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8/1/2019
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Panel: Salivary Gland Pathology and
Benign Oral Cavity Lesions
Boyd Gillespie, MDCharlie Harkins, MDBruce Campbell, MD
Joel Blumin, MDModerator: Michael Stadler, MD
August 8-11, 2019 | The American Club | Kohler, WI
Learner Objectives
• After this presentation you should:– 1) Recognize a few classic presentations of
common benign oral lesions– 2) Understand how best to work-up parotid
masses– 3) Discuss the options for management of
parotid swelling in children
August 8-11, 2019 | The American Club | Kohler, WI
Case #1
• 41yo male presents with chief complaint of recurrent painful sores in his mouth
August 8-11, 2019 | The American Club | Kohler, WI
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Case #1• History:
– Duration: over last year or so – Frequency: variable, “flares” every few months– Severity: pain is 2-8/10– Location: lips, cheeks, roof of mouth– Timing: last ”a few weeks” – Treatment to date: none
August 8-11, 2019 | The American Club | Kohler, WI
Case #1
• Exam:
August 8-11, 2019 | The American Club | Kohler, WI
Recurrent Aphthous Stomatitis• Most common recurrent oral ulcerative lesions
– 20-40% of population– Up to 2/3 of young adults– Frequency lessens with age
• Three forms– Minor– Major– Herpetiform
August 8-11, 2019 | The American Club | Kohler, WI
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Recurrent Aphthous Stomatitis
• Minor RAS• <10 mm• Yellow fibrinous base• Erythematous, sharply
marginated periphery• Anterior oral cavity• Duration of 7-10 days
August 8-11, 2019 | The American Club | Kohler, WI
Recurrent Aphthous Stomatitis
• Major RAS• >10 mm• Posterior oral cavity• Deep craters, painful• Duration of 6+ weeks• Marker for HIV disease
progression
August 8-11, 2019 | The American Club | Kohler, WI
Recurrent Aphthous Stomatitis
• Herpetiform RAS• <2 mm• Shallow ulcers• Similar herpes (HHV),
but no vesicular phase prior to ulceration
August 8-11, 2019 | The American Club | Kohler, WI
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Case #1
• What do you tell the patient? • Do they need a biopsy? • Do you follow these patients? • Treatments?
August 8-11, 2019 | The American Club | Kohler, WI
Recurrent Aphthous Stomatitis• Etiology
– Unknown, idiopathic– Local physical trauma? – Associated disorders
• Crohn’s disease, Behçet’s syndrome, Celiac disease, IBS– Medications
• NSAIDs, β-blockers
• Biopsy/Histopathology– Non-specific ulceration, epithelial necrosis, neutrophilic
infiltrate– Direct Immunofluorescence: nonspecific
August 8-11, 2019 | The American Club | Kohler, WI
Recurrent Aphthous Stomatitis
• Management– Oral hygiene– Avoidance of exacerbating factors– Pain control – topicals and coating
agents
August 8-11, 2019 | The American Club | Kohler, WI
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Topical Analgesics & Coating Agents
• 2% viscous lidocaine: – May be applied directly to surface of ulcers or used as
a swish and spit• Sucralfate suspension:
– Sulfated polysaccharide complexed with aluminum hydroxide
– Protective barrier for mucosal ulceration• Diphenhydramine, Aluminum hydroxide,
magnesium hydroxide, and simethicone suspensions– Swish and spit
August 8-11, 2019 | The American Club | Kohler, WI
Topical Corticosteroids• Dexamethasone elixir 0.5 mg/5 cc
– 5 mL swish and spit three to four times daily. It is important to keep in mouth for at least 5min and to not rinse mouth out after use or eat/drink for 30min after
• Clobetasol 0.05% gel or ointment– Apply a small amount to the area of involvement two to three times
daily– Works best if the mucosa is dried (gauze) prior to the application– Do not rinse afterward and avoid eating or drinking for 30 minutes
• Triamcinolone acetonide 0.1% in Orabase– Orabase is a thick, paste-like material that may adhere better to
isolated lesions but does not appeal to many patients.
