SALIVARY GLAND—-DANIEL TODD, MDPAROTID GLAND 14-28 G, 6 X 3 CM, TRIANGULAR SHAPE, NL NOT PALPABLE UNILOBULAR (NOT TRULY BILOBAR) DUCTS ½ STRIATED, ½ INTERCALATED PRIMARILY SEROUS SECRETIONS FROM ACINUS GLANDS PRODUCES 90% OF SALIVA (1500 ML/DAY)? BLUESTONE&STOOL–SAY 25%—MUCH MORE SENSITIVE TO PARASYMPATHETIC STIM (SIALOGOGUES) INTIMATELY ASSOC. WITH LAT PHARYNGEAL SPACE STENSON’S DUCT RUNS PARALLEL TO, 1 CM BELOW, ZYGOMATIC ARCH–ALONG A LINE FROM TRAGUS TO MID UPPER LIP–TURNS AROUND THE ANT. BORDER OF THE MASSETER—PIERCES THE BUCCINATOR—EMPTIES OPPOSITE MAXILLARY 2ND MOLAR—MAY HAVE AN ACCESSORY DUCT ENVELOPED BY SUP. LAYER OF DCF—THICKENS TO FORM STYLOMANDIBULAR LIGAMENT WHICH SEPARATES IT FROM THE SUBMANDIBULAR GLAND SENSATION OVER THE PAROTID = GREATER AURICULAR C2, C3 AND AURICULOTEMPORAL V3 INNERVATION INF SALIVATORY NUC—CN IX (JACOBSON’S)—TYMPANIC BR—TYMPANIC PLEXUS(ON PROMONTORY)—LESSER SUP. PETROSAL N.—FORAMEN OVALE—OTIC GANGLION—AURICULOTEMPORAL (V3)—PAROTID DEVELOPES LATER EMBRYOLOGICALLY AND THUS ENVELOPES AND INTIMATELY ASSOC WITH LYMPH NODES AVG ABOUT 30 LYMPH NODES IN THE PAROTID SUBMANDIBULAR GLAND 10 GRAMS, 2ND LARGEST, 5% OF SALIVA, WALNUT SIZED BLUESTONE & STOOL SAY 70% BLOOD SUPPLY BY LINGUAL AND FACIAL A(FACIAL A RUNS RIGHT THROUGH IT) ARTIFICIALLY DIVIDED INTO DEEP AND SUPERFICIAL LOBE BY POST BORDER OF MYLOHYOID 2/3 SEROUS, 1/3 MUCOUS SUP. SALIVATORY NUCLEUS–CN VII(NERVUS INTERMEDIUS)–CHORDA TYMPANI–SUBMANDIBULAR GANGLION(LOXLEY’S/LANGLEY’S)–POST GANGLIONICS B WHARTON’S DUCT–RUN BETWEEN MYLOHYOID AND HYOGLOSSUS–SUPERIOR TO CNXII, INF. TO LINGUAL N(LINGUAL N CROSS–EMPTY INTO LAT LINGUAL FRENULUM (BEWARE IN ANKYLOGLOSSIA REPAIR) INVESTED BY SUP LAYER OF DCF–THICKENS TO FORM STYLOMANDIBULAR LIG. WHICH SEPARATES IT FROM PAROTID–RAMUS MANDIBULARIS N RUNS IN IT NO INTRAGLANDULAR NODES SUBLINGUAL GLAND SMALLEST, ALMOND SIZE, 5% OF SALIVA ENDODERMALLY DERIVED BLOOD SUPPLY = Br OF THE LINGUAL ARTERY 2/3 MUCOUS, 1/3 SEROUS SUP. SALIVATORY NUCLEUS–CN VII(NERVUS INTERMEDIUS)–CHORDA TYMPANI–SUBMANDIBULAR GANGLION(LOXLEY’S/LANGLEY’S)–POST GANGLIONICS IMMEDIATELY ON MYLOHYOID MUSCLE IN FOM(NEAR SYMPHYSIS OF MANDIBLE) NO DISCRETE CAPSULE (NOT INVESTED BY SUP. DCF) NUMEROUS DUCTS OF RIVINUS(POST TO WHARTONS)–OCCASIONALLY COALESC TO FORM BARTHOLIN’S DUCT—EMPTY ON LINGUAL PLICAE(PLICAE SUBLINGULARIS) USUALLY THE ORIGIN OF A RANULA”MEANS FROG BELLY APPEARANCE”=SIALOCELE—PTYALOCELE= A SUBLINGUAL GLAND RETENTION CYST—-SHOULD REMOVE IT TO PREVENT RECURRENCE! MINOR SALIVARY GLANDS GLANDS OF BLANDIN—ANTEROLINGUAL SEROUS GUSTATORY GLANDS OF VON EBNER—NEAR CIRCUMVALLATE PAPILLAE WEBER’S GLANDS—-SUP TONSILLAR POLE—-ETIOLOGY OF PTA -MINOR -HIGHEST CONCENTRATION IS ON HARD PALATE -SALIVA IS MUCUS -THE SUBUNIT -COMPOSED OF AN ACINI WHICH DRAINS INTO A DUCTAL SYSTEM CONSISTING OF INTERCALATED, STRIATED, AND EXCRETORY SEGMENTS CAVEATES: 3,7,9, AND 10 ARE THE CN’S WITH AUTONOMIC COMPONENTS VIDIAN NEURECTOMY MAY LEAD TO XEROPTHALMIA BOGARAD SYNDROME (GUSTATORY TEARING)—SYNDROME OF CROCADILE TEARS—FROM AFRICAN FOLKLORE—THE CROCADILE CRIED IN SYMPATHY FOR THE ONE HE ATE—-A SYNKINESIS FROM THE LESSER TO THE GREATER SUP PETROSAL NERVE FROM LESION IN THE PERIGENICULATE REGION—T-BONE Fx OR RAMSEY HUNT SYNDROME FREY SYNDROME—DAMAGE TO THE POST GANGLIONIC PARASYMPATHETICS TRAVELING IN THE AURICULOTEMPORAL NERVE RESULTING IN A CROSS INNERVATION OF THE LOCAL SWEAT GLANDS—-NEW RX FOR ALL HYPERHYDROSIS—BOTOX SIALORRHEA=DROOLING=PTALYSM=HYPERSALIVATION A BIG PROBLEM IN NEURO IMPAIRED PTS—70% SUBMAND AND SUBLINGUAL, 20% PAROTID, 10% MINOR
