Salivary Gland Disease and Surgery by murplelake77

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									Salivary Gland Disease and
          Surgery
      Paul Schalch, MD
          Case Presentation
• 81 yo M w 20 year hx of progressively enlarging right
  parotid mass.
• Hx of prior resection (superficial parotidectomy?).
• More recently, I&D for abscess.
• Recently, rapid increase in size.
• Smooth, firm, non-tender, no skin discoloration, non-
  mobile.
• Right pharyngeal fullness, uvula displaced to the
  left, firmness on palpation.
• VII intact.
• No LNs or neck masses.
            Work-up: FNA
• Sensitivity 85-99%, specificity 96-100%.
• Easy to perform, low morbidity.
• Certain pathologic variants can lead to false
  negatives for malignancy (basal cell
  adenomas vs. adenoid cystic ca,
  mucoepidermoid ca vs. obstruction,
  oncocytoma vs. acinic cell ca.
• Does it change management?
                          Stewart CJ: Fine-needle aspiration cytology of
                          salivary gland: a review of 341 cases. Diagn
                          Cytopathol 2000; 22:139-146.
                          Heller KS: Value of fine needle aspiration biopsy of
                          salivary gland masses in clinical decision-
                          making. Am J Surg 1992; 164:667-670.
                 FNA
• Abundant amorphous debris with
  benign acinar cells and few atypical
  keratinized squamous cells, cannot rule
  out malignancy.
         Work-up: Imaging
• CT: superior to physical exam and other
  imaging modalities.
• Does not provide specific info regarding
  histologic diagnosis, but provides info about
  bilateralism and benign vs. malignant
  masses.
• MRI superior to CT in demonstrating internal
  architecture.
• Location in relationship to fascial planes and
  spaces (for operative planning).
                              Rabinov JD: Imaging of salivary gland
                              pathology. Radiol Clin North
                              Am 2000; 38:1047-1057.
                              Shah GV: MR imaging of salivary
                              glands. Magn Res Imag Clin North
                              Am 2002; 10:631-6.
               MRI Report
• 6.3 x 3.2 x 6.1 cm multi-lobular mass with
  peripheral enhancement involving the
  superficial and deep lobes of the right
  parotid gland. Slightly increased T1 and T2
  signals, with scattered areas of low T2 signal
  throughout. Mass extends into
  parapharyngeal and pterygoid spaces, with
  mass effect displacement of the
  nasopharynx. Likely a pleomorphic adenoma
  but cannot exclude malignant degeneration
  of mass.
    Incidence – Salivary Gland
             Tumors
• 3-4% of all head and neck
neoplasms.




                              From: Hanna EY, Lee S, Fan CY, Suen JY. Chapter 60: Salivary Gland
                              Physiology. In: Cummings et al. (Eds.). Cummings: Otolaryngology –
                              Head and Neck Surgery, 4th Ed. 1998, Mosby, Philadelphia, PA.
Benign vs. Malignant – Site of
           Origin




                From: Hanna EY, Lee S, Fan CY, Suen JY. Chapter 60: Salivary Gland
                Physiology. In: Cummings et al. (Eds.). Cummings: Otolaryngology – Head
                and Neck Surgery, 4th Ed. 1998, Mosby, Philadelphia, PA.
Memorial Sloan-Kettering: 35-Year Period
                     THE DISTRIBUTION OF 2807 SALIVARY NEOPLASMS


                                           Number of Patients                    Percent
   Histology

   Pleomorphic adenoma                                   1274                      45.4

   Warthin's tumor                                        183                       6.5
   Benign cyst                                            29                        1.0
   Lymphoepithelial lesion                                17                        0.6
   Oncocytoma                                             20                        0.7
   Monomorphic adenoma                                     6                        0.2
   Mucoepidermoid carcinoma                               439                      15.7
   Adenoid cystic carcinoma                               281                      10.0
   Adnocarcinoma                                          225                       8.0
   Malignant mixed tumor                                  161                       5.7
   Acinic cell carcinoma                                  84                        3.0
   Epidermoid carcinoma                                   53                        1.9
   Other (anaplastic)                                     35                        1.3
   Total                                                 2807                      100


