42.Salivary Gland Disorders

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42 Salivary gland disorders JOHN D. LANGDON

Developmental disorders (Table 42.1)

Aplasia/aenesis

!onenital absen"e o# one or more o# t$e ma%or salivar& lands "an o""'r b't is ver&

rare. $en it does it is 's'all& t$e parotid land t$at is a##e"ted.

D'"t atresia

Aain t$is disorder is etremel& rare. *s'all& t$e s'bmandib'lar d'"t in t$e #loor o#

t$e mo't$ #ails to "an'late d'rin embr&oloi"al development. T$e ne+born in#ant

presents +it$in 2 or , da&s o# li#e +it$ s'bmandib'lar s+ellin on t$e a##e"ted side

d'e to a retention "&st in t$e s'bmandib'lar salivar& land.

!onenital #ist'la

-atients +it$ bran"$ial "le#t anomalies present 's'all& +it$ 'nilateral painlesss+ellins in t$e reion o# t$e parotid. arel& t$e& are bilateral. T$e& #orm sin's tra"ts

eit$er in t$e "rease be$ind t$e pinna or in #ront o# t$e tra's. T$e& dis"$are saliva

intermittentl&. Abs"ess #ormation d'e to se"ondar& in#e"tion ma& o""'r. !omplete

s'ri"al e"ision o# t$e sin's tra"t is essential. T$e disse"tion is o#ten ver& etensive

and #'ll disse"tion o# t$e #a"ial nerve ma& be re'ired.

0"topi" and aberrant salivar& tiss'e

0"topi" salivar& tiss'e "an develop an&+$ere +it$in t$e territor& o# t$e #irst and

se"ond bran"$ial ar"$es in t$e lateral ne" p$ar&n or middle ear. 3alivar& tiss'e is

re'larl& #o'nd in l&mp$ nodes +it$in t$e ne" and "an be mistaen #or metastati"

disease +$en #o'nd in a ne" disse"tion spe"imen.

Alt$o'$ rare t$e most "ommonl& re"onised e"topi" salivar& tiss'e is t$e 3ta#nebone "&st. T$is presents as an as&mptomati" "learl& demar"ated radiol'"en"& at t$e

anle o# t$e mandible belo+ t$e in#erior dental "anal. t is #ormed b& an invaination

into t$e bone o# t$e lin'al aspe"t o# t$e mandible b& an e"topi" lobe o# t$e ad%a"ent

s'bmandib'lar salivar& land.

A""essor& lobes

An a""essor& parotid lobe is t$e most "ommon developmental anomal&. t o""'rs in

as man& as 25 per "ent o# s'b%e"ts. ts position is "onstant arisin #rom t$e $ori6ontal

"omponent o# t$e parotid d'"t as it"rosses t$e masseter m's"le. ts importan"e lies in

t$e #a"t t$at an& o# t$e diseases t$at "an a##e"t t$e salivar& lands ma& involve t$e

a""essor& lobe and lead to dianosti" "on#'sion as t$e possibilit& is not "onsidered.

T$is is be"a'se t$e s&mptoms and sins are not +it$in t$e normal anatomi"al territor&o# t$e parotid.

n#lammator& disorders (Table 42.2)

7iral

8'mps

T$e m'mps vir's is a param&ovir's and is t$e most "ommon "a'se o# a"'te pain#'l

parotid s+ellin a##e"tin "$ildren. T$e disease starts +it$ a prodromal period o# 1 or

2 da&s d'rin +$i"$ t$e "$ild eperien"es #everis$ness "$ills na'sea anoreia and

$eada"$e. T$is is t&pi"all& #ollo+ed b& pain and s+ellin o# one or bot$ parotid

lands. T$e parotid pain "an be ver& severe and is ea"erbated b& eatin or drinin.

3&mptoms resolve spontaneo'sl& a#ter 9:15 da&s.

n a "lassi"al "ase o# m'mps t$e dianosis is based on t$e $istor& and "lini"al

eamination. Ho+ever t$e presentation ma& be at&pi"al or sporadi" or $ave


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predominantl& 'nilateral or even s'bmandib'lar involvement. n t$is sit'ation paired

blood spe"imens taen approimatel& 15 da&s apart are 'sed to "on#irm t$e dianosis.

One episode o# in#e"tion "on#ers li#elon imm'nit&.

A n'mber o# ot$er viral aents :!osa"ie A and ; parain#l'en6a 1 and , enteri"

"&topat$oeni" $'man orp$an vir'ses (0!HO) and l&mp$o"&ti" "$oriomeninitis :

"an all "a'se identi"al sins and s&mptoms.;a"terial

A"'te as"endin ba"terial sialadenitis a##e"ts mostl& t$e parotid lands. Histori"all& it

+as des"ribed in de$&drated "a"$e"ti" patients o#ten #ollo+in ma%or abdominal

s'rer& +$en t$e patient +as on a i. 42.1).

T$e "lini"al presentation is o# t$e onset o# tender red pain#'l parotid s+ellin over a

#e+ $o'rs. T$ere is asso"iated malaise p&reia and o#ten reional l&mp$adenopat$&.-ain is ea"erbated on attemptin to eat or drin. T$e parotid s+ellin ma& be di##'se

b't o#ten itis lo"alised to t$e lo+er pole o# t$e land pres'mabl& be"a'se t$e in#e"tion

tends to lo"alise 'nder t$e e##e"t o# ravit&.

# t$e land is entl&


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bet+een , and &ears alt$o'$ it $as been reported in in#ants as &o'n as 4 mont$s.

T$e dianosis is based on t$e "$ara"teristi" $istor& and is "on#irmed b& sialorap$&

+$i"$ s$o+s a ver& "$ara"teristi" p'n"tate siale"tasis o#ten liened to a sno+ storm

aainst a dar ni$t s& (>i. 42.,).

Traditionall& t$e episodes o# parotitis $ave been treated +it$ antibioti" and s&mptoms

settle +it$in ,:9 da&s on s'"$ a reime. O""asionall& re"'rrent episodes are so#re'ent t$at prop$&la"ti" antibioti"s are re'ired #or a period o# mont$s or &ears.

3pontaneo's resol'tion o# s&mptoms seems to o""'r at p'bert&.

3pe"i#i" eldman d&e test on t$e ser'm. T$e disease #ollo+s a

sel#?limitin "o'rse and resolves spontaneo'sl& a#ter +ees or mont$s. # s&mptoms

are severe t$e patient is treated +it$ a ,? or 4?+ee "o'rse o# p&rimet$amine and

s'lp$adia6ine.

Deep m&"oses>'nal in#e"tions o# t$e salivar& lands o""'r onl& in imm'no"ompromised patients

and are most "ommonl& seen in $'man imm'node#i"ien"& vir's (H7)?positive

patients. 3alivar& landinvolvement is 's'all& %'st one mani#estation o# a more

eneralised in#e"tion. T$e patient presents +it$ a t'mo'r?lie s+ellin o# t$e a##e"ted

land. O#ten t$ere is etensive "entral ne"rosis. >res$ material is needed #or "'lt're

and identi#i"ation o# t$e oranism. Treatment is b& appropriate s&stemi" anti#'nal

"$emot$erap&.