SIALOGOGUES PRIMARILY AFFECT THE PAROTID DROOLING = NL UNTIL AGE 2 Rx: OBSERVATION, ORAL MOTOR (SPEECH) THERAPY, POSITIONING, MEDS—ANTICHOLINERGICS, BIOFEEDBACK SURGERY—-ABLATIVE VS REROUTING ABLATIVE—TYMPANIC NEURECTOMY—TENDS TO BE TEMPORARY, GLAND EXCISIONS, DUCT LIGATION REROUTING WHARTONS DUCT TO POST OC NEW EVIDENCE THAT BOTOX INJECTIONS MY BE A GOOD OPTION—CERTAINLY GOOD FOR FREY SYNDROME LONG TERM DENTAL CARE IS NECESSARY XEROSTOMIA DENTAL PROBLEMS, DYSPHAGIA—-USUALLY SECONDARY TO RT, RENAL FAILURE, SARCOID, OR SJOGRENS SIALOLITHIASIS PAIN AND SWELLING OF AFFECTED GLAND THAT IS USUALLY WORSENED POST-PRANDIALLY–CAN PRESENT AS ACUTE SIALOADENITIS AFFECTS PEOPLE USUALLY IN THE 5TH TO 8TH DECADE MALE > FEMALE PATHOGENESIS—SALIVARY STASIS-NIDUS FOR FORMATION-CHEMICAL COMPOSITION OF SALIVA LOCATION—SUBMANDIBULAR – 80%—–PAROTID – 19% * SUBMANDIBULAR FELT TO BE MOST COMMON SECONDARY TO INCREASED PH AND VISCOSITY OF SALIVA, INCREASED CALCIUM AND PHOSPHATE COMPOSITION, AND ANTIGRAVITATIONAL FLOW -SUBMANDIBULAR – 90% ARE RADIOPAQUE (LIKE RENAL STONES) PRIMARY SALIVARY GLAND FOR STONES(80% OF ALL)–1/3 MUCOUS AND DUCT IS VERTICLE–STONES ARE 85% RADIO-OPAQUE (LIKE RENAL STONES)—STONES GROW AROUND A NIDUS—-MEDULLA—-GROW A CORTEX CONCENTRICALLY–-TEND TO GROW AT A RATE OF 1 MM PER YEAR -PAROTID – 10% ARE RADIOPAQUE -PLAIN FILMS, CT SCANNING, ULTRASOUND CAN ALL BE USED BUT SIALOGRAPHY IS THE GOLD STANDARD MOST ARE COMPOSED OF CALCIUM PHOSPHATE AND CARBONATE ON CARBOHYDRATE MATRIX IF GOUT ASSOCIATED WILL BE MAINLY URIC ACID—-RADIOLUSCENT HYPERPARATHYROIDISM—CA—RADIO-OPAQUE IF IT IS IN THE DUCT IT IS USUALLY EASY TO DIAGNOSIS AND TREAT IN THE CLINIC SHOCK WAVE LITHOTRIPSY MAY BE A GOOD TREATMENT—-IF RECALCITRANT JUST REMOVE THE GLAND SIALOSIS=SIALADENOSIS=ENLARGED GLAND—-OFTEN USED INTERCHANGABLY WITH SIALENITIS MAY REPRESENT AN AUTOIMMUNITY: BLL=BENIGN LYMPHOEPITHELIAL LESION= PRIMARY OR SECONDARY SJOGREN’S, SICCA COMPLEX, BENIGN EPITHELIAL LESION OF GODWIN, GODWIN’S TUMOR, MIKULICZ SYNDROME/DISEASE, CHRONIC PUNCTATE PAROTITIS/SIALECTASIS—LOOK FOR ASSOC LACRIMAL GLAND ABNL—REALLY OVER ALL A GOOD Px AND YOU WOULD BE BETTER OFF JUST FOLLOWING THESE FOLKS AS THEY HAVE LITTLE TO GAIN AND A LOT TO LOOSE—MIGHT BE ABLE TO GET THE Dx WITH Hx, PE, AND A LABIAL Bx (60%)—OTHERWISE CONSIDER SCHIRMER’S TEST, SLIT LAMP WITH 1% ROSE BENGAL STAINING OF CONJUNCTIVA, SALIVARY FLOW RATES OR SIALOGRAPHY (PUNCTATE SIALECTASIS “BUNCH OF GRAPES”—A SUPERFICIAL PAROTID FOR Bx—Dx AND Rx MAY BE NOT A BAD IDEA BUT IT CAN BE A DIFFICULT DISSECTION—MUST FOLLOW INDEFINITELY AS 5% MAY DEV A LYMPHOPROLIFERATIVE NEOPLASM (LYMPHOEPITHELIAL CA) AND THERE IS A HIGHER ASSOC (44X) WITH B-CELL NHL BEWARE OF PERSISTENT STIMULATION (BULEMIA) OR OTHER DRUG RXNS SIALENITIS—USUALLY RELATES INFECTIOUS RO INFLAMMATORY ETIOLOGY—-CAN BE INTERCHANGABLE WITH SIALOSIS BUT IS USUALLY REFERRED TO BY THE NAME OF THE PRIMARY GLAND INVOLVED—-PAROTITIS OR SUBMANDIBULAR SIALENITIS DIVIDED INTO ACUTE VS CHRONIC AND OBSTRUCTIVE VS NONOBSTRUTIVE