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13 • Facial Skin and Neck
213
A
Fig. 13.5 This patient presented with acute necrotising ulcerative gingivitis (A) that was associated with bilateral tender lymphadenitis (B).
infection of the oro-facial mucocutaneous complex by herpes simplex virus, varicella zoster virus, coxsackie viruses
and paramyxovirus often cause generalised cervical lymphadenitis. Glandular fever is a disorder mainly affecting teenagers and young adults. It is typically transmitted in saliva
and is sometimes termed “kissing disease”. Affected patients
can present with fever, malaise, pharyngitis, skin rashes, and
cervical lymphadenitis. Although self-limiting, the diagnosis
can be important for those who are experiencing problems
with their work or educational course, as well as for limiting
the spread of the infection. Infection by cytomegalovirus and
human immunodeficiency virus may rarely mimic glandular
fever.
Fungal and Protozoal Infections
Protozoal infections such as toxoplasmosis may rarely be
acquired through contact with animal faeces, soil or contaminated foods. Fungal infections such as histoplasmosis,
cryptococcus, and coccidioides in lymph nodes are very
rare and typically found in immunosuppressed patients.
Sarcoidosis
Granulomatous inflammation that contrasts to mycobacterial infection in that it is non-caseating may be caused by
sarcoidosis. The cause of sarcoidosis is not known and it can
be a challenging diagnosis to make. The lungs are principally affected and there may be fever, malaise, weight loss
and cervical lymphadenopathy in addition to pulmonary
signs and symptoms. The salivary glands and oral mucosa
may be affected. Sometimes the diagnosis is made only from
a core biopsy of the affected lymph node or from an oro facial
tissue biopsy.
Haematological Malignancy
Lymphoma and leukaemia may cause enlargement of
groups of lymph nodes or generalised lymphadenopathy.
The affected lymph nodes feel rubbery and can be matted
together. When such nodes are encountered, the clinical
history must be considered. General symptoms such as
night sweats, fatigue, malaise, weight loss and pyrexia often
accompany haematological malignancy. Lymphoma classification is complex but the disease is divided into Hodgkin
B
and non-Hodgkin types. Accounting for around 10% of all
lymphomas, Hodgkin lymphoma affects mainly teenagers
and young adults. The typical presentation is with cervical
lymphadenopathy, and the disease may be seen first in dental practice. Early diagnosis is related to an excellent prognosis and fast track referral is indicated when Hodgkin
lymphoma is suspected. Depending on stage and subtype,
cure rates of 80% can be achieved by chemotherapy. The
non-Hodgkin lymphomas are a diverse group of diseases,
most commonly derived from the B cell lineage and less
commonly from T cell precursors. High- and low-grade
variants of B cell lymphoma are recognised. Leukaemia is
characterised by circulating malignant cells in the blood
and lymphadenopathy is often a feature seen after the diagnosis has been made. However, in middle-aged and older
adults, chronic lymphocytic leukaemia may present with
cervical lymphadenopathy.
Secondary Malignancy
Lymph nodes in the neck that contain metastatic carcinoma
tend to be hard on palpation and may be fixed to adjacent
tissue. However, where involved nodes contain small metastatic deposits, they may be mobile. Necrosis can lead to
such extensive cystic change that branchial cyst is mimicked. Squamous cell carcinoma of the head and neck is the
most common primary tumour to metastasise to neck nodes
(see Chapter 12). The location of such a metastatic deposit
tends to reflect the site of origin. For example, skin carcinoma arising from the scalp, face and ears often spreads to
intra-parotid, para-parotid and facial nodes, whereas carcinoma of the lip typically metastasises to level I neck nodes.
Oral cancer tends to spread to the submental, sublingual
and submandibular nodes (level I) at first, whilst oro-pharyngeal cancer typically spreads to the jugulo-digastric and
jugulo-omohyoid nodes (level II) nodes. Naso-pharyngeal
cancer often produces bulky bilateral neck nodes. Where the
primary tumour is not identified, biopsy material of metastatic squamous cell carcinoma can be tested for high risk
human papiloma virus (HPV) (identifying a primary in the
oro-pharynx) and Epstein-Barr virus (EBV) (identifying a
primary in the naso-pharynx). In a proportion of cases no
primary cancer is found clinically, and the patient is treated
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Master Dentistry
Fig. 13.6 Imaging showing extra-nodal extension of metastatic squamous carcinoma.
for cancer of unknown origin. An important point to note is
that when a metastatic deposit breaches the lymph node
capsule (known as extra-nodal extension, see Chapter 12),
this indicates that the carcinoma is aggressive and signals
an adverse prognosis. Increasingly it is possible to recognise
extra-nodal extension by imaging (Fig. 13.6).
