Malignant Neoplasms Malignant Neoplasms Of Of

the Salivary Glandsthe Salivary Glands

EPIDEMIOLOGYEPIDEMIOLOGY

11..Malignant Salivary Neoplasms Malignant Salivary Neoplasms accounting accounting for approximatelty 6% of for approximatelty 6% of

all head & neck malignanciesall head & neck malignancies..22..These Tumors represent at an These Tumors represent at an

average age of 56.6 years of ageaverage age of 56.6 years of age..33..The most common being The most common being

Mucoepidermoid CarcinomaMucoepidermoid Carcinoma that was that was also the most common histologic also the most common histologic finding in Postradiation Salivary Gland finding in Postradiation Salivary Gland MalignanciesMalignancies..

Risk Factors & Protective Risk Factors & Protective FactorsFactors

Clinical findingsClinical findings

--In approximately 75% patients these In approximately 75% patients these tumors present as a painless masstumors present as a painless mass..

--6%6% to 13% of cases are initially seen with to 13% of cases are initially seen with facial nerve palsyfacial nerve palsy..

--Trismus,Cervical Trismus,Cervical adenopathy,Fixation,Looseadenopathy,Fixation,Loose

Dentition,Bleeding,Numbness,Constant Dentition,Bleeding,Numbness,Constant pain,Skin Involvement & Facial Nerve pain,Skin Involvement & Facial Nerve palsy suggest the presence of Malignancypalsy suggest the presence of Malignancy..

IMAGINGIMAGING

Well-Defined,mobile tumors of ParotidWell-Defined,mobile tumors of Parotid & &

Submandibular Glands may be Submandibular Glands may be approachedapproached

Without imaging study and Radiologic Without imaging study and Radiologic evaluation is helpful to ascertain the evaluation is helpful to ascertain the location & extent of location & extent of Deep massesDeep masses and and Parapharyngeal InvolvementParapharyngeal Involvement..

Sialography & UltrasoundSialography & Ultrasound

--SialographySialography::

Although tumors may cause Obstruction or Stricture,but the Although tumors may cause Obstruction or Stricture,but the presence & nature of a mass not revealed by sialographypresence & nature of a mass not revealed by sialography..

--UltrasoundUltrasound::

The appearance of benign & malignant disease is similar by The appearance of benign & malignant disease is similar by USUS

Even with Color-Flow DopplerEven with Color-Flow Doppler..

--But US is useful to provide Guidance in obtaining FNA But US is useful to provide Guidance in obtaining FNA specimen from Deep Parotid & Parapharyngeal Space specimen from Deep Parotid & Parapharyngeal Space massmass..

--US is also useful as the initial evaluation of children with US is also useful as the initial evaluation of children with suspected salivary disease,because it can determine the suspected salivary disease,because it can determine the presence of mass without radiationpresence of mass without radiation..

CT SCANCT SCAN

--Contrast CTS provides exellent detail of the Contrast CTS provides exellent detail of the tumortumor

Volume,its relation to vascular & bony structures Volume,its relation to vascular & bony structures and Surveillance of the regional lymph nodesand Surveillance of the regional lymph nodes..

Its also the best modality for evaluation ofIts also the best modality for evaluation of

Parapharyngeal Space & Deep lobe of Parotid Parapharyngeal Space & Deep lobe of Parotid gland and defining gland and defining Cortical BoneCortical Bone Involvement Involvement,,

Although MRI better defines Although MRI better defines Bone MarrowBone Marrow

InvolvenentInvolvenent..

Extension of Parotid Tumor Into Parapharyngeal Extension of Parotid Tumor Into Parapharyngeal SpaceSpace

Cortical Bone ErosionCortical Bone Erosion

MRIMRI

--MRI provides exellent soft tissue detailMRI provides exellent soft tissue detail..

--MRI can combined with MRA for MRI can combined with MRA for evaluation of vascular anatomy evaluation of vascular anatomy without the need for arterial without the need for arterial catheterization & Fluoroscopycatheterization & Fluoroscopy..

--DisadvantagesDisadvantages::

Cortical bony landmarks are shown as Cortical bony landmarks are shown as image voidimage void..