                                     Spiro RH: Salivary neoplasms: overview of a 35-year experience
                                     with 2,807 patients. Head Neck Surg 1986; 8:177-184.
  Embriology and Microscopic
           Anatomy
• Ectodermal origin.
• 4-6th week of gestation.
• Serous and mucous cells, arranged in
  acini, drained by series of ducts.
• Parotid: serous acini.
• Submandibular: serous and mucinous
  acini.
• Minor SG: mucinous acini.
From: Elluru RG, Kumar M. Chapter 56: Salivary Gland Physiology. In: Cummings et al. (Eds.).
Cummings: Otolaryngology – Head and Neck Surgery, 4th Ed. 1998, Mosby, Philadelphia, PA.
    Cellular Origins of Salivary
         Gland Neoplasms
• Multicenter theory:
  – Each type originates from a distinctive cell
    type.
  – E.g. Whartin’s / oncocytic: striated duct
    cells.
  – Acinic cell: acinar cells.
  – Mixed: intercalated and myoepithelial
    cells.

                 Dardick I: Mounting evidence against current histogenetic
                 concepts for salivary gland tumorigenesis. Eur J
                 Morphol 1998; 36:257-261.
    Cellular Origins of Salivary
         Gland Neoplasms
• Bi-cellular reserve cell theory:
  – All tumors arise from the basal cells of
    either the excretory or intercalated ducts.
  – These cells act as reserves, with the
    potential to differentiate into various
    epithelial cell lines.
  – E.g. pleomorphic adenomas and oncocytic
    tumors: intercalated ducts.
  – SCC and mucoepidermoid tumors:
    excretory ducts.
                  Batsakis JG: Histogenesis of salivary gland neoplasms: a
                  postulate with prognostic implications. J Laryngol
                  Otol 1989; 103:939-944.
      Anatomy – Parotid Gland
•   Superior/posterior: EAC.
•   Posterior: mastoid, anterior aspect of SCM.
•   Superior/anterior: temporo-mandibular joint.
•   Anterior: masseter, medial pterygoid, ascending mandibular
    raums.
•   Parotid space: zygomatic arch above, stylohyoid and posterior
    belly of digastric below.
•   Capsule: investing (superficial) layer of deep cervical fascia.
    Contains greater auricular nerve.
•   Platysma.
•   Deep lobe: behind mandibular ramus, immediately lateral to the
    superior constrictor (parapharyngeal space). Division based on
    facial nerve.
•   20% of cases: small, detached accessory parotid gland
    between zygomatic arch and parotid duct.
         Structures within…
• External carotid artery: divides into the maxillary
  artery and superficial temporal artery (gives off
  tranverse facial branch). Also, small posterior
  auricular artery.
• Retromandibular vein: formed by union of maxillary
  and superficial temporal veins. It then bifurcates,
  fuses with the retroauricular vein and becomes EJ.
  Anterior branch joins facial vein and then joins IJ.
• Facial nerve.
• Parotid duct (Stensen’s): emerges anteriorly, passes
  across masseter, traverses buccinator and opens
  into oral cavity opposite second upper molar.
• ~ 20 lymph nodes within the parotid gland.
Gray H. Anatomy of the human
body. 1918.
 Describe the Autonomic
Innervation of the Salivary
          Glands
Segal K, Lisnnyansky I, Nageris B, Feinmesser R. Parasympathetic innervation of the salivary
glands. Op Tech Otolaryngol Head Neck Surg 1996;7:333-338.
Segal K, Lisnnyansky I, Nageris B, Feinmesser R. Parasympathetic innervation of the salivary
glands. Op Tech Otolaryngol Head Neck Surg 1996;7:333-338.
Segal K, Lisnnyansky I, Nageris B, Feinmesser R. Parasympathetic innervation of the salivary
glands. Op Tech Otolaryngol Head Neck Surg 1996;7:333-338.
Treatment Options
             Complications
•   Facial nerve injury.
•   Frey Sx.
•   Sialocele/fistula.
•   Hematoma.
•   Deformity.
       Facial Nerve Injury
• Incidence of paralysis 3-5%.
• Transient dysfunction 8-65%.
• Paresis more common, resolves within
  6-18 months.
• Primary re-anastomosis.
• Cable graft (greater auricular nerve).
• XII to VII transposition.
• Jump graft.
                             Frey Sx
• AKA auriculotemporal Sx, gustatory sweating.
• Up to 30% have symptoms.
• Over 90% if starch-iodine test is used.
• Post-ganglionic parasympathetic nerve fibers from
  the otic ganglion reconnect with sympathetic fibers
  of the sweat glands upon healing.
• Medical Tx: antiprespirants, Botox, 3% scopolamine
  cream.
• Surgical Tx: SMAS flaps, rotation SCM flaps,
  AlloDerm, transmeatal tympanic neurectomy
  (Jacobson’s n.).
• Can be prevented by not resecting portions of the
  parotid not involved with tumor (in cases of benign
  tumors).                 Clayman MA, Clayman SM, Seagle MB. A review of the
                                      surgical and medical treatment of Frey syndrome. Ann
                                      Plast Surg 2006;57:581-584.
                                      Sinha UK, Saadat D, Doherty CM, Rice DH. Use of
                                      AlloDerm implant to prevent Frey syndrome after
                                      parotidectomy. Arch Facial Plast Surg 2003;5:109-112.
    Salivary Fistula/Sialocele
• Caused by residual parotid tissue, left behind after
  incomplete resection.
• Rough surface of parotid tends to secrete saliva into
  surrounding tissues.
• Fistula may form through drain site.
• Application of continuous pressure w/ dressing
  helps.
• Contained saliva causes sialocele.
• Sometimes needs needle decompression.
• Treatment options similar to Tx for Frey Sx: Botox,
  anticholinergics, even XRT.