Other types of malignant tumour can metastasise to
lymph nodes in the neck, including salivary and thyroid
malignancy. Rarely metastasis from a distant site is found,
including breast, lung, colorectal and prostate cancer.
OTHER CAUSES OF LYMPHADENOPATHY
Enlarged lymph nodes may be associated rarely with a
range of disorders other than those described above. Metabolic, endocrine and deposition disorders along with drug
reactions can cause lymphadenopathy.
Cysts of the Neck
Branchial (cleft) cyst is also known as lympho-epithelial
cyst. It typically arises anterior to the sternomastoid muscle
border and may be confused with an upper cervical lymph
node (Fig. 13.7A and B). The cyst is lined by squamous
epithelium and lymphoid tissue is present in the capsule.
The cyst is thought to arise from remnants of brachial
arches and the lining often resembles tonsil crypt epithelium morphologically. Branchial cysts typically contain
semi-solid yellow-grey material and they may become
infected. Careful pathological assessment is required after
removal because cystic metastatic deposits of squamous
carcinoma can resemble branchial cyst.
Dermoid cysts arise from enclaved remnants after fusion
of embryonic processes and therefore occur in the midline.
Dermoid cysts can occur above or below the mylohyoid
muscle, and consequently may project into the floor of the
mouth or into the submental area of the neck. Rarely midline dermoid cysts can become lateralised and occur adjacent to the submandibular gland.
Plunging ranula is a cystic mass in the anterior submandibular area caused by obstruction of a sublingual gland
(Fig. 13.8). Extravasated mucin tracks through the mylohyoid muscle tissue plane and there may or may not be an
associated swelling in the floor of the mouth. On CT or MRI
scanning a small ‘tail’ can be seen extending into the sublingual gland and this finding distinguishes the plunging
ranula from the dermoid cyst.
A B
Fig. 13.7 Coronal and axial MRI images (different sequences), showing second brachial cleft cyst on the left side of the neck. At the level of the larynx
(A); anterior to the sternocleidomastoid muscle (B).
Fig. 13.8 Plunging ranula caused by mucous extravasation from the
sublingual gland.
Other cysts to be aware of in the neck are the thyroglossal
tract cyst which also occurs in the midline adjacent to the
hyoid bone (Fig. 13.9A and B). Typically, this cyst is seen in
younger patients and can be recognised by its movement up
and down during swallowing. Epidermal cysts and thyroid
cysts are also well recognised to occur in the neck.
Although the suprahyoid neck is the main area that relates to dentistry, swellings and enlargement of the thyroid
gland (goitre) are relatively common and can often be
recognised in the clothed patient. Single or multiple thyroid
nodules can occur but diffuse thyroid swelling is also possible. Most thyroid enlargements are benign but patients
should seek advice as cysts, adenomas and even thyroid
carcinoma can present in this way. Also in the lower neck,
it is important to be aware of that supraclavicular nodes
may be become enlarged in lymphoma, lung cancer and a
variety of reactive processes.
13 • Facial Skin and Neck
215
Self-Assessment Questions
TRUE/FALSE
1. The following are features of basal cell carcinoma affecting
the face:
a. A biopsy would be expected to show islands of basophilic
cells with frequent mitosis and apoptosis
b. Keratin horn material is typically present on the
surface
c. A high cure rate can be achieved by surgery or
radiotherapy
d. Small blood vessels may run over the surface producing
a telangiectatic appearance
e. Multiple basal cell carcinomas, odontogenic keratocysts,
pits of the palms and soles, and skeletal malformations
can occur in a syndrome
2. The following are features of malignant melanoma
affecting the skin visible in the clothed patient:
a. Melanomas are the fifth most common cancer in the
United Kingdom and show an increasing incidence
b. Melanomas are more common in sun-exposed skin
than non-exposed skin but can occur anywhere on
the skin
c. Having a relative with melanoma and a fair skin
increases the risk of developing melanoma
d. Melanomas developing in the extremities and nail
beds (acral malignant melanoma) is more common
in dark-skinned people than lighter-skinned people
e. Melanoma always develops from a pre-existing mole
(melanocytic naevus)
3. Thyroglossal tract cyst has the following characteristics:
a. It is most common in people over 40 years of age
b. The cyst lumen can be lined by respiratory or squa-
mous epithelium and thyroid tissue is often present in
the cyst capsule
A B
Fig. 13.9 Coronal (A) and axial (B) MRI images showing midline infrahyoid thyroglossal duct cyst “nestled” deep to the strap muscles.
