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than 8 mm invasion in depth shows 100% of 5-year survival;
>8 mm invasion carries 5-year survival <50%.
ADENOCARCINOMA OF SALIVARY GLANDS
It is 3% of parotid and 10% of submandibular and minor
salivary gland tumours.
It is equal in both sexes; It is common in children
It can be tubular, papillary and undifferentiated.
20% involve facial nerve clinically.
Undifferentiated type is aggressive.
SRB's Manual of Surgery
SQUAMOUS CELL CARCINOMA OF
SA
LIVARY GLANDS
It is rare in salivary glands.
In salivary glands, parotid is the common site.
It is almost never seen in minor salivary glands.
It is classified as high grade tumour.
It is common in men (3:1).
It occurs in 6th or 7th decade. It is aggressive nonencapsu-
lated tumour arising from ductal system.
It grows rapidly causing pain, facial palsy, skin fixity, ulcera-
tion.
It spreads commonly to neck nodes.
It carries poor prognosis.
Radical parotidectomy and RT is the treatment of choice.
Diagnosis is by FNAC, Orthopantomogram (OPG) and CT scan.
Excision of both superficial and deep lobes of the gland is
done.
Malignant tumours of submandibular salivary gland:
They are hard, nodular, often get fixed to skin, muscles,
hypoglossal nerve and mandible.
Diagnosis is by FNAC of primary tumour and of lymph nodes
when involved, CT scan and OPG.
Treatment:
¾
Wide excision, with removal of adjacent muscle, soft
tissues and mandible.
¾
If lymph nodes are involved, block dissection of neck
(Classical neck dissection) is done.
SUBMANDIBULAR SALIVARY
GL
AND TUMOURS
Benign tumours:
They are commonly pleomorphic adenomas, are smooth,
firm or hard, bidigitally palpable, without involving adjacent
muscles or hypoglossal nerve or mandible bone.
A
B
Figs. 4.29A and B: Submandibular salivary gland tumour both
external as well as intraoral look.
Fig. 4.30: Submandibular salivary gland tumour
which is malignant. Patient underwent wide excision.
Fig. 4.31: Submandibular salivary gland tumour in old female.
GENERAL FEATURES OF MALIGNANT SALIVARY
B
TUMOURS
x Fixation
x Resorption of adjacent bone
x Pain and anaesthesia in the skin and mucosa
x Muscle paralysis
x Skin involvement and nodularity
x Involvement of jaw and masticatory muscle
x Nerve involvement (facial nerve in parotid or hypoglossal nerve
in submandibular salivary gland)
x Blood spread when occurs, commonly to lungs
x Mandibular branch of 5th cranial nerve may be involved when
tumour tracks along the auriculotemporal nerve to the base of
the skull causing severe pain in the distribution area
TNM Staging of Malignant Salivary Tumours (AJCC, 8th Edition,
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2018, Clinical Staging)
T—Tumour
Tx —Tumour cannot be assessed.
T0 —No evidence of primary tumour.
Tis—
Carcinoma in situ.
T1 —Tumour <2 cm without extraparenchymal spread.
T2 —Tumour 2–4 cm, without extraparenchymal extension
T3 —Tumour >4 cm—or with extraparenchymal spread.—but no
facial nerve spread.
T4 — T4a: Spread to facial nerve, skin, mandible, ear canal. T4b:
Spread to base of skull, pterygoid plates and encased external
carotid artery.
Note: Extraparenchymal extension is clinical or macroscopic evidence
of invasion of tissues. Microscopic evidence alone does not constitute
extraparenchymal extension.
N – Nodal spread
Nx – Nodes cannot be assessed.
N0 – No regional lymph node spread.
N1 – Regional single node <3 cm with ENE (-).
N2 – N2a: Single ipsilateral node <3 cm with ENE (+); OR single
ipsilateral node 3-6 cm with ENE (-). N2b: Multiple ipsilateral nodes
<6 cm in size and ENE (-). N2c: Bilateral or contralateral nodes <6
cm with ENE (-).