UNDERLYING Dz: VIRAL MUMPS, OTHER VIRAL AGENTS(ECHO, COXSACKIE A, EBV, CMV,PARAINFLUENZA) SARCOID UVEOPAROTID FEVER OF HEERFORDT (HEERFORDT-WALDENSTROM SYNDROME)—IRIDOCYCLITIS, PAROTITIS, FACIAL PARESIS LYMPHOEPITHELIAL CYSTS OF THE PAROTID–PRIMARILY B, IN THE TAIL OF THE PAROTID–Rx IS CONSERVATIVE–CT AND FNA FOR Dx, MAY DO SERIAL FNA FOR PALLIATION–CAN OFTEN SCLEROSE WITH TETRACYCLINE BACTERIAL PAROTITIS ACUTE “CELIAC PAROTITIS”—ASSOC WITH ABD INFXNS DEHYDRATION IMMUNOCOMPROMISE PARTIAL OBSTRUCTION PRIMARILY STAFF AUREUS Rx: REHYDRATION, IVF, IV ABX WARM COMPRESSES, SIALOGOGUES, ORAL IRRIGATTIONS, MASSAGE CN 7 PARALYSIS OR SEPSIS ARE INDICATIONS FOR I & D—USUALLY VIA MODIFIED BLAIR INCISION THE CAPSULE INDURATES AND FLUCTUANCE CAN BE DIFFICULT TO DETECT—-MAY GET A CT I&D AND BLUNLTY OPEN PARELLEL TO THE NERVE BRANCHES CHRONIC–PROBABLY SECONDARY TO OBSTRUCTION ACTINOMYCOSIS
TB—GRANULOMATOUS ON FNA (ATYPICAL NTM—-COMMON IN PEDS—HIGH ANT TRIANGLE UNILAT LA(LEVELS I AND II)—OVERLYING SKIN LOOKS INFLAMED—SLIGHLY + TO – PPD, NL CXR, OFTEN NO HX OF EXPOSURE—Rx CLASSICALLY COMPLETE EXCISION – NEW LIT ON CURRETAGE –ESPECIALLY OVER THE FACIAL NERVE—OR LONG TERM MACROLIDES)RECURRENT BACTERIAL PAROTITIS OF CHILDHOOD A RARE ENTITY—PRIMARILY STREP PNEUMO OROFACIAL SPACE INFXNS LUDWIGS ANGINA=SUBLINGUAL AND SUBMANDIBULAR (INFXOUS SUPRAHYOID COMPARTMENT SYNDROME) SPACE INFXN BRUNNER’S ABCESS=FOM ABCESS PTA (QUINCY) MANDIBULAR SPACE BUCCAL SPACE MASTICATOR SPACE CANINE SPACE PARAPHARYNGEAL, LAT PHARYNGEAL, PTERYGOMAXILLARY,PHARYNGOMAXILLARY, PTERYGOPHARYNGEAL, PHARYNGOMANDIBULAR SPACE ABSCESS RETROPHARYNGEAL SPACE ABSCESS NECROTIZING SIALOMETAPLASIA—-SITS IN THE JUNCTION BETWEEN INFLAMMATORY AND NEOPLASTIC DISORDERS A BENIGN LESION WHICH REPRESENTS A NONSPECIFIC RXN OF SALIVARY GLANDS AND MUCOUS GLANDS TO ISCHEMIA!!! GLANDS RETAIN THEIR ARCHITECTURE—CAN BE IN THE NOSE—EPISTAXIS LESION OFTEN RESEMBLING CARCINOMA AT THE JUNCTION OF THE HARD AND SOFT PALATE—CELLS HAVE UNDERGONE METAPLASTIC CHANGES BUT THE GLANDS RETAIN THEIR NORMAL ARCHITECTURE—PROPIGATED BY SMOKING Dx = Bx—-DIFF Dx = SCCA, FOLLICULAR LYMPHOID HYPERPLASIA, AND MINOR SALIVARY GLAND CA Rx = OBSERVATION AND SYMPTOMATIC TREATMENT SALIVARY NEOPLASMS ALL ECTODERMAL EXCEPT SUBLINGUAL (ENDODERMAL) -MYOEPITHELIAL CELLS SURROUND THE ACINI AND INTERCALATED DUCTS -BASAL CELLS OF THE INTERCALATED AND EXCRETORY DUCTS ARE THE SOURCE OF NEW CELLS PATHOGENESIS—2 THEORIES: MULTICELLULAR THEORY -DIFFERENT NEOPLASMS ARISE FROM DIFFERENT SUBUNITS OF THE GLAND –ACINI – ACINIC CELL CA –INTERCALATED DUCTS/ MYOEPITHELIAL CELLS – ADENOID CYSTIC CA, MIXED TUMORS, MYOEPITHELIOMA, POLYMORPHOUS LOW GRADE ADENOCA –STRIATED DUCTS – ONCOCYTIC TUMORS –EXCRETORY DUCTS – SCCA AND MUCOEPIDERMOID CA -HIGH GRADE ADENOCA IS THOUGHT TO ARISE FROM ANYWHERE PRIMITIVE UNCOMMITTED CELL ORIIGN THEORY WORKUP IMAGING FINE NEEDLE—-90% SENS AND 75% SPEC —–FROZEN SECTION IS NO MORE ACCURATE——DO NOT EVER SACRIFICE THE FACIAL NERVE BASED ON THESE TESTS—–IN THIS INSTANCE AN OPEN BIOPSY WITH PERMANENT HISTOPATHOLOGY MAY BE APPROPRIATE HISTOCHEMISTRY (PTAD-MITOCHONDRIAL STAIN) GOOD IN WARTHINS AND ONCOCYTOMA PAS + ACINIC CELL CA AND OTHERS IMMUNOHISTOCHEMISTRY—S-100, SMA, HMB-45, LCA, ECT¼. MANAGEMENT OF THE N0 NECK IS CONTROVERSIAL BUT¼ CONSIDER A