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384
Manipal Manual of Surgery
mandibular tunnel of Patey and push the pharyngeal
wall, tonsil and soft palate. These tumours are called
dumb-bell tumours.
Differential diagnosis of swelling in parotid region
(Key Box 36.7)
Key Box 36.7
Differential Diagnosis of Swelling
in the Parotid Region
1. When it involves the preparotid region and angle of
mandible
Preparotid lymph node enlargement: It may be
enlarged due to tuberculosis, metastasis or in nonHodgkin’s lymphoma. Sebaceous cyst in preparotid region
Preauricular dermoid cyst (young patients)
Mesenchymal tumours such as lipoma, neurofibroma
Haemangioma, lymphangioma (Fig. 36.12)
2. When it involves lower pole of parotid
Upper jugular chain lymph node enlargement—
metastatic or tubercular
Branchial cleft cyst
Epithelial inclusion cyst
Investigations
Slow growing parotid tumours should not be subjected
to biopsy for two reasons:
• Injury to the facial nerve.
• Seeding of tumour cells in the subcutaneous plane
which causes recurrence in about 40–50% of cases.
1. Ultrasound is the first investigation. It can
recognise the organ of origin and can detect solid
areas. It can assess neck lymph nodes also. Cystic
areas represent necrosis. Thus ultrasound guided
fine needle. Fine needle aspiration cytology
(FNAC) is done to confirm the diagnosis and rule
out malignancy.
. CT scan is done when the tumour is arising from the
2
deep lobe. It helps to define the extraglandular
spread, the extent of parapharyngeal disease,
cervical lymph nodes and bony infiltration.
Indications for CT scan
a. Suspected bone destruction at skull base
b. Suspected involvement of mandible
c. To assess neck nodes (Fig. 36.13)
3. FNAC of the lymph nodes that are palpable in the
neck in cases of malignancy of the parotid gland.
4. X-ray of the bones (mandible and mastoid process)
to look for bony resorption, if malignancy is
Section II • General Surgery
suspected.
Fig. 36.13: CT scan showing parotid tumour
5. MRI is a better investigation. However, it is
expensive—CT scan and MRI lack specificity for
differentiating between benign and malignant
lesions.
Indications for MRI (Fig. 36.14)
• Delineating the interface between tumour and
normal salivary gland.
• Better imaging of the parapharyngeal space.
• Evaluating perineural spread, e.g. adenoid cystic
carcinoma.
• Facial nerve status may be better appreciated.
Fig. 36.14: MRI showing parotid tumour
Salivary Glands
385
Before we discuss treatment, let us study a few termino-
logies of parotidectomy.
Parotidectomy
• Superficial: When superficial lobe is removed (superficial to
facial nerve).
• In cases of deep lobe enlargement, whole gland has to be
removed—tot
• Superficial (partial) adequate: Only tumour with small portion
of cuff of parotid gland is removed. Entire lobe is not removed.
• Total: Removal of the entire parotid gland.
• Radical: Total parotidectomy with or without removal of skin,
petrous temporal bone, temporomandibular joint, facial nerve
with selective neck dissection.
• Extended: Total parotidectomy + sacrifice facial nerve +
removal of adjacent structures which are infiltrated such as
mandible or masseter muscle, etc.
Extracapsular Dissection
• It is an alternative method of dissection of parotid gland
• Here, nerve is not dissected
• Hence, less invasive
• Temporary facial nerve paralysis is also very less—less than 10%
• Dissection is started in the plane just above parotid fascia
(shining)
• After raising skin flaps, a cruciate incision is made over the
surface of the tumour
around 2 mm.
al parotidectomy.
, flaps raised, tumour is dissected all
Treatment of Pleomorphic Adenoma
• Superficial parotidectomy (Fig. 36.15 and Key Box 36.8).
• It is the standard surgery done for benign pleomorphic
adenoma. It means removal of the entire lobe containing the tumour which is superficial to the facial nerve.
Facial nerve should always be preserved. Enucleation should never be done as it causes recurrence
and can injure facial nerve. It is difficult to remove a
recurrent tumour.
