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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