216
Master Dentistry
c. The cyst occurs in the midline and moves up and
down on swallowing or protruding the tongue
d. It is advised that the anterior part of the hyoid bone
is removed surgically along with the cyst
e. Speaking with a hoarse voice is a common sign of
thyroglossal tract cyst
4. Warthin tumour is most common in the parotid gland,
but ectopic variants can present in the upper neck
a. After pleomorphic adenoma, Warthin tumour is the
second most frequent benign salivary tumour
b. Around 7%–10% of Warthin tumours are bilateral
and they can also rarely be multifocal
c. In fine needle aspiration biopsy, any one of the fol-
lowing features is considered diagnostic for Warthin
tumour: oncocytic epithelium, lymphocytes, necrotic
proteinaceous material
d. Warthin tumour is more common in smokers than in
non-smokers
e. Warthin tumours are commonly detected as an inci-
dental finding when PET imaging is used for other
purposes
Single Best Questions
1. A 13-year-old female patient presented with a painless
neck swelling that appeared suddenly. She had recently
had an upper respiratory tract infection and noticed irritation in the area that subsequently became swollen. A
fluctuant swelling was found in the upper neck just anterior to the border of sternocleidomastoid between muscle
and skin. A fine needle aspirate biopsy showed thick mucopurulent material and microscopically there was a
proteinaceous fluid containing lymphocytes, neutrophils
and macrophages with occasional bland squamous cells.
What is the most likely diagnosis?
a. Thyroglossal tract cyst
b. Reactive lymphadenitis
c. Branchial cleft cyst
d. Metastatic HPV associated oro-pharyngeal carcinoma
e. Dermoid cyst
2. A 12-year-old boy presented with painless enlarged
lymph nodes in the right neck at levels I, III and IV. The
nodes had slowly grown over the last month. He had
been sent home from school feeling tired, itchy and
feverish. The lymph nodes felt rubbery on palpation.
Ultrasound examination showed the enlarged nodes to
be rounded and have a homogeneous echotexture, with
no discernible hilum.
What is the most likely diagnosis?
a. Hodgkin disease
b. Sarcoidosis
c. Cat-scratch fever
d. Chronic lymphatic leukaemia (CLL)
e. IgG4 related disease
3. A 56-year-old man attended your practice for regular
dental care. You had referred him to the Dental Hospital 3 years ago because of widespread leucoplakia. He
has reduced his smoking to five cigarettes per day, and
he takes 12 units of alcohol weekly. A biopsy at the
Dental Hospital 4 months ago was reported as severe
dysplasia. He now presents with a 2 cm mass in the left
submandibular triangle. On palpation, the mass feels
hard and appears fixed to adjacent structures.
What is the most appropriate first management step?
a. Take a DPT and look for dental problems on the left side
b. Examine the oral mucosa, update the history and
refer by fast track
c. Prescribe antibiotics and review in 2 weeks
d. Advise the patient that he should see his GP urgently
about the neck lump
e. Check the flow of saliva from the left submandibular
orifice
4. A 46-year-old Chinese man who had recently moved into
your area presented with enlarged lymph nodes on both
sides of his neck that has slowly increased in size over
2 months. He had never had any dental care previously
and had chronic gingivitis, tooth staining but no caries.
His medical history included previous viral hepatitis and
glandular fever. On questioning he mentioned that he had
been experiencing difficulty with breathing and speech for
3 months. He had experienced nosebleeds twice recently.
There were multiple firm neck nodes on palpation.
What is the most likely diagnosis?
a. Laryngeal carcinoma
b. Reactive lymphadenitis
c. Non-Hodgkin lymphoma
d. Nasopharyngeal carcinoma
e. HIV infection
5. A 62-year-old man asks for an urgent appointment because of pain and swelling under the right angle of the
jaw worsening over the last week. He has no significant
social or medical history and is a never-smoker and nondrinker. On examination, a tender 2 cm mass is palpable
in right level I in the neck. You ascertain that the pain
and swelling are intermittent and worse at mealtimes. A
foul taste is sometimes present in the mouth.
What is the most likely diagnosis?
a. Chronic obstructive sialadenitis
b. Hodgkin lymphoma
c. Eagle syndrome
d. Pleomorphic adenoma
e. Squamous carcinoma of the retromolar area
6. A 63-year-old outdoor road worker attends your practice for the first time as a dental emergency. You notice
that he has a 2.5 cm flat, circumscribed, reddish-brown
patch on the left cheek skin with a rough, scaly, dull
surface. No lymphadenopathy is present on examination. He says it has been there for over 2 years, and although it has steadily increased in size, it is not causing
him any problems. It started when hot tar splashed onto
the area some years ago.