PROPHYLACTIC SELECTIVE REGIONAL DISSECTION AND/OR POST OP RT IF: HIGH GRADE MUCOEP, UNDIFFERENTIATED CA, HIGH GRADE ADENOCA, CARCINOMA EX PLEOMORPHIC ADENOMA, OR SCCA OF THE PAROTID—ALSO FOR SUBMANDIBULAR OR SUBLINGUAL GLAND CA ERR ON THE SIDE OF TOO MUCH—EASY ENOUGH TO DO A SELECTIVE NECK THROUGH YOUR MODIFIED BLAIR INCISION POST OP RT—PROBABLY NEVER A BAD IDEA—NEUTRON BEAM MIGHT BE MORE EFFECTIVE IN ADENOID CYSTIC CA HAVE A SECOND OPINION ON BOARD BEFORE TAKING THE FACIAL NERVE—IF YOU TAKE IT DO FROZENS UNTIL CLEAR FACIAL NERVE MONITOR MAY BE APPROPRIATE FOR RECURRENT BENIGN DZ –LOCATION -PAROTID -80% -SUBMANDIBULAR -10-15% -SUBLINGUAL/MINOR -5-10% –MALIGNANCY RATE -OVERALL -20-25% -PAROTID -20% -SUBMANDIBULAR -50% -SUBLINGUAL/MINOR ->60% –AGE -95% OF TUMORS OF SALIVARY GLANDS ARE IN ADULTS AND ONLY 5% IN CHILDREN -50-65% OF TUMORS IN CHILDREN ARE BENIGN –HISTOLOGY -ADULT -PAROTID BENIGN – PLEOMORPHIC ADENOMA CA – MUCOEPIDERMOID CA -SUBMANDIBULAR BENIGN – PLEOMORPHIC ADENOMA CA – ADENOID CYSTIC CA
-SUBLINGUAL/MINOR BENIGN -PLEOMORPHIC ADENOMA CA -ADENOID CYSTIC CA –CHILDREN -MOST COMMON BENIGN – HEMANGIOMA -MOST COMMON BENIGN PRIMARY SALIVARY TISSUE – PLEOMORPHIC ADENOMA –MOST COMMON MALIGNANT – MUCOEPIDERMOID CA—-IN EVERY GLAND DIFFERENT WAYS TO LOOK AT IT: MOST COMMON BENIGN TUMOR OF SALIVARY GLAND TISSUE IN ALL AGE GROUPS IN ALL GLANDS IS PLEOMORPHIC ADENOMA (MOST COMMON TUMOR IN KIDS = HEMANGIOMA) MOST COMMON CANCER IN EVER SALIVARY GLAND IN EVERY AGE GROUP IN THE MUCOEP (EXCEPT ADULT SUBMANDIBULAR, SUBLINGUAL, AND MINOR SALIVARY GLANDS = ADENOID CYSTIC) 80% OF SALIVARY NEOPLASMS INVOLVE THE PAROTID—AND OF THESE 80% ARE BENIGN MOST COMMON BENIGN ENTITY IS MIXED TUMOR FOLLOWED BY WARTHINS CERTAINLY ONLY 50% OF MASSES REPRESENT NEOPLASMS—-SO A PAROTID MASS HAS ABOUT 10% CHANCE OF BEING A MALIGNANT CA—MOST COMMON IS MUCOEPIDERMOID CA BENIGN DZ I. PLEOMORPHIC ADENOMA = BENIGN MIXED TUMOR—50% OF ALL SALIVARY TUMORS— ACCOUNTS FOR 65% OF ALL BENIGN SALIVARY LESIONS—PRIMARILY IN THE PAROTID MAY BE ASSOCIATED WITH PRIOR RADIATION EXPOSURE?—PROBABLY NO SIG ETIOLGIC ENTITIES FEMALE > MALE PRIMARILY 5TH DECADE WELL DELINIATED SLOW GROWING FIRM, MOBILE, NONTENDER—OFTEN IRREGULAR DECEPTIVELY APPEAR ENCAPSULATED (MICROSCOPIC FINGERS–MUST REMOVE WITH CLEAR MARGINS) HISTOPATHOLOGY—-SEEN ONE—SEEN ONE, OF THE MYOEPITHELIAL CELL—ECTODERMAL WITH MUCOID, CHONDROID, OSSEOUS, AND MYXOID ELEMENTS–MICROSCOPIC -EPITHELIAL COMPONENTS FORM A TRABECULAR PATTERN IN THE MESENCHYMAL STROMA WHICH CAN BE FIBROID, MYXOID, OSTEOID, OR CHONDROID NEED 3 ELEMENTS TO MAKE THE Dx: EPITHELIAL, MYOEPITHIAL, AND STROMAL—ANY ONE OF THESE MAY DOMINATE RARELY UNDERGO MALIGNANT DEGENERATION—-CARCINOMA EX PLEOMORPHIC ADENOMA (MAY BE PROPENCIATED AFTER RT) IF YOU GET A RECURRENT TUMOR—PROBABLY USE THE FACIAL NERVE MONITOR TRANSFORMATION TO CA MORE COMMONLY OCCURS WHEN THE RECURRENCE IS IN THE DEEP LOBE II. MONOMOPHIC ADENOMAS—-ONLY EPITHELIAL OR RARELY MYOEPITHELIAL PATTERN PRESENT—NO STROMAL/MESENCHYMAL PATTERN INCLUDES WARTHINS, ONCOCYTOMA, MYOEPITHELIOMA, AND BASAL CELL, CLEAR CELL, CANALICULAR WARTHINS TUMOR=PAPILLARY CYSTADENOMA LYMPHOMATOSUM=ADENOLYMPHOMA PRIMARILY IN TAIL OF PAROTID–EXCLUSIVELY LOCATED IN PAROTID GLAND SECOND MOST COMMON BENIGN LESION—5-6% OF ALL SALIVARY MASSES MALE 5:1 WHITE > BLACK PRIMARILY OLDER PTS SLOW GROWING, NON-TENDER CYSTIC MASS—-RUBBERY, SMOOTH 2-6% B—12-14% MULTICENTRIC—-MOST COMMON B NEOPLASM HIGH MITO(HIGH ACTIVITY ON NUC MED SCAN)—CAN NOT EXCRETE R.A. DYE–CAN SEE A LOT OF MITOCHONDRIA ON E.M. LOW INTENSITY ON T-1 MRI—ISO TO HIGH INTENSITY ON PROTON AND T-2 MRI HIGH CONCENTRATION OF MITOCHONDRIA ON E.M.