3ar"oid

3ar"oidosis $as a predeli"tion #or salivar& tiss'e $'t onl& rarel& is salivar& s+ellin

t$e presentin #eat're. -arotid land involvement o""'rs in 15 per "ent o# "ases

"lassi"all& as part o# Heer#ordt=s s&ndrome +$i"$ "omprises parotid s+ellin anterior'veitis #a"ial pals& and #ever. Cerostomia ma& be a prominent #eat're. A less 's'al


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presentation is +it$ bilateral parotid and s'bmandib'lar s+ellin +$i"$ is one o# t$e

"a'ses o# 8i'li"6= s&ndrome. n ea"$ o# t$ese presentations salivar& involvement is

+idespread and representative $istolo& "an be obtained #rom a minor salivar& land

biops&. arel& t$e patient +ill present +it$ a lo"alised t'mo'r?lie s+ellin in one

parotid land : t$e so?"alled sar"oid pse'dot'mo'r. n t$e absen"e o# ot$er sins or

s&mptoms t$e dianosis is onl& liel& to be made #ollo+in parotid s'rer& #or apres'med neoplasm.

eener=s ran'lomatosis

Alt$o'$ t$e t&pi"al presentation is "$roni" ran'lomato's 'l"eration and destr'"tion

in t$e nasop$ar&n or sometimes t$e oral "avit& eener=s ran'lomatosis "an

involve t$e ma%or salivar& lands. Dianosis is based on t$e $istoloi"al #indin o#

ne"rotisin arteritis o#ten asso"iated +it$ n'mero's iant "ells and ran'lomas.

-'lmonar& and renal involvement is ver& "ommon. Treatment is b& "&totoi"

"$emot$erap& s'"$ as "&"lop$osp$amide or a6at$ioprine. T$e pronosis is poor.

Gran'lomato's disease o# minor salivar& lands

Gran'lomato's "$eilitis 8elersson:osent$al s&ndrome (re"'rrent #a"ial

pals&/#a"ial s+ellin/#iss'red ton'e) and !ro$n=s disease all a##e"t t$e minor salivar&lands o# t$e lips. !$eilitis land'laris is a rare disorder mainl& o# ad'lt males in

+$om t$e lo+er lip be"omes s+ollen and $ard. T$e labial salivar& lands be"ome

nod'lar and t$eir ori#i"es are in#lamed and s+ollen.

Alleri" sialadenitis

A variet& o# potential allerens "a'sin a"'te parotid s+ellin $as been identi#ied.

3ome #oods dr's (most #re'entl& "$loramp$eni"ol and tetra"&"line) metals s'"$ as

ni"el and pollens $ave been in"riminated.

adiation sialadenitis

>ollo+in t$e start o# t$erape'ti" irradiation +$en t$e parotid lands are +it$in t$e

radiation #ield t$e patient develops an a"'te parotitis 's'all& a#ter 24 $o'rs. T$e

lands are s+ollen and tender and t$ere is a mared rise in salivar& am&lase and t$e

salivar& #lo+ rate is red'"ed. T$e rea"tion is sel#?limitin and resolves a#ter 2 or ,

da&s even t$o'$ t$e radiot$erap& "ontin'es. T$is rea"tion is 'ite distin"t #rom t$e

permanent radiation atrop$& t$at o""'rs +it$ t$erape'ti" doses above 95 G& +$i"$

develops proressivel& some +ees a#ter t$e radiation $as been "ompleted.

H'man imm'node#i"ien"& vir's?asso"iated sialadenitis

!$roni" parotitis in "$ildren is almost pat$onomoni" o# H7 in#e"tion. n ad'lts a

si""a s&ndrome and l&mp$o"&ti" in#iltration o# t$e salivar& lands are more 's'al.

T$e presentation o# H7?asso"iated sialadenitis is ver& similar to "lassi"al 3%oren=s

s&ndrome. Dr& mo't$ dr& e&es and s+ellin o# t$e salivar& lands toet$er +it$

l&mp$adenopat$& s'est t$e dianosis. Histoloi"all& t$e "ondition "losel&resembles 3%oren=s s&ndrome and di##erentiation ma& be di##i"'lt. Ho+ever

a'toantibodies in"l'din antin'"lear r$e'matoid #a"tor 33?A and 33?; are absent

'nless t$e patient "oin"identall& $as a "onne"tive tiss'e disorder. A"'ired

imm'node#i"ien"& s&ndrome (AD3)?asso"iated l&mp$oma presentin as salivar&

land s+ellin $as also been des"ribed.

Anot$er presentation o# salivar& land disease in H7?positive patients is m'ltiple

parotid "&sts "a'sin ross parotid s+ellin and sini#i"ant #a"ial dis#i'rement. On

imain +it$ "omp'terised tomorap$& (!T) or maneti" resonan"e imain (8)

t$e parotids $ave t$e appearan"e o# 3+iss "$eese +it$ m'ltiple lare "&sti" lesions.

T$e lands are not pain#'l and t$ere is no red'"tion in salivar& #lo+ rates. 3'rer&

ma& be indi"ated to improve t$e appearan"e (>i. 42.4).3ialadenitis o# minor salivar& lands


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A"'te ne"rotisin sialometaplasia is an 'n's'al "ondition +$i"$ +as #irst des"ribed in

1@,. t o""'rs onl& on t$e $ard palate in t$e molar reion in t$e va'lt o# t$e palate

mid+a& bet+een t$e midline and t$e inival marin. t is onl& seen in $eav&

smoers. t $as a "$ara"teristi" appearan"e +$i"$ resembles a "ar"inoma +it$ "entral

'l"eration and raised er&t$emato's marins. T$e 'l"er ma& be as m'"$ as , "m in

diameter. As itso "losel& resembles a "ar"inoma t$e dianosis is o#ten made on t$ebasis o# a s'ri"al biops&. T$e lesions are sel#?$ealin b't o#ten tae 15:12 +ees to

resolve (>i. 42.9).

Obstr'"tion and tra'ma (Table 42.4)

-apillar& obstr'"tion

O""asionall& a ro'$ 'pper molar toot$ or an overetended dent're #lane +ill irritate

t$e parotid papilla. # t$is is s'##i"ient to "a'se 'l"eration +it$ "onse'ent

in#lammation and oedema t$is ma& obstr'"t salivar& #lo+ parti"'larl& at meal times

+$en t$e #lo+ rate is in"reased. n t$is sit'ation t$e patient $as "lassi"al rapid onset

pain and s+ellin at meal times.

# t$e tra'ma to t$e parotid papilla "ontin'es t$ere +ill be proressive s"arrin and#ibrosis in t$e so#t tiss'es and permanent stenosis o# t$e papilla "an o""'r. A

papillotom& +ill be re'ired. T$is is a simple pro"ed're per#ormed 'nder lo"al

anaest$esia. A probe is inserted into t$e ori#i"e o# t$e papilla and +it$ a s"alpel blade

t$e papilla is split open b& in"isin do+n on to t$e probe. T$is la&s open t$e papilla

and divides t$e stenosis allo+in #ree drainae o# saliva.

3tone #ormation (sialolit$iasis)

0i$t& per "ent o# all salivar& stones o""'r in t$e s'bmandib'lar land 15 per "ent

o""'r in t$e parotid @ per "ent in t$e s'blin'al land and t$e remainder o""'rs in t$e

minor salivar& lands. t is believed t$at t$e ma%orit& o# stones o""'rs in t$e

s'bmandib'lar lands be"a'se t$eir se"retions "ontain m'"'s and t$e vis"osit& is

$i$er. 0i$t& per "ent o# s'bmandib'lar stones are radio?opa'e and "an be

identi#ied 'sin plane radiorap$s. ;& "ontrast t$e ma%orit& o# parotid stones are

radiol'"ent and "annot be dete"ted on plane radiorap$& (>i. 42.).

T$e "lassi"al presentation is o# a"'te pain and s+ellin at meal times. Onset is rapid

: +it$in a min'te o# startin t$e meal : and t$e s+ellin resolves over a period o#

abo't 1 $o'r a#ter t$e meal is "ompleted.