N3 – N3a: Single ipsilateral node >6 cm with ENE (-). N3b: single ipsilateral node >3 cm with ENE (+) OR multiple ipsilateral or contralateral
or bilateral any sized nodes with ENE (+) OR single contralateral node
of any size with ENE (+).
Note: ENE means extra nodal extension; ENE
tases <2 mm; ENE
biopsy; f is for FNA
of the cricoid; l is nodes below the lower border of cricoid.
M – Distant metastases
cM0 – Distant spread not present.
cM1 – Distant metastases present.
pM1 – Distant metastases, microscopically confirmed.
Staging
Stage 0 – Tis N0 M0
Stage I – T1 N0 M0
Stage II – T2 N0 M0
Stage III – T3 N0 M0; T0,T1,T2,T3 N1 M0
Stage IV – IVA: T4a N0/N1 M0; T0,T1,T2,T3,T4a N2 M0. Stage IVB:
Any T N3 M0; T4b Any N M0. Stage IV
is macroscopic >2 mm. Suffix – sn is for SLN
ma
C or core biopsy; u is nodes above lower border
is microscopic metas-
mi
C: Any T Any N M1.
¾
Conservative approach for benign tumours in high risk
surgical candidates may be thought of.
CT scan: It is to see the deep lobe of the parotid: the
involvement of bone, extension into the base of the skull;
relation of tumour to internal carotid artery, styloid process,
deep lobe tumour, parapharyngeal space extension. Neck
nodes are better assessed. Bony changes in the foramina,
erosions and sclerotic margins in fissures or canals,
enlarged diameter of canal and fissure are the
CT features
of perineural spread.
MRI: It is very useful to find out perineural spread, bone
marrow involvement, skull base, internal architecture and
intracranial extensions, recurrent tumours. Replacement of
perineural fat with tumour, contrast (gadolinium) enhancement, increased size of the nerve are features of perineural
spread.
A
407
CHAPTER 4 Salivary Glands
MANAGEMENT OF MALIGNANT
SALIVARY TUMOURS
Specic Investigations
FNAC.
¾
FNAC also confirms possibility of (35% of patients)
lymphoma/inflammatory masses.
¾
FNAC allows preoperative counselling regarding nature of
tumour, likely extent of resection (conservative/radical),
management of facial nerve (high grade adenoid cystic),
and likelihood of neck dissection (high grade).
¾
But FNAC may cause haematoma leading to difficulty
in surgical dissection. Sampling problem, difficulty in
finding histological type.
B
Figs. 4.32A and B: CT scan pictures of parotid tumours.
Others: OPG; Blood grouping and cross-matching; required
amount of blood is kept ready; FNA
Note:
• Sialogram is not useful in assessment of tumour.
• MRI shows better soft tissue definition than CT scan.
It’s your imagination that can take you anywhere.
C of lymph node.
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Treatment
In Parotid
Surgery
INDICATIONS FOR SURGERY
B
x T1, T2, T3 tumours of low grade—total conservative parotidec-
tomy
x T4 tumours, high grade tumours, SCC—radical parotidectomy
It includes facial nerve sacrifice, may involve resection of skin,
mandibular ramus, masseter muscle, infratemporal fossa dissection,
subtotal petrosectomy.
SRB's Manual of Surgery
Note: In T1 low grade, superficial parotidectomy is often practiced.
a. Radical parotidectomy is done which includes removal of
both lobes of parotid, soft tissues, part of the mandible
with facial nerve.
¾
It is done in high grade malignant tumours and squamous
cell carcinoma.
¾
Facial nerve is reconstructed using greater auricular
nerve, or sural nerve. All branches except buccal branch
are repaired using cable graft. Nerve graft is not a
contraindication for future RT.
¾
Often lateral tarsorrhaphy or temporal sling reconstruction is done.
b. Total conservative parotidectomy is becoming popular in
many parotid malignancies.
