Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4434_Библиотеки_им_академика_М_И_Перельмана.pdf
8 Salivary Glands Tumours andIts Surgery
211
a
c
b
d
Fig. 8.34 (a–d) The tumour has inltrated the skin which necessitate resection of tumour together with the skin
Fig. 8.35 The excised tumour mass is labelled with
suture ties to orientate for histopathology examination as
it is important to delineate which area is free of tumour or
affected by tumour. This can be used to plan for adjuvant
radiation dose post-operatively and to address the exact
site of second surgery if recurrence develops
Fig. 8.36 The surgical defect post removal of the parotid
tumour and neck dissection. Extensive skin ap is needed
to cover this defect
212
Fig. 8.37 The skin ap is harvested from the deltoid
region (arrow) and sutured to the neck skin and parotid
area (star). The skin closure is done in two layers. The
deltoid skin defect will be grafted with skin graft,
which can be harvested from the lower limb later
N. Mat Lazim
a
Fig. 8.38 The recurrent adenoid cystic carcinoma post total parotidectomy (a, b) (arrow)
8.7.4 Cases ofRecurrent
Adenocystic Carcinoma
inaYoung Female
b
incision is designed to incorporate 1.0–2.0cm
margins of the tumour (Fig.8.39). This ensures
that a free negative margin is achieved
post-operatively.
This is the case of a young lady presented with a
history of right total parotidectomy and neck dissection at another centre for adenoid cystic carcinoma of right parotid gland. On clinical
examination, there was a mass with irregular surface and margin, and it was hard in consistency
(Fig.8.38a, b). The FNAC report conrms that it
was a recurrent carcinoma. She was planned for
excision of the recurrent tumour.
Intraoperatively, after a palpation of the
mass to dene the margin of the mass, a skin
After skin incision is made with a blade, the
recurrent tumour mass is dissected and
retracted. This exposes the carotid artery, IJV,
and vagus nerve, underneath the mass
(Fig. 8.40). These structures should be preserved along with the hypoglossal nerve
(Figs.8.41 and 8.42).
The mass is removed in total with the skin and
measured accordingly for a record (Fig. 8.43).
The specimen is sent to pathology lab for a
detailed histopathology examination.
8 Salivary Glands Tumours andIts Surgery
Fig. 8.39 The skin incision is marked around the recurrent tumour
213
Fig. 8.41 The tumour mass has been removed. The IJV is
visualized (star), and medial to it is common carotid artery
(blue star). The hypoglossal nerve runs across horizontally
on the carotid (white arrow). The spinal accessory nerve is
seen lateral to IJV and going into SCM (black arrow)
Fig. 8.40 The skin island has been excised, and the
recurrent tumour tissue is dissected (white arrow) exposing the carotid sheath (IJV (black arrow), carotid artery,
and vagus nerve underneath. The SCM muscle is visible
laterally (arrow)
a
Fig. 8.43 (a, b) The tumour mass which is removed together with the skin
Fig. 8.42 The hypoglossal nerve is shown with a
forceps
b
214
N. Mat Lazim
8.8 Complications Post Parotidectomy
Complications from parotidectomy are multiple
and can be divided into intraoperative and postoperative. Intraoperative complications range
across bleeding from external jugular vein or retromandibular vein puncture, greater auricular
nerve injury, or transection of facial nerve
branches.
Post-operative complications include:
1. Early complications:
(a) Marginal mandibular nerve paralysis
(b) Haematoma or seroma
(c) Pain and discomfort
2. Late complications:
(a) Retromandibular depression
(b) Frey’s syndrome
(c) Permanent facial nerve paresis
Managing these complications is also challenging and requires a multidisciplinary team
approach. The patient should have warned of the
possible complications to avoid unwanted medicolegal issues. This is critical as facial nerve
paresis causes signicant facial asymmetry,
which impairs patient’s facial appearance.
In case of anticipated signicant retromandibular depression that can occur, for instance, after
removal of huge parotid pleomorphic adenoma,
sternomastoid rotational ap can be performed
during the surgery in order to reduce the cosmesis impairment of retromandibular depression.
Subdermal fat graft can also be performed as an
alternative option. However, with fat graft, the
long-term complication is fat atrophy, which may
facilitate repeat fat graft procedure.
Frey’s syndrome is a critical complication
from parotid surgery as it causes pain and discomfort to patients and involuntary sweating in
the cheek region during mastication and eating.