Ho+ever t$is "lassi"al pi"t're onl& o""'rs +$en t$e stone "a'ses almost "omplete

obstr'"tion o#ten +$en it is impa"ted at t$e openin o# $arton=s d'"t. 8ore o#ten

t$e stone "a'ses onl& partial obstr'"tion and is l&in eit$er +it$in t$e $il'm o# t$e

land or +it$in t$e d'"t in t$e #loor o# t$e mo't$. n t$is sit'ation t$e patient ma&

"omplain o# o""asional s+ellin o#ten +it$ minimal dis"om#ort or o# a "$roni"all&enlared mass in t$e s'bmandib'lar trianle +it$ episodes o# d'll a"$in pain. T$is

res'lts #rom "$roni" ba"terial in#e"tionarisin in an obstr'"ted land +it$ salivar&

stasis and poor empt&in. O#ten a salivar& stone is totall& as&mptomati" and is

dis"overed "oin"identall& d'rin radiorap$& #or ot$er reasons. # a stone is identi#ied

on plane radiorap$s no ot$er investiation is ne"essar&. -arotid stones o#ten impa"t

at t$e parotid papilla or alternativel& tae on a i. 42.@). # t$e

stone is trapped at t$e d'"t papilla it "an o#ten be released b& entl& probin and

"arr&in o't dilatation o# t$e papilla. t ma& $e ne"essar& to slit t$e d'"t in order to

release t$e stone.

# t$e stone is l&in in t$e s'bmandib'lar d'"t in t$e #loor o# t$e mo't$ anterior to t$epoint at +$i"$ t$e d'"t "rosses t$e lin'al nerve (se"ond molar reion) t$e stone "an


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be released b& openin t$e d'"t lonit'dinall& (>i. 42.E). t is important to pass a

lare s't're aro'nd t$e d'"t proimal to t$e stone so t$at d'rin t$e operative

pro"ed're t$e stone "annot be displa"ed ba"+ards in t$e d'"t. On"e t$e stone $as

been released t$e +all o# t$e d'"t s$o'ld be s't'red to t$e m'"osa o# t$e #loor o# t$e

mo't$ to maintain an openin #or t$e #ree drainae o# saliva. No attempt s$o'ld be

made to repair t$e d'"t +all as t$is +ill lead to stri"t're #ormation. A parotid stonelo"ated at t$e "on#l'en"e o# t$e "olle"tin d'"ts "an be released s'ri"all& b& raisin a

prea'ri"'lar #lap eposin t$e parotid d'"t and aain in"isin it lonit'dinall& to

release t$e stone.

Obstr'"tion in and aro'nd t$e d'"t +all

3"arrin and #ibrosis in t$e d'"t +all stri"t're #ormation +ill also res'lt in obstr'"tion

to salivar& #lo+. t o#ten res'lts as a "ompli"ation o# lon?standin sialolit$iasis $'t it

ma& o""'r as a res'lt o# tra'ma parti"'larl& to t$e #loor o# t$e mo't$. 3'bse'ent

$ealin and s"arrin "an res'lt in a stenosis o# t$e d'"t. n patients +it$ masseteri"

$&pertrop$& t$e parotid d'"t ma& be stret"$ed aro'nd t$e anterior border o# t$e

m's"le and t$is ma& "a'se obstr'"tion o# salivar& #lo+ at meal times.

8'"o"eles8'"'s retention "&sts and m'"'s etravasation "&sts arise in t$e minor salivar&

lands as a res'lt o# me"$ani"al damae to t$e land or its d'"t. T$e "ommon sites

are on t$e m'"osal aspe"t o# t$e lo+er lip parti"'larl& in patients +it$ a deep overbite

and in t$e b'""al m'"osa posteriorl& +$ere an 'pper +isdom toot$ is er'ptin

b'""all&. T&pi"all& t$e patient presents +it$ a $istor& o# re"'rrent s+ellins t$at

develop over da&s or +ees r'pt're and t$en re"'r a#ter a #e+ +ees. T$e "&sts

rarel& e"eed 1 "m in diameter and are tense bl'is$ sessile s+ellins. T$e treatment is

not to t$e "&st itsel# b't to t$e 'nderl&in minor land +$i"$ s$o'ld be e"ised 'nder

lo"al anaest$esia.

A ran'la is no more t$an a lare m'"o"ele arisin #rom t$e s'blin'al land.

!lassi"all& t$e ran'la presents as a lare tense bl'is$ s+ellin in t$e #loor o# t$e

mo't$ anteriorl& o#ten displa"in t$e ton'e (>i. 42.). Ho+ever t$e ran'la ma&

p's$ its +a& t$o'$ t$e midline m&lo$&oid de$is"en"e in t$e #loor o# t$e mo't$ and

enter t$e s'bmental spa"e presentin as a midline s+ellin in t$e 'pper ne". T$is is

t$e


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malinant. n addition t$e& s$o+ t$e relations$ip o# t$e t'mo'r to ot$er anatomi"

str'"t'res and $elp +it$ t$e plannin o# s'bse'ent s'rer&.

Open s'ri"al biops& o# intrinsi" neoplasms o# t$e ma%or lands is absol'tel&

"ontraindi"ated. At least @9 per "ent o# all parotid t'mo'rs and more t$an 95 per "ent

o# all s'bmandib'lar land t'mo'rs +ill prove to be benin pleomorp$i" adenomas.

T$is t'mo'r +$i"$ is onl& poorl& en"aps'lated is ver& tense and i# an in"ision is madeinto it t$e "ontents o# t$e t'mo'r b'rst into t$e s'rro'ndin tiss'e planes and it is

impossible to eradi"ate t$e mi"ros"opi" spillae o# t'mo'r "ells. # t$is $appens t$e

patient +ill develop m'ltiple lo"al t'mo'r re"'rren"es over man& &ears 'nless t$e&

are s'b%e"ted to radi"al postoperative radiot$erap& +$i"$ is best avoided in t$e

manaement o# benin disease. !learl& i# t$ere is sin in#iltration or 'l"eration an

open biops& is essential to establis$ a preoperative dianosis 'pon +$i"$ to plan

s'rer&. >or t'mo'rs o# t$e minor salivar& lands parti"'larl& in t$e palate t$ere is a

m'"$ $i$er "$an"e o# t$e t'mo'r bein malinant and as it is not ne"essar& to open

'p ot$er tiss'e planes to ain a""ess to t$e t'mo'r as open in"isional biops& is

important.

>ine needle aspiration (>NA) biops& is a sa#e alternative to open biops& o# a ma%orland. 0viden"e s'ests t$at provided t$e needle a'e does not e"eed 1E G t$ere

is no ris o# seedin viable t'mo'r "ells. Alt$o'$ advo"ates o# t$is te"$ni'e "laim

$i$ a""'ra"& and spe"i#i"it& t$ere is inevitabl& a $i$ ris o# samplin error.

0pit$elial t'mo'rs

3event&?#ive per "ent o# all salivar& epit$elial t'mo'rs arise in t$e parotid lands and

o# t$ese onl& 19 per "ent are malinant. J'st over 15 per "ent o""'r in t$e

s'bmandib'lar lands and o# t$ese approimatel& one?t$ird are malinant. Abo't 19

per "ent o# t'mo'rs o""'r in t$e minor salivar& lands and nearl& $al# o# t$ese +ill be

malinant. T'mo'rs arisin in t$e s'blin'al lands are rare (5., per "ent) b't nearl&

all o# t$em +ill be malinant. ;ot$ benin t'mo'rs : adenomas : and malinant

t'mo'rs

: "ar"inomas : o""'r.

