’s Disease: all cases of recurrent parotid gland swelling that are nonautoimmune

Common Causes

  • amyloidosis
  • duct stricture
  • bulimia
  • lymphadenitis
  • lead and mercury toxicity
  • chronic fatty infiltration
  • from alcohol
  • hypovitaminosis
35
Q

What is Sialadenosis?

A

Pathophysiology

secondary to underlying endocrine or metabolic
pathology (cirrhosis, diabetes, malnutrition, ovarian, thyroid, or pancreatic insufficiency) or medications (hypertensive medications, catecholamines, iodine-containing compounds)

Symptoms

recurrent bilateral nontender parotid swelling (painful
sialadenosis is associated with antihypertensive medications)

Diagnosis

clinical history and exam

Treatment

treat underlying disease or change medications

36
Q

Most common location for salivary gland cysts?

A
  • Parotid glands

Risks: sialoadenitis, sialolithiasis, trauma

W/U and Management

  1. CT scan or U/S to confirm cystic nature
  2. FNA to evaluate for malignant cellsmay observe or inject with sclerosing agents (tetracycline)
  3. Surgical excision for cosmesis, recurrent lesions, solid lesions, abnormal cytology
37
Q

Describe the features of Benign Lymphoepithelial Cysts

A
  • increased incidence since HIV epidemic
  • may progress to pseudolymphoma

Symptoms

multiple, bilateral parotid cysts

Diagnosis

clinical history and exam, biopsy

Histopathology

lymphoreticular infiltrate, clusters of lymphoid
tissue (germinal centers), acinar atrophy, ductal metaplasia

Treatment

aspiration or excision (superficial parotidectomy)

38
Q

Describe the features of a Mucous Retention Cyst and Ranula

A

Pathophysiology

obstruction of minor salivatory glands

Mucous Retention Cysts: true cysts of the minor salivary glands (lined with epithelial layer)

  • *Ranulas**: mucous retention cyst of the floor of mouth
  • *Plunging Ranula:** extension into hyoid muscles, may present as a neck mass

Symptoms

cystic mass on floor of mouth

Diagnosis

clinical history and exam, biopsy

Treatment

excision or marsupialization

39
Q

What other cysts occur in salivary glands?

A

Mucoceles: not a true cyst, extravasation of mucus into soft tissue, usually from trauma to duct (Post-traumatic Sialocele)

Also can get Dermoid and Epidermoidal cysts

40
Q

Describe features of Benign Salivary Gland Tumors

A

Risk

radiation (latency of 7–30 yrs); alcohol and smoking not associated with most salivary neoplasms (except Warthin’s tumors)

  • Multicellular Theory: neoplastic cells originate from their counterparts (eg, oncocytic tumors from striated duct; acinar tumors from acinar cells)
  • Biocellular Theory: all neoplastic cells differentiate from basal cells found in excretory and intercalated ducts
  • 80% of parotid tumors are benign; 80% of salivary neoplasms are located in the parotid
  • in general, the smaller the gland the more likely malignant
41
Q

Describe the features of Pleomorphic Adenoma (Benign Mixed Tumor)

A
  • benign heterogeneous tumor composed of variable epithelial and myoepithelial components
  • most common tumor of each gland (may also be found in the respiratory tract and nasal cavity)
  • slightly more common in women

Symptoms

slow growing (over years), **unilateral**, **painless**, firm mass (usually toward the tail of the parotid); rarely progresses to dysphagia (pharyngeal extension), dyspnea, or hoarseness (laryngeal involvement), or facial nerve palsies; deep lobe (10%) involvement
 may present with intra-oral swelling

Complications

rare malignant transformation (_Carcinoma Ex-
Pleomorphic Adenoma and Sarcoma_) or “benign” metastasizing

Diagnosis

biopsy specimen (parotidectomy), FNA

Treatment

surgical resection with wide margin for pseudopod extensions to prevent recurrence
(>90% 10-year cure, approximately 30% recurrence rate for enucleation alone), radioresistant

42
Q

Describe the histopathology of Pleomorphic Adenoma

A

Cellular Components

  1. Myoepithelial component: spindle shaped with hyperchromatic nuclei, may be more than one cell layer thick
  2. Epithelial components: varied growth patterns (trabecular, solid, cystic, papillary)
  3. Stromal components: product of myoepithelial cells: myxoid, chondroid, fibroid, or osteoid components
  • fibrous pseudocapsule (except minor glands)
  • micro-pseudopod extensions
43
Q

Describe the features of Warthin’s Tumor (Papillary Cystadenoma Lymphomatosum)

A

Pathophysiology

entrapped lymphoid tissue (parotid is the last
gland embryologically to be encapsulated), ectopic ductal epithelium that develops within intraparotid lymph nodes, or hypersensitivity disease resulting in metaplasia of the duct

  • Second most common salivary gland tumor
  • Almost exclusively found in middle-aged to elderly men
  • Almost always involves the parotid
  • 10% bilateral (synchronous or metachronous);
  • 10% multicentric
  • Rare malignant transformation