Frey’s syndrome can be assessed via the symptom assessment and the more objective test of
Minor starch iodine test. In our practice, even
though patients do not have any complaints to
suggest Frey’s syndrome, the Minor starch iodine
test is positive. This implies that the incidence of
Frey’s syndrome can be underestimated if a
proper objective test is not carried out.
Management of Frey’s syndrome can be
divided into intraoperative procedures and postoperative procedures. Intraoperative procedures
include the elevation of thicker skin ap, preserving greater amount of periparotid tissues, and
doing partial-thickness sternomastoid rotational
ap. Post-operative procedures include Botox
injection and anticholinergic injection such as
aluminium hydroxide.
8.9 Submandibular Gland
Surgery
Submandibulectomy is most commonly performed for submandibular gland tumours, both
benign and malignant. Other indications for submandibulectomy are sialolithiasis or sialadenosis. Submandibulectomy is also performed as
part of neck dissection. Multiple critical structures need to be addressed correctly during submandibulectomy. These include marginal
mandibular nerve, facial artery and vein, hypoglossal nerve, lingual nerve, and submandibular
duct.
In case of malignant submandibular gland
tumour, inltration to mandible or skin or presence of neck metastases will justify the extirpation of these structures. Marginal mandibulectomy
or segmental mandibulectomy can be performed
accordingly depending on the degree of
involvement. Large skin excision together with
primary tumour necessitates reconstruction with
free ap and skin grafting. The most common
neck dissection practised for submandibular
malignancy is supraomohyoid or anterolateral
neck dissection.
8.9.1 Steps inSubmandibulectomy
This is the case of a young Malay lady who presented with an extensive right submandibular
swelling. It is a multilobulated mass with limited
mobility and measuring 8.0 cm × 10.0 cm and
hard in consistency (Fig.8.44).
8 Salivary Glands Tumours andIts Surgery
215
a
Fig. 8.44 Right submandibular mass in a young female,
which is multilobulated. (a) Huge submandibular mass
with FNAC conrmed as pleomorphic adenoma. (b)
a
Fig. 8.45 The skin incision is designed at the epicentre
of the mass and two nger breadths below the mandible to
preserve the marginal mandibular nerve. (a)
Submandibular tumour extends from right mandible superiorly to 2.0cm above clavicle. The skin incision has been
b
Multilobulated rm to hard mass with intact right marginal mandibular nerve
b
drawn on the epicenter of the mass, two ngerbreadth
below mandible and along the skin crease. (b) The
tumoural mass has been outlined to facilitate dissection
later. The landmarks were palpated and orientated to the
mass margins
1. Assessment of detailed characteristics of submandibular mass at the outpatient clinic and
preparing patient for surgery with a wellinformed consent:
Step 1: Patient’s positioning and designing
of skin incision
Patient is made to lie supine with neck
hyperextended and face turned to contralateral side. The intubation airway tube is
placed away from the surgical eld, on the
left side of the oral cavity. The landmark is
identied, which includes the inferior border of mandible, the margin of the mass,
the midline, the anterior border of SCM,
and the external jugular vein.
The skin incision is designed so as to avoid
marginal mandibular nerve injury and good
access to the inferior pole of the mass, by
placing the incision along the skin crease,
two nger breadths below the mandible and
at the epicentre of the mass (Fig. 8.45).
Stage of skin incision is favourable so that
216
N. Mat Lazim
a
Fig. 8.46 The subplatysmal skin ap elevation. (a) Skin
incision is made using blade size 15 along the marked
area. (b) Platysma muscle is thinned out. Subplatysma
a
Fig. 8.47 The marginal mandibular nerve and greater
auricular nerve are both preserved. (a) Marginal mandibular nerve runs supercial to submandibular tumour cap-
b
cb
ap is raised superiorly and inferiorly, following on the
capsule of the mass. (c) Multilobulated and rm mass is
dissected meticulously
sule, is reected superiorly. (b) The tumoural mass is
dissected, with greater auricular nerve (black probe) lateral to the mass is preserved
it can avoid unnecessary skin cut. In this
case, the skin incision is prepared in continuity with skin incision for parotid gland in
case it is affected by the tumour.