Some Important Steps of Superficial
arotidectomy (Key Box 36.9)
P
1. Adequate exposure by an incision which starts in
front of tragus of ear, vertically descends downwards,
curves round the ear lobule up to the mastoid process
and is carried downwards in the neck (‘Lazy S’
incision).
2. Recognising the facial nerve at surgery
• Facial nerve lies 1 cm inferomedial to the bony
cartilaginous junction of external auditory canal
(Conley’s pointer).
• In very difficult cases, identify styloid process and
nerve is superficial to it.
• Trace the posterior belly of digastric up to the mas-
toid process.
Facial nerve is in between the muscle
and tympanic plate (immediately above the muscle).
• A nerve stimulator may be used.
3. Developing a plane: Facial nerve and retromandi-
bular vein divide the parotid gland into superficial
and deep lobes. Benign tumours do not invade this
faciovenous plane of Patey.
4. Gentle handling, good suction and perfect haemo-
stasis help in clear recognition of the nerve.
5. In toto removal—the tumour along with the lobe to
avoid spillage (which is one of the causes of recurrence)
(Fig. 36.16).
6. Good suction drainage of the wound is necessary to
avoid haematoma, wound infection, etc.
Fig. 36.15: Superficial parotidectomy: Facial nerve divides the
gland into superficial and deep lobes. The entire superficial lobe
is removed preserving the facial nerve
Key Box 36.8
Superficial Parotidectomy
Indicated in pleomorphic adenoma and other benign
neoplasms.
Tumour along with the normal lobe is removed.
Preserve the facial nerve, even in malignant tumours
unless grossly involved.
Avoid rupture of the gland.
Enucleation should not be done as it causes recurrence.
Key Box 36.9
What should be Done in Parotid Surgery?
Wide exposure by an adequate skin flap.
Always identify facial nerve (best way to avoid injury).
Minimum surgery to be done is superficial parotid-
ectomy (enucleation can cause recurrence and injury
to facial nerve).
Always try to preserve facial nerve even in malig-
nancies unless it is directly infiltrated.
If facial nerve is excised, try to reconstruct immediately
by nerve graft—greater auricular or sural nerve.
Always ‘drain’ the cavity.
Buccal nerve can be excised without any repair.
Section II • General Surgery
386
Fig. 36.16: Superficial parotidectomy specimen—avoid rupture
of the gland at surgery
Manipal Manual of Surgery
Total conservative parotidectomy: Excision of super-
ficial and deep lobe of parotid gland while preserving
the facial nerve.
Complications of Parotidectomy (Key Box 36.10)
Key Box 36.10
Complications of Parotidectomy
Flap necrosis—avoid acute bending of the incision and
to use gentle retraction
Facial nerve palsy—careful identification
Fluid collection: Blood or seroma—perfect haemostasis
and drain should be used
Fistula salivary duct should be ligated
Frey syndrome—occurs in 10% of the cases
Observe 5Fs. “Details are given later”
Indications for Postoperative Radiotherapy
• If the deep lobe is involved
• If the lymph nodes are involved
• High grade tumours
• If margins are positive
• Perineural invasion
• Lymphovascular invasion
Postoperative Radiotherapy
T3/T4 cancer: Adenoid cystic carcinoma recurrent
tumours.
ADENOLYMPHOMA (WARTHIN’S TUMOUR, PAPILLARY
CYSTADENOMA LYMPHOMATOSUM)
• Adenolymphoma is not a lymphoma. It is a misnomer
(vide infra).
• It is a benign parotid tumour and next common to
pleomorphic adenoma. It constitutes about 10% of
Section II • General Surgery
parotid tumours.
• Origin of adenolymphoma: During development,
some parotid tissues get included within lymph
nodes (preparotid) which are present within the
parotid sheath.
Histology
• It is composed of double-layered eosinophilic
epithelium. The inner cells are columnar.
• Presence of lymphatic tissue in the stroma and lymph
follicles is characteristic of adenolymphoma (hence
the name).
Clinical Features (Table 36.3)
• Middle-aged or elderly
males are commonly
affected—usually they
are smokers.
• Can be bilateral, in
some cases (10%).
• It has smooth surface,
round border with
soft, cystic consistency
(Fig. 36.17).
