Salivary neoplasms Flashcards
Which salivary gland is more prone to development of benign neoplasms?
Parotid gland 80% are benign
Submandibular 50% are benign
Minor glands 10% are benign
Which salivary glands have the highest malignancy rate?
minor salivary glands
What is the classification of salivary neoplasms?
PRIMARY
- > epithelial
- > non-epithelial
- > lymphoepithelial
- > lymphoma
SECONDARY
What is the sub-classification of epithelial salivary neoplasms?
BENIGN (adenoma)
- pleomorphic (most common)
- Wathin’s (monomorphic): papillary cystadenolymphomatosum
- Oxyphil: oncocytoma
MALIGNANT (adenocarcinoma)
- mucoepidermoid
- acinic cell
- adenoid cystic
- squamous cell carcinoma
- carcinoma ex pleomorphic adenoma
- undifferentiated
What are the types of non-epithelial salivary neoplasms?
- hemangioma: most common benign tumor in pediatrics
- lymphangioma
- neurofibroma
Which benign salivary neoplasm occurs mainly in the parotids, & in common with HIV & Sjogren?
Lymphoma (NON-HODGKIN)
Which benign salivary neoplasm occurs mainly in the parotids, & in common with HIV & Sjogren?
Lymphoma (NON-HODGKIN)
What are the types of lymphoepithelial salivary neoplasms?
- Godwin’s tumor: benign & bilateral
- Eskimoma: malignant & rare (affects submandibular)
What are the types of lymphoepithelial salivary neoplasms?
- Godwin’s tumor: benign & bilateral
- Eskimoma: malignant & rare (affects submandibular)
How is a pleomorphic adenoma described grossly & histologically?
GROSS
- lobulated encapsulated
- contains cartilages, cystic spaces, & solid tissues
HISTOLOGICALLY
- epithelial cell, myoepithelial cells, stromal cells
- mucoid material with myxomatous changes
What are the clinical features of a pleomorphic adenoma?
- unilateral single painless smooth firm lobulated
- mobile swelling in front of the parotid with positive CURTAIN SIGN (can never move above zygomatic arch)
- ear lobule is lifted
- facial nerve in not involved
What are the features of malignant transformation?
- recent increase in size
- pain & nodularity
- involvement of skin & ulceration
- involvement of masseter
- involvement of facial nerve
- hard fixed immobile neck lymph nodes
What are the important investigations that should be done to diagnose a pleomorphic neoplasm?
- sonography: initially
- FNAC: diagnostic
- CT & MRI: status of deep lobe, local extension & spread
How should a salivary pleomorphic neoplasm be treated?
- if only superficial lobe: conservative superficial parotidectomy
- if both lobes: total conservative parotidectomy
enucleation is avoided due to high recurrence because of psuedopods (incomplete capsule)
Which tumor is composed of a double layer of columnar epithelium with papillary projections into cystic spaces with lymphoid tissues in the stroma, that only occurs in the parotid gland’s lower pole?
Warthin’s tumor = Adenolymphoma = Papillary cystadenolymphomatosum
DOES NOT TURN INTO MALIGNANCY
What are the clinical features of Warthin’s tumor?
- bilateral non tender
- common in males
- common in old people
- only in lower part of superficial lobe of parotid gland
- slow growing, smooth, soft, cystic, fluctuant swelling
What is the diagnostic method of investigation in case of papillary cystadenolymphomatosum (Warthin’s tumor)?
99TECHNETIUM SCAN -> hot nodule
fnac could be used as well
What is the treatment of papillary cystadenolymphomatosum?
conservative superficial parotidectomy
What tumor is characterized by presences of oncocytes & its red color? How should it be treated?
Oxyphil adenoma (oncocytoma)
Surgical removal
What is the commonest malignant salivary gland tumor?
Mucoepidermoid tumor
What are the types of mucoepidermoid tumor?
low grade: mucus cells mainly
high grade: epidermoid cells mainly
facial nerve involvement is late
What are the clinical features of a mucoepidermoid tumor?
- swelling in parotid or submandibular region
- slowly increasing in size
- attains large size, hard, nodular, with involvement of skin & lymph nodes
Which malignant salivary neoplasm is characteristically soft & cystic but can involve the facial nerve or neck lymph nodes?
Acinic cell tumor
What is the most severe malignant salivary neoplasms & where does it commonly occur?
adenoid cystic carcinoma
- in submandibular & minor salivary glands
What is invaded in adenoid cystic carcinoma?
- facial nerve (very early) & shows perineural spread
- periosteum & bone medulla early & spreads extensively
poor prognosis
How should adenoid cystic carcinoma be treated?
RADICAL parotidectomy & radical radiotherapy
What are the general features of malignant salivary tumors?
- pain & anesthesia in the skin & mucosa
- rapid rate of growth
- fixation, irregular, nodular, ill-defined edge, hard
- resorption of adjacent bone
- infiltration of skin, muscles, vessels, & nerves (facial nerve in parotid/hypoglossal nerve in submandibular)
- involvement of jaw & mastication muscles
- spread to LUNGS
What is the most important method of investigation in case of malignancy?
MRI -> shows better soft tissue definition
What investigations are used in malignant salivary gland tumors?
- CT: to see deep lobe of parotid, involvement of bone, extension into base of skull, relation of tumor to vessels
- MRI: better soft tissue definition
- FNAC: from tumor or lymph node
- incisional biopsy: only from minor salivary glands
How should a malignancy in the parotid gland be treated surgically?
RADICAL PAROTIDECtOMY
- removal of both lobes of parotid, soft tissues, part of the mandible with the facial nerve
- facial nerve is reconstructed using GREATER AURICULAR NERVE or SURAL NERVE
- radical neck dissection if lymph nodes are involved
How should a malignant tumor in the submandibular gland be treated surgically?
WIDE EXCISION with removal of adjacent muscle, soft tissues & mandible
- block dissection of neck in case of lymph node involvement
Why is radiotherapy used in case of malignant salivary tumors?
- reduce chances of relapse
- more useful in ADENOID CYSTIC & squamous cell carcinoma
- adjuvant or neo-adjuvant therapy (pre-op to try to shrink the tumor)
What are the post-parotidectomy complications?
GENERAL
- hemorrhage
- SSI
- flap necrosis
SPECIFIC
- Frey’s syndrome
- Facial nerve injury
What are the clinical features of Frey’s syndrome?
AKA auriculo-temporal syndrome & gustatory sweating
- flushing, sweating, pain, hyperaesthesia in the skin over the face innervated by the auriculotemporal nerve whenever salivation is stimulated (mastication)
How is Frey’s syndrome prevented OR treated?
PREVENT
- avoid overdissection
- insert flap like sternomastoid muscle of temporal fascia as a barrier over the parotid bed
TREAT
- Jacobsen nerve neurectomy
- injection of botulinum toxin to the affected skin
What are the causes of facial nerve injury?
- trauma
- surgical complications
- Bell’s palsy (viral infection)
What are the clinical features of facial nerve injury?
- inability to wrinkle brow (frontalis)
- drooping eyelid, inability to close eye (orbicularis oculi)
- inability to puff cheek, asymmetric smile (buccinator)
- drooping corner of mouth, dry mouth (facial expression muscles)
How should facial nerve injury be treated?
- conservative & reassurance (30% are temporary)
- if persistent: surgical intervention
What surgeries could be done incase of facial nerve injuries?
STATIC
- suspension surgery using temporal fascia
- lateral tarsoraphy
- upper eyelid weights
DYNAMIC
- muscle transfer (temporal to masseter)
- free muscle graft (Gracilis)
- nerve grafts (Sural nerve)