Step 2: Skin Flap elevation
The skin incision is carried out with a blade
size 15 or monopolar diathermy with a ne
Colorado tip. The subplatysmal ap is
raised superiorly to the inferior border of
mandible and inferiorly till the inferior
border of the mass. The dissection is
carried out on the tumour capsule without
breaching of the capsule (Fig.8.46).
Step 3: The dissection
Laterally, the dissection continues to the
lateral border of the mass, avoiding the
injury to the greater auricular nerve (GAN),
as it lies supercial to sternocleidomastoid
muscle. The marginal mandibular nerve
identied on the superior part of the tumour
capsule and reected superiorly over the
skin ap (Fig.8.47).
8 Salivary Glands Tumours andIts Surgery
217
ab
Fig. 8.48 The dissection continues while maintaining an
intact capsule of the mass. (a) Marginal mandibular nerve
is retracted superiorly while tumoural mass dissected and
a
Fig. 8.49 (a, b) The hypoglossal nerve (a) is visible deep to the tendon of digastric muscle (b)
The dissection continues medially and
deep to the mass, releasing the tumour
from the surrounding tissue. The posterior
belly of digastric is identied, and dissection continues to expose the mylohyoid
muscle. The capsule of the mass is maintained intact (Fig.8.48).
Step 4: The identication of lingual nerve,
submandibular duct, and hypoglossal
nerve
The mylohyoid muscle is retracted
superior- anteriorly. By doing this, the lingual nerve and submandibular duct can be
identied when the dissection continues.
retracted inferiorly. (b) The pedicle of tissue at deep
aspect of the mass before the mass is excised in total. (c)
The capsule of the mass remains intact
b
Due to the lingual nerve that passed medially, hooks around the submandibular duct,
and runs laterally to the posterior part of
the gland, traction of the submandibular
glands inferiorly makes the ‘V’-shape gure of lingual nerve. The apex of the V is
where the duct is. The duct can be ligated
as proximal as possible, and the lingual
nerve is preserved.
The hypoglossal nerve can be found about
1.0cm below to lingual nerve, and it lies
just medial to the posterior belly of digastric muscle (Figs.8.49 and 8.50). In some
cases, the hypoglossal nerve can be low
c
218
N. Mat Lazim
a
Fig. 8.50 The mass is retracted superiorly. Both hypoglossal nerve and lingual nerve are preserved (a). The mass
weighed 600mg is removed in total (b)
lying due to ptotic submandibular glands
and adjacent structures.
Step 5: Extirpation of the mass
b
subcutaneous tissue is secured with Vicryl
3.0, and the skin is closed with white Vicryl
3.0 subcuticular (Fig.8.51).
Once the mass is out, the surgical bed is
irrigated with warm saline and homeostasis is secured. Any blood oozes will be cau-
8.9.2 Post-operative Assessment
terized with bipolar diathermy. All nerves
are tested before wound is closed in two
layers. The Redivac drain size 19 is
secured.
Step 6: Surgical bed assessment and
wound closure
After removal of the mass, the surgical bed
is checked for any active bleeding. Warm
saline can be irrigated and observed for the
bleeding area. The bipolar is used to secure
the bleeders. The lingual nerve and hypoglossal nerve are re-tested for
functionality.
The drain size 10 is secured with Sal 2.0.
The wound is closed in two layers. The
During post-operative assessment on day 1, the
wound area is inspected for any haematoma and
marginal mandibular nerve paresis. The patient
is asked to clench her teeth, and apparent paresis
of the MM on the affected side can be visualized
with the evident loss of depression of angular
oris inferior (Fig. 8.52). The patient is prescribed with dexamethasone for 3days to reduce
oedema and improve the marginal mandibular
paresis.
The drain should be checked for drainage to
rule out blocked or kinked drain. The resultant
collection might compress the nerve and worsen
the paresis.
8 Salivary Glands Tumours andIts Surgery
219
a
c
Fig. 8.51 The digastric muscle is visible (a) and retracted inferiorly (b) to expose the hypoglossal nerve (tip of nerve
probe) (b). The skin is closed in two layers, and a Redivac drain is secured (c, d)
b
d
ab
Fig. 8.52 Postoperatively, the drain is in situ (a). There is right marginal mandibular nerve paresis as evident by loss
of depression of left lower lip (b)
220
N. Mat Lazim
8.10 Complications
ofSubmandibulectomy
Xerostomia and decreased salivary ow in a resting position are specic long-term complications
after submandibulectomy because the submandibular glands are responsible for 70% of resting
salivary ow. Up to 22% of operated patients can
be affected with it. Other complications might
include a heterotrophic scar, keloid formation,
injuries to the submandibular duct, ranula, and
intraoperative bleeding. Damage to the hypoglossal nerve or to the cervical branch of the facial
nerve is possible especially in a junior surgeon’s
hand.