—-+PTAH VISCID FLUID ON ASPIRATION HISTOPATH—LYMPHOID STROMA ON PATH—-SNAP Dx –HISTOPATH—PAPILLARY AND CYSTIC LESION COMPOSED OF EPITHELIAL AND LYMPHOID COMPONENTS CHARACTERISTIC IMMUNOHISTOCHEMISTRY—BUT NOT A HARD Dx ONCOCYTOMA=OXYPHILIC ADENOMA = “ONCOCYTOSIS” ONCOCYTIC CELLS = LARGE EPITHELIAL CELLS WITH CHARACTERISTIC BRIGHT EOSINOPHILIC CYTOPLASM CONTROVERSY ON WHETHER IT IS A TRUE NEOPLASM OR A REACTIVE HYPERPLASTIC/METAPLASTIC PROCESS RARE—ALMOST EXCLUSIVLEY PAROTID M=F; AGE IS USUALLY 50+ GROSS -FIRM, RUBBERY, NON-CYSTIC MASS (HIGH ACTIVITY ON NUC SCAN–HIGH MITOCHONDRIA)—NO LYMPHOID STROMA – HISTOPATH– -LARGE PLUMP GRANULAR POLYHEDRAL EOSINOPHILIC CELLS WITH SMALL DENTED CENTRAL NUCLEI AND EM WOULD SHOW SIGN. NUMBER OF MITOCHONDRIA IN CELLS PAS AND MITOCHONDRIAL STAIN (PTAH) +
BASAL CELL ADENOMA BASALOID APPEARING MONOMORPHIC ADENOMA HISTOPATH–SMALL ISOMORPHIC CELLS WITH UNIFORM HYPERCHROMATIC ROUND TO OVAL NUCLEI AND INDISTINCT CYTOPLASM SCANT STROMA, PERIPHERAL NUCLEAR PALLISADING DIVIDED INTO SOLID, TRABECULAR, TUBULAR, AND MEMBRANOUS TYPES CANALICULAR ADENOMA PREDILECTION FOR THE MINOR SALIVARY GLANDS OF THE UPPER LIP MYOEPITHELIOMA PRIMARILY PAROTID OF THE MYOEPITHELIAL CELL—-USUALLY OF THE SPINDLE CELL VARIETY SEBACEOUS ADENOMA CYSTADENOMA III. DUCTAL PAPILLOMAS SIALADENOMA PAPILLIFERUM INTRADUCTAL PAPILLOMA INVERTED DUCTAL PAPILLOMA IV NON-EPITHELIAL HEMANGIOMA, CAPILLARY TYPE MOST COMMON SALIVARY GLAND TUMOR IN THE PEDIATRIC POPULATION ANGIOMA, LIPOMA, NEUROLEMMOMA, AND NEUROFIBROMA MALIGNANT PAROTID LESIONS = 20% OF NEOPLASMS MUCOEPIDERMOID CA MOST COMMON MALIGNANT TUMOR OF PAROTID AND SECOND MOST COMMON OF OTHER GLANDS IN ADULTS THE PRIMARY CA IN EVERY SALIVARY GLAND IN PEDS REPRESENTS 30% OF SALIVARY MALIGNACIES BUT LESS THAN 10% OF ALL SALIVARY NEOPLASMS PRIMARILY FROM THE EPITHELIAL CELLS OF THE INTERLOBULAR/INTERLOBULAR EXCRETORY DUCTS SECONDARILY FROM THE MUCOUS PRODUCING CELLS (GOBLETS)—-SEE BOTH ON HISTOPATH–+MUCIN STAIN USUALLY 3RD TO 5TH DECADE 13% PRESENT WITH PAIN—PRIMARILY PRESENT AS AN ASX MASS Px = GRADE–(LOW GRADE HAS HIGH MUCIN/EPIDERMOID RATIO)–AS THE GRADE GETS WORSE(HIGHER) THEY BECOME MORE LIKE SCCA 90% LOW GRADE (INDOLENT—MUCOUS FILLED—FEEL CYSTIC) 10% HIGH GRADE (AGGRESSIVE)—90% SOLID—LOOKS LIKE POORLY DIFF SCCA PAS STAIN +—PERIODIC ACID SCHIFF STAIN—+MUCIN STAIN PRIMARILY LAT LOBE OF PAROTID HIGH RISK OF BREAST CA ASSOC. WITH PRIOR RT Rx -GLAND EXCISION AS APPROPRIATE WITH WIDE MARGINS; FACIAL NERVE SACRIFICE IF INVOLVED; ? ELECTIVE NECK DISSECTION FOR HIGH GRADE LESIONS + THERAPEUTIC NECK FOR CLINICAL DZ -POST-OP XRT FOR HIGH GRADE LESIONS, LYMPH NODE DZ, PNS, AND +MARGINS -PROGNOSIS -LOW GRADE – 70-90% 5 YR SURVIVAL-HIGH GRADE -45% 5 YR SURVIVAL ACINIC CELL CA 18% OF ALL SALIVARY GLAND MALIGNACIES, 6.5% OF ALL TUMORS SECOND MOST COMMON SALIVARY CA IN CHILDREN 3% B—-MOST COMMON B CA 15% LN METS AT Dx -FAIRLY RARE TUMOR WHICH IS USUALLY LOW-GRADE