SALIVARY GLANDS (INFLAMMATION & TUMORS)

1. SALIVARY GLANDS(INFLAMMATION & TUMORS) DR. P.S.M AMEER ALI PROFESSOR OF SURGERY Y.M.C.H

2. INTRODUCTION • SALIVARY GLANDS MAINLY COMPRISE OF 3 MAJOR AND MANY MINOR GLANDS • THE MAIN GLANDS ARE PAROTID,SUBMANDIBULAR & SUBLINGUAL GLANDS AND MINOR GLANDS NUMBER AROUND 400 AND ARE EVENLY DISTRIBUTED ALL OVER THE ORAL CAVITY • COMMON PATHOLOGYS : 1)SALIVARY CALCULI 2)SALIVARY GLAND INFLAMMATION 3)SALIVARY GLAND TUMORS

3. SALIVARY CALCULUS&SIALADENITIS • 80% OF THE ABOVE PATHOLOGY INVOLVES THE SUBMANDIBULAR GLAND AS THIS GLAND’S SECRETION IS VISCOUS AND DRAINAGE IS NON-DEPENDENT • 80% OF THE SALIVARY CALCULI ARE RADIO-OPAQUE • COMPOSITION – CALCIUM PHOSPHATE AND CALCIUM CARBONATE • CAUSES OF SIALADENITIS – BACTERIAL AND VIRAL INFECTION, TRAUMA OF WHARTON’S DUCT RESULTING IN STRICTURE. • SIALADENITIS CAN BE EITHER ACUTE OR CHRONIC

4. CLINICAL FEATURES : 1)PAIN,SWELLING SEEN IN SUBMANDIBULAR REGION 2)WHARTON’S DUCT IS PALPABLY SWOLLEN & TENDER 3)PAIN DURING MASTICATION 4)AS THE CONDITION BECOMES CHRONIC MULTIPLE STONE FORMATION OCCURS 5)FIRM TENDER SWELLING ON BI-DIGITAL PALPATION INVESTIGATIONS – TOTAL COUNT,ESR,INTRA ORAL XRAYS,SIALOGRAM. FNAC TO RULE OUT NEOPLASM

5. TREATMENT – ANTIBIOTICS & ANTIINFLAMMATORYS TO REDUCE THE ACUTE STAGE FOLLOWED BY SURGERY 1)IF THE CALCULUS IS IN THE DUCT THEN IT IS REMOVED WITH AN INCISION MADE ON THE DUCT 2)IF THE CALCULUS IS IN THE GLAND THEN ENTIRE GLAND IS EXCISED NOTE – INCISION FOR SURGERY MUST BE MADE 2CM BELOW MANDIBULAR MARGIN TO AVOID INJURY TO MARGINAL MANDIBULAR NERVE

6. PAROTID ABSCESS • ACUTE BACTERIAL SIALADENITIS OF THE PAROTID GLAND AS PAROTID FASCIA IS THICK THE ABSCESS WILL NOT SHOW ANY SIGNS OF FLUCTUATION UNTIL LATE STAGE CAUSES – VIRAL,BACTERIAL(STAPHYLOCOCCUS&SYPHILIS), HIV,POST RADIOTHERAPY,SJOGREN’S SYNDROME. CLINICAL FEATURES 1)PYREXIA,MALAISE,PAIN & TRISMUS

7. 2) RED,TENDER,WARM & FIRM SWELLING IN THE PAROTID REGION WITH CHARACTERISTIC BRAWNY SWELLING 3)PALPABLE LYMPH NODES 4)SEVERE BACTEREMIA CAN LEAD TO FEBRILE EPISODES 5) PURULENT FOUL SMELLING SALIVA FROM THE STENSON’S DUCT INVESTIGATIONS – USG(PAROTID) , PUS FOR C/S SIALOGRAM CONTRAINDICATED IN ACUTE STAGE

8. TREATMENT – 1)APPROPRIATE ANTI BIOTIC COVERAGE 2)INCISION & DRAINAGE WITH BLAIR’S INCISION WHICH IS MADE VERTICALLY IN FRONT OF THE TRAGUS COMPLICATIONS- SEPTICAEMIA,SEVERE TRISMUS,INVOLVEMENT OF EXTERNAL AUDITORY CANAL,PAROTID FISTULA

9. SALIVARY NEOPLASMS • CLASSIFICATION : EPITHELIAL – 1.ADENOMAS a)PLEOMORPHIC ADENOMA b)MONOMORPHIC ADENOMA c)ADENOLYMPHOMA(WARTHIN’S TUMOR) d)OXYPHIL ADENOMAS e)ONCOCYTOMA 2.CARCINOMAS a)MUCO EPIDERMOID CARCINOMA b)ACINIC CELL CARCINOMA c)ADENOID CYSTIC CARCINOMA d)ADENOCARCINOMA, SQUAMOUS CELL CARCINOMA,CARCINOMA IN PLEOMORPHIC ADENOMA & UNDIFFERENTIATED CARCINOMA

