Write up for DNB = Training Programmes

&n= bsp; =20 Write up for DNB Training Programmes.

Name=20 of the speciality : General = Surgery=20
Name=20 of the topic: Salivary Gland=20 Tumours.=20
Name=20 of the Expert: Prof. Vikram Kate = MS,=20 FRCS (Ed.), FRCS (Glasg.), Ph.D.=20
Name=20 of the Hospital:=20 Jawaharlal Institute of Postgraduate Medical Education & Research=20 (JIPMER), Pondicherry.

5. =20 Introduction: Salivary = gland tumours=20 are uncommon and represent 2-4% of head and neck neoplasms. The glands = are=20 divided into major and minor salivary gland categories. The major = salivary=20 glands are the parotid, the submandibular, and the sublingual glands. = The minor=20 glands are dispersed throughout the upper aerodigestive tract. Almost = 75% of the=20 salivary gland tumors arise in the parotid gland of which usually 15% = are=20 malignant. 10% of the salivary gland tumours arise in the submandibular = glands=20 and the remaining 15% in the sublingual and minor salivary glands. One = third of=20 the submandibular and more than half of the minor salivary gland tumours = are=20 malignant. Pleomorphic adenoma is the commonest benign tumour of the = salivary=20 glands and mucoepidermoid carcinoma is the commonest malignant tumour.=20

Clinical=20 Features:
1. History=20

=B7 =20 Mode of=20 onset of the swelling, duration, rate of growth, any ulceration if it = has=20 occurred.

=B7 =20 Exact=20 site where it started differentiates a submandibular from a lower pole = parotid=20 tumour.

=B7 =20 If the=20 swelling increases in size with meals and becomes painful =96 suggestive = of=20 sialolithiasis =96 unlikely to be a tumour.

=B7 =20 History=20 suggestive of facial nerve involvement =96 inability to close the eyes = tightly,=20 food bolus collecting in the cheek, deviation of the angle of the=20 mouth.

=B7 =20 History=20 suggestive of trismus indicates infiltration of malignant tumour in the=20 massetter or pterygoid muscles.

=B7 =20 Any=20 other swellings in the neck if present are suggestive of lymph nodal = metastases.=20

Physical=20 examination

=B7 = Examination=20 of the ear lobule. Commonly lifted by parotid = tumours.

=B7 = Physical=20 examination of the swelling =96 site, size, surface, consistency, = mobility and=20 plane of the swelling. Fixity of parotid tumours to massetter / mastoid = /=20 mandible evaluated. Fixity of submandibular or other salivary tumours to = mandible evaluated.

=B7 = Intraoral=20 examination

o =20 Medial=20 displacement of the lateral oropharyngeal wall and tonsillar bed for = enlargement=20 of deep lobe parotid tumours.

o =20 Examination=20 of Stensen=92s and Wharton=92s duct for inflammation, discharge of fluid = or stones.=20 Sialadenitis can mimic salivary gland tumour. Bidigital examination of = Stensen=92s=20 duct and palpation of the Wharton=92s duct in the floor of the=20 mouth.

o =20 Bidigital=20 examination of the parotid gland to evaluate deep lobe enlargement.=20

o =20 Bidigital=20 examination of the submandibular gland swelling to differentiate from=20 submandibular lymph nodal enlargement. As submandibular swelling = enlarges on=20 either side of mylohyoid muscle, it is palpable bidigitally.=20

=B7 = Examination=20 of the facial, lingual and hypoglossal nerves. Facial involved with = malignant=20 parotid tumour and lingual / hypoglossal with malignant submandibular = gland=20 tumour.

=B7 = Evaluation=20 of trismus if patient has complained in history.

=B7 = Examination=20 of the cervical lymph nodes.

Investigations=20

=B7 = Fine=20 needle aspiration cytology is the investigation of choice to confirm=20 diagnosis.

=B7 = CT and=20 MRI are the most useful imaging techniques to evaluate the extent of the = spread=20 of the salivary gland tumours. It also helps in identifying deep lobe=20 enlargement of the parotid tumours.

=B7 = Open=20 and true cut needle biopsy is contraindicated as it leads to tumour = seeding.=20 Open biopsy can be done if the tumour has = ulcerated.

Differential=20 diagnosis

=B7 = Enlarge=20 lymph nodes; soft tissue tumours and sialadenitis are common conditions = which=20 can simulate the clinical picture of a salivary gland tumour.

=B7 = DD of=20 salivary gland tumours:

o =20 Pleomorphic=20 adenoma is the commonest benign tumour.

o =20 Mucoepidermoid=20 carcinoma is the commonest malignant tumour.

o =20 Other=20 benign tumours include Warthin=92s tumour (papillary cystadenoma = lymphomatosum)=20 and rarely oncocytoma, lipoma, hemangioma.

o =20 Other=20 malignant tumours include acinic cell adenocarcinoma, adenoid cystic = carcinoma,=20 squamous cell carcinoma, carcinoma ex-pleomorphic adenoma.

Management:=20
1. Non-surgical=20 management

Surgery=20 is the mainstay of treatment for salivary gland tumours.
Radiotherapy=20 (RT) is indicated for the treatment of malignant salivary gland = tumours.=20 Indications for RT in malignancy include
=20
RT=20 may be indicated following excision of recurrent pleomorphic adenoma = to=20 reduce the possibility of further recurrence. =

Surgical=20 management

Superficial=20 parotidectomy is the treatment of choice for benign parotid gland = tumours of=20 the superficial lobe. Total parotidectomy is done when deep lobe is=20 involved.=20
Excision=20 of the submandibular gland, sublingual or minor salivary gland is = the=20 treatment of choice for benign tumours of these = organs.=20
Incisions=20 for the excision of the parotid and submandibular gland = -=20
The=20 nerves at risk during salivary gland surgery =96
Malignant=20 tumours of the parotid =96
Malignant=20 tumours of other salivary glands =96=20
Complications=20 of surgery for salivary glands=20

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