BUT CAN HAVE UNPREDICTABLE COURSE -MOSTLY FOUND IN PAROTID -F:M 2:1 -MAY PRESENT WITH MULTIFOCAL DZ GROSS – WELL CIRCUMSCRIBED MASS MICROSCOPIC – AMYLOID STROMA–-LIKE MEDULLARY CA OF THE THYROID—HISTOLOGICALLY BASOPHILIC HOMOLOGOUS/UNIFORM CELLS—OFTEN IN SHEETS PAS +—-HISTOCHEMICAL STAIN—USEFUL IN CONFIRMING THIS ENTITY SEROUS CELLS WITH LYMPHOID INFILTRATES *PATTERNS -MICROCYSTIC, PAPILLARY, FOLLICULAR, AND SOLID BUT OF LITTLE PROGNOSTIC SIGNIFICANCE Rx -GLAND EXCISION AS APPROPRIATE WITH WIDE MARGINS; FACIAL NERVE SACRIFICE IF INVOLVED; NO ELECTIVE NECK DISSECTION BUT NEED THERAPEUTIC NECK DISSECTION FOR CLINICAL DZ -POST-OP XRT ONLY FOR ADVANCED DISEASE
-PROGNOSIS – 70- 80% 5 YR SURVIVAL;50% 20 YR SURVIVAL ADENOID CYSTIC–FORMERY CALLED CYLINDROMA OF THE MYOEPITHELIAL CELL? VS THE INTERCALATED DUCTS AND ACINI MOST COMMON MALIGNANT TUMOR OF THE SUBMANDIBULAR, SUBLINGUAL, AND MINOR GLANDS OF ADULTS REPRESENTS 12% OF ALL SALIVARY MALIGNACIES HIGH RATE OF PERINEURAL INVASION–20% PRESENT WITH FACIAL PARALYSIS, 25% PRESENT WITH PAIN–MOST PRESENT WITH Asx MASS—-GROSS – MINIMALLY ENCAPSULATED MASS WITH SIGN. LOCAL INVASION 50% HAVE BONE INVASION AT TIME OF Dx FEMALE > MALE–AGE USUALLY IN 40+ MOST COMMON ON THE PALATE GROSSLY DECEPTIVELY APPEAR ENCAPSULATED SUBTYPES—CRIBRIFORM=MOST COMMON,TUBULAR/DUCTULAR=BEST PROGNOSIS, SOLID/=WORST BE SURE TO GET CXR HISTOPATH—-PRIMARILY HYALIN CRIBRIFORM PATTERN—–SWISS CHEESE APPEARANCE HALLMARK OF DZ IS HIGH PROPENSITY TO PERINEURAL SPREAD IN 80% FOUND EQUALLY IN ALL GRADES “NEUROTROPISM”—–IF YOU ARE GOING TO TAKE NERVE AND RECONSTRUCT—NEED TO DO INTRAOP FROZENS UNTIL CLEAR TREATMENT IS SURGERY—NO ELECTIVE NECK DISSECTION FOR N0 PTS PROGNOSIS -62% 5 YR SURVIVAL AND 40% 10 YR SURVIVAL—-FOLLOW LONG TERM--ANNUAL CXR *SHOULD TREAT LOCOREGIONAL DZ AGGRESSIVELY DESPITE DM (DISTANT METS) GIVEN PROLONGED SURVIVAL EVEN IN PTS WITH DM—–CONSIDER POST OP RT—-NEUTRON BEAM ADENOCA PRIMARILY PAROTID FEMALES>MALE -PROGNOSIS – AVERAGE SURVIVAL IS LESS THAN 2.5 YRS POLYMORPHOUS LOW GRADE ADENOCA =TERMINAL DUCT CA, SEBACEOUS CA, SALIVARY DUCT CA, CYSTADENOCA PART OF THE NEW WHO (1990) CLASIFICATION DERIVED VIA IMMUNOHISTOCHEMICAL STAINING TECHNIQUES TUMOR USUALLY FOUND ON THE HARD PALATE—62%, BUCCAL MUCOSA=17%, 10% UPPER LIP, 6% RMT FEMALE 4:1 MALIGNANT MIXED-(CARCINOMA EX PLEOMORPHIC ADENOMA) AGGRESSIVE—HIGH INCIDENCE OF DISTANT METS RT CAN INCREASE INCIDENCE OF MALIGNANT DEGENERATION TUMOR FELT TO BE ASSOCIATED WITH A PRE-EXISTING PLEOMORPHIC ADENOMA OCCURS IN ASSOCIATION WITH 3-4% OF ALL PLEOMORPHIC ADENOMAS; 7% OF RECURRENT PLEOMORPHIC TUMOR -MOST COMMONLY FOUND IN MAJOR GLANDS -USUALLY PRESENTS AS A RAPID EXPANSION OF AN EXISTING MASS WHICH HAS BEEN STABLE FOR 10-15 YEARS -AGE IS USUALLY 60+ *SUBTYPES – 1. CARCINOMA IN SITU OF BENIGN MIXED TUMOR 2. CARCINOMA EX PLEOMORPHIC ADENOMA – METS HAVE ONLY TUMOR = METASTASIZING PLEOMORPHIC ADENOMA 3. METASTASIZING MIXED TUMOR – METS HAVE BENIGN AND MALIGNANT TUMOR PRESENT 4. CARCINOSARCOMA EPITHELIAL-MYOPITHELIAL CELL CA = CLEAR CELL CA = GLYCOGEN RICH CLEAR CELL CA = TUBULAR CA = MALIGNANT MYOEPITHELIOMA BASAL CELL ADENOCA SCCA VERY SIMILAR TO HIGH GRADE MUCOEP—BAD Px -USUALLY OCCURS IN PAROTID OR SUBMANDIBULAR GLAND -MUST DIFFERENTIATE FROM METASTATIC NODE AND HIGH GRADE MUCOEPIDERMOID