Symptoms

slow growing, painless, cystic, compressible mass

Diagnosis

surgical biopsy (parotidectomy), FNA (thick, turbid fluid), radiosialography (concentrates technetium-99m due to the presence of high mitochondrial content of oncocytes)

Treatment

superficial or deep parotidectomy

44
Q

Describe the histopathology of Warthin’s Tumor

A

Biphasic Layers

  1. Epithelial component: lines papillary projections; double lining of oncocytes; inner or luminal cells, nonciliated, tall columnar nuclei at luminal aspect; outer or basal cells are round, cuboidal with vesicular nuclei
  2. Lymphoid component: mature lymphocytes with germinal centers
  3. Mucous secreting cells
  • Oncocytic Cell: metaplasia (cytoplasmic alteration) of myo- or epithelial cells
45
Q

Describe the features of Oncocytoma (Oxyphilic Adenoma)

A
  • rare, benign tumor exclusively of oncocytic cells (1% of salivary gland tumors)
  • rare “malignant” low-grade tumor transformation

Symptoms

slow growing, painless mass

Diagnosis

surgical biopsy (parotidectomy), radiosialography (concentrates technetium-99m due to the presence of high mitochondrial content of oncocytes), FNA

Treatment

superficial or deep parotidectomy

Histopathology

  • encapsulated
  • oncocytic cells (see Warthin’s tumor)
  • granularity from mitochondria
46
Q

Describe features of Monomorphic Adenoma

A
  • similar to pleomorphic except no mesenchymal stromal component: predominantly an epithelial component or (rarely) the myoepithelial component
  • more common in the minor salivary glands (upper lip)
  • 12% bilateral

Diagnosis

surgical biopsy (parotidectomy)

Treatment

superficial or deep parotidectomy

Types

  1. Basal Cell Adenoma: mostly basaloid cells, rare malignant potential
  2. Myoepithelioma Adenoma: monomorphic adenoma that has predominately myoepithelial cells
  3. Clear Cell Adenoma: must evaluate for metastatic renal primary
  4. Membranous Adenoma
  5. Glycogen Rich Adenoma
47
Q

General features of Pediatric Salivary Gland Neoplasms

A
  • hemangiomas and pleormorphic adenomas are the most common benign parotid tumors of childhood
  • excluding hemangiomas, salivary gland infections, and lymphangiomas, >50% of parotid solid masses are malignant
  • well-differentiated mucoepidermoid tumors are the most common salivary gland malignancy in children
48
Q

Describe hemangiomas

A
  • benign tumor of endothelial origin
  • usually discovered at birth
  • more common in Caucasian females
  • 50% association with cutaneous hemangiomas
49
Q

Describe features of Capillary Hemangiomas

A
  • constant shape, enlarges in proportion to growth of child
  • may involve facial nerve

Symptoms

lobulated, dark red and bluish mass overlying skin

Histology

unencapsulated, capillary sized vessels, may invade facial nerve

Treatment

avoid surgery in childhood; tattooing, cryotherapy, laser obliteration

50
Q

Describe features of Cavernous Hemangiomas

A
  • may enlarge rapidly
  • 60% spontaneously resolve by 4–6 years old
  • less chance of regression than capillary hemangiomas

Treatment

corticosteroid therapy, may consider surgery if lesion can be completely removed, failure to involute, rapid growth threatens perioral, periorbital, or nasal tip regions

51
Q

Describe features of Salivary Gland Malignancies

A

Symptoms

malignancy suggested by the presence of a slow growing discrete mass (although may present as rapidly growing mass), facial nerve involvement, constant pain, cervical lymphadenopathy

Diagnosis

preoperative FNA is often utilized to counsel patient of risk of facial nerve involvement and malignancy, confirmation must be determined by a superficial parotidectomy (incisional biopsies are
contraindicated due to the possibility of tumor seeding and violation of tumor margins)

Poor Prognostic Indicators

submandibular gland involvement
(parotid gland more favorable), parapharyngeal space involvement, high-grade tumors, larger size, facial nerve or skin involvement, painful tumors, recurrence, regional lymph nodes, distant metastasis
(more common in adenoid cystic and undifferentiated tumors)

52
Q

Describe features of Mucoepidermoid Carcinoma

A

Features

components of epidermoid, mucinous, and intermediate
cells, high- and low-grade tumors

  • most common salivary gland malignancy in children and adults (adenoid cystic carcinoma is the most common in the submandibular gland)
  • most commonly found in the parotid
  • commonly induced by radiation
  • 30–70% overall regional metastatic potential
53
Q

What are the types of Mucoepidermoid Carcinoma?