Positron Emission Tomography (PET)Positron Emission Tomography (PET)

PET imaging seems to have to role in PET imaging seems to have to role in the the STAIGINGSTAIGING to rull out distant & to rull out distant & regional metastases not identified in regional metastases not identified in other modalities and may be useful other modalities and may be useful to to Follow-UpFollow-Up

Patients with known salivary Patients with known salivary malignancy after treatmentmalignancy after treatment..

Fine-Needle Aspiration Biopsy (FNAB)Fine-Needle Aspiration Biopsy (FNAB)

--FNAB of Salivary Glands has a FNAB of Salivary Glands has a Sensitivity of 60% to 73% for Sensitivity of 60% to 73% for detection of malignancydetection of malignancy..

--In Non-Diagnostic specimens the rate In Non-Diagnostic specimens the rate ofof

Malignant disease was 16%Malignant disease was 16%..

--Of particular concern is the Of particular concern is the diffrentiation between a Low-grade diffrentiation between a Low-grade malignancy & Benign diseasemalignancy & Benign disease..

Open Bx and Fozen SectionOpen Bx and Fozen Section

Open BiobsyOpen Biobsy::

May be indicated when tumors ofMay be indicated when tumors of Parotid & Parotid & Submandibular gland are suspicious for Submandibular gland are suspicious for LymphomaLymphoma

Or when the Or when the Facial nerveFacial nerve is involved and is involved and resection of the tumor would require its resection of the tumor would require its resectionresection..

Frozen SectionFrozen Section::Most helpful in determining the presence of Most helpful in determining the presence of malignancy in upper Cervical/Subdigastric lymph malignancy in upper Cervical/Subdigastric lymph

nodesnodes . .

STAGINGSTAGING

Prognosis & SurvivalPrognosis & Survival

There are some factores that are asociated with There are some factores that are asociated with poorer prognosis and lower survivalpoorer prognosis and lower survival::

11..High-Grade tumorsHigh-Grade tumors..

22..Facial nerve involvementFacial nerve involvement..

33..Submandibular locationSubmandibular location . .

44..Positive nodesPositive nodes..

55..Tumor SizeTumor Size>3cm>3cm..

66..Perineural InvasionPerineural Invasion..

77..Adenoid Cystic Adenoid Cystic Carcinoma,SCC,Adenocarcinoma,MalignantCarcinoma,SCC,Adenocarcinoma,Malignant

Mixed tumor & Undiffrentiated carcinomaMixed tumor & Undiffrentiated carcinoma..

88..Age>60 yrsAge>60 yrs..

Histologic SubtypesHistologic Subtypes

Mucoepidermoid CarcinomaMucoepidermoid Carcinoma

--The most common Salivary Malignancy in Children & AdultsThe most common Salivary Malignancy in Children & Adults..

--Low-Grade tumors have a higher percentage of Mucinous cells Low-Grade tumors have a higher percentage of Mucinous cells whereaswhereas

Epithelial cells predominate in High-Grade tumorsEpithelial cells predominate in High-Grade tumors . .

--The presence of 4 or more mitoses per 10 high-power The presence of 4 or more mitoses per 10 high-power fields,Necrosisfields,Necrosis,,

Neural invasion,Intracystic component Neural invasion,Intracystic component <20% and Anaplasia <20% and Anaplasia indicatesindicates

High-Grade behaviorHigh-Grade behavior..

--Site of OccurrenceSite of Occurrence::

Mucoepidermoid CarcinomaMucoepidermoid Carcinoma

TreatmentTreatment

11..Surgical ResectionSurgical Resection..

22..Postoperative Irradiation reserve for patientsPostoperative Irradiation reserve for patients withwith::

..Positive MarginsPositive Margins,,

..Nodal MetastasisNodal Metastasis,,

..and High-Grade Malignanciesand High-Grade Malignancies..

Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma

--The most common malignancy of Submandibular & Minor Salivary The most common malignancy of Submandibular & Minor Salivary GlandsGlands..

--Oral Cavity & Palate are the most common sites of origin of this tumorOral Cavity & Palate are the most common sites of origin of this tumor..

--This tumor represented by 3 distinct histologic patternsThis tumor represented by 3 distinct histologic patterns::

11..Cribriform Pattern:Cribriform Pattern: has a Glandular architecture & Best prognosis has a Glandular architecture & Best prognosis..

22..Tubular Pattern:Tubular Pattern: has a clinical prognosis of Intermediate nature has a clinical prognosis of Intermediate nature..

