Salivary Gland Disease and Surgery

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Salivary Gland Disease and Surgery

• Paul Schalch, MD

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Case Presentation

• 81 yo M w 20 year hx of progressively enlarging
  right parotid mass.
• Hx of prior resection (superficial
  parotidectomy?).
• More recently, ID for abscess.
• Recently, rapid increase in size.
• Smooth, firm, non-tender, no skin discoloration,
  non-mobile.
• Right pharyngeal fullness, uvula displaced to the
  left, firmness on palpation.
• VII intact.
• No LNs or neck masses.

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Work-up FNA

• Sensitivity 85-99, specificity 96-100.
• Easy to perform, low morbidity.
• Certain pathologic variants can lead to false
  negatives for malignancy (basal cell adenomas vs.
  adenoid cystic ca, mucoepidermoid ca vs.
  obstruction, oncocytoma vs. acinic cell ca.
• Does it change management?

Stewart CJ  Fine-needle aspiration cytology of
salivary gland a review of 341 cases.   Diagn
Cytopathol  2000 22139-146. Heller KS  Value
of fine needle aspiration biopsy of salivary
gland masses in clinical decision-making.   Am J
Surg  1992 164667-670.
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FNA

• Abundant amorphous debris with benign acinar
  cells and few atypical keratinized squamous
  cells, cannot rule out malignancy.

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Work-up Imaging

• CT superior to physical exam and other imaging
  modalities.
• Does not provide specific info regarding
  histologic diagnosis, but provides info about
  bilateralism and benign vs. malignant masses.
• MRI superior to CT in demonstrating internal
  architecture.
• Location in relationship to fascial planes and
  spaces (for operative planning).

Rabinov JD  Imaging of salivary gland pathology.
  Radiol Clin North Am  2000 381047-1057. Shah
GV  MR imaging of salivary glands.   Magn Res
Imag Clin North Am  2002 10631-6.
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MRI Report

• 6.3 x 3.2 x 6.1 cm multi-lobular mass with
  peripheral enhancement involving the superficial
  and deep lobes of the right parotid gland.
  Slightly increased T1 and T2 signals, with
  scattered areas of low T2 signal throughout. Mass
  extends into parapharyngeal and pterygoid spaces,
  with mass effect displacement of the nasopharynx.
  Likely a pleomorphic adenoma but cannot exclude
  malignant degeneration of mass.

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Incidence Salivary Gland Tumors

• 3-4 of all head and neck neoplasms.

From Hanna EY, Lee S, Fan CY, Suen JY. Chapter
60 Salivary Gland Physiology. In Cummings et
al. (Eds.). Cummings Otolaryngology Head and
Neck Surgery, 4th Ed. 1998, Mosby, Philadelphia,
PA.
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Benign vs. Malignant Site of Origin
From Hanna EY, Lee S, Fan CY, Suen JY. Chapter
60 Salivary Gland Physiology. In Cummings et
al. (Eds.). Cummings Otolaryngology Head and
Neck Surgery, 4th Ed. 1998, Mosby, Philadelphia,
PA.
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Memorial Sloan-Kettering 35-Year Period
THE DISTRIBUTION OF 2807 SALIVARY NEOPLASMS
Spiro RH  Salivary neoplasms overview of a
35-year experience with 2,807 patients.   Head
Neck Surg  1986 8177-184.
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Embriology and Microscopic Anatomy

• Ectodermal origin.
• 4-6th week of gestation.
• Serous and mucous cells, arranged in acini,
  drained by series of ducts.
• Parotid serous acini.
• Submandibular serous and mucinous acini.
• Minor SG mucinous acini.

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From Elluru RG, Kumar M. Chapter 56 Salivary
Gland Physiology. In Cummings et al. (Eds.).
Cummings Otolaryngology Head and Neck Surgery,
4th Ed. 1998, Mosby, Philadelphia, PA.
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Cellular Origins of Salivary Gland Neoplasms

• Multicenter theory
• Each type originates from a distinctive cell
  type.
• E.g. Whartins / oncocytic striated duct cells.
• Acinic cell acinar cells.
• Mixed intercalated and myoepithelial cells.

