DISORDERS OF SALIVARY GLANDS-1- tumors,stones

PPT on salivary gland tumors and stones

1. DISORDERS OF SALIVARY GLANDS Talha Ahmed

2. ANATOMY 600 to 1000 in number 1-5mm in diameter Distributed all over the oral cavity and oropharynx Not seen over the Anterior 1/3 rd of hard palate and Gingivae

3. Parotid Gland Largest salivary gland 2 lobes – Superficial and Deep divided by the Facial Nerve

4. 3 surfaces Antero medial Postero medial Lateral 3 Borders Anterior Posterior Medial

5. Relations

6. 80% of gland overlies the masseter and the mandible 20% extends medially through the stylomandibular tunnel ( retromandibular portion)

7. Parotid Capsule The investing layer of deep cervical fascia splits between the angle of mandible and mastoid process to enclose the gland.

8. Parotid Duct ~ Stensen’s Duct 5cm in length, 2-3mm in diameter Emerges from the anterior surface of gland Lies 1cm below the zygomatic arch

9. Faciovenous plane of Patey Surgical Importance Divides parotid into two lobes Facial nerve is Superficial

10. Facial Nerve VIII Intra cranial and Extra cranial course Only nerve which has motor, sensory, special visceral afferent and parasympathetic supply Divides the parotid gland – Parotid sandwich Pes anserinus (Goose foot)

11. Identification of Facial nerve Conley’s point – 1cm deep and below the tip of the inferior portion of the cartilaginous canal Inferomedial to tragal pointer Lateral to styloid process Deep to posterior belly of digastric Hamilton-Bailey technique

12. Nerve supply Parasympathetic – Auriculotemporal nerve - + causes watery secretion Sympathetic – Sympathetic plexus around ECA (which in turn originates from the superior cervical ganglion) - + causes scanty, viscous & thick secretion

13. Vascular supply Arterial – ECA Venous – EJV

14. Submandibular Gland J shaped gland located in digastric triangle 2 lobes – Superficial & Deep divided by the mylohyoid muscle Submandibular gland duct – Wharton’s Duct – opens beside the frenulum of tongue along with the sublingual duct

15. Relations

16. Relations

17. Rule of 2

18. Sublingual Gland Located in floor of mouth Drains directly into oral mucosa or via SM gland duct 8-20 Ducts of Rivinus SL duct of Bartholin Joins the SM gland duct

19. Saliva Daily production of 1-1.5 liters Water – 99.2% & Organic compounds like mucin , amylase, lysozyme, IgA, Amylase

20. Functions Swallowing Keeps mouth moist Solvent for taste buds Facilitates speech Rinses oral cavity and keeps it clean Antibacterial Neutralizes gastric acid in regurgitation Digestion – Hydrolysis of starch by amylase

21. Salivary Gland Disorders

22. 1. Developmental – Agenesis, Atresia, Aberrancy 2. Inflammatory – Bacterial Sialadenitis – Acute and Chronic Viral Sialadenitis – Mumps, Coxsackie A Post irradiation sialadenitis 3. Obstructive and Traumatic – Sialolithiasis Stenosis & Stricture 4. Cystic – Mucus retention, extravasation, Ranula 5. Autoimmune – Sjogren’s syndrome 6. Functional and Metabolic – Sialorrhoea , Xerostomia , Cirrhosis, Sialadenosis 7. Neoplastic

23. Sialolithiasis 80% in the Submandibular gland 80% of them are Radiopaque Calcium phosphate/carbonate stones Parotid gland (20%) Rare in Sublingual gland (1%) Usually single stone

24. Calculi are more common in the Submandibular gland because – Viscous nature of secretions Mucin content Calcium content Non dependent drainage Stasis Hooking of nerve by submandibular duct

25. Sialadenitis Infection and Inflammation of the salivary glands Pathogenesis – Retrograde contamination of the salivary ducts and parenchymal tissues by bacteria inhabiting the oral cavity (Bacterial ascending infection) Stasis of salivary flow through the ducts and parenchyma promotes inflammation