CA (MUCIN +) MALIGNANT ONCOCYTOMA—HIGH INCIDENC IN ESKIMOS UNDIFFERENTIATED CA/ SMALL CELL CA -? RELATIONSHIP TO EBV -VERY AGGRESSIVE TUMOR WITH 60% REGIONAL AND 90% DISTANT METASTASES -PROGNOSIS -POOR, MOST LETHAL OF ALL SALIVARY GLAND MALIGNANCIES NON-EPITHELIAL MALIGNANCIES SARCOMA LYMPHOMA—-INTRAPARENCHYMAL VS INTRANODAL—-USUALLY IS A WELL DIFFERENTIATED NON HODGKIN’S PAROTID IS PRIMARY GLAND FOR MET Dz AND LYMPHOMA AS IT DEVELOPES LATEST EMBRYOLOGICALLY AND HAS LN WITH IN IT AND AROUND IT SJOGREN’S, BENIGN EPITHELIAL LESION OF GODWIN, MIKULICZ SYNDROME, CHRONIC PUNCTATE PAROTITIS INREASES RISK OF NHL (44X)
METASTATIC DZ -USUALLY IS A SKIN CA (MELANOMA OR SCCA) SUBMANDIBULAR GLAND EXCISION—STEPS: NERVE STIMULATOR AND BIPOLAR UP DRAW INCISIONS–BE PREPARED FOR A ND INCISION 3 CM BELOW THE MANDIBLE (10 CM) RAISE PLATYSMAL FLAP (MAY CUT DIRECTLY DOWN TO THE GLAND IF OPERATING FOR NON-ONCOLOGIC Dz) MMN OVERLIES THE FACIAL VEIN IN THE SUP DCF (LIGATE THE VEIN AND RAISE THIS SAFETY FLAP) SAFETY FLAP–REFLECT FASCIA UP OFF THE SUBMAX GLAND TO PROTECT MARGINAL MANDIBULAR N-SEW IT UP TO THE FLAP (START AT ANT. — CUT OVER THE ANGLE OF THE MANDIBLE)
MAY TAKE FACIAL VEIN UP WITH SAFETY FLAP AS MMN IS SUPERFICIAL TO IT—-ID AND CUT IT DO LAYERED DISSECTION FROM ANGLE TO SYMPHYSIS ALONG INF EDGE OF MANDIBLE—BIG BITES WILL COME ACROSS SEVERAL VASCULAR STRUCTURES– INCLUDING FACIAL ARTERY AND VEIN ONLY NERVOUS STRUCTURE DEEP TO MMN AND SUP TO MYLOHYOID IS THE NERVE TO THE MYLOHYOID FREE UP SUBMAX GLAND SUP TO MYLOHYOID USE LAP TO RETRACT SUBMAX GLAND INF. (ID MYLOHYOID AND NERVE TO MYLOHYOID) USE ARMY NAVY FOR RETRACTION OF MYLOHYOID ANTERIORLY WILL COME ACROSS THE FACIAL(EXT MAXILLARY) ARTERY X 2–REALLY ONLY LARGE ARTERY IN THIS AREA, VEIN X 1 STICK TIE ARTERY ON PTS SIDE—-OFTEN EXITS POST GLAND—KNOW IT LOOK FOR “V” OF LINGUAL N. (CLAMP AT LOXLEY’S/LANGLEY’S GANGLION)-THEORETICALLY LEAVE IT TO PRESERVE POST GANGLIONIC PARASYMP INNERVATION TO IPSI SUBLINGUAL GLAND) CLAMP AND CUT WHARTON’S WHILE VISUALIZING 12 DISSECT OUT THE GLAND LEAVE GANGLION–FOR REMAINING SUBLINGUAL GLAND EXPLORE ENTIRE DIGASTRIC TRINGLE MAY LEAVE A HEMOVAC DRAIN IN PAROTIDECTOMY LITERATURE STATES ? THAT YOU REALLY NEVER NEED TO DO AN ELECTIVE NECK DISSECTION FOR ANY TYPE OF PAROTID CA WITH N0 STATUS—-DO POST OP RT FOR ADENOID CYSTIC, ADENO CA, MUCOEP AND MALIGNANT MIXED CONSIDER A PROPHYLACTIC SELECTIVE FUNCTIONAL NECK IF: HIGH GRADE MUCOEP, UNDIFFERENTIATED, OR SCCA, SUBMANDIBULAR CA, HIGH GRADE ADENOCA, CARCINOMA EX PLEOMORPHIC ADENOMA, OR NECK Dz ALWAYS CONSIDER SALIVARY GLAND AS A POSSIBLE ETIOLOGY OF THE “UNKNOWN PRIMARY”!!!!!!—-BEEN THERE W/U A PAROTID MASS WITH A FNA—23 GUAGE BUTTERFLY NEEDLE ON A SMALL CALIBER SYRINGE—HAVE AN ASSISTANT HELP WITH SUCTIONING AFTER FREEING UP THE PLUNGER CONSIDER A C-T SCAN—MAY GET BY WITHOUT ONE IF THE TUMOR IS SUPERFISCIAL AND MOBILE AND NO FACIAL PARESIS—-ANY VARIABLES—GET ONE WOULDN’T CHANGE ANYTHING BASED ON FROZEN RESULTS—SO WHY GET THEM KEY LANDMARKS FOR ID OF MAIN TRUNK 1. CARTILAGENOUS TRAGAL POINTER–CUT DOWN ON IT WITH SMALL METZ LIKE YOU ARE TRYING TO CUT IT—-WILL CLEARLY FEEL THE BONEY EAR CANAL BELOW THIS 2. MASTOID TIP 3. POST. BELLY OF DIGASTRIC 4. STYLOID PROCESS 5. TEMPOROPAROTID FASCIA 6. TYMPANOMASTOID SUTURE LINE(THOUGHT TO