What is the most likely diagnosis?
a. Malignant melanoma
b. Squamous cell carcinoma
c. Basal cell carcinoma
d. Haemangioma
e. Facial scar
7. A 38-year-old man attends your practice for routine
dental care. On extra-oral examination, you note a pigmented patch on the left temporal skin that has a raised
black nodular area in the centre. The patient has no
significant medical history. The patient says the pigmented patch had been there for years. Recently it
became itchy and he scratched it. The left facial node
was palpable and firm nodes in left neck in levels I–III
were also present.
What is the most likely diagnosis?
a. Pigmented seborrhoeic keratosis
b. Epidermal cyst
c. Lentigo maligna melanoma
d. Squamous cell carcinoma
e. Post inflammatory pigmentation
8. A 38-year-old woman from Morocco attended with bilateral neck swellings. She had no known medical history
and but had a persistent cough that had never been investigated. Her saliva was sometimes flecked with blood after
coughing. In the oral cavity, her periodontal condition
was poor. For many months, she had been experiencing
night sweats and malaise. Multiple enlarged tender lymph
nodes were found bilaterally in the neck at all levels. The
left supraclavicular node was enlarged and painful. A
sinus tract was present in the skin over the node.
What is the most likely diagnosis?
a. Non-Hodgkin lymphoma
b. Transitory lymphadenitis
c. Glandular fever
d. Tuberculosis
e. Sarcoidosis
13 • Facial Skin and Neck
Fig. 13.11 Swelling of the soft tissue over the angle of the mandible.
217
Case History Questions
CASE HISTORY 1
Daniel is a 60-year-old man who had a lightly pigmented
patch on the skin lateral to the outer canthus of the eye for
many years (Fig. 13.10). He has no symptoms and no signifi-
cant medical history. He is an outdoor person who works in
the gardening industry. The pigmentation had deepened and
the patch had increased in size recently. His dentist noticed
the change and Daniel was seen by the local dermatology
service. A biopsy was taken and the pathologist reported that
there were confluent runs of atypical melanocytes at the epidermal interface. No melanocytes were present in the dermis.
a. What is the differential diagnosis?
b. Discuss the principles of further management
Fig. 13.10 Lentigo maligna involving the lower eyelid and outer
canthus skin.
CASE HISTORY 2
Brian is a 64-year-old man who presented as a dental
emergency. On extra-oral examination, a soft mobile swelling was found overlying the right mandible (Fig. 13.11).
The swelling had slowly enlarged over a period of years
and was painless. A non-urgent referral was made to the
hospital through the GP and the swelling was removed.
The pathologist described the specimen as an encapsulated
mass of yellow tissue that floated in the formalin container.
The histology showed sheets of adipocytes of variable
size separated by broad septa containing hyperchromatic
cells and occasional lipoblasts were seen. MDM-2 and
p16 overexpression were found by molecular pathology
techniques.
a. What is the most likely diagnosis?
b. What is the significance of the histological and molecu-
lar findings?
Self-Assessment Answers
TRUE/FALSE
1. a. True. Basal cell carcinoma is formed of small round
cells resembling the epidermal basal cells. They are
arranged in sheets or nests and are supported by
abundant fibrous stroma. Mitotic figures are frequent
but there is also frequent apoptosis and overall
increase in cell number is small resulting in slow
clinical growth
b. False. Keratin horn material is found on the surface
of squamous cell carcinomas, giving them a dull
appearance
c. True. Basal cell carcinoma is most often treated by
surgery, but radiotherapy can also offer a high cure
rate with minimal adverse effects
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Master Dentistry
d. True. Small blood vessels often cover the surface
of basal cell carcinomas producing a telangiectatic
appearance
e. True. The features are found in naevoid basal cell
naevus syndrome (NBCCS, Gorlin’s syndrome, OMIM
109400). Some affected individuals also have distinctive facial features and variable other features.
Most cases of NBCCS are caused by mutations in the
PTCH1 gene and less commonly in the SUFU and
PTCH2 genes.