8.11 Prognosis ofPatients
withSalivary Gland Tumours
Patients’ quality of life after radical cancer
removal depends on the extent of resection, the
preservation of the facial nerve, and the preservation of neighbouring structures such as the greater
auricular nerve, hypoglossal nerve, muscles of
mastication, and mandible.
The removal of one or more branches of the
facial nerve leads to long-term functional decits, and cable grafting and neural repair techniques are essential for the reconstruction and
recovery of the resected facial nerve. Facial nerve
asymmetry is disguring and affects normal
speech, eating, and facial expression, which is
important for social integration. In addition, if the
patient had neck dissection at the time of parotidectomy, complications from neck dissection can
be troublesome like vocal cord paresis or spinal
nerve injury. This is compounded if the patient
had adjuvant radiation that causes tissue brosis.
8.12 Conclusion
Salivary gland surgery is critical as it involves
multiple important neurovascular structures. For
parotid gland surgery, the facial nerve needed to
be identied and preserved. The submandibulectomy poses complications of hypoglossal nerve
and lingual nerve paralysis. In case of malignant
tumour, neck dissection needed to be incorporated in the initial surgery to ensure a better treatment outcome for this patient. In short, the
surgeon needs to master the surgical anatomy and
skills in order to perform an effective
parotidectomy.
References
1. Basset CA, Cappello F, Rappa F, et al. Molecular
chaperones in tumors of salivary glands. J Mol
Histol. 2020;51(2):109–15. https://doi.org/10.1007/
s10735- 020- 09871- y.
2. Eskander A, Irish J, Freeman J, et al. Overview
of major salivary gland cancer surgery in Ontario
(2003- 2010). J Otolaryngol Head Neck Surg.
2014;43(1):50. Published 2014 Dec 10. https://doi.
org/10.1186/s40463- 014- 0050- 6.
3. Emodi O, El-Naaj IA, Gordin A, Akrish S, Peled
M. Supercial parotidectomy versus retrograde partial supercial parotidectomy in treating benign
salivary gland tumor (pleomorphic adenoma). J Oral
Maxillofac Surg. 2010;68(9):2092–8. https://doi.
org/10.1016/j.joms.2009.09.075.
4. Choi JS, Cho BH, Kim HJ, Kim YM, Jang
JH.Identication of new genes of pleomorphic adenoma. Medicine (Baltimore). 2019;98(51):e18468.
https://doi.org/10.1097/MD.0000000000018468.
5. Peraza A, Gómez R, Beltran J, Amarista
FJ. Mucoepidermoid carcinoma. An update and
review of the literature. J Stomatol Oral Maxillofac
Surg. 2020;121(6):713–20. https://doi.org/10.1016/j.
jormas.2020.06.003. Epub 2020 Jun 18.
6. Gupta A, Koochakzadeh S, Neskey DM, Nguyen SA,
Lentsch EJ. Carcinoma ex pleomorphic adenoma: a
review of incidence, demographics, risk factors, and
survival. Am J Otolaryngol. 2019;40(6):102279.
https://doi.org/10.1016/j.amjoto.2019.102279.
7. Lobo R, Hawk J, Srinivasan A. A review of salivary gland malignancies: common histologic types,
anatomic considerations, and imaging strategies.
Neuroimaging Clin N Am. 2018;28(2):171–82.
https://doi.org/10.1016/j.nic.2018.01.011.
8. Psychogios G, Bohr C, Constantinidis J, etal. Review
of surgical techniques and guide for decision making
in the treatment of benign parotid tumors [published
correction appears in Eur Arch Otorhinolaryngol. 2020
Aug 29]. Eur Arch Otorhinolaryngol. 2021;278(1):15–
29. https://doi.org/10.1007/s00405- 020- 06250- x.
9. Nahlieli O. Complications of traditional and
modern therapeutic salivary approaches.
Complicanze degli approcci terapeutici tradizionali e moderni alle ghiandole salivari. Acta
Otorhinolaryngol Ital. 2017;37(2):142–7. https://doi.
org/10.14639/0392- 100X- 1604.