26. Predilection for

27. Etiology

28. Acute Sialadenitis Sudden onset of pain, swelling and tenderness in the region of involved gland Dysphagia, trismus High grade fever Double chin appearance due to oedema Opening of duct is inflamed and swollen Calculus may be seen

29. Chronic Sialadenitis Salivary colic – Pain more during mastication Swelling disappears 2 hours post meal/stimulus (Secretion ↑ during mastication  Gland size ↑) Tender, enlarged gland Calculus can be seen and palpated Pus ++ Lingual colic – Referred pain to the tongue due to irritation of lingual nerve in SM gland sialadenitis

30. Diagnosis History and Examination Intraoral X ray – Plain occlusal films Effective for Intraductal & radiopaque stones Intraglandular, radiolucent and small stones may be missed CBC and ESR USG – demonstrate stones FNAC – to r/o other pathology CT of head and neck – when in doubt

31. Treatment of Sialadenitis Symptomatic and supportive care Hydration Sialagogues IV Antibiotics Analgesics Treatment of underlying cause (Stones)

32. Treatment of Sialolithiasis

33. Stones in duct removed by opening it longitudinally

34. Sialoadenectomy (SM gland) Approach – Extraoral , incision made 2-4cm below and parallel to the mandible in the submandibular triangle NO raising of flaps – to avoid injury to marginal mandibular nerve Facial artery ligated twice Take care of lingual nerve and hypoglossal nerve Mylohoid retracted so as to approach the deep lobe

35. Complications Hemorrhage Infection Injury to – Marginal mandibular nerve Lingual nerve Hypoglossal nerve Nerve to mylohyoid – anesthesia over submental skin

36. Parotid Abscess As a result of acute bacterial sialadenitis of parotid gland Parotid fascia is thick and tough which encloses the gland – hence parotid abscess does not show fluctuation S. aureus (commonest), S. viridans , Viral

37. Clinical Features Fever, Malaise Pain Trismus Warm, tender, well localized & firm swelling in the parotid region Tender palpable lymph nodes Pus/Turbid saliva expressed from stensens duct

38. Management USG of parotid region Pus for C/S from stensens opening Needle aspiration done to confirm pus Sialogram is contraindicated Proper hydration, mouth wash, nutrition IV antibiotics Incision and Drainage under G/A – Blair’s incision

39. BLAIR’S INCISION

40. Complications Laryngeal/Pharyngeal oedema leading to respiratory distress – may need tracheostomy and steroids Septicaemia Rupture into External auditory meatus

41. Parotid Fistula

42. Duct Fistula Following superficial parotidectomy Profuse and persistent Surgical treatment - Duct should be ligated using non absorbable suture as far as possible anteriorly – to allow normal secretion from deep lobe Gland fistula From raw surface of the gland Mild and subsides Anticholinergic drugs

43. Causes Following superficial parotidectomy Following drainage of parotid abscess, ruptured abscess Following biopsy Trauma Recurrence of malignancy

44. Clinical features and Diagnosis Abnormal discharge in the region of parotid Increases during mastication Tenderness and Induration Trismus Sialography – Gland/Duct fistula MR Fistulogram

45. Treatment Anticholinergics – hyoscine bromide Radiotherapy Auriculotemporal nerve (PS secretomotor supply) is cut Newman Seabrock’s procedure Total Conservative parotidectomy in failed cases

46. Newman Seabrock’s Operation Probe passed into parotid duct intraorally and thru the external opening of fistula Dissection over the fistula & duct and fistulectomy done Tantalum stent passed into the duct across the severed ends and duct sutured over it Stent removed in 3 weeks

47. Salivary Neoplasms

48. WHO Classification of Salivary Gland Neoplasms – 2017

49. 1% of head and neck tumors Benign tumors – F>>M Malignant tumors – M=F Genetic, Eskimos Recurrent Infections caused by mumps, EBV Radiation (~ Mucoepidermoid carcinoma) Smoking (~ Warthin’s tumor) Environment and Diet – Nickel, Cadmium, Silica, hair dyes, Deficiency of Vitamin A

50. Incidence Incidence of malignancy is Inversely proportional to the size of the gland - In parotid it is 20% - In submandibular gland it is 50% - In sublingual and minor salivary glands it is 90%