Contd...
x T3, T4 tumours
x High grade tumours
x Perineural spread
x Adenoid cystic carcinomas
x Deep lobe tumour
x Vascular involvement
x Close clearance margin
x Multiple neck nodes involvement
x Recurrent malignant tumours
x Recurrent pleomorphic adenoma
x Spillage after surgery for pleomorphic adenoma
x Residual/refractory tumours/nerve involvement
x Inadequate clearance margin
Note:
– It is given in 3–6 weeks after surgery. Dose is 50–70 Gy;
1.5–2.0 Gy in 5–8 weeks
– RT is delayed for 6 weeks if nerve grafting is done
– Neuron beam therapy is used
Complications
x Xerostomia
x Osteoradionecrosis of temporal bone/mandible
x Skin ulcers, mucositis
x Fibrosis of optical apparatus, brainstem injury
x Trismus due to fibrosis of masseter, pterygoids and TM joint
x Otitis media, localized hair loss
INDICATIONS FOR FACIAL NERVE SACRIFICE
B
x Preoperative weakness/paralysis of nerve
x Intraoperative evidence of gross invasion even in presence of
normal preoperative function
x Tumours transgressing through facial nerve from superficial to
deep lobe
x Nerve stump is checked for frozen section for negative margins,
if positive mastoidectomy and nerve dissection in temporal bone
is needed
COMPLICATIONS OF SURGERY
B
x Haemorrhage; Infection, flap necrosis; Fistula
x Frey’s syndrome; Facial nerve palsy; Facial numbness
x Numbness in ear lobule due to injury to great auricular nerve
x Sialocele
Postoperative radiotherapy
It is quite useful to reduce the chances of relapse. Usually,
external radio therapy is given. It is given in all carcinomas, but
more useful in adenoid cystic and squamous cell carci nomas.
INDICATIONS FOR RADIOTHERAPY
B
x T3, T4 tumours
x High grade tumours
x Perineural spread
x Adenoid cystic carcinomas
x Deep lobe tumour
x Vascular involvement
x Close clearance margin
Contd...
A
B
Figs. 4.33A and B: Recurrent parotid tumour right side. Note the scar
of previous surgery. It was adenoid cystic carcinoma. Recurrence has
occurred after 6 years. Patient underwent radical parotidectomy. Neck
nodes were involved in this patient even though it is rare in adenoid
cystic carcinoma. Patient needs radiotherapy and chemotherapy.
Chemotherapy
It is also given. Drugs given here depends on tumour type.
Intra-arterial chemotherapy is beneficial. But overall efficacy
of chemotherapy is very less compared to RT. 5 FU, cisplatin,
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doxorubicin, epirubicin, cetuximab are used.
Preoperative radiotherapy
It is given in large tumours to reduce the size and make it
better operable, i.e. to down stage the disease.
If lymph nodes are involved, which is confirmed by FNAC,
radical neck dissection is done. It is also done in N0 with
high-grade tumour or T3/T4 tumours.
In Submandibular Salivary Gland
Wide excision of the gland is done, with removal of mandible, and
soft tissues around—extraglandular excision. If lymph nodes are
involved, then block dissection of the neck is done.
MINOR SALIVARY GLAND TUMOURS
It is 10% of salivary tumours.
It is common in palate (40%), lip, cheek. Palate is the
commonest site.
10% are benign—commonly pleomorphic adenomas.
90% are malignant—commonly adenoid cystic carcinomas.
They present as submucosal, firm swelling often with an ulcer
over the summit. If it is malignant, then extension into the
palate, maxilla, pterygoids can occur often with involvement
of the lymph node.
Differential diagnosis is squamous cell carcinoma.
Investigations are—Incision or punch biopsy; CT scan head
and neck (must); FNA
C of the lymph node.
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CHAPTER 4 Salivary Glands
BA
Figs. 4.34A and B: Minor salivary gland tumour in the palate. Palate
is the common site of minor salivary gland tumour.
A
Treatment
Wide excision often with palatal excision or maxillec tomy is
done—for malignancy.
If the tumour is less than 1 cm in size excision biopsy is
done with 1 cm clearance margin. If the tumour is more
than 1 cm in size, initially incision biopsy is done and then
wide excision is done. Even in larger defect in hard palate
region, it usually re-epithelialise if once left open to allow it to
granulate. If bony palate is infiltrated then that part of palate
bone is removed to get a clearance; area is reconstructed by
moulds, synthetic materials.