33..Solid Pattern:Solid Pattern: is more Epithelial in nature & associated with poor is more Epithelial in nature & associated with poor prognosisprognosis..

--It is charecterized by Slow growth,local recurrence,Disnant metastasis It is charecterized by Slow growth,local recurrence,Disnant metastasis and Neurotropic spread,often leading to recurrences at skull baseand Neurotropic spread,often leading to recurrences at skull base..

--LUNGSLUNGS are The most common site of Distant Metastases are The most common site of Distant Metastases..

TreatmentTreatment

--Complete Surgical Excision + Postoperative Complete Surgical Excision + Postoperative IrradiationIrradiation..

--Elective Lymphadenectomy is not used routinelyElective Lymphadenectomy is not used routinely..

--Neutron particle therapy is the most efficacious Neutron particle therapy is the most efficacious form ofform of

radiation therapyradiation therapy..

--EGFR EGFR (Epidermal Growth Factor Receptor) inhibitor (Epidermal Growth Factor Receptor) inhibitor reducereduce

the risk of Reccurence and/or Disnant Metastasisthe risk of Reccurence and/or Disnant Metastasis..

Acinic Cell CarcinomaAcinic Cell Carcinoma

--Accounting for 6% to 8% of all Salivary malignancyAccounting for 6% to 8% of all Salivary malignancy..

--It is associated the Best survival rate of any Salivary It is associated the Best survival rate of any Salivary malignancymalignancy..

--This tumor occures most commonly in the Parotid Gland & is This tumor occures most commonly in the Parotid Gland & is thethe

second most common Salivary Malignancy of Parotid gland in second most common Salivary Malignancy of Parotid gland in ChildrenChildren..

--RxRx::

Complete Surgical resection + Neck Dissection limited to the Complete Surgical resection + Neck Dissection limited to the Therapeutic setting Therapeutic setting..

Postoperative RadiationPostoperative Radiation is not Routinely advocated is not Routinely advocated . .

Squamous Cell CarcinomaSquamous Cell Carcinoma

--Primary SCC of Salivary Glands is rare & most SCCs are the result Primary SCC of Salivary Glands is rare & most SCCs are the result of Lymphatic,Direct Spread & metastasis from of Lymphatic,Direct Spread & metastasis from Scalp,Face,External AuditoryScalp,Face,External Auditory

Canal and Aerodigestive tract SCCCanal and Aerodigestive tract SCC..

--High-Grade Mucoepidermoid Carcinoma may be mistaken for High-Grade Mucoepidermoid Carcinoma may be mistaken for SCC,which may be recognized by routine use of Mucicarmine & SCC,which may be recognized by routine use of Mucicarmine & PASPAS..

--Parotid Gland: The most common siteParotid Gland: The most common site..

--RxRx::

11..Aggressive Surgical Resection withAggressive Surgical Resection with

22..Regional LymphadenectomyRegional Lymphadenectomy& &

33..Postoperative Radiation TherapyPostoperative Radiation Therapy & &

44..Elective Neck DissectionElective Neck Dissection..

Malignant Mixed TumorMalignant Mixed Tumor

--Ex-Pleomorphic Adenoma,Carcinomasarcoma and Metastasizing mixedEx-Pleomorphic Adenoma,Carcinomasarcoma and Metastasizing mixed

tumor: to BONE & LUNGS are similar but distinct malignanciestumor: to BONE & LUNGS are similar but distinct malignancies..

these accounts for 5% to 12%these accounts for 5% to 12%

of Salivary Gland malignancies, which most commonly arise in the 6of Salivary Gland malignancies, which most commonly arise in the 6 thth decadedecade

--Malignant Degeneration can occur in 3% to 7% of Pleomorphic AdenomaMalignant Degeneration can occur in 3% to 7% of Pleomorphic Adenoma..

a typical clinical history includes a longstanding salivary mass that beingsa typical clinical history includes a longstanding salivary mass that beings

to to rapidly enlargerapidly enlarge..

--Most common site: Most common site: Parotid GlandParotid Gland..

--Submaxillary & Minor Salivary Gland tumors has a reccurence rate that isSubmaxillary & Minor Salivary Gland tumors has a reccurence rate that is

twice that of those with Parotid tumorstwice that of those with Parotid tumors..

--RxRx::

Surgical Resection,Elective Lymphadenectomy & Postoperative RadiationSurgical Resection,Elective Lymphadenectomy & Postoperative Radiation..