• Classically, situated at
the lower pole of
Fig. 36.17: Adenolymphoma
parotid elevating the ear lobule. Sometimes it may
be multicentric.
• This tumour affects only parotid gland (very, very
rarely other glands may be affected).
Table 36.3 Comparison between pleomorphic adenoma
and adenolymphoma
Features Pleomorphic Adenolymphoma
adenoma
1. Incidence 70–80% 10%
2. Sex Common in females Common in males
3. Number Single Sometimes multiple
4. Site Unilateral Bilateral
5. Clinical Nodular, firm Smooth, soft cystic
feature
6. Histology Pleomorphism Double layer epithelium
and lymphoid tissue
99m
7.
Tc-Per- Cold spot Hot spot
technetate
scan
8. Treatment Superficial Superficial
parotidectomy parotidectomy
Salivary Glands
387
Treatment
It has got a well-defined capsule. Hence, enucleation
used to be done earlier but not now. Superficial
parotidectomy is the treatment of choice.
MUCOEPIDERMOID TUMOUR
• As the name itself suggests, it consists of sheets of
epidermoid cells and cystic spaces lined by mucus
secreting cells (Fig. 36.18).
• In childhood, it is the
commonest parotid
tumour. It is benign,
slow growing but hard
in consistency. (Adenolymphoma and mixed
tumours are firm but
mucoepidermoid tumour
is hard.) Parotid is the
commonest site. In cases
of minor salivary glands,
palate is the commonest
Fig. 36.18: Mucoepidermoid
carcinoma
site.
• Mucoepidermoid tumours can infiltrate local tissues,
lymph nodes or skin. Hence, a few consider that
mucoepidermoid tumours are always carcinomatous.
• Well-differentiated tumours behave like benign
tumours, intermediate ones are aggressive and
undifferentiated tumours metastasise early. Mucoepidermoid carcinoma is the most common malignant
epithelial neoplasm of salivary gland.
• The low grade tumours are composed of predomi-
nantly mucus secreting cells. High grade tumours
have predominantly epidermoid cells.
• Benign tumours need excision and malignant tumours
need radical parotidectomy. Radiation is required in
the postoperative period.
OTHER TUMOURS
Acinic Cell Tumour
• These are the uncommon parotid tumours. Commonly
occur in women.
• The cells resemble those of serous acini and this
tumour also has properties of invasion such as mucoepidermoid tumour. It tends to be soft and sometimes
cystic.
Oxyphil Adenoma
Also called oncocytoma. It occurs exclusively in the
parotid gland. It is a solid tumour and occurs in the
sixth decade of life.
Adenoid Cystic Carcinoma
• It is a highly malignant tumour consisting of cords
of dark staining cells with cystic spaces containing
mucin. It also consists of myoepithelial cells and duct
epithelium.
• Even though slow growing, it spreads along the peri-
neural tissue, may invade periosteum or medullary
at a distance. This bone resorption results in bony
bone
tenderness.
• These tumours have a high incidence of distant
metastasis but in general they display indolent
growth. Skin lesions are common as it spreads
along the nerve tissue, which leads to treatment failure.
• Local infiltration, lymphatic and blood spread, and
local recurrence are important features.
• It is hard and fixed and can produce anaesthesia of
the skin overlying the tumour.
• Early cases are treated by radical parotidectomy with
block dissection of the neck. However, many cases
present late to the hospital. Thus, palliative radiotherapy is given to reduce pain and to arrest progress
of the disease.
Summary of Malignant Salivary Gland Tumours
(Figs 36.19 to 36.23 and Table 36.4)
To find out the exact type of malignant tumour is of
interest to pathologists. Clinically, one can suspect
malignancy when a salivary tumour has one of the
following features:
• Rapidly growing neoplasm.
• Change in consistency (the tumour tends to be
hard).
• Fixity to underlying muscle such as masseter as in
parotid tumours.
• Fixity to mandible as in parotid or submandibular
tumour.
• Involvement of facial nerve as in 80% of cases of
malignant parotid tumours.
• Resorption of adjacent bone such as mastoid, tender-
ness as in adenoid cystic carcinoma.
• Significant hard nodes in the neck.