Adenomas

O# t$e variet& o# benin adenomas t$at $as been des"ribed onl& t+o : t$e

pleomorp$i" adenoma and art$in=s t'mo'r:arise +it$ an& #re'en"&.

T$e pleomorp$i" adenoma o""'rs at an& ae (mean 42 &ears) and $as an e'al se

in"iden"e. t a""o'nts #or at least @9 per "ent o# parotid t'mo'rs and more t$an 95 per

"ent o# s'bmandib'lar t'mo'rs. t a""o'nts #or rat$er less t$an 95 per "ent o# minorland t'mo'rs. !lini"all& t$e t'mo'r $as t$e tet're o# "artilae and $as an irre'lar

and bosselated s'r#a"e. n t$e palate t$e overl&in m'"osa is rarel& 'l"erated. 7er&

rarel& a#ter a n'mber o# &ears t$e t'mo'r ma& 'ndero malinant "$ane and #or t$is

reason all patients presentin +it$ pleomorp$i" adenomas s$o'ld be advised to

'ndero s'ri"al removal o# t$e t'mo'r (>i. 42.12).

T$e art$in=s t'mo'r o""'rs onl& in t$e parotid land +$ere it a""o'nts #or

approimatel& 19 per "ent o# all neoplasms. t is a disease o# t$e elderl& +it$ a mean

ae o# presentation o# 5 &ears. Histori"all& it $ad a maleF#emale ratio o# 4F1 b't it is

no+ be"omin in"reasinl& "ommon in #emales. e"ent eviden"e s'ests t$at t$is

t'mo'r is related to "iarette smoin. t is also 'n's'al in t$at in

15 per "ent o# "ases it arises eit$er bilaterall& or is m'lti"entri" in t$e one land. tdoes not 'ndero malinant "$ane.


8/17

!ar"inomas

T$e a"ini" "ell "ar"inoma and t$e m'"oepidermoid "ar"inoma alt$o'$ 'ndo'btedl&

malinant t'mo'rs +it$ a potential #or lo"al invasion and metastati" spread are

#re'entl& ver& lo+ rade $istoloi"all& and do not re'ire t$e radi"al treatmentneeded #or more aressive t'mo'rs. Toet$er t$e& a""o'nt #or onl& 9 per "ent o# all

t'mo'rs at an& sire. T$e m'"oepidermoid t'mo'r is m'"$ more "ommon in t$e *3A

+$ere it #orms 15 per "ent o# all salivar& neoplasms.

T$e adenoid "&sti" "ar"inoma adeno"ar"inoma s'amo's "ell "ar"inoma and

'ndi##erentiated "ar"inoma are all aressive malinant t'mo'rs t$at "arr& a poor

pronosis reardless o# treatment. T$e adenoid "&sti" "ar"inoma is "$ara"terised b&

relentless perine'ral spread alon t$e "ranial nerves and into t$e brain. Ho+ever it

ro+s etremel& slo+l& and alt$o'$ inevitabl& #atal t$e 9? and 15?&ear s'rvival

#i'res are @5 per "ent and 45 per "ent respe"tivel&. t is also 'n's'al in $avin a

predile"tion #or distant metastasis to t$e l'ns +$ere it prod'"es o#ten m'ltiple

"annon ball t'mo'rs +$i"$ remain s&mptomless #or man& &ears. T$e ot$er"ar"inomas mentioned above $ave 9?&ear s'rvival #i'res o# aro'nd 29:,9 per "ent.

8anaement o# epit$elial t'mo'rs

;ot$ benin and malinant t'mo'rs arisin in t$e parotid or s'bmandib'lar lands are

treated s'ri"all& b& e"ision +it$ s'ri"al "learan"e. n t$e parotid land t$is is b&

eit$er s'per#i"ial or total parotide"tom& a""ordin to t$e lo"ation o# t$e t'mo'r.

*nless t$e patient presents +it$ #a"ial nerve pals& (indi"atin a malinant t'mo'r) t$e

#a"ial nerve is al+a&s preserved. n t$e s'bmandib'lar land treatment is al+a&s b&

e"ision o# t$e land. # +$en a de#initive pat$oloi"al dianosis is re"eived t$e

t'mo'r is malinant t$en t$e patient s$o'ld re"eive radi"al postoperative

radiot$erap&. n t$ose "ases +$en t$e t'mo'r involves sin or ot$er ad%a"ent

str'"t'res or +$ere t$ere is l&mp$ati" metastasis t$e patient s$o'ld 'ndero radi"al

e"ision in"l'din a ne" disse"tion and sa"ri#i"in an& str'"t'res invaded b&

t'mo'r and aain treated +it$ postoperative radiot$erap&.

-leomorp$i" adenomas arisin in t$e minor salivar& lands "an be treated b& lo"al

e"ision +it$ a 9?mm marin. T$e& do not invade perioste'm and so in t$e palate

t$e& s$o'ld be e"ised s'bperiosteall&. 8'"oepidermoid "ar"inomas and a"ini" "ell

"ar"inomas re'ire rat$er more radi"al e"ision +it$ a 15?mm marin and +$en t$e&

are sit'ated in t$e palate palatal #enestration s$o'ld be 'ndertaen. -ostoperative

radiot$erap& is onl& indi"ated #or $i$?rade t'mo'rs or i# t$e marins are not "lear.>or t$e remainin "ar"inomas arisin in t$e minor salivar& lands radi"al s'ri"al

e"ision and postoperative radiot$erap& are indi"ated. n t$e palate t$is +ill be b&

maille"tom&.

Nonepit$elial t'mo'rs

A variet& o# nonepit$elial t'mo'rs "an arise in t$e salivar& lands. Haemaniomas

and l&mp$aniomas ("&sti" $&romas) o""'r in "$ild$ood. Haemaniomas o""'r

mostl& in t$e parotid and appear s$ortl& a#ter birt$ and ro+ proressivel& #or several

mont$s. T$e ma%orit& 'nderoes spontaneo's reression b& 2 &ears o# ae. >emales

are more #re'entl& a##e"ted. L&mp$aniomas are less "ommon. T$e& ma& a##e"t an&

o# t$e salivar& lands. T$e& #orm spone?lie m'lti"&sti" lesions. >i#t& per "ent aremani#est b& 12 mont$s and 5 per "ent +ill be evident b& t$e end o# t$e se"ond &ear.


9/17

T$e& do not 'ndero spontaneo's invol'tion. T$e& #re'entl& etend into t$e ne"

and mediastin'm and "an 'ndero dramati"all& rapid ro+t$ "a'sin respirator&

obstr'"tion. Treatment is b& "omplete s'ri"al e"ision b't t$is ma& be te"$ni"all&

ver& di##i"'lt.

Ne'ro#ibromas and ne'rilemmomas are t$e "ommonest nonepit$elial t'mo'rs arisin

in ad'lts. !lini"all& t$e& arenor distin'is$able #rom ot$er salivar& t'mo'rs and are onl& dianosed #ollo+in

s'rer& #or a pres'med epit$elial t'mo'r. Lipomas o""'r in t$e parotids parti"'larl&

in ad'lt males. T$e& are treated b& s'ri"al e"ision.