August 8-11, 2019 | The American Club | Kohler, WI
Show me the data!• 2011 systematic review, 43 randomized trials:
– Variety of topical, systemic, and destructive Tx were “effective in reducing pain and promoting ulcer resolution”
– All low quality studies/data
• 2012 Cochrane Review, 25 randomized trials: – Insufficient evidence to support a relative benefit
of any systemic treatments studied– Low quality, high risk of bias
August 8-11, 2019 | The American Club | Kohler, WI
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Case #2
• 10yo female with recurrent and painful right cheek swelling
August 8-11, 2019 | The American Club | Kohler, WI
Case #2• History:
– Right side: Swelling, pain, redness, dry mouth?– 3 episodes over last few years, last 1-2 days– Most recent episode was the “worst yet”– Dry mouth since these episodes started
• Exam: – Slight edema of right preauricular region– Pictures of recent flares showing impressive
swelling
August 8-11, 2019 | The American Club | Kohler, WI
Case #2
• Next Steps?– Follow and treat conservatively?– Labs? – Image?
August 8-11, 2019 | The American Club | Kohler, WI
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Juvenile Recurrent Parotitis (JRP)• Etiology unknown, treatment debated
• Clinical Presentation: – Recurrent inflammation of parotid gland(s), can be
associated with with fever and/or malaise– Flares usually last for 1 or 2 days, in rare cases for
weeks– The interval between flares may even last for some
yrs.– Age of onset: between 4mo and 15yrs, usually self-
limiting with puberty
August 8-11, 2019 | The American Club | Kohler, WI
Juvenile Recurrent Parotitis (JRP)
• Management options?
August 8-11, 2019 | The American Club | Kohler, WI
Juvenile Recurrent Parotitis (JRP)
• Treatment: – Controversial– Goals: relieve symptoms, prevent parenchymal
damage– Abx: usually first line tx, limited data to support
• JRP associated with bacterial infection???
– Sialogogues– Massage
August 8-11, 2019 | The American Club | Kohler, WI
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Juvenile Recurrent Parotitis (JRP)
• Treatment (cont.): – Ductal ligation– Ductal Steroid irrigations– Sialendoscopy +/- steroid irrigations– Parotidectomy
August 8-11, 2019 | The American Club | Kohler, WI
Show me the data!
• The quality of the available evidence on the treatments of JRP is poor.
• Only one RCT over a 28yr period – which supported the effectiveness of the concomitant use of Bear Bile and Huangqi on the prevention of JRP recurrences.
August 8-11, 2019 | The American Club | Kohler, WI
Raun WH et al, J. Zhejiang Univ. Sci., 2013
Show me the data!
• Sialendoscopy can help! • Or is it just the irrigations and/or steroids?
August 8-11, 2019 | The American Club | Kohler, WI
Zenk J et al, Curr Otorhinolaryngol Rep (2014)
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Case #3
• 44yo female with “weird white patches” on the inside of her cheek
August 8-11, 2019 | The American Club | Kohler, WI
Case #3
• HISTORY: – Painless– Sometimes associated with smalls sores on
her cheek and tongue– ”flares up” at times– Present for last 2-3 years, worse lately
August 8-11, 2019 | The American Club | Kohler, WI
Case #3
• Exam:– Fine white plaques of
the superficial mucosa
– Seen bilaterally, fairly symmetric
– Nontender– No other findings on
H+N examination
August 8-11, 2019 | The American Club | Kohler, WI
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Case #3
• Next Steps?
August 8-11, 2019 | The American Club | Kohler, WI
Lichen Planus• Chronic, T-cell mediated inflammatory,
autoimmune? condition
• Pathogenesis not fully understood, causes are unproven
• Clinical presentation: Ranges from reticular white plaques to mucosal erythema, erosions, ulceration, and hyperkeratotic plaques
• Most often symmetric and bilateral
Lichen PlanusReticular Reticular
Erythematous/Atrophic Erosive
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Lichen Planus
• Management Options?