• They are treated by radical sialoadenectomy with
radical block dissection of the neck. Radiotherapy is
used as a palliative treatment.
Section II • General Surgery
388
Manipal Manual of Surgery
MALIGNANT PAROTID TUMOURS
Fig. 36.19: Low grade mucoepidermoid
carcinoma—had restricted mobility due
to fixity to masseter
Fig. 36.22: Carcinoma parotid—late stage
with involvement of platysma—platysma sign
Fig. 36.20: Adenoid cystic carcinoma—
perineural spread is common with this
tumour
Fig. 36.23: Same patient in Fig. 36.22 also had
facial nerve paralysis
Table 36.4 Comparison between submandibular and parotid tumours
Fig. 36.21: High grade muco-epidermoid
carcinoma—rapidly growing and dilated
veins over the sur
face
Submandibular tumour Parotid tumour
• Incidence Uncommon Common
• Malignancy 50% of tumours 10–20%
• Location Submandibular triangle
• Deep lobe involvement Intraorally felt in the floor of mouth Tonsillar shift, can also be felt in the lateral wall
• Surgical treatment of Small tumours—intracapsular submandibular Total conservative parotidectomy for malignant
malignant tumour excision
Large tumours—radical excision with or without Facial nerve should always be preserved.
sacrifice of ‘2’ nerves—lingual and hypoglossal
• Lymph nodes Selective neck dissection—supraomohyoid Selective neck dissection (lateral) levels II, III, IV
dissection and V lymph nodes
neck
• Warthin’s Does not occur here Exclusively occurs in the parotid gland
Section II • General Surgery
Parotid region
tumours
Salivary Glands
389
OPERATIVE PHOTOGRAPHS (Figs 36.24 to 36.27)
Fig. 36.24: Methylene blue is
used to mark the site of incision
and part to be raised
Fig. 36.26: Strap muscles are
divided as a part of supraomohyoid block dissection
Fig. 36.25: Flaps are elevated
Fig. 36.27: Specimen of
tumour with surrounding fat,
fascia and lymphatic tissue
FREY’S SYNDROME—GUSTATORY SWEATING
• Auriculotemporal nerve passes through the fork of
common carotid artery, passing between neck of the
mandible and sphenomandibular ligament.
Here it supplies parotid gland and ascends and supply
auricle. Lastly, it crosses the root of zygomatic process
of temporal bone. Kindly refer to Flowchart
Flowchart 36.2: Trigeminal nerve and its branches
36.2.
• Frey’s syndrome occurs after surgery for parotid
tumours, surgery in the region of temporomandibular joint or due to injury to the parotid gland. Injury
to the auriculotemporal nerve can occur at a site
where it turns around the neck of the mandible. The
injury manifests at a later date, e.g. 2–3 months.
• Because of the injury, postganglionic para-
sympathetic fibres from otic ganglion unite with
sympathetic fibres of superior cervical ganglion
which supplies the vessels and sweat glands over
the skin overlying parotid region (Key Box 36.11 and
Fig. 36.28).
Key Box 36.11
Parts Supplied by Auriculotemporal Nerve
Auricular part:
– External acoustic meatus
– Tympanic membrane surface
– Skin of auricle above external acoustic meatus
Temporal part: Hairy skin of the temple
• As a result of this, whenever the act of chewing or
mastication is started, there is increased sweating and
hyperaesthesia in the region supplied by auriculotemporal nerve (cutaneous branch of mandibular
division of trigeminal nerve). Hence, it is called
auriculotemporal syndrome.
• Diagnosis: Starch
iodine test—paint
the affected area with
iodine and allowed it
to dry before applying the dry starch.
• The starch turns blue
on exposure to iodine
in the presence of
sweat.
Fig. 36.28: Frey’s syndrome
Prevention
Principle is to provide a barrier between the skin and
parotid bed by using temporalis fascial flap or sternomastoid muscle flap.
Treatment
• Reassurance, aluminium chloride—antiperspirant
which is a useful astringent
• Denervation by tympanic neurectomy
• Latest treatment includes injection of botulinum
toxin into the affected skin.