2. a. True. Melanomas are the fifth most common cancer
in the UK. Around 16,000 new cases are diagnosed
annually and there are around 2,300 deaths each
year in the UK. The incidence has steadily increased
and may be related to greater exposure to ultra-violet
radiation
b. True. Melanomas are more common in sun-exposed
skin than non-exposed skin and can occur at any
cutaneous location. They can also arise from mucosa, including the lining of the oral cavity
c. True. A family history of melanoma and a having
a fair complexion increase the risk of developing
melanoma
d. True. Acral malignant melanoma is more common
in dark-skinned people than in white people
e. False. Melanoma can develop from a pre-existing mole
but also can be unrelated to a melanocytic naevus. On
the facial skin melanoma can develop from a premalignant pigmented lesion known as lentigo maligna
3. a. False. Over 90% of thyroglossal tract cysts present in
children under 10 years of age but they can occur in
adults.
b. True. The pathological features are quite variable
and the cyst lumen can be lined by respiratory or
squamous epithelium. Normal thyroid tissue is often
present in the cyst capsule.
c. True. The cyst occurs in the midline and moves up
and down on swallowing or protruding the tongue.
d. True. Thyroglossal tract cysts are mostly treated by
the Sistrunk procedure where the anterior part of the
hyoid bone is removed surgically along with the cyst.
This ensures that any remnants of the thyroglossal
tract are excised and reduces recurrence.
e. True. A hoarse voice is a common sign of a thyro-
glossal tract cyst, along with throat pain, dysphagia,
redness and tenderness of the skin overlying the
laryngeal prominence and sometimes formation of a
sinus tract.
4. a. True. Warthin’s tumour is the second most frequent
benign salivary tumour.
b. True. 7%–10% of Warthin’s tumours are bilateral
and they can rarely be multifocal
c. False. In fine needle aspiration cytology, diagnosis is
based on finding any two of the following features:
oncocytic epithelium, lymphocytes, necrotic proteinaceous material.
d. True. Warthin’s tumour is much more common in
smokers than in non-smokers.
e. True. Imaging using Tc99-pertechnetate, thallium
and FDG-PET can reveal Warthin’s tumours, which
are avid for these tracers. Diagnostic confusion with
metastatic disease can therefore sometimes occur.
Single Best Answers
1. A branchial cleft cyst is the most likely diagnosis. The
age, location and fluctuant nature are typical. Branchial
cleft cyst often presents when infected, most often after
pharyngitis. Thyroglossal duct cyst occurs only in the
midline. Reactive lymphadenitis is typically painful or
tender and noncystic. Metastatic HPV associated squamous carcinoma is a major differential diagnosis for
branchial cyst but is unlikely at this age and the FNAB
showed bland epithelial cells. Dermoid cyst typically
occurs in the midline and only very rarely lateralises.
2. Hodgkin disease is the most likely diagnosis. The affected
lymph nodes characteristically feel rubbery and the ultrasound features suggest that the lymph node has been
infiltrated by lymphoma. Sarcoidosis normally affects
people aged 20 or over and is very rare in childhood.
Cat-scratch fever is a bacterial disease caused by Barton-
ella henselae that can spread from a kitten scratch on
skin to cause enlarged lymph nodes. These are typically
in the axilla or groin and not the neck. Chronic lymphatic leukaemia is a disease of the middle aged and elderly group. IgG4 related disease typically affects salivary glands in the head and neck rather than lymph
nodes.
3. The history suggests that malignant transformation has
occurred. The oral cavity should be examined, history
updated and a fast track referral undertaken in a reassuring and professional manner. Any dental problems
should be noted, and it would be appropriate to check for
submandibular sialadenitis but induration (fixation to
tissue) would be not be expected in that condition. There
is no indication for a DPT. Prescribing antibiotics without a reason is inappropriate and would result in delay.
Direct fast track referral to a consultant in oral and maxillofacial surgery is indicated; sometimes patients fail to
follow up on a verbal suggestion that they should see
their doctor.
4. The most likely diagnosis is nasopharyngeal carcinoma.
Ethnic origin and exposure to Epstein-Barr virus are risk
factors. The difficulty with breathing, speech and nosebleeds points to a possible primary lesion in the nasopharynx. Laryngeal carcinoma does affect the voice but is less
likely. The history is too long for a reactive lymphadenitis.
Non-Hodgkin lymphoma is an important differential diagnosis but the nodes would be expected to feel rubbery
rather than firm. HIV infection can mimic many disorders
but is less likely to produce nasopharyngeal symptoms.
5. The features point to a diagnosis of chronic obstructive sialadenitis affecting the right submandibular
gland as the most likely diagnosis. A calculus may be
present in the submandibular duct. Infected saliva can
result in a foul taste in the mouth when the gland
empties. Hodgkin disease is not associated with
obstructive symptoms. Eagle syndrome can produce a
sharp pain on swallowing in the submandibular
triangle but is due to an unusually long stylohyoid
process and does not cause swelling. Pleomorphic adenoma in the submandibular gland would typically
present as a firm to hard, mobile nodule. It could be
associated with secondary obstructive symptoms but
is less likely as a diagnosis. Squamous cell carcinoma
13 • Facial Skin and Neck
219
in the oral cavity can certainly spread into the submandibular triangle but would be expected to produce
a hard mass and obstructive symptoms would be unusual. The oral mucosa should always be carefully
examined to exclude oral cancer in a case like this,
even though the patient has no risk factors.