Malignant lymphomas

Tr'e etranodal l&rnp$oma arisin in t$e salivar& lands :'s'all& t$e parotids : is

rare. 8ore "ommon is l&mp$oma arisin #rom t$e l&mp$ nodes eit$er on t$e s'r#a"e

o# t$e lands or +it$in t$e paren"$&ma o# t$e land. L&mp$oma also arises in t$e

salivar& lands as a "ompli"ation o# H7 disease and also in benin l&mp$oepit$elial

lesion and 3%oren=s s&ndrome. T$e pea in"iden"e #or nonHodin=s l&mp$oma is

t$e sit$ and sevent$ de"ades and #emales are t+i"e as liel& as males to be a##e"ted.3alivar& land l&mp$omas 's'all& present as #irm painless s+ellins and more t$an

5 per "ent o""'r in t$e parotids. # t$e l&mp$oma is "on#ined to t$e parotid treatment

is b& parotide"tom& +it$ postoperative radiot$erap&. # t$ere is eviden"e o# spread

be&ond t$e salivar& land treatment is b& pol&"$emot$erap& a""ordin to t$e

a""epted proto"ols based on $istoloi"al "$ara"terisation.

Unclassified and allied conditions

3ialosis is an 'n"ommon nonin#lammator& "a'se o# salivar& s+ellin 's'all&

a##e"tin t$e parotid lands s&mmetri"all&. t is 's'all& asso"iated +it$ metaboli" and

endo"rine "onditions s'"$ as al"o$ol ab'se diabetes mellit's prenan"& maln'trition

and some dr's ('s'all& s&mpat$omimeti"s). t 's'all& a##e"ts middle aed and

elderl& ad'lts +$o present +it$ bilateral so#t parotid s+ellins. ;iops& o# t$e lands

reveals etensive #att& repla"ement b't ot$er+ise normal tiss'es. No treatment is

no+n to be e##e"tive b't sometimes parotide"tom& is re'ired to "orre"t t$e

dis#i'rement.

Ne"rotisin sialometaplasia benin l&mp$oepit$elial lesion salivar& d'"t "&sts

B'ttner t'mo'r and "&sti" l&mp$oid $&perplasia o# H7 disease "an all mimi"

salivar& land neoplasia. 3imilarl& bran"$ial "&sts and dermoids "an present

dianosti" "on#'sion on o""asion. As $as alread& been dis"'ssed bot$ sar"oid and

tooplasmosis "an present as parotid pse'dot'mo'rs.

Degenerative conditions(Table 42.)

Sjogrens syndrome

3%oren=s s&ndrome is an a'toimm'ne "ondition "a'sin proressive destr'"tion o#

t$e salivar& and la"$r&mal lands. n 1,, 3%oren #irst des"ribed t$e asso"iation o#

erato"on%'n"tivitis si""a (dr& e&es) and Cerostomia (dr& mo't$). 3$ortl& t$erea#ter

$e noted t$at t$ese s&mptoms #re'entl& o""'rred in patients +it$ r$e'matoid art$ritis

(A). t $as sin"e been realised t$at 3%oren=s s&ndrome "an o""'r in asso"iation +it$

an& "onne"tive tiss'e disorder. ndeed t$e asso"iation is ver& m'"$ "ommoner in

man& "onne"tive tiss'e disorders t$an it is +it$ r$e'matoid art$ritis. Onl& 19 per "ent

o# patients +it$ A develop 3%oren=s s&ndrome +$ereas ,5 per "ent o# patients +it$s&stemi" l'p's er&t$ematos's and nearl& all patients +it$ primar& biliar& "irr$osis do


10/17

so. T$is "ombination o# dr& e&es dr& mo't$ and a "onne"tive tiss'e disorder : most

o#ten A as t$is is b& #ar t$e most #re'ent "onne"tive tiss'e disorder : is "alled

se"ondar& 3%oren=s s&ndrome. T$e same "ombination o# dr& e&es and dr& mo't$ b't

+it$o't asso"iation +it$ a "onne"tive tiss'e disorder is no+n as -rimar& 3%oren=s

s&ndrome. -rimar& 3%oren=s s&ndrome also di##ers #rom se"ondar& 3%oren=s

s&ndrome b& virt'e o# more severe erostomia and erop$t$almia more +idespreadd&s#'n"tion o# ot$er eo"rine lands a $i$er in"iden"e o# developin l&mp$oma and

a di##erent antibod& pro#ile.

>emales are a##e"ted more o#ten t$an males in t$e ratio o# 15F1. T&pi"all& t$e& are

middle aed. T$e presentin "omplaint is 's'all& o# t$e 'nderl&in "onne"tive tiss'e

disorder and onl& later does t$e patient be"ome a+are o# a ritt& #eelin in t$e e&es

d'e to dr& e&es or o# dr& mo't$. O""asionall& t$ere is enlarement o# t$e parotid

lands bilaterall& and even more rarel& t$e enlared parotids are pain#'l (>i. 42.1,).

3'perin#e"tion o# t$e mo't$ +it$ !andida albi"ans is #re'ent. Less #re'entl& t$e

patient develops ba"terial sialadenitis d'e to as"endin in#e"tion #rom t$e mo't$. T$e

"ondition does not invariabl& proress to total erostomia and #or an& individ'al

patient it is nor possible to predi"t t$e o't"ome. T$e "$ara"teristi" #eat'res o# t$e"ondition are proressive l&mp$o"&ti" in#iltration a"inar destr'"tion and proli#eration

o# d'"t epit$eli'm o# all salivar& and la"$r&mal tiss'e.

T$e dianosis is o#ten based on t$e "$ara"teristi" $istor&. No laborator& investiation

is pat$onomoni" o# eit$er primar& or se"ondar& 3%oren=s s&ndrome. Ho+ever t$e

#ollo+in investiations are 's'all& 'ndertaenF

1. 3ialorap$& reveals t$e proressive damae #rom p'n"tate siale"tasis to total

paren"$&mal destr'"tion leavin no more t$an a rossl& dilated d'"t (>i. 42.14).

2. Labial salivar& land biops& "an be misleadin parti"'larl& i# onl& one minor land

is $arvested. T$e "$ara"teristi" l&mp$o"&ti" in#iltration is #o"al and a sinle land

ma& not s$o+ t$e "$anes. A minim'm o# t$ree lands s$o'ld be s'bmitted to t$e

pat$oloist.

,. 0stimation o# salivar& #lo+ ma& be 'n$elp#'l as t$e normal variation in #lo+ rates

maes t$e interpretation o# t$e res'lts di##i"'lt.

4. 7iral stainin o# t$e "ornea +it$ rose ;enal and eamination o# t$e "ornea +it$ a

slit?lamp is a ver& sensitive assessment o# a dr& e&e.

9. A'toantibod& s"reen. 3ee Table 42.@.

. ;lood tests 's'all& s$o+ a moderatel& raised er&t$ro"&te sedimentation rate (03)

and a mild mi"ro"&ti" anaemia (t$e anaemia o# "$roni" disease).

T$e manaement o# 3%oren=s s&ndrome m'st be s&mptomati". No no+n treatment

modi#ies or reverses t$e erostomia and erato"on%'n"tivitis si""a. Arti#i"ial tears are

essential to prote"t t$e "ornea. >or t$e dr& mo't$ vario's arti#i"ial saliva preparationsare available b't o#ten t$e patient pre#ers to 'se #re'ent drins and learns to "arr& a

bottle o# +ater +it$ t$em at all times. # patients are to 'se saliva s'bstit'tes it is

important t$at i# t$e& are dentate t$e prod'"t s$o'ld not $ave a lo+ pH and s$o'ld

"ontain #l'oride as rampant dental "aries are a #re'ent "ompli"ation. T$ere is also

in"reased in"iden"e o# developin l&mp$oma in patients +it$ 3%oren=s s&ndrome.

T$e ris is $i$est in t$ose +it$ primar& 3%oren=s s&ndrome. 8ono"&toid ;?"ell

l&mp$oma is t$e 's'al "ompli"ation. ts onset is o#ten $eralded b& imm'noloi"al

"$anes (#allin imm'nolob'lin levels #allin titre o# r$e'matoid #a"tor risin ;2?

mi"rolob'lin titre risin ser'm ma"rolob'lin titre and t$e appearan"e o#

mono"lonal li$t "$ains in t$e ser'm and 'rine) l&mp$adenopat$& and +ei$t loss.