August 8-11, 2019 | The American Club | Kohler, WI
Lichen Planus• Management
– No Tx necessary for asymptomatic patients
– No known cure
– Primary goal of treatment are alleviation of symptoms and inflammation to prevent scarring
– Mainstays of treatment: • 1st line: Topical Steroids (also intralesional or systemic)• Topical Calcineurin Inhibitors - cyclosporin, tacrolimus• Oral hygiene, avoidance of trauma/mechanical irritation,
smoking cessation
August 8-11, 2019 | The American Club | Kohler, WI
Show me the data!
• Randomized, placebo-controlled trial with 40 patients showed superiority with topical corticosteroid treatment
• Systematic review of various randomized trials of corticosteroids: no evidence of superiority (pain as outcome) of any one corticosteroid
August 8-11, 2019 | The American Club | Kohler, WI
Cheng S et al, Cochrane Database Syst Rev, 2012
Voute AB et al, Oral Surg Oral Med Oral Path, 1993
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Case #4
• 48yo female with incidental finding on CT scan of right sided parotid mass– Asymptomatic– Nonpalpable– No other lumps/bumps within face/neck
August 8-11, 2019 | The American Club | Kohler, WI
August 8-11, 2019 | The American Club | Kohler, WI
Parotid Gland Neoplasms
Benign (75-80%)• Pleomorphic Adenoma (65-85%)• Warthin’s Tumor (20-30%)• Other (5-10%)
– Oncocytoma– Monomorphic Adenomas
Malignant (20-25%)• Mucoepidermoid Ca (30-40%)• Adenoid Cystic Ca (15-20%)• Ca ex-pleomorphic (10-15%)• Acinic Cell Ca (10%)• Adenocarcinoma NOS (4-5%)• Basal Cell AdenoCa (3-4%)• Clear Cell AdenoCa (3-4%)• Myoepithelial Ca (2-3%)• Salivary Duct Ca (2-3%)• Other (10%)
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Workup of Parotid Mass
History– Onset, duration, behavior, associated
symptoms, pain, facial function
– ROS: dry eyes/mouth, weight loss, fevers
– PMHx: Skin/other cancers, autoimmune dz, Sarcoidosis, Sjogren syndrome
– Vast majority are asymptomatic
August 8-11, 2019 | The American Club | Kohler, WI
Workup of Parotid MassPhysical Examination
– Inspection/Palpation• Size, location, consistency, mobility• Skin changes, sinus tracts• Facial motion
– Oral Exam • Trismus• Stensen’s duct• Fullness in OP - Parapharyngeal extension?
– Neck Exam
– Cranial Nerve Exam
August 8-11, 2019 | The American Club | Kohler, WI
Case #4
• How would you approach this particular patient? – Biopsy? – Management?