10. NON-EPITHELIAL : 1)HAEMANGIOMA 2)LYMPHANGIOMA 3)NEUROFIBROMA LYMPHOMAS : USUALLY IN NON-HODGKIN’S SECONDARY TUMORS FROM HEAD & NECK LYMPHOEPITHELIAL TUMORS OF MINOR GLANDS

11. PLEOMORPHIC ADENOMA • COMMONEST SALIVARY GLAND TUMOR • 80% INVOLVES THE PAROTIDS • CALLED AS MIXED TUMOR AS IT CONTAINS EPITHELIAL,MYOEPITHELIAL,PSEUDOCARTILAGE CELLS TO NAME A FEW. • EVEN THOUGH IT IS CAPSULATED TUMOR MAY COME OUT AS PSEUDOPODS • CAN OCCUR AS A “DUMB BELL TUMOR” IF BOTH SUPERFICIAL & DEEP LOBES ARE INVOLVED

12. CLINICAL FEATURES : 1)USUALLY UNILATERAL 2)RAISED EAR LOBULE 3)PAINLESS,SMOOTH,FIRM,LOBULATED & MOBILE SWELLING WHICH CANNOT BE MOVED ABOVE THE ZYGOMA (CURTAIN SIGN) 4)OBLITERATION OF RETRO MANDIBULAR GROOVE 5)FACIAL NERVE IS NOT INVOLVED 6)CAN TURN INTO MALIGNANCY SIGNS OF MALIGNANCY – INCREASE IN SIZE,NODULARITY,INVOLVEMENT OF SKIN,INVOLVEMENT OF MASSETER,FACIAL NERVE PALSY AND INVOLVEMENT OF NECK NODES

13. INVESTIGATIONS : 1)FNAC 2) CT / MRI TO SHOW IF BONE INVOLVEMENT IS PRESENT & MALIGNANT FEATURES IF PRESENT TREATMENT : SURGERY – SUPERFICIAL PAROTIDECTOMY WITH PRESERVATION OF FACIAL NERVE WITH LAZY ‘S’ INCISION

14. ADENOLYMPHOMA(WARTHIN’S TUMOR) • CALLED ALSO AS PAPILLARY CYSTADENOMA LYMPHOMATOSUM • BENIGN TUMOR OCCURING USUALLY IN LOWER POLE OF THE PAROTID GLAND • OCCURS DUE TO TRAPPING OF LYMPH TISSUE INTO THE PAROTID DURING DEVELOPMENT • COMPOSED OF DOUBLE LAYER OF COLUMNAR EPITHELIUM • MORE COMMON IN MALES & ELDERLY, USUALLY BILATERAL

15. SLOW GROWING,SMOOTH,SOFT,CYSTIC & FLUCTUANT SWELLING • INVESTIGATIONS - FNAC , TECHNITIUM PERTECHNATE SCAN (HOT SPOT) • ADENOLYMPHOMA DOES NOT TURN MALIGNANT • TREATMENT – SUPERFICIAL PAROTIDECTOMY

16. MUCOEPIDERMOID TUMOR • COMMONEST MALIGNANT SALIVARY GLAND TUMOR • SLOWLY PROGRESSIVE, CAN BE LOW GRADE OR HIGH GRADE • FACIAL NERVE INVOLVEMENT OCCURS LATE • C/F : SWELLING WHICH IS SLOWLY PROGRESSIVE,HARD,NODULAR WITH SKIN INVOLVEMENT • FNAC WITH CT/MRI CONFIRMS DIAGNOSIS • TREATMENT – RADICAL PAROTIDECTOMY FOLLOWED BY RADIOTHERAPY

17. TNM STAGING OF SALIVARY TUMORS • T (TUMOR) Tx – TUMOR NOT ASSESSIBLE T0 – NO EVIDENCE OF PRIMARY TUMOR T1 – TUMOR < 2CM T2 – TUMOR IS 2-4CM T3 – TUMOR IS 4-6CM T4 – TUMOR IS >6CM (INVOLVING FACIAL NERVE &ADJACENT STRUCTURES)

18. N (LYMPH NODE) Nx – NODES NOT ASSESSED N0 – REGIONAL NODES NOT INVOLVED N1 – SINGLE IPSILATERAL NODE <3cm N2a– SINGLE IPSILATERAL NODE 3-6cm N2b- MULTIPLE IPSILATERAL NODES < 6cm N2c- BILATERAL NODES <6cm N3 – SINGLE NODE > 6CM

19. M (METASTASIS) M0 – NO TUMOR SPREAD M1 – TUMOR SPREAD TO DISTANT SITES

20. COMPLICATIONS OF PAROTIDECTOMY • FACIAL NERVE INJURY • HAEMORRHAGE • SALIVARY FISTULAS • FLAP NECROSIS • FREY’S SYNDROME (GUSTATORY SWEATING) • SIALOCELE • GREATER AURICULAR NERVE INJURY

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