6. The features are most likely to be caused by a squamous cell carcinoma. This can originate in a burn and
is associated with ultra-violet exposure related to his
occupation. It a slow growing and metastasis can be a
late event. The absence of lymphadenopathy therefore
does not exclude cutaneous squamous carcinoma.
Malignant melanoma is typically pigmented and has
an irregular border with a heterogeneous appearance.
Basal cell carcinomas are characteristically pearly or
shiny rather than dull on the surface. Haemangioma
and facial scar would not be expected to increase in size
progressively.
7. A diagnosis of lentigo maligna melanoma is most likely.
The features suggest that metastasis has already occurred to ipsilateral lymph nodes. Recent change in any
pigmented lesion is suspicious of malignant transformation. Pigmented seborrheic keratosis is a common lesion
on the temple but typically affects older patients and has
a greasy ‘stuck on’ appearance. Epidermal cysts are not
typically pigmented and present as an enlarging fluctuant swelling. Squamous cell carcinoma can be pigmented
but is less likely to arise in a pre-existing pigmented
patch. Post inflammatory skin pigmentation is stable and
tends to fade with time.
8. Tuberculosis is the most likely diagnosis. The disease is
more prevalent in Africa and other developing countries than in Western countries. HIV may predispose
and testing should be offered in a case like this. The
patient is likely to have pulmonary tuberculosis
and haemoptysis is a suspicious sign. One would also
consider lung cancer and a chest radiograph would be
a useful early investigation for this patient. The involvement of a supraclavicular node and formation of a
sinus tract are also in keeping with tuberculosis. In
Hodgkin lymphoma the nodes are usually rubbery and
painless. The history is too long for transitory lymphadenitis or glandular fever. Sarcoidosis is not associated
with haemoptysis or sinus tract formation.
Case History Answers
1. a. Using the ABCDE criteria (Table 13.2), the lesion should
be considered as a possible malignant melanoma. Pigmented basal cell carcinoma is less likely and a biopsy is
mandatory. The biopsy provided a diagnosis of lentigo
maligna. Although no invasive cells were present the
pathologist would examine the excised lesion to look for
a focus of invasive malignant melanoma.
b. Lentigo maligna is a potentially malignant skin disor-
der and Daniel was advised to have the lesion excised.
A special technique called Moh’s surgery was used
because this allows the entire circumferential margin
of the excised skin specimen to be checked using
frozen section control at the time of excision. No invasive melanoma was found in the excised specimen.
2. a. The differential diagnosis includes a soft tissue neoplasm such as lipoma or vascular lesion, facial lymph
node or a cyst.
b. The consultant surgeon thought the most likely diag-
nosis was lipoma and this was in keeping with the
macroscopic appearance after the tumour was
removed. However, the histology and molecular pathology indicated a diagnosis of atypical lipomatous
tumour. The significance of the pathological findings
is that recurrence is more likely than with a lipoma.
14
Salivary Gland Disease
CHAPTER OUTLINE
Overview‚ 220
14.1 Anatomy‚ 220
14.2 Investigations‚ 220
14.3 Salivary Gland Disorders‚ 223
Overview
Secretion of saliva is key to oral health and function.
Altered salivary secretion may result from systemic disorders such as neurological disease, endocrine disturbances,
cancer and commonly unwanted effects of drugs. Sjögren’s
syndrome is an important autoimmune disease that can
result in dry mouth. The salivary glands can be affected by
any condition that blocks the duct, whether extra- or intraductal blockage or duct wall thickening. A number of
tumours can also affect the glands themselves. The surgical
management of salivary glands is described.
14.1 Anatomy
LEARNING OBJECTIVE
You should:
• know the position of the salivary glands and the associ-
ated structures.
14.4 Surgery‚ 232
Self-Assessment: Questions‚ 233
Self-Assessment: Answers‚ 236
PAROTID GLAND
The parotid gland is the largest of the paired salivary
glands. It occupies the region between the ramus of the
mandible and the mastoid process, extending upwards to
the external acoustic meatus, and is essentially pyramidal
in shape. The external carotid artery (deep), the retromandibular vein (intermediate) and the facial nerve (superficial)
pass through the gland. The majority of the gland lies
superficial to the facial nerve. Stenson’s duct runs through
the cheek and drains into the oral cavity opposite the maxillary second permanent molar tooth.