August 8-11, 2019 | The American Club | Kohler, WI
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FNA Biopsy• Goals:
– Is surgery a recommended option?– Benign vs. Malignant – Definitive Diagnosis
• Advantages: – Simple, minimally invasive, well-tolerated, accurate – May be useful in patients unable/unwilling to have surgery– Aids in preoperative planning and patient counseling
• Disadvantages: – Unnecessary? Will it change ultimate management?– Poor Sensitivity?– Variability in reported results – Cost– Tumor Seeding – extremely rare
August 8-11, 2019 | The American Club | Kohler, WI
Tissue Diagnosis Techniques: Best Practices
• FNA bx– Reasonable to perform, but may not be necessary in all situations– Results are likely dependent on both sampling and cytopathologist
experience– Consider US-guidance, especially for cystic lesions
• Core needle bx – Consider if FNA is nondiagnostic or indeterminate AND it will assist in
management of the patient– Consider if lymphoma is high on differential
• Intraoperative Frozen Section Analysis– May be useful in certain situations - assist in intraoperative decision
making regarding extent of necessary/appropriate surgery– Recommend discussing with pathologist prior to performing
August 8-11, 2019 | The American Club | Kohler, WI
Imaging• Potentially unnecessary in many cases
– Particularly useful with larger lesions and malignant suspicion
• Can assist in treatment planning and patient counseling– Differentiate between neoplastic and non-neoplastic processes– Assess local extent/invasion– Detect regional and/or distant metastatic lesions
• Common Options: – MRI – best initial test for salivary gland lesions– CT – most commonly utilized imaging test– US – utilized as first line imaging in much of Europe
August 8-11, 2019 | The American Club | Kohler, WI
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Extent of Surgery
Classification of Surgical Techniques: • Extracapsular Dissection• Limited/Partial superficial parotidectomy• Superficial parotidectomy• Total parotidectomy• Radical/Extended parotidectomy
August 8-11, 2019 | The American Club | Kohler, WI
Surgery for Benign Parotid Tumors
9 Studies, 1882 patients• Mean reduction of 75% in rate of transient facial nerve paralysis (8% versus
20.4%)• 88% reduction in symptomatic Frey’s syndrome (4.5% versus 26.1%)• Similar rates of recurrence and permanent facial paralysis – mean f/u 2-10yr
• Note: Intraoperative decision-making process in these studies leads to morbidity outcomes and recurrence rates likely favoring ECD due to preferential use of ECD in easier, more straightforward cases
August 8-11, 2019 | The American Club | Kohler, WI
Surgery for Benign Parotid Tumors
Limited/partial/conservative superficial parotidectomy • Shown to be equivalent or better in terms of
recurrence rates and surgical morbidity when compared to superficial parotidectomy
– 363 cases of superficial parotid lesions– 70% were pleomorphic adenomas– 0.8% recurrence rate (median f/u of 6yrs)– 2.5% permanent facial paralysis rate
August 8-11, 2019 | The American Club | Kohler, WI
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Facial Nerve Monitoring
• 7 publications, 546 patients, benign and malignant, superficial and total
• Immediate post-op weakness - lower when FNM was utilized– 22.5% vs 34.9% (p = 0.001)
• Permanent weakness – lower, but not statistically significant– 3.9% vs 7.1% (p = 0.18)
• NNT : 9 patients/cases to prevent 1 immediate postop facial nerve weakness
August 8-11, 2019 | The American Club | Kohler, WI
Summary• Do
– Consider symptomatic treatment for the benign oral lesions discussed today
– Consider offering steroid irrigations versus sialendoscopy for JRP
– Offer appropriate extent of surgery for patients with various parotid masses
– Consider biopsy of oral lesions when diagnosis is unclear
August 8-11, 2019 | The American Club | Kohler, WI
Summary• Do not:
– Overtreat benign conditions of the oral cavity, especially if asymptomatic
– Omit biopsy of oral lesions if the diagnosis remains unclear
– Be unprepared to perform the appropriate extent of surgery for a parotid mass if/when additional intraoperative information is uncovered
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Thank you
Questions?
August 8-11, 2019 | The American Club | Kohler, WI
Case #5
• 62yo male presents with complaints of bilateral parotid swelling
August 8-11, 2019 | The American Club | Kohler, WI
Case #5HISTORY: • Non-painful• ”Always” enlarged• Wife noticed over last 6 months• No other associated symptoms
EXAM: • Bilateral, symmetric enlargement• Soft, no discrete masses• Good salivary flow from ducts
August 8-11, 2019 | The American Club | Kohler, WI
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Case #5
August 8-11, 2019 | The American Club | Kohler, WI
Bilateral Parotid Enlargement
Bilateral Parotid Enlargement
August 8-11, 2019 | The American Club | Kohler, WI
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Sialadenosis
• Bilateral, persistent painless, soft, non-neoplastic, non-inflammatory swelling
• Causes: DM, alcoholism, liver dz, eating disorders, antihypertensives, other endocrinopathies
• Related to autonomic neuropapthy?
August 8-11, 2019 | The American Club | Kohler, WI
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