A

Low-Grade (Well-Differentiated)

Histopathology

more mucinous cystic elements, aggregates of
mucoid cells with strands of epithelial cells, positive keratin staining

  • approximately 70% 5-year survival

Treatment

superficial or total parotidectomy (for deep lobe
involvement), radical neck dissection for clinically positive nodes

High-Grade (Poorly-Differentiated)

  • aggressive (<50% 5-year survival)

Histopathology

less mucinous elements, more solid nests of
cells, requires mucin staining to differentiate from squamous cell carcinoma, positive keratin staining

Treatment

superficial or total parotidectomy (for deep lobe
involvement) with elective neck dissection (selective
supraomohyoid neck dissection); radical neck dissection for clinically positive nodes; consider adjuvant radiation therapy for advanced tumors, regional disease, close or near surgical margins,
or bone or neural involvement

54
Q

Describe the features of Adenoid Cystic Carcinoma (Cylindroma)

A

Features

high-grade tumor, aggressive, insidious growth (over
several years), perineural spread (facial paralysis), local recurrence and distant metastasis (may present >5 years later).

Associated with an MYB translocation

  • most common submandibular and minor gland malignancy

Histopathology

low-grade have cribiform (nests of cells with round
spaces, “Swiss cheese” appearance) or cylindromatous (tubular pattern) pattern, high-grade has more solid pattern (dense cellular pattern with few spaces)

Prognosis

high-grade associated with poor prognosis (<20% 5-year survival), low-grade up to a 100% 5-year survival

Treatment

radical surgical resection (facial nerve resection if involved), consider adjunctive radiation therapy (or neutron beam); long-term follow-up required because of indolent course and possible distant
metastasis, consider elective neck dissection versus postoperative radiation to the neck

55
Q

What are other types of Malignant Mixed Tumors?

A
  • Carcinoma Ex-Pleomorphic Adenoma: 2–3% malignant transformation from pleomorphic adenomas, carcinoma components only (arises from epithelial component)
  • Metastasizing Mixed Tumor: distinct from carcinoma expleomorphic, emains histologically benign
  • Carcinosarcoma: contains components of both carcinomas and sarcomas
  • Noninvasive Carcinoma: carcinoma in situ within a pleomorphic
  • adenoma
56
Q

Describe the features of Acinic Cell Carcinoma

A

Features

  • low-grade, better prognosis (63–87% 10-year survival)
  • second most common salivary gland cancer in pediatrics
  • 3% bilateral
  • most commonly found in the parotid (serous acinar cells)

Histopathology

serous acinar cells or clear cytoplasm cells, several
configurations (microcystic, papillary, solid, follicular), lymphoid infiltrate

Treatment

surgical excision with wide margins, neck dissection for positive nodes only, adjuvant radiation therapy may be considered for advanced disease

57
Q

List other Salivary Gland Malignancy Types

A
  • Squamous Cell Carcinoma: high-grade, aggressive, often not the primary (must evaluate for primary)
  • Lymphomas: rare as a primary site although may arise from intraglandular lymphoid tissue (from embryonic development), associated with Sjögren’s Syndrome
  • Adenocarcinoma: high-grade, aggressive, originates from terminal tubules or intercalated ducts
  • Malignant Oncocytoma: similar to the benign form with distant metastasis and local invasion
  • Epithelial-Myoepithelial Carcinoma (Clear Cell): low-grade
  • Salivary Duct Carcinoma: high-grade, similar to ductal carcinoma of the breast
  • Undifferentiated Carcinoma: highly aggressive, worst prognosis, predominantly “small cell”
58
Q

What are the minor salivary glands in the anterior lingual region called?

A

Glands of Blandin-Nuhn

59
Q

What percentage of parotid, submandibular, and sublingual neoplasms are malignant?

A

Parotid: 20-25% malignant

Submandibular: 45-50% malignant

Sublingual: 70% malignant

However, because 75-80% of salivary gland neoplasms are located in the parotid gland, this gland is still the most common salivary gland to be affected with a malignant neoplasm

Ratio of 40:10:1

(malignant tumors of the parotid, submandbular, and sublingueal glands)

60
Q

How many lymph nodes are in the superficial and deep lobes of the parotid gland?

A

Superficial ~ 16

Deep ~ 4-6

61
Q

What is Mikulicz’s disease?

A

Benign lymphoepithelial lesion

All cases of recurrent parotid gland swelling that are nonautoimmune

Causes: amyloidosis, duct stricture, bulimia, lymphadenitis, lead and mercury toxicity, etoh abuse, hypovitaminosis

62
Q

What is Mobius syndrome?

A

wide spectrum of abnormalities secondary to
central brain stem and peripheral neuromuscular defects resulting in bilateral or unilateral facial and abducens nerve palsies;

other signs and symptoms include club foot (talipes equinovarus), tongue weakness, mixed hearing loss, mental retardation, external ear
deformities, and ophthalmoplegia

63
Q

What is a Kuttner tumor?

A

Chronic sclerosing sialadenitis

  • Is a chronic inflammatory disease of the salivary gland
  • Clinically, it produces a firm swelling of the glands and may be difficult to distinguish from neoplasia
  • The diagnosis can only be made histologically and should not be difficult if the pathologist is aware of the condition’s existence
64
Q

What are Ebner’s glands?

A

Aka Von Ebner’s Gland

  • exocrine glands in the floor of mouth
  • serous salivary glands
  • in posterior 1/3rd of tongue
  • secrete lingual lipase
  • innervated by glossopharyngeal nerve

ENT (17 decks)

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