Pleomorphic adenoma; Flashcards
(17 cards)
What is a pleomorphic adenoma? [1]
Pleomorphic adenomas are the most common salivary gland tumour. They most commonly occur in the parotid gland
- Within the parotid gland, 80% of neoplasms are benign, and of these, 80% are pleomorphic adenomas.
Clinical features of pleomorphic adenomas? [+]
Size: Can vary, but typically measures between 2 to 6 cm.
Consistency: Often described as rubbery or firm.
Typically slow-growing, with some lesions present for years before seeking medical evaluation.
No tethering or ulceration
Generally painless - however, if rapid expansion occurs due to cystic degeneration or haemorrhage within the tumour, it might cause discomfort or pain.
Facial Nerve Function: - Intact in almost all presentations, as pleomorphic adenoma rarely invades the facial nerve.
Describe the physical exam findings of pleomorphic adenomas [+]
Upon palpation, the mass is typically smooth and mobile.
Its non-adherent nature to overlying skin or deep structures is a classic feature.
However, in long-standing cases, it can become adherent due to fibrous tissue development..
What is a key concern need to assess for with ?pleomorphic adenoma [1]
Assessing the facial nerve function is crucial during the examination to rule out malignancy or other pathology.
Ix for pleomorphic adenomas? [2]
Ultrasound guided fine needle aspiration / core needle biopsy
* This provides a tissue diagnosis prior to definitive treatment as well as
* Ultrasound scan may also provide high resolution imaging which is cost effective
Further imaging may be required for surgical planning to assess local invasion:
* CT scan
* MRI scan
Mx for pleomorphic adenomas? [2]
An urgent referral (within 2 weeks) should be made for persistent unexplained lumps in the parotid or submandibular glands.
The mainstay of treatment is surgical. Pleomorphic adenomas are removed due to their risk of malignant transformation and to allow for a definitive tissue diagnosis to be made.
Surgical options include:
* Superficial parotidectomy
* Superficial lobe of parotid is removed
* Extracapsular dissection
* Less tissue is removed- this carries a lower risk of complications
The main complication of pleomorphic adenomas is []
The main complication of pleomorphic adenomas is malignant transformation
The main complication of pleomorphic adenomas is malignant transformation.
What are other complications? [3]
Facial nerve injury
* This is the most important complication due to the parotid gland’s intimate relationship with CN VII
* This may cause symptoms such as dribbling from the angle of the mouth or corneal drying depending on the branches affected.
Frey’s syndrome
* This causes ‘gustatory sweating’ i.e. facial sweating in response to salivary gland stimuli
Salivary fistula
Describe what is meant by presbycusis [2]
Presbycusis is a common age-related hearing loss that affects individuals over the age of 65.
It is characterized by a gradual decline in hearing ability, particularly in the high-frequency range. The exact cause of presbycusis is not fully understood, but it is believed to be due to a combination of genetic and environmental factors, including exposure to loud noises and ototoxic medications.
Mx for presbycusis? [4]
Hearing aids: These devices amplify sounds according to the patient’s specific hearing loss profile. Selecting appropriate hearing aids should consider factors such as cosmetic preferences, manual dexterity limitations, and cost constraints.
Assistive listening devices (ALDs): ALDs like personal FM systems or induction loops can enhance speech understanding in challenging listening environments by reducing background noise levels.
Cochlear implants: In cases of severe-to-profound presbycusis unresponsive to conventional amplification methods, cochlear implantation may be considered as a viable treatment option.
Tinnitus management: For patients experiencing tinnitus, a multidisciplinary approach involving sound therapy, cognitive behavioural therapy (CBT), and relaxation techniques may be beneficial.
What are the clinical features of presbycusis? [+]
- Gradual onset of hearing loss, typically affecting high-frequency sounds
- Difficulty understanding speech, especially in noisy environments
- Need for increased volume on the television or radio
- Difficulty using the telephone
- Loss of directionality of sound
- Worsening of symptoms in noisy environments
- Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
- Tinnitus (Uncommon)
What are sialolithiasis? [1]
Where do they commonly occur? [1]
**Salivary gland stones (sialolithiasis) **are a common complaint. They primarily affect the submandibular glands but are also seen in the parotid and sublingual glands. In severe cases they can cause obstruction of the flow of saliva, infection and abscess formation.
What are key risks for salivary gland stone development? [+]
Gout
Diuretics and Anticholinergic medications
Other risk factors include smoking, trauma and hypovolaemia
Clinical features of salivary gland stones? [+]
Patients usually present with pain and swelling of the affected gland, usually triggered when salivary flow is stimulated, such as eating or chewing.
* Symptoms will often resolve slowly after mealtimes as the flow of saliva slows.
Not all stones are symptomatic - some may be found incidentally on imaging.
Patients may some times present with a hard, palpable lump within the salivary duct or orifice.
Ix for salivary gland stones? [+]
Salivary gland stones are usually diagnosed clinically based upon history and examination alone. Sometimes a stone may be seen at the opening of the salivary duct into the oral cavity.
Imaging can be used if there is diagnostic doubt or there is suspicion of secondary infection/abscess formation. Both CT and ultrasound are highly sensitive for detection of stones.
* Imaging is essential if salivary gland malignancy is possible, but NICE guidelines 2016 advise not to delay referral by organising imaging in primary care and to instead refer to head & neck under the two-week-wait pathway.
* If an infective or inflammatory cause of salivary gland swelling is being considered appropriate bloods/swabs may be sent.
Mx of salivary gland stones? [+]
Most salivary gland stones are managed conservatively in primary care. If symptoms are recurrent the patient may be referred to an ENT specialist for further management. There are no NICE guidelines specifying when referral is appropriate.
Advise patients to remain well hydrated
Stop medications (if able) that can impair saliva flow, such as amitriptyline
Encourage saliva flow my advising the patient to suck on citrus fruits/sweets
NSAIDs can be used to relieve any pain
Describe the most common complication of salivary gland stones? [1]
Tx? [1]
The most common complication is secondary bacterial infection of the duct cause by obstruction of the outflow of saliva.
* Patients will present with a warm, tender swelling of the duct and systemic signs of infection. Parotid abscess may cause facial secondary facial nerve palsy.
* Treatment is with antibiotics, if abscess, tracking infection or sepsis is suspected the patient should be referred for same day ENT assessment.
* Recurrent infection within the same gland (chronic sialadenitis) can lead to atrophy and cessation of saliva production.