Section II • General Surgery
390
Manipal Manual of Surgery
RARE CAUSES OF SALIVARY
GLAND ENLARGEMENT
1. Sjögren’s Syndrome
It is the diffuse infiltration of salivary and lacrimal glands
with lymphocytes resulting in enlargement of glands
and slow destruction of acini. Thus, clinical features
include dry eyes (keratoconjunctivitis sicca) and dry
mouth (xerostomia). These along with a third component rheumatoid arthritis, form the triad of Sjögren’s
syndrome (primary).
• 30% of patients with systemic lupus erythematosus
and all patients with primary biliary cirrhosis develop
Sjögren’s syndrome. This is termed secondary
Sjögren’s syndrome.
• Other features: This disease is 10 times more common
in females and presents with painful enlargement of
the glands.
• Complications
. Lymphomatous transformation (high in primary).
1
2. Oral candidiasis.
2. Mikulicz Disease
Due to autoimmune mechanism, symmetrical enlargement of all salivary glands and lacrimal gland enlargement occur. Dry mouth and narrow palpebral fissures
are diagnostic of this condition.
Key Box 36.12
Parotid Fistula
Any surgery on the parotid gland—superficial paroti-
dectomy, drainage of abscess, surgery for carcinoma
cheek, facio-maxillary trauma are the causes.
Discharging watery fluid, exaggerated by keeping lime
in the mouth.
Fistulogram confirms the diagnosis.
Exploration and excision of fistula and ligation of duct
is required.
MINOR SALIVARY GLAND TUMOUR (Fig. 36.29)
• Even though they are called minor, numberwise they
are major (many), about 450 in number.
• They are mucus secreting.
• They can present as mucus retention cyst (common
in lip) or as malignant tumour.
• 90% of minor salivary gland tumours are malignant.
• Since they are submucosal, they start as a submucous
nodule (very important point in the history) to
differentiate from carcinoma buccal mucosa/lip, etc.
• As they grow, they ulcerate. Ulceration is a feature
of malignancy.
• Slowly lymph nodes get enlarged.
• Treatment of benign cyst/tumour is by simple
excision and malignant tumour is by wide excision.
3. Drugs
Carbimazole and thiouracil can cause enlargement of
salivary glands.
4. Metabolic Disorders
Diabetes and acromegaly are the other causes.
5. Granulomatous Sialoadenitis
These are rare, painless swellings. Following are the
causes:
• Tuberculosis
• Sarcoidosis—commonly affects parotid gland wherein
it is called pseudotumour
• Toxoplasmosis
• Cat-scratch disease
• Wegener’s granulomatosis
PAROTID FISTULA
It is an uncommon condition which commonly occurs
Section II • General Surgery
after surgery on the parotid gland (Key Box 36.12).
SURGERY FOR FACIAL NERVE PALSY
INDICATIONS FOR DIFFERENT TYPES OF SURGERY
1. Early immediate nerve repair, in case of injury to the
nerve.
2. Late nerve crossing by suturing peripheral branches
of facial nerve to one of the following nerves:
• Hypoglossal nerve, spinal accessory nerve
• Phrenic nerve.
Fig. 36.29: Minor salivary gland tumour in the palate. Laser
excision was done
Salivary Glands
391
3. Surgery to achieve movement in longstanding facial
palsy (usually after 1 year).
A. Static Procedures
• Suspension of lips, cheek and angle of mouth to
zygomatic bone or temporal fascia using fascia lata,
palmaris longus tendon or other alloplastic materials.
• Medial canthoplasty to reduce epiphora.
• Lateral tarsorrhaphy (canthoplasty) to prevent expo-
sure keratitis due to widened palpebral fissure.
B. Dynamic Procedures
• Muscle transfer with carefully preserved muscle
nerve and vessel, e.g. temporalis muscle transfer,
masseter muscle transfer.
• Cross face nerve transplantation using sural nerve.
Using microscope, sural nerve is sutured to the two
or three relatively insignificant branches of facial
nerve (selected by intraoperative electric stimulation)
on normal side. Other end of the sural nerve is
sutured to distal end of the divided facial nerve on
paralysed side.
• Free neurovascular gracilis muscle graft using micro-
vascular
PRINCIPLES OF NERVE REPAIR
1. Preoperative assessment of motor and sensory
system.