51. Pleomorphic Adenoma AKA Mixed Salivary tumor Commonest salivary neoplasm Most common in Parotid and in the Superficial lobe Biphasic with Epithelial and Stromal components Capsulated tumor but may have Pseudopods which can extend beyond the main limit of tumor Malignant transformation in long standing cases (>15 yrs ) – Carcinoma ex pleomorphic adenoma

52. Pathology Grossly – Cartilages Cystic spaces Solid tissue Microscopically Epithelial cells Myoepithelial cells Mucoid material with myxomatous changes Cartilages

53. Clinical Features of Parotid Neoplasm Swelling below, behind and infront of the ear lobule Raised ear lobule Painless, smooth, firm, mobile swelling Curtain’s sign + - cannot be moved above the zygomatic bone Deviation of uvula and pharyngeal wall towards midline – Deep lobe tumor Facial nerve, masseter, skin, lymph node, recent increase in size, pain and bone involvement with restricted joint movements– Malignancy transformation

54. Warthin’s Tumor AKA Adenolymphoma AKA Papillary Cystadenoma Lymphomatosum 2 nd most common Benign tumor Does not turn into malignancy Occurs only in parotid, usually in the lower pole of the superficial lobe Due to the trapping of the jugular lymph sacs in parotid during development Smoking (8 times risk) Bilateral (10% cases) Elderly White Males ~ 60 years

55. Slow growing, painless parotid swelling Smooth surface involving the lower pole Often Bilateral Investigations 1. Hot spot on Technitium 99 pertechnetate scan – Due to the high mitochondrial content - Diagnostic 2. FNAC

56. Mucoepidermoid Carcinoma Commonest malignant tumor in parotid 2 nd common malignant tumor in SM, SL & minor salivary glands Parotid is commonest site, Palate is the commonest minor salivary gland site Radiation commonest etiological factor Commonest malignant tumor in childhood

57. Gross Unencapsulated solid tumor Cystic spaces Microscopy Mucin cell - + ve for PAS, - ve for diastase Epidermoid cell Clear cell

58. Clinical Features Swelling which is slowly increasing in size Hard, nodular Involvement of skin, lymph nodes & facial nerve Pain

59. Adenoid Cystic Carcinoma AKA Cylindromatous carcinoma 2 nd most common malignant tumor overall Commonest malignant tumor of SM, SL and minor salivary glands Palate commonest site Rare in parotid High affinity for perineural spread Invades periosteum and bone medulla early Extensive spread to lungs, liver and bones

60. Clinical Features Slow growing Facial ( LMN palsy ) & trigeminal nerve involvement High recurrence rate

61. Management of Salivary gland Neoplasms

62. Open biopsy is CONTRAINDICATED in parotid tumors due to Injury to facial nerve Seeding and Recurrence Parotid fistula due to injury to the duct

63. Facial Nerve PRESERVED Facial Nerve SACRIFICED

64. Operative Considerations Lazy ‘S’ incision/Modified Blair’s incision Be wary of the Facial nerve NOT the bleeding Flap is reflected just up to the anterior margin of parotid never beyond Removal of parotid by dissecting it away from the facial nerve using bipolar cautery

65. Complications of RT – Osteoradionecrosis of mandible Xerostomia Mucositis /Skin ulcers Trismus Localized hair loss

66. Complications of Parotidectomy 5 F’s

67. Frey’s Syndrome AKA Gustatory sweating/ Auriculotemporal syndrome Due to injury to the auriculotemporal nerve Where in post-ganglionic parasympathetic fibres from otic ganglion become united with the sympathetic fibres from the superior cervial ganglion ( Pseudo synapse ) Inappropriate regeneration of the damaged parasympathetic autonomic nerve fibres to the overlying skin

68. Clinical features Flushing, erythema, sweating , pain in the skin innervated by the auriculotemporal nerve whenever salivation is stimulated . ( Gustatory sweating) Minor’s Starch Iodine test Involved skin painted with iodine and dried. Dried starch applied over this area. Blue color appears due to sweating in this area

