245 - Salivary Gland Panel - Stadler...• Mucoepidermoid Ca (30-40%) • Adenoid Cystic Ca (15-20%) • Ca ex-pleomorphic (10-15%) • Acinic Cell Ca (10%) • Adenocarcinoma NOS

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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


Case #1

• 41yo male presents with chief complaint of recurrent painful sores in his mouth


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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


Case #1

• Exam:


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


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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



• Major RAS• >10 mm• Posterior oral cavity• Deep craters, painful• Duration of 6+ weeks• Marker for HIV disease

progression



• Herpetiform RAS• <2 mm• Shallow ulcers• Similar herpes (HHV),

but no vesicular phase prior to ulceration


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Case #1

• What do you tell the patient? • Do they need a biopsy? • Do you follow these patients? • Treatments?


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



• Management– Oral hygiene– Avoidance of exacerbating factors– Pain control – topicals and coating

agents


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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


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.


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


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Case #2

• 10yo female with recurrent and painful right cheek swelling


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


Case #2

• Next Steps?– Follow and treat conservatively?– Labs? – Image?


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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


Juvenile Recurrent Parotitis (JRP)

• Management options?



• Treatment: – Controversial– Goals: relieve symptoms, prevent parenchymal

damage– Abx: usually first line tx, limited data to support

• JRP associated with bacterial infection???

– Sialogogues– Massage


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• Treatment (cont.): – Ductal ligation– Ductal Steroid irrigations– Sialendoscopy +/- steroid irrigations– Parotidectomy


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.


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?


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


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


Case #3

• Exam:– Fine white plaques of

the superficial mucosa

– Seen bilaterally, fairly symmetric

– Nontender– No other findings on

H+N examination


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Case #3

• Next Steps?


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?


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


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


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



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


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


Case #4

• How would you approach this particular patient? – Biopsy? – Management?


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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


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


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


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Extent of Surgery

Classification of Surgical Techniques: • Extracapsular Dissection• Limited/Partial superficial parotidectomy• Superficial parotidectomy• Total parotidectomy• Radical/Extended parotidectomy


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


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


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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


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


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?


Case #5

• 62yo male presents with complaints of bilateral parotid swelling


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


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Case #5


Bilateral Parotid Enlargement

Bilateral Parotid Enlargement


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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?


Documents

245 - Salivary Gland Panel - Stadler...• Mucoepidermoid Ca (30-40%) • Adenoid Cystic Ca (15-20%) • Ca ex-pleomorphic (10-15%) • Acinic Cell Ca (10%) • Adenocarcinoma NOS