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Flashcards in 14 Disease of the Salivary Glands Deck (22):
1

Describe the anatomy, including surrounding structures and involved neurovascular innervation, of the parotid gland.

  • The parotid gland is located in the lateral face, bordered by the masseter anteriorly and medially, the zygomatic arch superiorly, the tragal cartilage and the sternocleidomastoid muscle (SCM) posteriorly, and the ramus of the mandible and SCM inferiorly.
  • The external carotid artery lies medial to the parotid and gives off the maxillary artery and the superficial temporal artery, which course through the gland. Venous drainage uses the maxillary and superficial temporal veins that form the retromandibular vein, which joins the external jugular vein via the posterior facial vein.
  • Stensen’s duct courses superficial to the masseter muscle and enters into the oral mucosa adjacent to the second upper molar.

After it exits from the stylomastoid foramen, the facial nervebranches to form the the postauricular and posterior belly of the diagastric before entering the parotid gland posteriorly.

Parasympathetic secretomotor innervation is provided through the glossopharyngeal nerve.

2

Describe the relevant anatomy of the submandibular gland.

Describe the relevant anatomy of the submandibular gland.

The submandibular gland is found inferior and deep to the mandible, in the submandibular triangle. This triangle is defined by the anterior and posterior bellies of the digastric muscle, and the mandibular body. Wharton’s duct courses deep to the lingual nerve and enters the oral cavity at the anterior floor of the mouth. Parasympathetic secretomotor innervation is provided through the chorda tympani nerve.

3

Describe the anatomy of the sublingual gland.

Describe the anatomy of the sublingual gland.

The sublingual gland is located adjacent to the lingual frenulum and superficial to the mylohyoid muscle. The parasympathetic innervation is provided by the chorda tympani nerve. The sublingual gland drains into the oral cavity through the ducts of Rivinus.

4

What is the most commonly implicated bacteria in acute suppurative sialadenitis? How is it treated?

What is the most commonly implicated bacteria in acute suppurative sialadenitis? How is it treated?

Staphylococcus aureus is the most common bacteria causing sialadenitis. Treatment consists of antibiotics with β-lactamase resistance such as amoxicillin-clavulanate, hydration, warm compresses, and sialagogues (such as lemon wedges).

5

What are some available treatment options for sialolithiasis?

What are some available treatment options for sialolithiasis?

  1. Conservative management with sialagogues, warm compresses, antibiotics, and hydration
  2. Open sialolithotomy
  3. Sialendoscopy with use of wire baskets, balloons, and grasping forceps
  4. Lithotripsy (laser, shockwave—not FDA approved in the U.S.)
  5. Excision of salivary gland

6

What is the most common viral infection of the parotid?

What is the most common viral infection of the parotid?

Mumps is still the most common cause of viral parotitis. Peak age is 4 to 6 years of age and bilateral involvement is common. It is associated with orchitis, encephalitis, and sensorineural hearing loss. Most, but not all, mumps infections have been eliminated with vaccination.

7

What is the most common parotid abnormality associated with HIV?

What is the most common parotid abnormality associated with HIV?

Diffuse lymphoepithelial cystic disease. HIV should be ruled out in any patient with cystic parotid disease.

8

Describe common granulomatous diseases of the salivary glands and some pertinent features.

Describe common granulomatous diseases of the salivary glands and some pertinent features.

Tuberculosis: Diagnosed by PPD, FNA, culture showing acid-fast bacilli, and chest x-ray

Atypical mycobacteria: Workup includes chest x-ray, PPD, and tissue culture

Actinomycosis: Gram-positive actinomyces with pathognomonic sulfur granules. Treatment includes penicillin G, erythromycin, clindamycin

Cat-scratch disease: Caused by Bartonella henselae. Treated with azithromycin

Toxoplasmosis: Caused by Toxoplasma gondii. Treated with pyrimethamine and sulfadiazine plus folinic acid

Sarcoidosis: Noncaseating granulomas are the hallmark of this disease. Usually responds to steroids

9

What is the diagnostic test of choice for Sjogren syndrome?