                                Nageris B, Feinmesser R. Complications of
                                parotidectomy: surgical techniques of repair.
                                Op Tech Otolaryngol Head Neck Surg
                                1996;7:374-376.
   Surgical Management
               Incisions




Rhytidectomy               Modified Blair
Surgical Management




      Harrell M, Levy D, Elam M. Superficial parotidectomy for
      benign parotid lesions. Op Tech Otolaryngol Head Neck Surg
      1996;7:315-322.
Facial Nerve Identification – There’s
More than One Way to Skin a Cat…
• Tragal pointer (10 mm inferior and deep).
• Marginal mandibular or buccal branches
  (centripetal approach).
• Tympanomastoid suture (Tabb HG, 1985).
• Styloid process.
• Posterior belly of the digastric.
• Superficial temporal and retromandibular
  veins (Kawakami S, 1994).
       Facial Nerve Monitoring

• Witt RL. Facial nerve monitoring: the
  standard of care? Otolaryngol Head
  Neck Surg 1998;119:468-470.
  – 69 consecutive patients w/ parotid tumors
    that underwent surgery.
  – 16 “high-risk” patients excluded.
  – Most were PA or WT.
  – No statistical difference between both
    groups.
What about neck dissection?
• Must be done when nodes clinically or
  radiologically evident.
• National Cancer Institute: 41% positive node
  rate in the presence of major salivary gland
  malignancy.
• Predictors: age, hystopathologic type, VII
  involvement, extraglandular involvement,
  grade and size.
• Levels I to III if tumor > 4 cm, SCC, adeno ca,
  high-grade mucoepidermoid ca.
                            Bhattacharyya N, Fried MP: Nodal metastasis in
                            major salivary gland cancer. Arch Otolaryngol Head
                            Neck Surg 2002; 128:904.
             X-RT/Chemo
• XRT improves overall survival: high-grade
  tumors, positive margins, VII, perineural
  spread, LNs, mets and recurrence.
• More effect in advanced disease.
• Local control, palliation.
• Complications: RIF, osteoradionecrosis.
• Chemo: recurrent, metastatic and
  unresectable disease.
                        Spiro RH, Armstrong J, Harrison L: Carcinoma of major
                        salivary glands: recent trends. Arch Otolaryngol Head
                        Neck Surg 1989; 115:316.
                        Ruzich JC, Ciesla MC, Clark JI: Response to paclitaxel
                        and carboplatin in metastatic salivary gland cancer: a
                        case report. Head Neck 2002; 24:406.
               Pathology
•   Mucoepidermoid carcinoma.
•   Low grade.
•   Abundant infarction necrosis.
•   0/18 zone II lymph nodes.
  Prognosis – Mucoepidermoid
          Carcinoma
• 40% incidence of local recurrence.
• 15% incidence of spread to regional
  LNs and distant sites.
• 5-year survival rate 80%.
• Female>male, mean age 47 years.
• Prognosis depends on clinical stage,
  site, grading and margins.
                     Evenson JW. Malgnant neoplasms of the salivary glands.
                     In: Thompson LDR (Eds.). Head and neck pathology.
                     Churchill Livingston, Philadelphia, PA, pp. 321-370.

								
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