Dardick I  Mounting evidence against current
histogenetic concepts for salivary gland
tumorigenesis.   Eur J Morphol  1998 36257-261.
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Cellular Origins of Salivary Gland Neoplasms

• Bi-cellular reserve cell theory
• All tumors arise from the basal cells of either
  the excretory or intercalated ducts.
• These cells act as reserves, with the potential
  to differentiate into various epithelial cell
  lines.
• E.g. pleomorphic adenomas and oncocytic tumors
  intercalated ducts.
• SCC and mucoepidermoid tumors excretory ducts.

Batsakis JG  Histogenesis of salivary gland
neoplasms a postulate with prognostic
implications.   J Laryngol Otol  1989 103939-944
.
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Anatomy Parotid Gland

• Superior/posterior EAC.
• Posterior mastoid, anterior aspect of SCM.
• Superior/anterior temporo-mandibular joint.
• Anterior masseter, medial pterygoid, ascending
  mandibular raums.
• Parotid space zygomatic arch above, stylohyoid
  and posterior belly of digastric below.
• Capsule investing (superficial) layer of deep
  cervical fascia. Contains greater auricular
  nerve.
• Platysma.
• Deep lobe behind mandibular ramus, immediately
  lateral to the superior constrictor
  (parapharyngeal space). Division based on facial
  nerve.
• 20 of cases small, detached accessory parotid
  gland between zygomatic arch and parotid duct.

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Structures within

• External carotid artery divides into the
  maxillary artery and superficial temporal artery
  (gives off tranverse facial branch). Also, small
  posterior auricular artery.
• Retromandibular vein formed by union of
  maxillary and superficial temporal veins. It then
  bifurcates, fuses with the retroauricular vein
  and becomes EJ. Anterior branch joins facial vein
  and then joins IJ.
• Facial nerve.
• Parotid duct (Stensens) emerges anteriorly,
  passes across masseter, traverses buccinator and
  opens into oral cavity opposite second upper
  molar.
• 20 lymph nodes within the parotid gland.

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Gray H. Anatomy of the human body. 1918.
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Describe the Autonomic Innervation of the
Salivary Glands
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Segal K, Lisnnyansky I, Nageris B, Feinmesser R.
Parasympathetic innervation of the salivary
glands. Op Tech Otolaryngol Head Neck Surg
19967333-338.
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Segal K, Lisnnyansky I, Nageris B, Feinmesser R.
Parasympathetic innervation of the salivary
glands. Op Tech Otolaryngol Head Neck Surg
19967333-338.
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Segal K, Lisnnyansky I, Nageris B, Feinmesser R.
Parasympathetic innervation of the salivary
glands. Op Tech Otolaryngol Head Neck Surg
19967333-338.
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Treatment Options
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Complications

• Facial nerve injury.
• Frey Sx.
• Sialocele/fistula.
• Hematoma.
• Deformity.

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Facial Nerve Injury

• Incidence of paralysis 3-5.
• Transient dysfunction 8-65.
• Paresis more common, resolves within 6-18 months.
• Primary re-anastomosis.
• Cable graft (greater auricular nerve).
• XII to VII transposition.
• Jump graft.

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Frey Sx

• AKA auriculotemporal Sx, gustatory sweating.
• Up to 30 have symptoms.
• Over 90 if starch-iodine test is used.
• Post-ganglionic parasympathetic nerve fibers from
  the otic ganglion reconnect with sympathetic
  fibers of the sweat glands upon healing.
• Medical Tx antiprespirants, Botox, 3
  scopolamine cream.
• Surgical Tx SMAS flaps, rotation SCM flaps,
  AlloDerm, transmeatal tympanic neurectomy
  (Jacobsons n.).
• Can be prevented by not resecting portions of the
  parotid not involved with tumor (in cases of
  benign tumors).