What is the diagnostic test of choice for Sjogren syndrome?

Minor salivary gland biopsy of 3 to 5 glands is submitted from a lower lip biopsy, looking for lymphocytic infiltration. A positive test requires more than 1 focus per 4 mm2, where each focus contains at least 50 lymphocytes.

10

List benign tumors of the salivary glands. Which is most common? Which can present bilaterally?

List benign tumors of the salivary glands. Which is most common? Which can present bilaterally?

  • Pleomorphic adenoma
  • Basal cell carcinoma
  • Sebaceous lymphadenoma
  • Oncocytoma
  • Myoepithelioma
  • Inverted ductal papilloma
  • Monomorphic adenoma
  • Clear cell adenoma
  • Warthin’s tumor
  • Oncocytic papillary cystadenoma
  • Sialadenoma papilliferum
  • Hemangioma

The most common benign tumor of salivary glands is pleomorphic adenoma. Warthin’s tumor presents bilaterally in up to 10% of cases 

11

Warthin’s tumor is an eponym for what? What are some of the epidemiologic features?

Warthin’s tumor is an eponym for what? What are some of the epidemiologic features?

Warthin’s tumor is an eponym for papillary cystadenoma lymphomatosum. It is more often found in women in the sixth or seventh decade of life. It is also related to cigarette smoke exposure even though it is benign.

12

List malignant tumors of the salivary glands. Which is most common? Which can present bilaterally?

List malignant tumors of the salivary glands. Which is most common? Which can present bilaterally?

  • Mucoepidermoid carcinoma
  • Adenoid cystic carcinoma
  • Acinic cell carcinoma
  • Basal cell carcinoma
  • Epithelial-myoepithelial tumor
  • Hyalinizing clear cell carcinoma
  • Squamous cell carcinoma
  • Undifferentiated carcinoma
  • Malignant mixed tumor
  • Salivary duct carcinoma
  • Adenocarcinoma
  • Carcinoma ex pleomorphic adenoma
  • Polymorphous low-grade adenocarcinoma
  • Metastases

 

The most common malignancy of the parotid gland is mucoepidermoid carcinoma. Acinic cell carcinoma presents bilaterally in 3% to 5% of cases (Table 14-2).

13

Describe the initial workup of a salivary gland mass.

Describe the initial workup of a salivary gland mass.

Fine needle aspiration biopsy and imaging (contrasted CT or MRI) are frequently ordered during the workup. The combination can help differentiate benign from malignant processes and often provide a diagnosis.

14

Describe the staging of salivary gland tumors.

Describe the staging of salivary gland tumors.

  • TX: Primary tumor cannot be assessed.
  • T0: No evidence of primary tumor.
  • T1: Tumor ≤2 cm in greatest dimension without extraparenchymal extension.
  • T2: Tumor >2 cm but ≤4 cm in greatest dimension without extraparenchymal extension.
  • T3: Tumor >4 cm and/or tumor having extraparenchymal extension.
  • T4a: Moderately advanced disease. Tumor invades skin, mandible, ear canal, and/or facial nerve.
  • T4b: Very advanced disease. Tumor invades skull base and/or pterygoid plates and/or encases carotid artery.

 

  • NX: Regional lymph nodes cannot be assessed.
  • N0: No regional lymph node metastasis.
  • N1: Metastasis in a single ipsilateral lymph node, ≤3 cm in greatest dimension.
  • N2: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension.
  • N2a: Metastasis in a single ipsilateral lymph node, >3 cm but ≤6 cm in greatest dimension.
  • N2b: Metastases in multiple ipsilateral lymph nodes, ≤6 cm in greatest dimension.
  • N2c: Metastases in bilateral or contralateral lymph nodes, ≤6 cm in greatest dimension.
  • N3: Metastasis in a lymph node, >6 cm in greatest dimension.

15

Describe the histology of mucoepidermoid carcinoma. How does this affect prognosis?