Reconstruction by dental plates, skin grafting, or flaps are
done.
Lymph node block dissection of the neck is done if involved.
Excision with primary closure is done for benign tumours.
POINTS TO BE REMEMBERED
B
x Salivary gland tumours are usually benign in an adult
x It is rare in children but when it occurs, it is commonly malignant
x Clinical and FNAC are diagnostic methods
x Open biopsy is contraindicated
x Sialogram is not useful in salivary tumours
x CT scan or MRI are always needed
x Nerve should be preserved in benign lesions
x Nerve can be sacrificed to achieve clearance in malignancies
B
Figs. 4.35A and B: Minor salivary gland tumour of hard palate. It is
excised with 1 cm margin; area is allowed to granulate and epithelialise.
PAROTID LYMPHOMA
Parotid lymphoma can occur from the lymph nodes in the
gland or from parotid parenchyma.
It can occur in HIV patients; lymphoepithelial diseases and
in Sjögren’s syndrome.
Common in elderly.
Disease may be confined to parotid gland or may involve
other nodes in neck, mediastinum.
When it is confined to parotid total parotidectomy with radio-
therapy and later chemotherapy is the treatment.
When many other nodes are involved chemotherapy is the
choice therapy.
Note:
Lymphoma occasionally can occur in other salivary glands also (10% of
all salivary lymphomas).
In time of test, family is best.
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PAROTIDECTOMY
Superficial/lateral parotidectomy (Patey): It is removal of
superficial lobe of the parotid in front of the faciovenous plane
of Patey.
Partial (functional) parotidectomy: It involves resection of
parotid pathology with normal parotid tissue, done in benign
pathology and low grade malignancies. Here main facial
nerve trunk is identified but there is no need to dissect the
branches.
Total conservative parotidectomy: Here both superficial and
deep lobes of the parotid are removed preserving the facial
SRB's Manual of Surgery
nerve. Dissection along the faciovenous plane is carried out to
identify the branches of the facial nerve retaining the isthmus/
tumour-bearing area. Nerve branches are retracted aside to reach
the deep lobe which is removed entirely by dissecting off the
branches of facial nerve carefully without injuring them. This is
the right technique even though many advocate removing superficial lobe initially then deep lobe separately. Retromandibular
vein is ligated here.
Radical parotidectomy: Involves removal of both lobes of
parotid with facial nerve, fat, fascia, masseter, pterygoid,
buccinator along with neck lymph node dissection. Facial nerve
is sacrificed. Its branches whenever possible can be saved as
additional advantage of survival not thereby removing uninvolved
branches. On table frozen section biopsy of cut ends of nerve
are needed. Ends of the cut nerve branches are tagged by fine
sutures for eventual nerve grafting using great auricular nerve
or sural nerve. Often radical parotidectomy is combined with
removal of temporomandibular joint, mastoid process and
external auditory meatus with less additional benefit. Mastoidectomy is done to visualize the clear proximal part of the facial
nerve. Reconstruction of the main trunk, marginal mandibular,
temporal and buccal branches are done to maintain eye closure
and good oral competence.
Extended total parotidectomy: Removal of the superficial and
deep parotid gland also may be extended to involve adjacent
structures.
Suprafacial extracapsular parotidectomy: It is done for
benign tumour (pleomorphic adenoma) at lower pole wherein
all branches of facial nerve need not be dissected. Under
general anaesthesia, with preauricular incision superficial
muscular aponeurotic system layer (SMAS [SMAS is a
fibrous network that invests the facial muscles, and connects
them with the dermis; platysma inferiorly; zygomatic arch
superiorly; facial nerve courses deep to the SMAS and the
platysma]) is exposed with subplatysmal plane. Flap is raised
1 cm beyond the tumour area. Tumour circumference is
marked and cruciate incision is placed over the fascia; incision is deepened to raise four flaps. Blunt and careful sharp
dissection is done away from the tumour capsule with a
margin of 3 mm; normal parotid is retracted all around and
dissection is carried out. Facial nerve branches whenever
visible carefully dissected off the field without injuring it.