Clayman MA, Clayman SM, Seagle MB. A review of
the surgical and medical treatment of Frey
syndrome. Ann Plast Surg 200657581-584. Sinha
UK, Saadat D, Doherty CM, Rice DH. Use of
AlloDerm implant to prevent Frey syndrome after
parotidectomy. Arch Facial Plast Surg
20035109-112.
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Salivary Fistula/Sialocele

• Caused by residual parotid tissue, left behind
  after incomplete resection.
• Rough surface of parotid tends to secrete saliva
  into surrounding tissues.
• Fistula may form through drain site.
• Application of continuous pressure w/ dressing
  helps.
• Contained saliva causes sialocele.
• Sometimes needs needle decompression.
• Treatment options similar to Tx for Frey Sx
  Botox, anticholinergics, even XRT.

Nageris B, Feinmesser R. Complications of
parotidectomy surgical techniques of repair. Op
Tech Otolaryngol Head Neck Surg 19967374-376.
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Surgical Management
Incisions
Rhytidectomy
Modified Blair
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Surgical Management
Harrell M, Levy D, Elam M. Superficial
parotidectomy for benign parotid lesions. Op Tech
Otolaryngol Head Neck Surg 19967315-322.
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Facial Nerve Identification Theres More than
One Way to Skin a Cat

• Tragal pointer (10 mm inferior and deep).
• Marginal mandibular or buccal branches
  (centripetal approach).
• Tympanomastoid suture (Tabb HG, 1985).
• Styloid process.
• Posterior belly of the digastric.
• Superficial temporal and retromandibular veins
  (Kawakami S, 1994).

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Facial Nerve Monitoring

• Witt RL. Facial nerve monitoring the standard of
  care? Otolaryngol Head Neck Surg
  1998119468-470.
• 69 consecutive patients w/ parotid tumors that
  underwent surgery.
• 16 high-risk patients excluded.
• Most were PA or WT.
• No statistical difference between both groups.

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What about neck dissection?

• Must be done when nodes clinically or
  radiologically evident.
• National Cancer Institute 41 positive node rate
  in the presence of major salivary gland
  malignancy.
• Predictors age, hystopathologic type, VII
  involvement, extraglandular involvement, grade
  and size.
• Levels I to III if tumor gt 4 cm, SCC, adeno ca,
  high-grade mucoepidermoid ca.

Bhattacharyya N, Fried MP  Nodal metastasis in
major salivary gland cancer.   Arch Otolaryngol
Head Neck Surg  2002 128904.
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X-RT/Chemo

• XRT improves overall survival high-grade tumors,
  positive margins, VII, perineural spread, LNs,
  mets and recurrence.
• More effect in advanced disease.
• Local control, palliation.
• Complications RIF, osteoradionecrosis.
• Chemo recurrent, metastatic and unresectable
  disease.

Spiro RH, Armstrong J, Harrison L  Carcinoma of
major salivary glands recent trends.   Arch
Otolaryngol Head Neck Surg  1989 115316.
Ruzich JC, Ciesla MC, Clark JI  Response to
paclitaxel and carboplatin in metastatic salivary
gland cancer a case report.   Head
Neck  2002 24406.
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Pathology

• Mucoepidermoid carcinoma.
• Low grade.
• Abundant infarction necrosis.
• 0/18 zone II lymph nodes.

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Prognosis Mucoepidermoid Carcinoma

• 40 incidence of local recurrence.
• 15 incidence of spread to regional LNs and
  distant sites.
• 5-year survival rate 80.
• Femalegtmale, mean age 47 years.
• Prognosis depends on clinical stage, site,
  grading and margins.

Evenson JW. Malgnant neoplasms of the salivary
glands. In Thompson LDR (Eds.). Head and neck
pathology. Churchill Livingston, Philadelphia,
PA, pp. 321-370.