. Microsurgical tools should be available.
2
3. Tension-free repair should be done. If tension-free
repair is not possible, then nerve graft can be used.
4. Primary repair when conditions permit.
5. Delayed repair should be done in case of extensive
injury.
Microsurgical Techniques
• 4X magnification needed.
• 9–0/10–0 nylon is used for repair.
• Ends prepared with microscissors. First suture to be
loose to ease the alignment of other sutures.
• Avoid postural manoeuvre to avoid tension. Nerve
can be mobilised 1–2 cm proximally and distally for
tension-free suturing but not more than that.
Conduits
• To place a polyglycolic acid tube to bridge the gap
rather than to perform nerve grafting.
• Indications
–
techniques.
PERIPHERAL NERVE REPAIR AND TRANSFERS
Donor nerve harvest not possible due to availability and associated morbidity
– Patients who decline autogenous nerve graft
harvest
– Nerve gap of not more than 3 cm.
• Principle of conduits
Nerve regeneration and proximal and distal axonal
–
matching result from a combination of neurotropism and contact guidance.
TYPES
ve Grafting
I. Ner
• Indications
–
If a tension-free repair is not possible
– If the nerve gap is more than 3 cm
– Can be used in place of conduits
• Principle
The graft should be oriented in a reverse fashion
–
from its native position so that the regenerating
fibres are not diverted from the distal neurorrhaphy site and distal stump. Misalignment
should be avoided.
• If the nerve gap is small, fascicular matching can be done
• If the nerve gap is long, techniques of awake stimula-
tion or histochemical staining may be used.
• Donor sources for nerve grafting: Posterior inter-
osseous nerve, medial antebrachial cutaneous nerve
for small digital nerves, sural nerve for nerve gaps
involving larger nerves, greater auricular nerve.
II. Nerve Transfer
• It is used for reconstruction of proximal nerve
injuries.
• Drawbacks of nerve graft that become the merits of
nerve transfer:
Grafting across a proximal nerve injury has poor
–
functional outcomes.
– Timely re-innervation may not be possible if the
target muscle is too far from the regenerating site.
• A nerve transfer converts a high level nerve injury to
a low level nerve injury by recruiting expendable
nerve fascicles from the donor nerve to innervate
critical nerves close to their target end organs.
• Donor nerves are preferentially selected according
to their proximity to the target site.
• Criteria for nerve transfers
An expendable donor nerve
–
– Donor nerve with a large number of pure axons
– Donor nerve near the target organ
– Donor motor nerve that innervates a muscle that
is synergistic to the target muscle
• Nerve transfers are done for both motor and sensory
nerves.
Section II • General Surgery
392
Manipal Manual of Surgery
Intersting most common (Key Box 36.13)
Key Box 36.13
Most Common for Salivary Gland Tumours
Most common benign parotid tumour in adults—pleomorphic adenoma.
Most common benign parotid tumour in children— haemangioma.
Most common type of cancer arising in the parotid glands is mucoepidermoid cancer.
Most common malignant tumour in submandibular gland—adenoid cystic carcinoma.
Most common minor salivary gland tumour is adeno-carcinoma.
Most common site of squamous cell carcinoma is sub-mandibular salivary gland.
Most common response to radiotherapy among the malignant tumours is adenoid cystic carcinoma.
1. Commonest tumour of minor salivary gland is:
A. Pleomorphic adenoma
. Warthin’s tumour
B
C. Malignant tumour
D. Mucoepidermoid tumour
2. Parotid duct opens opposite:
A. Upper canine tooth
. Lower canine tooth
B
C. Upper 2nd molar tooth
D. Lower 2nd molar tooth
3. Chronic parotitis in children is pathognomonic of
which infection?