Tumour capsule should not be ruptured to avoid spillage.
Entire tumour is removed with 2–3 mm margin. Fascia is
sutured back; suction drain is placed; wound is closed in
layers. This technique reduces the chances of facial nerve
injury and Frey’s syndrome.
STEPS IN PAROTIDECTOMY
B
x Lazy ‘S’ incision—modified Blair’s/Sistrunk’s approach and
raising the skin flaps or facelift incision
x Mobilisation of the gland
x Flap is reflected in front just up to anterior margin of the parotid;
never beyond. After identification of sternocleidomastoid great
auricular nerve is identified and can be sacrificed. Posterior belly
of digastric is identified.
x Location of stylomastoid branch of posterior auricular artery
is anterior to facial nerve trunk which enters the stylomastoid
foramen.
x Thrust the mosquito haemostat 5 mm in front of facial nerve;
open the blades for 5 mm; lift the blades for 5 mm.
x One should worry about the nerve but not small bleeding.
x Identification of facial nerve trunk.
x Dissection of the gland off the facial nerve using bipolar cautery.
x Removal of parotid—superficial/both.
x Distilled water (hypertonic) irrigation to kill spilled tumour cells.
x Haemostasis and closure with a suction drain.
Fig. 4.36: Incision for parotidectomy. Typical lazy ‘S’.
Fig. 4.37: ‘S’ shaped incision for parotidectomy.
B CA
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Figs. 4.38A to C: Steps in parotidectomy and demonstration of facial nerve. Note the placement of drain after surgery
(Courtesy: Professor Kishore
Fig. 4.39: On table exposure of facial nerve branches after superficial
parotidectomy for a benign tumour.
Chandra Prasad, ENT, Mangaluru; Dr Sampath, MS, ENT, Mangaluru).
become united to sympathetic nerves from the superior
cervical ganglion (Pseudos
ynapsis). There is inappropriate
regeneration of the damaged parasympathetic autonomic
nerve fibres to the overlying skin.
Auriculotemporal nerve has got two branches. Auricular
branch supplies external acoustic meatus, surface of
tympanic membrane, skin of auricle above external
acoustic meatus. Temporal branch supplies hairy skin of
the temple. Sweating and hyperaesthesia occurs in this
area of skin.
Causes: Surgeries or accidental injuries to the parotid;
Surgeries or accidental injuries to temporoman
dibular
joint.
411
CHAPTER 4 Salivary Glands
IDENTIFICATION OF FACIAL NERVE
B
x Facial nerve is 1 cm deep and below the tip of the inferior portion
of the cartilaginous canal—Conley’s point
x By nerve stimulator
x It is inferomedial to tragal point
x Deep to digastric muscle and tympanic plate
x Nerve is just lateral to the styloid process
x Tracing branch from distal to proximal (Hamilton-Bailey technique)
COMPLICATIONS OF PAROTIDECTOMY
B
x Facial nerve injury 25%
x Haemorrhage
x Salivary fistulas
x Infection—Flap necrosis is
common
x Frey’s syndrome
x Sialocele
x Numbness over the face and
ear—due to injury to great
auricular nerve. Female patients
find difficult to wear ear rings.
Spontaneous recovery may
occur in 1½ to 2 years.
FREY’S SYNDROME (Auriculotemporal
Syndrome, Gustatory Sweating);
(Lucie Frey—Polish Surgeon—1932)
Occurs in 10% of cases.
It is due to injury to the auriculotemporal nerve, wherein
post-ganglionic parasympathetic fibres from the otic ganglion
Features
Flushing, sweating, erythema, pain and hyperaesthesia in the
skin over the face innervated by the auriculotemporal nerve,
whenever salivation is stimulated (i.e. during mastication).
Condition causes real inconvenience to the patient.
Involved skin is painted with iodine and dried. Dry starch
applied over this area will become blue due to more sweat
in the area in Frey’s syndrome—Minor's Starch iodine test.