14.2 Investigations
LEARNING OBJECTIVES
You should:
• know the clinical features of salivary gland disease.
• know which investigations are suitable for which
symptoms.
MINOR SALIVARY GLANDS
The minor salivary glands are located in the submucosa
and include the labial, buccal, palatal and lingual glands.
SUBMANDIBULAR GLAND
The submandibular gland is intermediate in size between
the sublingual and parotid glands. It has a superficial part
in the neck, a deep part in the floor of the mouth, and it
wraps around the posterior edge of the mylohyoid muscle.
The superficial part is related to the facial artery, the facial
vein, the cervical branch of the facial nerve, the mylohyoid nerve and the submandibular lymph nodes. The deep
part is related to the lingual and hypoglossal nerves.
Wharton’s duct emerges from the deep part of the gland
and continues forward to empty at the sublingual papilla
in the floor of the mouth. The sublingual gland empties
into the floor of the mouth directly or through Wharton’s
duct.
220
HISTORY AND CLINICAL EXAMINATION
As always, symptoms are often indicative of the abnormality present. These can include:
n
slowly developing swelling or mass, suggesting a tumour
n
swelling (at the site of a major gland) associated with
sight/taste/smell of food, slowly subsiding subsequently,
suggesting obstruction
n
pain and swelling (of a major gland), perhaps with a bad
taste, suggesting infection
n
dry mouth, suggesting a wide range of causes, including
Sjögren’s syndrome.
Look for asymmetry and obvious extra- or intraoral
swelling. In the case of the major salivary glands, establish if one or both glands are affected. Always palpate
salivary glands bimanually. Consider whether a swelling is
firm or soft. Larger calculi may be palpable as hard masses.
In suspected inflammatory disease, see if clear saliva can
be expressed from the duct orifice or, alternatively, whether
14 • Salivary Gland Disease
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turbid, mucopurulent secretion indicative of infection is
present.
By far the most common salivary tumour is the pleomorphic adenoma that presents most often in the parotid gland
as a firm mobile nodule. Malignant tumours in the salivary
glands may present as fixed, firm, rapidly growing masses
with pain and sometimes skin involvement. Facial nerve
palsy is a sinister sign when a parotid mass is detected.
Lymph node metastasis in the regional nodes may be present. It should be remembered that some salivary malignancies (e.g., adenoid cystic carcinoma) may be insidious. They
may cause unilateral facial pain and remain undetected for
a considerable period.
Hypersalivation may be a feature of certain neurological
disorders. Sometimes it is confused with dribbling from the
angle of the mouth caused by loss of neuromuscular control.
Most commonly it may result from hyper-awareness of the
presence of saliva, potentially linked to a psychological disorder, when it is difficult to treat. It is sometimes seen in sialosis,
which presents as painless bilateral parotid gland swelling.
Dry mouth is a frequent complaint and there may be a
sensation of dry mouth (xerostomia) with no objective reduction in flow. Sialometry is a simple first-line investigation that can help to identify reduced salivary flow. The
most common cause of true dry mouth is the unwanted
effects of drugs with sympathomimetic or antimuscarinic
effect (e.g., tricyclic antidepressants and antihistamines).
Treatment of dry mouth is discussed later with Sjögren’s
syndrome.
(oblique occlusal) radiograph (Fig 14.1) with the beam angled anterosuperiorly while centred on the gland itself.
Lateral views may be useful, although again a calculus may
be superimposed upon bone and be difficult to identify.
Ultrasound
Alternatively, if ultrasound examination is selected to identify calculi, a high-frequency transducer is used to obtain
images in several planes of the gland. Bony superimposition
may prevent complete imaging of the deep lobe of the parotid and that part of the submandibular gland immediately adjacent to the mandible. Only calculi larger than
2 mm can be demonstrated on ultrasound. They present
as bright curvilinear foci, that block the passage of sound
beyond (acoustic shadowing) as shown in Fig 14.2.
SIALOMETRY
Normal whole unstimulated salivary flow rates can be assessed by asking the patient to gently dribble any saliva produced over a 5-minute period into a container. The normal
flow rate is 0.3–0.4 mL/min; a flow rate of #0.1 ml/minute
indicates a clinically significant xerostomia.
RADIOLOGY
Selection of imaging methods in suspected or known salivary gland disease is determined for each patient on the
basis of the question which the imaging investigation is
expected to answer.
Is There a Calculus Present?