NOT BE TOO HELPFUL) MAY FOLLOW BRANCHES RETROGRADE OR MASTOID SEGMENT ANTEROGRADE THE POSTAURICULAR A. CROSSES THE MAIN BRANCH OF THE FACIAL NERVE—-CAN GIVE YOU SOME SIG BLEEDING HANG CT SCANS PREP AND DRAPE FOR ADEQUATE VEIW OF FACE AND POSSIBLE IPSI NECK DISSECTION SMALL TAPE TO IPSI EYE OR TARSORRAPHY STITCH THE SURGEON STANDS ON THE IPSI SIDE MARK WITH METHYLENE BLUE—-OR CROSS HATCH MARKS INCISION-10 BLADE–NO NEED TO MAKE BIG POST AURICULAR FLAP(MAY NECROSE)–STAY TWO FINGER BREADTHS (3CM) BELOW THE ANGLE OF THE MANDIBLE CAN GO POST TO TRAGUS IF NOT RESECTING ANY SKIN BELOW ANGLE OF MANDIBLE=MODIFIED BLAIR INCISION ALTERNATIVELY CAN EXTEND INCISION POST ALONG HAIR LINE (JONAS JOHNSON) ?SAVE POST BR OF GREATER AURICULAR NERVE—-DISSECT IT OUT AND PULL IT POST—DO NOT WASTE MORE THAN 10 MINUTES HERE CAN RAISE ANT AND POST FLAPS WITH EITHER KNIFE OR JONES SCISSORS(CUT WITH IMPUNITY OVER THE PAROTID CAPSULE)–AND UNDER PLATYSMA RAISE POST FLAP TO EXPOSE ENTIRE TAIL RIASE FLAP OUT OVER MASSETER—-SEE THE BRANCHES OF THE FACIAL LNERVE UNDER A THIN LAYER OF FASCIA ON THE MASSETER—KEEP THIS FASCIA DOWN AND YOU ARE SAFE ID SCM—FOLLOW IT DEEP TO THE POST BELLY OF THE DIGASTRIC FOLLOW DIGASTRIC UP TO MASTOID TIP MAY SEN RAKES OR ALICE CLAMPS ON THE POST PAROTID–PULL ANT AND DIVIDE FROM THE CARTILAGENOUS EAR CANAL CUT DOWN ON THE CARTILAGE WITH SMALL METZ— LIKE YOU ARE TRYING TO CUT IT–EXPOSE TRAGAL POINTER (VAGINAL PROCESS)—-CAN LEAVE THE PERICHONDRIUM DOWN DIVIDE PLANE OF TISSUE BETWEEN CARTILAGENOUS EAR CANAL AND ANT MASTOID TIP WITH SOME IMPUNITY– HER YOU FIND THE SUP ANT SCM–CAN DEVELOPE A BROAD FRONT HERE WILL SEPARATE THE PAROTIDOCUTANEOUS LIGAMENTS AND PLATYSMAL-AURICULAR LIGAMENT ID AND CLEAN OFF SUPERFICIAL POST DIGASTRIC—NERVE IS ANT TO THIS!!! TRIANGLE BETWEEN SUP EDGE OF DIGASTRIC, CARTILAGENOUS TRAGAL POINTER, AND MASTOID PROCESS = AREA OF THE MAIN TRUNK OF THE FACIAL NERVE—CAN OFTEN PALPATE THE STYOID PROCESS (RIOLAN’S BOUQUET = STYLOPHARYNGEUS (9), STYLOGLOSSUS(12), AND STYLOHYOID (7)) DISSECT VERY CAREFULLY WITHIN THIS TRIANGLE WITH MCABE NERVE DISSECTOR MAY USE FINE TIP MOSQUITO—-AIM ANT AND SPREAD PARALLEL TO THE NERVE IDENTIFY THE MAIN TRUNK AND NOT A DIVISION DISTAL TO THE PES!—CAN USE THE STIMULATOR TO HELP YOU THE RETROMANDIBULAR /FACIAL VEIN IS ALWAYS ANT/MEDIAL TO THE NERVE–THE NERVE IS POST LAT TO THE VEIN—-LIFT UP THE VEIN FROM BELOW AND YOU WILL REMAIN OK NEED TO BE DEEP TO BE SURE YOU DO NOT MISS AN EARLY BIFURCATION
POSTAURICULAR ARTERY OR BRANCH OFTEN OVERLIES THIS–MAY USE NERVE STIMULATOR TO HELP YOURSELF BIPOLAR FOR HEMOSTASIS USE STIMULATOR SPARRINGLY AS THIS WEAKENS THE NERVE INF BRANCH OFTEN INTIMATELY ASSOCIATED WITH POST FACIAL VEIN DISSECT PARALLEL TO THE NERVE WITH McCABES SPREAD DIRECTLY ON THE NERVE—SPREAD—WITHDRAWL–RE-ENTER AND PUSH THROUGH (UP AND OUT)—BIPOLAR-CUT NEVER CUT THROUGH THE GLAND WITHOUT KNOWING THE EXACT LOCATION OF THE BRANCHES OF THE FACIAL NERVE CAN CUT WITH BIPOLAR SCISSORS OR A 12 BLADE OVER YOUR HEMOSTAT CAN USE ALLODERM SHEET(S) (THICK 3X7 CM)TO HELP RECONSTRUCT THE CONTOUR OF THE DEFECT AND PREVENT GUSTATORY SWEATING—-IF YOU DO NOT LIGATE STENSON’S THE PT MAY DESCRIBE A SWEET TASTE POST OPERATIELY SUCTION DRAIN (AND PRESSURE DSG?) 10 JP—BULB KERLEX AND FLUFFS FOR PRESSURE DSG OVER NIGHT X 2