69. GUSTATORY SWEATING

70. MINOR’S STARCH IODINE TEST

71. Jacobson’s Neurectomy Surgical treatment for Frey’s Syndrome Surgical division of the tympanic branch of the Glossopharyngeal nerve Below the round window of middle ear Intratympanic parasympathetic neurectomy

72. Prevention Can be prevented by placing Muscle – SCM Fascial - Temporalis Artificial membranes Over the parotid bed and underneath the skin

73. LMN Facial Nerve Injury Bell’s palsy – Idiopathic

74. Most debilitating symptom is – Exposure keratitis

75. Treatment

76. Questions asked in MAHE Exams Classification of Salivary gland neoplasms (∞ times!!!) Pleomorphic adenoma – Clinical features, complications, management (13 times) Warthin’s tumor (10 times) Frey’s Syndrome (10 times) Salivary calculus (6 times) Facial nerve – anatomy, LMN palsy, clinical features (6 times) Parotidectomy – indications, types, complications (5 times)

77. Which among the following is the most common neoplasm of salivary glands? (NEET 2018, 2020) (PLAB and MLE) Mucoepidermoid carcinoma Adenoid cystic carcinoma Pleomorphic adenoma Warthin’s Tumor Ans. Pleomorphic Adenoma

78. REMEMBER MC neoplasm of salivary glands: Pleomorphic adenoma MC malignant tumour of salivary glands: Mucoepidermoid carcinoma MC neoplasm of salivary glands in children: Hemangioma MC malignant tumour of salivary glands in children: Mucoepidermoid carcinoma MC malignant tumour of minor salivary glands: Adenoid Cystic carcinoma MC tumour with perineural infiltration: Adenoid Cystic carcinoma

79. Best diagnostic modality of parotid swelling is? (PLAB and MLE) FNAC Tru cut Biopsy Excision biopsy Enucleation Ans. FNAC

80. A 40 year old female presented with a progressively increasing swelling in the parotid region. On oral cavity examination the tonsils were pushed medially. FNAC was s/o of pleomorphic adenoma. What is the appropritate treatment? (INICET 2021) Superficial parotidectomy Radical parotidectomy Enucleation Total conservative parotidectomy Ans. Total conservative parotidectomy

81. True statement regarding Warthin’s tumor is? ( Plabable ) Common in females Most malignant Hot spot on Tc99 scan Most common tumor of minor salivary gland Ans. Hot spot on Tc99 scan

82. Tumor with perineural invasion is? (MLE, NEET 2018) Adenoid cystic carcinoma Acinic cell carcinoma Warthin’s tumor Mucoepidermoid carcinoma Ans. Adenoid cystic carcinoma

83. Commonest salivary gland to be afflicted with stones? (MLE, Plabable ) Sublingual Parotid Minor salivary glands Submandibular Ans. Submandibular

84. Nerves at risk during removal of submandibular gland are? ( Plabable , INICET 2020) Marginal mandibular branch of facial nerve, Glossopharyngeal nerve and Spinal accessory nerve Marginal mandibular branch of facial nerve, Lingual nerve and hypoglossal nerve Marginal mandibular branch of facial nerve, Lingual nerve and Spinal accessory nerve Hypoglossal nerve, Lingual nerve and Glossopharyngeal nerve Ans. Marginal mandibular branch of facial nerve, Lingual nerve and hypoglossal nerve

85. Which of the following is not a landmark for facial nerve during surgery? (MLE, NEET 2019) Digastric muscle Inferior belly of omohyoid Tragal pointer Retrograde dissection of distal branch Ans. Inferior belly of omohyoid

86. Frey’s syndrome is characterised by? (INICET 2020, Plabable ) Hyperhidrosis, enophthalmos and miosis Anhidrosis, enophthalmos and miosis Redness and sweating over the auriculotemporal nerve region during meals Pain over the distribution of the auriculotemporal nerve during meal Ans. Redness and sweating over the auriculotemporal nerve region during meals

87. Newman and Seabrock’s operation is used for? ( Plabable , MLE) Parotid fistula Recurrent chronic parotitis Parotid calculus Frey’s syndrome Ans. Parotid fistula

88. Thank you