A. HCV infection B. HBV infection
. HIV infection D. Syphilis
C
4. Which is the common site of calculi in submandibular salivary gland?
A. Superficial lobe B. Deep lobe
. Accessory lobe D. Duct
C
5. Deep lobe tumours of parotid gland present as
following features except:
A. Dysphagia
. Can push tonsils
B
C. Can push soft palate
D. Can block the external auditory meatus
7. Conley’s pointer refers to:
A. Location of facial nerve in relation to tragal cartilage
. Location of facial nerve in relation to posterior
B
belly of digastric
C. Location of facial nerve in relation to retromandi-
bular vein
D. Location of facial nerve in relation to pinna
8. Following are true for chronic hyperplastic
candidiasis except:
A. Invasion of Candida albicans
. Antifungal treatment helps
B
C. High malignant potential
D. Floor of the mouth is affected
9. Following benign tumours have high incidence of
recurrence except:
A. Adamantinoma
. Deep lobe tumours of parotid gland
B
C. Desmoid tumours
D. Diffuse lipomata
10. Recommended treatment of pleomorphic adenoma is:
A. Enucleation
. Excision
B
C. Superficial parotidectomy
D. Wide excision
6. The investigation of choice in deep lobe tumours of
parotid gland is:
A. CT scan
. Angiography
B
C. MRI
Section II • General Surgery
D. Ultrasound
11. Which benign tumour of parotid produces hot spot
in Technetium scan?
A. Pleomorphic adenoma
. Adenoid cystic carcinoma
B
C. Mucoepidermoid tumour
D. Adenolymphoma
Salivary Glands
393
12. Commonest parotid tumour in children is:
A. Pleomorphic adenoma
B.
Warthin’s tumour
C. Mucoepidermoid tumour
D. Lymphangioma
13. Most common malignant tumour in submandibular
salivary gland is:
A. Pleomorphic adenocarcinoma
B.
Adenoid cystic carcinoma
C. Mucoepidermoid tumour high grade
D. Acinic cell tumour
14. Following are true for precancerous lesions of lip/
oral cavity except:
A. Keratoacanthoma
Leukoplakia
B.
C. Erythroplakia
D. Submucous fibrosis
15. Following are features of carcinoma maxillary
antrum except:
A. Can cause asymmetry of face
B
Can cause proptosis
.
C. Can cause infraorbital nerve paralysis
D. Can cause buccal branch of facial nerve paralysis
16. Following are the boundaries of nasopharyngeal
space except:
A. Nasal fossae
B.
Basilar part of occipital bone
C. Body of sphenoid
D. Cribriform plate of ethmoid bone
17. Following are true for nasopharyngeal carcinoma
except:
A. Presents as high anterior cervical lymphadenopathy
Can present as trigeminal neuralgia
B.
C. Compression on IX and X cranial nerves
D. Can present as ophthalmoplegia
18. Following are painless ulcers in the tongue except:
A. Gummatous ulcers B. Carcinomatous ulcers
C.
Systemic diseases D. Tuberculous ulcers
19. Following are painful ulcers in the tongue except:
A. Gummatous ulcers B. Tuberculous ulcers
C.
Aphthous ulcers D. Dental ulcers
20. Following are true for syphilitic lesions of the tongue
except:
A. Snail track ulcers B. Gumma
Hutchinson’s wart D. Hunterian chancre
C.
21. Following are true for dental cyst except:
A. Upper jaw is commonly involved
B.
It is a large unilocular cyst
C. Cyst contains cholesterol crystals
D. Arises from unerupted tooth
22. Which one of the following swellings does not
contain cholesterol crystals?
A. Branchial cyst B. Sebaceous cyst
C
Dental cyst D. Hydrocele
.
23. Following are true for dentigerous cyst except:
A. Upper jaw is commonly involved
B
.
Produces egg-shell crackling
C. X-ray shows soap bubble appearance
D. Arises from unerupted tooth
24. Adamantinoma of the jaw has following features
except:
A. It is a malignant tumour
B.
It spreads within medullary bone
C. It is treated by wide excision
D. Mandible is the most common site
25. Which of the following is unilocular cyst?
A. Adamantinoma B. Dentigerous cysts
C
.
Epididymal cyst D. Dental cyst
Answers
1. C 2. C 3. C 4. D 5. D 6. C 7. A 8. D 9. D 10. C
11. D 12. C 13. B 14. A 15. D 16. D 17. A 18. D 19. A 20. D
21. D 22. B 23. A 24. D 25. D
Section II • General Surgery