Benign lymphoepithelial lesion


11/17

T$e term i. 42.19).

Xerostomia

A "omplaint o# dr& mo't$ is "ommon. t seems to be parti"'larl& #re'ent in

postmenopa'sal +omen +$o also "omplain o# a b'rnin ton'e or mo't$. Normal

salivar& #lo+ de"reases +it$ ae in bot$ men and +omen. T$e sit'ation is #'rt$er

"on#'sed as patients +it$ 3%oren=s s&ndrome are #re'entl& 'na+are o# $avin a dr&

mo't$ and patients +$o "omplain o# dr& mo't$ #re'entl& $ave normal salivar& #lo+

rates. T$e most "ommon "a'ses o# erostomia in order o# #re'en"& areF

"$roni" aniet& states and depressionI

de$&drationI

dr's : man& dr's $ave been impli"ated in "a'sin erostomia as an 'ndesirable

side e##e"t (Table 42.E)I

salivar& land diseases as des"ribed earlier.

Cerostomia "an be di##i"'lt to treat. Treatment is aimed at t$e relie# o# s&mptoms and

t$e avoidan"e or "ontrol o# "ompli"ations. >re'ent sips o# +ater $elp most patients.

Arti#i"ial salvias are nor +ell a""epted b't t$eir l'bri"ant properties ma& be

parti"'larl& 'se#'l at meal times. !$olineri" dr's s'"$ as pilo"arpine "an be triedb't t$eir side e##e"ts : diarr$oea and p'pillar& dilatation o#ten o't+ei$ an& bene#it.

ampant "aries and destr'"tive periodontal disease are ma%or "ompli"ations d'e to

oral in#e"tion. 8eti"'lo's oral $&iene and t$e +eel& 'se o# topi"al #l'oride are

essential. T$ere is a $i$ in"iden"e o# oral "andidiasis and anti#'nal dr's are

ne"essar&.

Sialorrhoea(Table 42.)

3ome dr's and pain#'l lesions in t$e mo't$ in"rease salivar& #lo+ rates. n normal

$ealt$ t$is is rarel& noti"ed as t$e e"ess saliva is s+allo+ed spontaneo'sl&. alse

pt&lism= is more "ommon and is a +ell?re"onised del'sional s&mptom or o""'rs d'e

to #a'lt& ne'rom's"'lar "ontrol leadin to droolin despite normal saliva prod'"tion.

*n"ontrollable droolin is 's'all& treated s'ri"all&. As t$e s'bmandib'lar land"ontrib'tes most restin saliva attention is dire"ted at t$ese lands bilaterall&. T$e


12/17

s'bmandib'lar d'"ts "an be mobilised and repositioned in t$e base o# t$e anterior

pillars o# t$e #a'"es. Alternativel& t$e t+o lands ma& be e"ised.

Surgery of salivary gland disease

T$e most "ommon indi"ation #or removal o# t$e s'blin'al salivar& land is in t$e

manaement o# a ran'la +$i"$ is a m'"o's etravasation/retention "&st o# t$e land.Neoplasms o# t$e s'blin'al land o""'r onl& rarel& b't nearl& all t'mo'rs at t$is site

+ill be malinant. n t$is sit'ation s'rer& is t$e same as t$at #or an& ot$er

malinan"& in t$e #loor o# t$e mo't$ : rese"tion +it$ a "lear marin o#ten involvin

t$e mandible and +$en ne"essar& en blo" +it$ a ne" disse"tion. ;e#ore an in"ision is

made it is $elp#'l to in#iltrate t$e #loor o# t$e mo't$ +it$ a lo"al anaest$eti"

"ontainin a vaso"onstri"tor. >or simple e"ision o# t$e s'blin'al land a linear

in"ision is made in t$e #loor o# t$e mo't$ parallel to and %'st lateral to t$e

s'bmandib'lar d'"t +it$ "are taen not to etend t$e in"ision more posteriorl& t$an

t$e #irst molar toot$ so as to avoid damae to t$e lin'al nerve (>i. 42.1). T$e

in"ision s$o'ld open t$e "avit& o# t$e ran'la and allo+ t$e m'"ino's "ontents to $e

aspirated. T$e s'bmandib'lar d'"t is no+ "are#'ll& identi#ied and retra"ted mediall&.3ta& s't'res passed t$ro'$ t$e marins o# t$e m'"osa are $elp#'l to aid retra"tion.

*sin bl'nt disse"tion +it$ s"issors t$e lin'al nerve is identi#ied. T$e s'blin'al

land +$i"$ lies ad%a"ent to t$e inner "orte o# t$e mandible is t$en mobilised and its

m'ltiple d'"ts +$i"$ drain into t$e s'bmandib'lar d'"t are divided "are#'ll& in order

nor to damae t$e d'"t itsel#. T$e anterolateral part o# t$e s'blin'al land ma& be

atta"$ed to t$e perioste'm o# t$e mandible b& #ibro's tiss'e and t$is m'st be divided

"are#'ll&. >ollo+in removal o# t$e land t$e m'"osa o# t$e #loor o# t$e mo't$ is

loosel& "losed +it$ t+o or t$ree plain 't s't'res. $en s'blin'al land e"ision is

ne"essar& #or a t'mo'r it s$o'ld be removed +it$ a +ide marin in"l'din a rim

rese"tion o# t$e mandible (>i. 42.1@).

!ompli"ations

Damae to t$e lin'al nerve posteriorl& or t$e s'bmandib'lar d'"t mediall& is

avoided b& "are#'l s'ri"al te"$ni'e. 8eti"'lo's $aemostasis is re'ired to avoid a

postoperative $aematoma in t$e #loor o# t$e mo't$.

Submandibular gland excision

T$e patient is positioned s'pine on t$e operatin table +it$ moderate ne" etension

and t$e "$in rotated to t$e opposite side. t is $elp#'l to $ave $ead?'p tilt on t$e

operatin table as t$is red'"es veno's enorement. >ollo+in ro'tine sin

preparation and drapin t$e in"ision is mapped o't. T$e line s$o'ld r'n +it$in a sin

"rease in t$e ne" at least , "m belo+ t$e lo+er border o# t$e mandible in order toavoid ris o# damain t$e mandib'lar bran"$ o# t$e #a"ial nerve as it loops do+n

belo+ t$e lo+er border o# t$e mandible. T$e in"ision s$o'ld be approimatel& @ "m

lon. T$e in"ision line is t$en in#iltrated +it$ "onventional dental lo"al anaest$eti"

sol'tion "ontainin 2 per "ent lino"aine and 1FE5 555 adrenaline. T$is res'lts in

some vaso"onstri"tion +$i"$ limits "apillar& oo6e and $elps to de#ine tiss'e planes.

T$e in"ision is made +it$ eit$er a n'mber 19 blade or a #ine "'ttin diat$erm& +$ilst

t$e assistant p'ts tension a"ross t$e in"ision line. T$e in"ision is made dire"tl& do+n

to plat&sma. T$e s'b"'taneo's #at is stripped +it$ #irm press're and a s+ab #rom t$e

'nderl&in m's"le #or approimatel& 1 "m on ea"$ side o# t$e in"ision as t$is

#a"ilitates a la&ered "los're later. T$e 'nderl&in plat&sma is t$en in"ised to t$e #'ll

etent o# t$e sin in"ision aain +it$ eit$er a blade or "'ttin diat$erm&. T$e assistant


13/17

"an no+ retra"t t$e +o'nd marins 'sin


14/17

be en"o'ntered r'nnin #rom t$e land t$ro'$ t$e 'nderl&in $&oloss's into t$e

lin'al veins. # t$ese veins are not tied or ade'atel& diat$ermised tro'blesome

bleedin ma& be en"o'ntered.