Treatment
Initially conservative and reassurance. Most often they
recover without any active treatment in 6 months. Antiperspirants, anticholinergics like scopolamine 3%, glycopyrrolate
1%, methyl sulfate, radiation 50 Gy are used.
Occasionally (10%) they require surgical division of the
tympanic branch of the glossopharyngeal nerve below the
round window of middle ear [i.e. intra tympanic parasympathetic (Jacobsen nerve) neurectomy].
Dermal/fat graft; avulsion of auriculotemporal nerve; interposi-
tion of temporal fascia, fascia lata, sternomastoid muscle, acellular human dermal collagen; alcohol injection—are all tried.
Note:
Incidence is higher with a flap elevation superficial to platysma. Elevation
of thick flap or insertion of fat flap under skin during surgery may reduce
the chance of Frey’s syndrome.
You will soon break the bow if you keep it always stretched.
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SRB's Manual of Surgery
Fig. 4.40: Parasympathetic and sympathetic supply of the parotid gland.
Otic ganglion located just below the foramen ovale close to mandibular
nerve relays the parasympathetic supply from glossopharyngeal
nerve through tympanic branch, tympanic plexus in middle ear and
then lesser superficial petrosal nerve. Post-ganglionic fibres run in
auriculotemporal nerve along with unrelayed sympathetic fibres from
middle meningeal plexus.
TREATMENT OF FREY’S SYNDROME
B
x Reassurance
x Jacobsen neurectomy (tympanic)
x Injection of botulinum toxin to the affected skin
x Antiperspirants like aluminium chloride
x Syndrome can be prevented on table by placing muscle (sterno-
mastoid) or fascial (temporalis) flaps or artificial membranes over
parotid bed, under the skin
FACIAL NERVE INJURY (Lower Motor Nerve
Lesion, Surgically Related)
Causes
Trauma; Surgery—parotidectomy, drainage of parotid
abscess
Compression of facial nerve—Bell’s palsy.
Incidence of temporary/transient facial nerve palsy after
parotidectomy is 30%. Recovery occurs usually in 12 weeks.
It is due to transection of trunk or branches or excessive
traction or over use of nerve stimulator.
Treatment
Nerve grafting using greater auricular nerve, sural nerve,
lateral cutaneous nerve of thigh or hypoglossal nerve.
Suspension of angle of mouth to zygomatic bone using
temporal fascia sling.
Lateral tarsorrhaphy—to prevent corneal ulcera tion.
Medial canthus reconstruction—to reduce epi phora.
Cross-facial nerve transplantation from opposite side using
its insignificant branches.
Dynamic neurovascular muscle graft.
Upper lid gold weights to protect cornea.
SURGERIES FOR FACIAL NERVE PALSY
B
x Static
– Suspension surgeries using temporal fascia
– Correction of medial canthus
– Lateral tarsorrhaphy—to prevent exposure keratitis due to
widened palpebral fissure
– Upper lid weights
x Dynamic
– Muscle transfer—temporal to masseter
– Free muscle graft. Gracilis muscle neurovascular transfer
– Cross-facial nerve transplant from opposite facial nerve to
injured facial nerve using sural nerve
– Nerve grafts
The House-Brackmann score
It is a score used in facial nerve palsy to grade the degree of
damage. It is done by measuring the upward movement of the
middle portion of the eyebrow top and the outward movement
of the angle of the mouth. Each reference point scores 1 point
for each 0.25 cm movement, up to a maximum of 1 cm. The
scores are then added together, to give a number out of 8. It is
a measure of the range of intentional movement of the patient’s
facial muscles. Even though it is a subjective scale, overall reliability is good and is the most commonly used. Electroneuronography is the other method used.
Clinical Features
Inability to close the eyelid.
Difficulty in blowing and clenching.
Drooping of the angle of the mouth.
Obliteration of nasolabial fold.
Loss of forehead wrinkles.
Wide palpebral fissure.
Epiphora.
BA
Figs. 4.41A and B: Features of post-parotidectomy facial nerve palsy.