Describe the histology of mucoepidermoid carcinoma. How does this affect prognosis?

Mucoepidermoid carcinoma is highlighted by the presence of mucinous and epidermoid cells. The amount of mucinous cells and the level of epidermoid differentiation determines the tumor grade. Low-grade tumors have a greater amount of mucinous cells compared to well-differentiated epidermoid cells. High-grade tumors have a dearth of mucinous cells with a preponderance of poorly differentiated epidermoid cells.

16

Describe the histology of adenoid cystic carcinoma. How does this affect prognosis?

Describe the histology of adenoid cystic carcinoma. How does this affect prognosis?

Adenoid cystic carcinoma is divided into three histologic subtypes:

  • The tubular pattern is characterized by tumor cells arranged in nests surrounded by variable amounts of eosinophilic, often hyalinized stroma. It has the best prognosis.
  • The cribriform subtype occurs most frequently. It is composed of islands of basaloid cells surrounding variably sized cyst-like spaces forming a “swiss cheese” pattern. It has an intermediate prognosis (Figure 14-2).
  • The solid pattern contains aggregates of basaloid cells without tubular or cystic formation. It has the worst prognosis.

17

What is the Hayes-Martin maneuver in submandibular gland removal?

What is the Hayes-Martin maneuver in submandibular gland removal?

The facial vessels run deep to the marginal mandibular nerve. Ligation of the vessels and subsequent superior retraction lift the nerve out of the surgical field and protect it from iatrogenic injury.

18

During a parotidectomy, what are some ways the facial nerve can be identified?

During a parotidectomy, what are some ways the facial nerve can be identified?

• 1 cm deep and inferior to the tragal pointer

• 6 to 8 mm anterior and inferior to the tympanomastoid suture line

• Superior to the cephalic portion of the posterior belly of the digastric muscle

• Superficial/lateral to the styloid process

• Retrograde dissection after finding the marginal mandibular branch as it passes over the facial artery and vein at the anterior border of the masseter muscle

• Retrograde dissection after finding the zygomatic branch as it courses over the zygomatic arch two thirds of the way from the tragus to the lateral canthus of the eye

• Mastoidectomy with anterograde nerve dissection

19

List the indications for postoperative radiotherapy of a parotid neoplasm.

List the indications for postoperative radiotherapy of a parotid neoplasm.

  • High-grade tumors
  • Gross or microscopic residual disease
  • Lymph node metastasis
  • Extraparotid extension
  • Tumors involving the facial nerve
  • Some deep lobe cancers
  • Recurrent disease

20

What is Frey’s syndrome? How is it treated?

What is Frey’s syndrome? How is it treated?

Frey’s syndrome is defined by gustatory sweating of the skin overlying the surgical site of a parotidectomy. This is caused by postoperative growth of the interrupted preganglionic parasympathetic nerve branches of the parotid into the superficial sweat glands. It is best avoided, but treatments do exist. These include: botox injection, topical antiperspirants, surgery to place an intervening layer of tissue or allograft between the skin and parotid bed, and Jacobson’s neurectomy (surgical interruption of the Jacobson’s nerve, which carries preganglionic parasympathetic nerves to the parotid).

21

What is the utility of facial nerve monitoring during parotidectomy?

 What is the utility of facial nerve monitoring during parotidectomy?  Controvery.

The use of facial nerve monitoring during a parotidectomy is a matter of surgeon preference. The monitor can be useful in confirming and anatomically identified nerve. It should never be relied on as the only means of identification. There are no death proving whether or not it's use decreases rates of facial nerve injury.

22

What is the role of elective neck dissection in treating a salivary gland malignancy?

What is the role of elective neck dissection in treating a salivary gland malignancy?  Controvery.

Elected neck dissection is generally reserved for high-grade tumors as the risk of microscopic metastasis to the neck is greater than 20%. Radiation therapy may be used, but surgical treatment of the neck allows for accurate staging. Recent evidence indicates that the risk of metastasis may be higher than previously reported, even in low-grade tumors, and may support the need for neck dissection.

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