T$e s'bmandib'lar salivar& land "an no+ be p'lled do+n+ards revealin t$e 7?

s$aped lin'al nerve. T$e ape o# t$e 7 is t$e point at +$i"$ paras&mpat$eti" se"reto

motor #ibres tet$er t$e lin'al nerve to t$e salivar& land. t is ver& important toidenti#& "are#'ll& t$e 7 o# t$e lin'al nerve and its paras&mpat$eti" #ibres as t$e latter

m'st be transe"ted to #ree t$e land (>i. 42.1). As t$ese #ibres are "'t t$e lin'al

nerve sprins #or+ards. >inall& t$e s'bmandib'lar d'"t is "lamped divided and tied

as #ar #or+ard as possible +it$ %'st eno'$ le#t to drain t$e ma%or s'blin'al land

+$i"$ empties into t$e d'"t. A t$in la&er o# loose "onne"tive tiss'e remains in t$e

land bed overl&in t$e $&polossal nerve.

T$e +o'nd is inspe"ted #or an& bleedin points a va"''m drain inserted and t$e

+o'nd "losed in la&ers 'sin a s'b"'ti"'lar s't're to "lose t$e sin. T$e +o'nd edes

are rein#or"ed +it$ sin "los're tapes.

omplications

T$ree "ranial nerves are at ris d'rin removal o# t$e s'bmandib'lar salivar& land

t$e mandib'lar bran"$ o# t$e #a"ial nerve t$e lin'al nerve (a bran"$ o# t$e t$ird

division o# t$e trieminal nerve) and t$e $&polossal nerve.

$en "$roni" in#e"tion and s'bse'ent #ibrosis $ave o""'rred it is sometimes

di##i"'lt to identi#& t$e lin'al nerve and t$e deep aspe"t o# t$e deep lobe ma& be

atta"$ed to t$e $&polossal nerve. At t$ese staes o# t$e operation t$e s'reon m'st

be "onvin"ed t$at t$ese str'"t'res $ave been identi#ied be#ore 'sin an& s$arp

disse"tion.

8eti"'lo's $aemostasis is re'ired t$ro'$o't t$e operation as man& o# t$e vessels

enterin and leavin t$e s'bmandib'lar land are onl& apparent +$en t$e land is

'nder tra"tion and as soon as t$e& are divided t$e vessels retra"t into t$e ad%a"ent

m's"le planes.

!arotidectomy

Treatment o# parotid t'mo'rs is b& s'per#i"ial parotide"tom& #or all benin t'mo'rs

in t$e s'per#i"ial lobe and total parotide"tom& #or all benin deep lobe and d'mb?bell

t'mo'rs. 3'"$ t'mo'rs in"l'din deep lobe t'mo'rs s$o'ld never be approa"$ed #rom

t$e p$ar&neal aspe"t. T$e #a"ial nerve is preserved in all "ases.

T$e pronosis #or malinant parotid t'mo'rs is poor. T$ere is little eviden"e t$at

radi"al parotide"tom& +$i"$ in"l'des sa"ri#i"in t$e entire #a"ial nerve addssini#i"antl& to t$e patient=s s'rvival. t does $o+ever "onsiderabl& in"rease t$e

morbidit&. >or t$is reason s'per#i"ial or total parotide"tom& #or malinant t'mo'rs is

'ndertaen +it$ preservation o# t$ose bran"$es o# t$e #a"ial nerve not

ma"ros"opi"all& invaded b& t'mo'r. T$is is #ollo+ed in all "ases o# malinant parotid

t'mo'rs b& radi"al radiot$erap&.

3imilarl& or more etensive t'mo'rs radi"al disse"tion +it$ as +ide a marin asis anatomi"all& appropriate +$ilst bein "ompatible +it$ reasonable re$abilitation


15/17

#ollo+ed b& radi"al radiot$erap& +ill ens're e"ellent lo"al "ontrol o# t'mo'r. T$e

radiot$erap& #ield s$o'ld in"l'de t$e s'll base in order to "ontrol t$e perine'ral

t'mo'r etensions.

>or an& malinant parotid t'mo'rs +it$ sin involvement #a"ial nerve +eaness

mandib'lar invasion etension into t$e in#ratemporal #ossa or l&mp$ node metastasis

radi"al rese"tion o#ten in "ontin'it& +it$ radi"al ne" disse"tion m'st be 'ndertaen+it$ re"onstr'"tion +it$ t$e 'se o# appropriate #laps and #ollo+ed b& radi"al

postoperative radiot$erap&.

Surgical techni"ue

$enever t$e #a"ilit& is available and t$e patient #ir $&potensive anaest$esia is 'sed

as t$is "onsiderabl& red'"es oo6in and t$'s maes it easier to tra"e t$e #a"ial nerve

#ibres. T$e in"ision line is in#iltrated +it$ lino"aine $&dro"$loride and 1FE5 555

adrenaline and t$e in"ision made +it$ a ni#e or #ine "'ttin diat$erm&. >ollo+in a

prea'ri"'lar in"ision etendin do+n+ards to "ontin'e in a s'itable sin "rease in t$e

ne" t$e sin #lap is raised in t$e plane o# t$e pre parotid #as"ia and t$en $eld #or+ardb& s't'rin t$e marins #or t$e #lap to t$e ad%a"ent to+els. T$e blood?#ree plane

anterior to t$e eternal a'ditor& meat's is opened 'p b& bl'nt disse"tion and t$is leads

t$e s'reon do+n to t$e base o# s'll %'st s'per#i"ial to t$e st&loid pro"ess and t$e

st&lomastoid #oramen. T$is plane is t$en entl& opened 'p in an in#erior dire"tion b&

bl'nt disse"tion 'ntil t$e tr'n o# t$e #a"ial nerve is seen. it$ lare posterior

t'mo'rs t$is plane ma& be di##i"'lt to open 'p. n t$is sit'ation it is $elp#'l to identi#&

t$e posterior bell& o# t$e diastri" m's"le in t$e "ervi"al etension o# t$e in"ision.

T$e anterior border o# t$e sterno"leidomastoid m's"le is mobilised and retra"ted

in#eriorl& to displa& t$e diastri" m's"le beneat$ it (>i. 42.25). T$is manoe'vre

ne"essitates se"tionin t$e reat a'ri"'lar nerve. T$e posterior bell& o# t$e diastri" is

tra"ed 'p+ards and ba"+ards to its insertion on to t$e mastoid +$i"$ lies

immediatel& belo+ t$e st&lomastoid #oramen t$'s leadin t$e operator to t$e #a"ial

nerve #rom belo+.

T$ere are #o'r anatomi"al landmars leadin to t$e identi#i"ation o# t$e tr'n o# t$e

#a"ial nerve as it leaves t$e st&lomastoid #oramen (>i. 42.21).

1. T$e "artilaino's eternal a'ditor& meat's #orms a pointer= at its anterior

in#erior border indi"atin t$e dire"tion o# t$e nerve tr'n.

2. J'st deep to t$e "artilaino's pointer is a reliable bon& landmar #ormed b& t$e

"'rve o# t$e bon& eternal meat's and its ab'tment +it$ t$e mastoid pro"ess. T$is

#orms a palpable roove leadin dire"tl& to t$e st&lomastoid #oramen. *n#ort'natel&

t$is roove is #illed +it$ #ibro#att& lob'les t$at o#ten mimi" t$e tr'n o# t$e #a"ialnerve +$i"$ "an lie as m'"$ as 1 "m deep to t$is landmar.