Note:
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• Accessory parotid tumour—Accessory parotid tumour is very rare
tumour arising from accessory parotid usually above the parotid duct
level in front of the masseter muscle. It can be benign or malignant.
Pleomorphic adenoma is common. Tumour behaves like tumour from
main parotid gland. Incidence is 1% of all parotid tumours. 30% of them
are malignant. It is located in a line at central 1/3rd of the line joining the
middle of the tragus to a point between the ala of the nose and vermilion
border of upper lip. FNA
anatomical location. Main parotid gland is usually normal. Surgery is the
treatment. Standard parotidectomy incision or direct cheek approach
can be used. But direct cheek approach can cause higher incidence of
buccal and zygomatic branches of facial nerve injuries (40%). Standard
parotidectomy approach has got less chance of nerve branch injuries.
Lymph node spread in the neck is dealt with radical dissection. Excision
cures the benign disease.
C confirms the diagnosis. CT scan confirms the
• Granulomatous sialadenitis—It is a rare condition presenting as painless
swellings of the parotid and submandibular salivary glands. It is due to
tuberculosis, sarcoidosis, toxoplasmosis, syphilis, cat scratch disease,
mycosis, Wegener’s granulomatosis, post radiotherapy.
Heerfordt’s syndrome is sarcoidosis of parotid swelling; anterior
uveitis; facial palsy and fever.
REMEMBER
B
x Taste sensation and general sensation (lingual nerve) should be
checked. Patient is not allowed to speak but asked to write in a
paper. Taste material is instilled on the surface of the diseased
side first and then normal side. Prior to each instillation patient
Contd...
Contd...
should wash his mouth with warm water. Usually four substances
are used. After 10 seconds patient should identify the substance
and write. Facial nerve serves 3 tastes—salt (rock salt) on the
tip of tongue; sweet using syrup on the tip of the tongue; sour
using lemon juice on the lateral aspect of the tongue. Bitter taste
is mediated by glossopharyngeal nerve and is tested using quinine
on posterior third of the tongue.
x Secretomotor fibres of parotid: Secretomotor preganglionic
fibres from inferior salivary nucleus → glossopharyngeal nerve →
tympanic branch → tympanic plexus → lesser superficial petrosal
nerve → otic ganglion → post-ganglionic fibres → auriculotemporal nerve, branch of mandibular division of trigeminal nerve
→ parotid gland.
x Secretomotor fibres of submandibular salivary gland: Pregan-
glionic fibres from superior salivary nucleus → facial nerve →
chorda tympani nerve → lingual nerve → Langley’s submandibular ganglion → postganglionic fibres → sub-mandibular and
sublingual salivary glands.
x Parotid gland is serous. Submandibular gland is mixed (major
is mucous). Sublingual is mucous. Minor salivary glands are
mucous except von Eber’s glands which empty into the circum-
vallate papillae and glands in the tongue tip.
x 70% of total saliva is from submandibular salivary gland. 25%
of saliva is from parotids. 10% of total salivary volume is from
minor salivary glands.
x Normal salivary secretion per day is 1500 mL. It is hypotonic fluid
with pH 7.0. It contains α-amylase.
413
CHAPTER 4 Salivary Glands
You may say you KNOW, but by your actions it is KNOWN.
C hapter Outline
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Chapter
5
Neck
·
Anatomy of Lymphatics
of Head and Neck
·
Thoracic Outlet
Syndrome
·
Cervical Rib
·
Branchial Cyst
·
Branchial Fistula
·
Pharyngeal Pouch
·
Laryngocele
·
Cystic Hygroma
·
Ludwig’s Angina
·
Parapharyngeal Abscess
·
Retropharyngeal
Abscess
·
Subhyoid Bursitis
·
Carotid Body Tumour
·
Torticollis
·
Sternomastoid Tumour
·
Tuberculous
Lymphadenitis
·
Cold Abscess
·
Secondaries in Neck
Lymph Nodes
·
Chemotherapy for Head
and Neck Cancers
ANATOMY OF LYMPHATICS OF
HEAD AND NECK
Waldeyer’s Lymphatic Ring (Inner)
It consists of adenoids above, lingual tonsil below and two
palatine tonsils and tubal tonsils laterally one on each side
(Fig. 5.1).
