Salivary Glands Three paired glands Parotid; largest of the major salivary glands Two Lobes divided by facial nerve Submandibular gland Deep to mylohyoid, superficial to hyoglossus Sublingual; Smallest of the salivary glands Common surgical disease; infection/calculi

Salivary Glands {Benign conditions} Mumps: Acute painful parotitis Viral in aetiology Self limiting Mikulicz’s Syndrome Bilateral enlargement of salivary & lacrimal glands Sjogren’s Syndrome Triad of dry eyes, dry mouth, dry joints Autoimmune Lymphocytic infiltration Pyogenic parotitis Surgical, debilitated patients Staphylococcus Swollen, painful parotid glands Pus from stensen’s duct

Salivary glands {Benign Tumours} Comprise 3% - 6% of all head & neck tumours Pleomorphic Adenoma Commonest tumour (53% - 71%) Slowly growing, painless, solitary, firm, smooth, moveable without nerve involvement Both mesenchymal/epithelial elements FNA, CT, MRI Superficial parotidectomy

Salivary Glands Tumours Warthin’s tumour(adenolymphoma, papillary cystadenoma lymphomatosum) 6% - 10% Benign, bilateral, parotid gland only, Older age group Superficial location Malignant potential non existent

Salivary Glands MalignantTumours Locally aggressive Grow along neural pathways, may access skull base and brain eventually Also lymphatic and haematogenous spread

Salivary Galnds Malignant Tumours Mucoepidermoid Carcinoma Commonest malignant tumour 50% of all salivary gland malignancies Parotid involved in 40% - 50% 75% are low grade & have good prognosis 1 – 5 year survival 85% High grade mucoepidermoid carcinomas invade locally, spread regionally & distant mets 5 year survival drops 30%

Salivary Glands Adenocystic carcinoma(Cylindroma) Commonly involves submandibular (35% - 40%), only 7% of parotid malignancies Slowly growing Perineural invasion 30% lymph node mets, 50% distant mets 5 year survival 75% 10 year survival 30% 20 year survival 13%

Salivary Glands Mixed malignant tumour Long standing pleomorphic adenoma Older age group Worse prognosis Lymph node mets 15% Distant mets 30% 5 year survival 40% - 50% 15% year survival 20%

Salivary Glands Acinic cell carcinoma Low grade Slow growing 10% of malignant parotid tumour Lymph node mets 10% Aggressive tumours Radical parotidectomy

Salivary Glands Squamous cell carcinomas Infrequent occurrence 1% - 5% May have skin infiltration Total radical parotidectomy_

Salivary Glands Evaluation & Diagnosis History & clinical examination Sialography – of no value CT scans CT sialography for retromandibular/parapharayngeal MRI Incisional biopsy containdicated FNAC

Salivary Glands Staging System T0 no clinical evidence of primary tumour T1 0.1 – 2.0 cms diameter without significant local extension T2 2.1 – 4 cms without local extension T3 4.1 – 6.0 cms without local extension T4a >6 cms without local extension T4b tumour of any size with significant extension

Salivary Glands Staging system N0 no evidence of regional nodal involvement N1 evidence of regional nodal involvement Nx regional nodes not assessed M0 no distant mets M1 distant mets eg., bone, lung, etc.

Salivary Glands Surgical complications Flap necrosis Seromas & haematomas Oropharangeal cutaneous fistulas Carotid rupture Thoracic duct fistula Pneumothorax Airway obstruction, dysphagia, oedema, loss of tongue mobility, superoir laryngeal nerve damage

Neck swellings Differential diagnosis Neck divided into ant. And posterior triangle by sternocleidomastoid Cervical lymphadenopathy commonest cause of neck swelling

Neck Swellings D/D (benign) Congenital swellings; branchial cleft swellings, thyroglossal duct cyst, laryngocoele, haemangiomas, cystic hygromas, dermoid. Inflammatory: acute & chronic lymphadenitis( infectious mononucleosis, toxoplasmosis, cat scratch fever, actinomycosis, histoplasmosis, tuberculosis traumatic: aneurysms, av malformation, torticollis, etc Pharyngeal pouch, cervical ribs, thyroid, etc

Neck swellings Branchial cleft cyst Remnants of incompletely obliterated branchial clefts/pouches Located anterior & deep to sternomastoid Painless swelling Young adults M= F ratio Unilateral, 75% on left side

Neck swellings Thyroglossal duct cyst 70% of all congenital cysts Arrested migration of thyroid Painless midline swelling Sistrunk operation

Neck swellings Csytic hygroma Collection of lymph sacs Present at the root of neck(post. Triangle), arm, groin. Pharyngeal pouch Pulsion divertuculum Uncoordinated swallowing Sternomastoid tumour Birth trauma, infarcted segment , fibrosis, torticollis

Neck swellings Cervical rib Extra cervical rib < 1% population Neurological and vascular problems Ranula Mucous containing cyst in floor of mouth Painless midline, spherical, smooth, fluctuant, transillumanant Dermoid cyst Midline, asymtomatic, painful when infected Laryngocoele Diverticulum of laryngeal ventricle Lined by epithelium Common in glass blowers/wind instruments musicians, etc

Neck swellings Tumours Benign; Carotid body tumour, lipoma, soft tissue tumour Malignant: skin tumours( SCC, BCC, melanomas), thyroid tumours, salivary gland tumours Carotid body tumour Sporadic occurrence 90% Familial 10% Unilateral, but bilateral/multicentric 10% sporadic, 50% bilateral familial Grows 0.5 cms/year

Schedule of Lectures V Med Salivary glands & Neck Swellings Skin & soft tissue tumours Benign & Malignant breast diseases Thyroid, parathyroid disorders, carcinoid, phaechromocytoma, MEN syndrome Oesophageal & gastric disorders Small bowel obstruction, Crohn’s disease, meckel’s, etc Colon & rectal diseases Hepatobiliary disorders

Lectures Pancreatic disorders Hernias Arterial & venous disorders Osteoarthritis Rheumatoid arthritis Fluid & electrolyte balance, nutrition Preoperative preparation, haemostasis & blood transfusion Trauma & burn Management Common urological problems Common orthopaedic problems Common cardiothoracic problems Common neurosurgical problems