Salivary Glands

• Three paired glandsParotid; largest of the major salivary glands

• Two Lobes divided by facial nerve• Submandibular gland Deep to mylohyoid,

superficial to hyoglossus• Sublingual; Smallest of the salivary

glands • Common surgical disease; infection/calculi

Salivary Glands{Benign conditions}

• Mumps: • Acute painful parotitis• Viral in aetiology• Self limiting

• Mikulicz’s Syndrome• Bilateral enlargement of salivary & lacrimal glands

• Sjogren’s Syndrome• Triad of dry eyes, dry mouth, dry joints• Autoimmune• Lymphocytic infiltration

• Pyogenic parotitis• Surgical, debilitated patients• Staphylococcus• Swollen, painful parotid glands• Pus from stensen’s duct

Salivary glands{Benign Tumours}

• Comprise 3% - 6% of all head & neck tumours• Pleomorphic Adenoma• Commonest tumour (53% - 71%)• Slowly growing, painless, solitary, firm, smooth,

moveable without nerve involvement• Both mesenchymal/epithelial elements• FNA, CT, MRI• Superficial parotidectomy

Salivary GlandsTumours

• Warthin’s tumour(adenolymphoma, papillary cystadenoma lymphomatosum)

• 6% - 10%

• Benign, bilateral, parotid gland only,

• Older age group

• Superficial location

• Malignant potential non existent

Salivary GlandsMalignantTumours

• Locally aggressive

• Grow along neural pathways, may access skull base and brain eventually

• Also lymphatic and haematogenous spread

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Salivary GalndsMalignant Tumours

• Mucoepidermoid Carcinoma• Commonest malignant tumour• 50% of all salivary gland malignancies• Parotid involved in 40% - 50%• 75% are low grade & have good prognosis• 1 – 5 year survival 85%• High grade mucoepidermoid carcinomas invade

locally, spread regionally & distant mets• 5 year survival drops 30%

Salivary Glands

• Adenocystic carcinoma(Cylindroma)• Commonly involves submandibular (35% - 40%),

only 7% of parotid malignancies• Slowly growing• Perineural invasion• 30% lymph node mets, 50% distant mets• 5 year survival 75%• 10 year survival 30%• 20 year survival 13%

Salivary Glands

• Mixed malignant tumour• Long standing pleomorphic adenoma• Older age group• Worse prognosis• Lymph node mets 15%• Distant mets 30%• 5 year survival 40% - 50%• 15% year survival 20%

Salivary Glands

• Acinic cell carcinoma

• Low grade

• Slow growing

• 10% of malignant parotid tumour

• Lymph node mets 10%

• Aggressive tumours

• Radical parotidectomy

Salivary Glands

• Squamous cell carcinomas

• Infrequent occurrence 1% - 5%

• May have skin infiltration

• Total radical parotidectomy_

Salivary GlandsEvaluation & Diagnosis

• History & clinical examination• Sialography – of no value• CT scans• CT sialography for

retromandibular/parapharayngeal• MRI• Incisional biopsy containdicated• FNAC

Salivary GlandsStaging System

• T0 no clinical evidence of primary tumour

• T1 0.1 – 2.0 cms diameter without significant local extension

• T2 2.1 – 4 cms without local extension

• T3 4.1 – 6.0 cms without local extension

• T4a >6 cms without local extension

• T4b tumour of any size with significant extension

Salivary GlandsStaging system

• N0 no evidence of regional nodal involvement

• N1 evidence of regional nodal involvement

• Nx regional nodes not assessed

• M0 no distant mets

• M1 distant mets eg., bone, lung, etc.

Salivary GlandsSurgical complications

• Flap necrosis• Seromas & haematomas• Oropharangeal cutaneous fistulas• Carotid rupture• Thoracic duct fistula• Pneumothorax• Airway obstruction, dysphagia, oedema, loss of

tongue mobility, superoir laryngeal nerve damage

Neck swellingsDifferential diagnosis

• Neck divided into ant. And posterior triangle by sternocleidomastoid

• Cervical lymphadenopathy commonest cause of neck swelling

Neck SwellingsD/D (benign)

• Congenital swellings; branchial cleft swellings, thyroglossal duct cyst, laryngocoele, haemangiomas, cystic hygromas, dermoid.

• Inflammatory: acute & chronic lymphadenitis( infectious mononucleosis, toxoplasmosis, cat scratch fever, actinomycosis, histoplasmosis, tuberculosis

• traumatic: aneurysms, av malformation, torticollis, etc

• Pharyngeal pouch, cervical ribs, thyroid, etc

Neck swellings

• Branchial cleft cyst• Remnants of incompletely obliterated

branchial clefts/pouches• Located anterior & deep to sternomastoid• Painless swelling• Young adults• M= F ratio• Unilateral, 75% on left side

Neck swellings

• Thyroglossal duct cyst

• 70% of all congenital cysts

• Arrested migration of thyroid

• Painless midline swelling

• Sistrunk operation

Neck swellings

• Csytic hygroma• Collection of lymph sacs• Present at the root of neck(post. Triangle), arm, groin.

• Pharyngeal pouch• Pulsion divertuculum• Uncoordinated swallowing

• Sternomastoid tumour• Birth trauma, infarcted segment , fibrosis, torticollis

Neck swellings• Cervical rib• Extra cervical rib• < 1% population• Neurological and vascular problems

• Ranula• Mucous containing cyst in floor of mouth• Painless midline, spherical, smooth, fluctuant, transillumanant

• Dermoid cyst• Midline, asymtomatic, painful when infected

• Laryngocoele• Diverticulum of laryngeal ventricle• Lined by epithelium• Common in glass blowers/wind instruments musicians, etc

Neck swellingsTumours

• Benign; Carotid body tumour, lipoma, soft tissue tumour• Malignant: skin tumours( SCC, BCC, melanomas),

thyroid tumours, salivary gland tumours

• Carotid body tumour• Sporadic occurrence 90%• Familial 10%• Unilateral, but bilateral/multicentric 10% sporadic, 50%

bilateral familial• Grows 0.5 cms/year

Schedule of Lectures V Med

• Salivary glands & Neck Swellings• Skin & soft tissue tumours• Benign & Malignant breast diseases• Thyroid, parathyroid disorders, carcinoid,

phaechromocytoma, MEN syndrome• Oesophageal & gastric disorders• Small bowel obstruction, Crohn’s disease,

meckel’s, etc• Colon & rectal diseases• Hepatobiliary disorders•

Lectures

• Pancreatic disorders• Hernias• Arterial & venous disorders• Osteoarthritis Rheumatoid arthritis• Fluid & electrolyte balance, nutrition• Preoperative preparation, haemostasis & blood

transfusion• Trauma & burn Management• Common urological problems• Common orthopaedic problems• Common cardiothoracic problems• Common neurosurgical problems