Outer Circular Chain of Nodes (Outer
Waldeyer’s Ring)
Occipital, postauricular, preauricular, parotid, facial, submandibular, submental, superficial cervical and anterior cervical.
Facial nodes are:
a. Superficial
¾
Upper—infraorbital.
¾
Middle—buccinator.
¾
Lower—supramandibular.
b. Deep groups—in relation to pterygoids.
Fig. 5.1: Inner and outer Waldeyer‘s ring anatomy.
Submandibular lymph nodes drain: The side of the nose; The
cheek; Angle of the mouth; Entire upper lip; Outer part of the
lower lip; The gums; Side of the tongue.
Submental lymph nodes:
Drain from the central part of the lower lip, floor of the mouth
and apex of the tongue.
Superficial cervical nodes: They lie on outer surface of the
sternomastoid around the external jugular vein. They drain the
parotid region and lower part of the ear.
Deep cervical lymph nodes: Upper deep cervical lymph
nodes—jugulodigastric nodes Below the digastric and in front
of IJV. Lower deep cervical lymph nodes—jugulo-omohyoid
nodes—Above the omohyoid and behind the IJV. They drain
the ipsilateral half of head and neck, finally form a jugular lymph
trunk from lower deep cervical nodes to join thoracic duct on the
left side, and the junction of right subclavian and right jugular
vein on right side.
RULE OF 7 IN THE NECK
B
x 7 days—inflammation
x 7 months—neoplasm
x 7 years—congenital defect
Note: The Rule of 7 provides a probable diagnosis of the neck mass
based on the average duration of the patient’s symptoms
RULE OF 80 IN THE NECK
https://t.me/medicina_free
B
x 80% of nonthyroid neck masses are neoplastic
x 80% of neoplastic neck masses are seen in males
x 80% of neoplastic neck masses are malignant
x 80% of malignant neck masses are metastatic
x 80% of metastatic neck masses are from primary sites above
the clavicle
415
CHAPTER 5 Neck
Fig. 5.3: Triangles of the neck and lymphatic drainage of the neck.
THORACIC OUTLET SYNDROME (TOS)
A
It is a syndrome complex due to neurovascular bundle compression in the thoracic outlet.
Compression may be by bony or
ligamentous or muscular structures. Thoracic outlet is bounded
by T1 vertebra behind, manubrium in front, first rib and costal
cartilage laterally.
Thoracic outlet has got two main spaces:
Scalene triangle is bound by scalenus anterior, scalenus medius
and first rib. It contains subclavian artery and brachial plexus.
Costoclavicular space is bound by clavicle, first rib, costo-
clavicular ligament and scalenus medius. It con tains subclavian artery and vein and brachial plexus.
Causes
Cervical rib; Long C7 transverse process.
Anomalous insertion of scalene muscles.
B
Scalene muscle hypertrophy; Scalene minimus.
Abnormal bands and ligaments.
Fracture clavicle or first rib; Exostosis.
Tumours in the region.
Brachial plexus trauma and diseases.
DIFFERENTIAL DIAGNOSIS OF TOS
B
x Carpal tunnel syndrome
x Cervical spondylosis
x Spinal canal tumours
x Shoulder myositis
x Angina
x Raynaud‘s disease
x Spinal stenosis
x Ulnar nerve compression,
epicondylitis
C
Figs. 5.2A to C: Lymph node enlargement due to various causes is
the commonest clinical finding in the neck. Nonspecific lymphadenitis,
tuberculosis, secondaries and lymphoma are common conditions:
(A) Tuberculosis; (B) Secondaries in lymph node; (
Do not worry and hurry so much rather walk this earth lightly and leave your mark.—Dr Saroj Kanna
C) Lymphoma.
Features
Common females (3:1).
Neurological symptoms (95%)
Paraesthesia.
Pain in shoulder, arm, forearm and fingers.
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