Plain Radiographs, or Ultrasound
Depending on availability and departmental preference,
one of these will be the first choice for all major glands.
Parotid Glands
Intraoral plain radiographs of the cheek (dental film placed
in the buccal sulcus over the parotid orifice) and an anteroposterior radiograph of the face, with the patient requested
to inflate the cheek, are required. Additional, lateral views
are often taken, but any calculus may be superimposed
upon bone or teeth and obscured.
Fig. 14.1 Oblique occlusal radiograph showing a large calculus in the
right submandibular duct. Macroscopically the calculus has a rough
nodular appearance caused by deposition of mineral on the surface as
it enlarges.
Submandibular Gland
The plain radiographic examination consists of a true occlusal radiograph of the floor of the mouth and a “special”
Fig. 14.2 Ultrasound image showing a calculus at the hilum of the
right parotid gland. Note posterior acoustic shadowing where the
calculus does not allow sonar transmission.
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Is There an Obstruction in the Duct System? What Is the Condition of the Duct System?
Sialography
Both these questions are best answered with sialography. In
order to visualize the salivary ductal architecture, a radioopaque contrast medium is introduced into the orifice of one
of the major salivary glands via a cannula. The media used
are all iodine-containing solutions (usually low osmolarity
aqueous solutions of iodine salts). The contrast is introduced
slowly until discomfort is felt by the patient. Alternatively, the
procedure is performed under fluoroscopic screening, allowing “real-time” imaging. Usually two images are made at
different angles (e.g., lateral and anteroposterior views).
After this, the cannula is removed and a “drainage” image
obtained, usually after stimulation using a sialogogue (e.g.,
citric acid solution, lemon juice). Digital subtraction may be
used to remove bone and tooth images, leaving the contrast
image in isolation (Fig 14.3).
The main sublingual duct cannot be cannulated and so
the main gland is not imaged by sialography.
Sialoplasty (balloon dilatation of strictures) and basket
retrieval of small mobile stones are carried out under fluoroscopic guidance by interventional radiologists. These
techniques can be of enormous benefit to patients in the
short term, but recurrence rates of obstruction are high.
Magnetic resonance sialography is an alternative available to patients with a contrast allergy or for those cases
where the obstruction could not be negotiated. The signal is
specially weighted to give an exaggerated fluid response,
highlighting areas of pooled saliva, such as those that collect behind a calculus or stricture.
Sialoendoscopy
This is offered in highly specialized salivary gland imaging
centres. Microendoscopes with a working diameter of 1 mm
are introduced into the parotid or submandibular ducts
allowing direct vision. These can also carry an irrigation
port, cutting equipment and baskets to perform interventional procedures without the need for ionizing radiation.
Is There a Mass Present?
Ultrasound
This is the “first-line” investigation for a mass, as the major
salivary glands (including sublingual) are superficial structures. At present the full extent of the deep lobe of the parotid
is beyond the imaging capability of even the lowest frequency
transducers, and if a deep lobe lesion is suspected, an alternative form of cross-sectional imaging (CT or MRI), becomes
necessary. Where a lesion is completely visualised on ultrasound and where there is no suggestion of malignancy, an ultrasound examination is often sufficient for surgical planning.
Is There an Abnormality of Gland Function?
Radio-isotope Imaging
This is a question usually asked in relation to Sjögren’s syndrome. The only radiological technique that can directly
assess function is radio-isotope imaging (nuclear medicine).
This uses a radiopharmaceutical injected intravenously.
The radiopharmaceutical is a molecule containing the isotope 99 m technetium pertechnetate (a gamma ray emitter). Once in the bloodstream, this is handled by the body in
the same way as iodine and is taken up by the salivary
glands and then secreted in saliva. The gamma rays are
detected by a gamma camera to produce an image representing the functional activity of the glands. It is possible to
quantify activity in addition to subjective assessment of images. This technique is also employed in rare cases where
aplasia of one or more major glands is suspected.
Biopsy
Biopsy of labial minor salivary lobules is sometimes used
when an underlying systemic disease is suspected (e.g.,
Sjögren’s syndrome). Incisional biopsies of intraoral salivary masses are undertaken through mucosa that will be
later removed as a planned surgical procedure.
On no account should a discrete salivary gland mass in a
major gland be subjected to incisional biopsy, this may lead
to recurrence and is usually unnecessary. For example,
there is a 9 in 10 chance that a single parotid mass is a
A
Fig. 14.3 (A) Digital subtraction sialogram of a normal parotid gland. (B) Digital subtraction removes the image of superimposed bone, allowing a clear
image of the typically fine ducts of the normal gland.
B