,. T$e anterior s'perior aspe"t o# t$e posterior bell& o# t$e diastri" m's"le is

inserted %'st be$ind t$e st&lomastoid #oramen.

4. T$e st&loid pro"ess itsel# "an be palpated s'per#i"ial to t$e st&lomastoid

#oramen and %'st s'perior to it. T$e nerve is al+a&s lateral to t$is plane and passes

obli'el& a"ross t$e st&loid pro"ess. A bran"$ o# t$e posta'ri"'lar arter& is 's'all&

en"o'ntered %'st lateral to t$e nerve.

On"e t$e #a"ial nerve tr'n $as been identi#ied t$e s'per#i"ial lobe o# t$e parotid "an

$e eteriorised b& openin 'p t$e plane in +$i"$ t$e bran"$es o# t$e #a"ial nerve r'n

bet+een t$e t+o lobes b& bl'nt disse"tion. nitiall& as it leaves t$e st&lomastoid#oramen t$e tr'n o# t$e #a"ial nerve t'rns abr'ptl& to be"ome more s'per#i"ial and


16/17

also divides into t$e larer 6&omati"o#a"ial tr'n and smaller "ervi"o#a"ial tr'n.

T$e #ive main bran"$es o# t$e nerve are t$en #ollo+ed perip$erall& t$ro'$ t$e

parotid 'ntil t$e s'per#i"ial lobe is "ompletel& #reed. T$is part o# t$e operation is

per#ormed 'sin #ine s"issors opened 'p in t$e plane o# t$e #a"ial nerve bran"$es

+it$ "are al+a&s taen to identi#& t$e nerve #ibre be#ore dividin parotid tiss'e (>i.

42.22).D'rin t$e lo+er part o# t$e disse"tion bran"$es o# t$e posterior #a"ial vein +ill be

en"o'ntered immediatel& deep to t$e marinal mandib'lar bran"$. Great "are m'st be

taen +$en vas"'lar "lamps are applied to t$ese bran"$es to avoid damain t$e

#a"ial nerve.

# t$e s'per#i"ial partotide"tom& is bein per#ormed #or "$roni" in#e"tion t$e d'"t

s$o'ld be tied o## as #ar #or+ard as possible to prevent re"'rrent as"endin in#e"tion

#rom t$e oral "avit&.

# t$e t'mo'r lies in t$e deep lobe o# t$e land a "onventional s'per#i"ial

parotide"tom& is per#ormed as des"ribed. Net t$e bran"$es o# t$e #a"ial nerve are

mobilised and li#ted on n&lon tapes to enable t$e deep lobe to be #reed aro'nd its

marins and removed +$en t$e mass is dropped do+n+ards (>i. 42.2,). As t$isspa"e is +ede s$aped +it$ its ape s'perior it is almost invariabl& possible to do

t$is. T$e deep lobe is "overed b& a "aps'le (t$e deep la&er o# t$e deep "ervi"al #as"ia

+$i"$ splits to envelope t$e parotid) and is s'rro'nded b& t$e parap$ar&neal #at.

T$'s it is relativel& eas& to mobilise t$e deep lobe b& bl'nt disse"tion +it$ eit$er

s"issors or a #iner. Onl& ver& rarel& is it ne"essar& to per#orm a mandib'lotom& to

ain a""ess to t$e deep lobe.

7er& rarel& most o#ten a#ter re"'rrent in#e"tion +it$ #ibrosis or previo's radiot$erap&

: t$e tr'n o# t$e #a"ial nerve "annot be "on#identl& identi#ied. n t$is sit'ation t$e

perip$eral bran"$es o# t$e nerve are identi#ied at t$e anterior border o# t$e parotid and

tra"ed "entrall& to+ards t$e st&lomastoid #oramen.

>ollo+in removal o# t$e parotid land t$e blood press'reis ret'rned to normal all

bleedin points are "ontrolled ava"''m drain is pla"ed and t$e +o'nd "losed in

la&ers. Apress're dressin is t$en applied #or 4E $o'rs.

omplications

-ermanent #a"ial nerve paral&sis #ollo+in s'per#i"ial or total parotide"tom& is rare

e"ept +$en bran"$es o# t$e #a"ial nerve $ave been deliberatel& sa"ri#i"ed. $en t$e

#a"ial nerve or its bran"$es are sa"ri#i"ed as a res'lt o# ma"ros"opi" t'mo'r

involvement an immediate nerve ra#t ma& be 'ndertaen 'sin "onventional

mi"rone'ral te"$ni'es.Temporar& +eaness d'e to ne'ropraia o""'rs in approimatel& ,5 per "ent o#

operations b't re"overs rapidl& 's'all& +it$in +ees. Anaest$esia o# t$e sin #lap

slo+l& resolves as t$e sensor& nerves reenerate #rom t$e perip$er&.

Anaest$esia o# t$e ear lobe d'e to se"tionin o# t$e reat a'ri"'lar nerve "an be

tro'blesome ?parti"'larl& in #emales +$o #ind it di##i"'lt to +ear earrins. e"over&

"an rae 'p to 1E mont$s and sometimes is never "omplete.

G'stator& s+earin (>re&=s s&ndrome) is a re'lar se'el to parotide"tom& o""'rrin

in 'p to 94 per "ent o# "ases. 3'ri"al manoe'vres to treat it on"e establis$ed are not

s'""ess#'l and most patients eit$er learn to live +it$ it or alternativel& 'se an

antiperspirant "ontainin al'mini'm "$loride.


17/17

3pillae o# a benin pleomorp$i" adenoma s$o'ld not o""'r i# a #ormal s'per#i"ial

parotide"tom& is 'ndertaen. Ho+ever t$ere are #o'r "ir"'mstan"es +$ere even +it$

meti"'lo's s'ri"al te"$ni'e t$is "an $appenF

etremel& lare pleomorp$i" adenomas o""'p&in t$e entire s'per#i"ial lobe

main mobilisation o# t$e land di##i"'ltI t'mo'rs t$at are intimatel& asso"iated +it$ bran"$es o# t$e #a"ial nerve re'irin

ver& deli"ate disse"tion alon t$e "aps'le o# t$e t'mo'r to release t$e nerveI

t'mo'rs +it$ lob'lar etensions etendin beneat$ t$e mastoid 6&omari" ar"$ or

mandibleI

some t'mo'rs t$at are abnormall& #riable +it$ even ro'tine retra"tion o# t$e

s'per#i"ial lobe res'ltin in r'pt're.# r'pt're o""'rs an etremel& "are#'l inspe"tion

o# t$e +o'nd m'st be 'ndertaen and t$e area t$oro'$l& irriated. n all s'"$ "ases

postoperative radiot$erap& s$o'ld be 'ndertaen in order to avoid m'ltiple

re"'rren"es d'e to t'mo'r seedin.

Ot$er tare "ompli"ations s'"$ as sialo"ele or salivar& #ist'a o""asionall& #ollo+

parotide"tom&. ;ot$ "ompli"ations are manaed "onservativel& and resolvespontaneo'sl& a#ter da&s or +ees. 7er& rarel& a parotid #ist'la persists despite

attempts at s'ri"al "los're. n t$is sit'ation postoperative radiot$erap& +ill destro&

t$e resid'al #'n"tionin a"inar tiss'e and allo+ t$e #lst'la to "lose.

adiot$erap&

-arotid t'mo'rs are o#ten "onsidered to be

Documents

42.Salivary Gland Disorders