Carcinoma ex-PleomorphicCarcinoma ex-Pleomorphic

AdenocarcinomaAdenocarcinoma

--Adenocarcinoma comprise 16% to 20% of Salivary malignancies Adenocarcinoma comprise 16% to 20% of Salivary malignancies thatthat

take origin from the Salivary Duct Unittake origin from the Salivary Duct Unit..

--Minor Salivary Glands are the most common site of origin & The Minor Salivary Glands are the most common site of origin & The PalatePalate

is the most common site in the oral cavityis the most common site in the oral cavity..

--Parotid Gland is the 2Parotid Gland is the 2ndnd most common site of origin most common site of origin..

--Paranasal Sinus & Nasal Cavity tumors presented at a late stage & Paranasal Sinus & Nasal Cavity tumors presented at a late stage & hadhad

a significantly worse prognosisa significantly worse prognosis..

--Clinical PresentationClinical Presentation::

11..Asymptomatic Swelling:80%Asymptomatic Swelling:80%

22..Pain:16%Pain:16%

33..Facial Nerve weakness:4%Facial Nerve weakness:4%

--Histologic ClassificationHistologic Classification::

Mucinous,Papillary,Trabecular & Sebaceous SubtypesMucinous,Papillary,Trabecular & Sebaceous Subtypes..

--Overall 51% of the patients experienced a Overall 51% of the patients experienced a recurrence atrecurrence at

the primary site, where as those with Sinonasal the primary site, where as those with Sinonasal TumorsTumors

had a 70% recurrencehad a 70% recurrence..

--Distant Metastasis developed in 26%,with the Distant Metastasis developed in 26%,with the LUNG being the predominant siteLUNG being the predominant site..

RxRx::

Surgical Resection & Postoperative RadiationSurgical Resection & Postoperative Radiation..

Polymorphous Low-Grade Adenocarcinoma(PLGA)Polymorphous Low-Grade Adenocarcinoma(PLGA)

--This Variant of Adenocarcinoma has a distinctly Indolent behaviorThis Variant of Adenocarcinoma has a distinctly Indolent behavior..--Its believed to PLGA originates from the Intercalated Duct portion of theIts believed to PLGA originates from the Intercalated Duct portion of the

Salivary SystemSalivary System..--The tumor predominantly involves the Minor Salivary gland of BuccalThe tumor predominantly involves the Minor Salivary gland of Buccal & &

Palatal mucosa,with a predilection of Perineural growth,and if oftenPalatal mucosa,with a predilection of Perineural growth,and if often confused with confused with Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma..

--Local recurrence & Distant Metastasis is very uncommon but Positive orLocal recurrence & Distant Metastasis is very uncommon but Positive or Uncertain surgical margins and a predominance of Papillary gowth Uncertain surgical margins and a predominance of Papillary gowth

patternpattern are associated with an adverse outcomeare associated with an adverse outcome..

--Conversely to other Salivary Malignancies the presence of pain was notConversely to other Salivary Malignancies the presence of pain was not associated with poorer prognosisassociated with poorer prognosis..

RxRx:: Complete wide local excision is the treatment of choice.Elective Neck

Dissection & postoperative Irradiation are not supported.

Salivary Duct CarcinomaSalivary Duct Carcinoma

--It’s a subtype of Adenocarcinoma and usually originates from ParotidIt’s a subtype of Adenocarcinoma and usually originates from Parotid..

--This tumor behaves aggressively,resulting with local & distant failureThis tumor behaves aggressively,resulting with local & distant failure

& & short survivalshort survival..

--Histologically,its described as islands of tumor with Comedo-NecrosisHistologically,its described as islands of tumor with Comedo-Necrosis

similar to that of Mammary Ductal Carcinomasimilar to that of Mammary Ductal Carcinoma..

--Radical Parotidectomy with Facial Nerve Sacrifice was believed toRadical Parotidectomy with Facial Nerve Sacrifice was believed to

confer better locoregional controlconfer better locoregional control..

--Postoperative Radiation is believed to yield better locoregional controlPostoperative Radiation is believed to yield better locoregional control..

--Neck Dissection are performed in patients with clinical disease,as well asNeck Dissection are performed in patients with clinical disease,as well as

Elective because the risk of metastasis is Elective because the risk of metastasis is > 25%> 25%..

LymphomaLymphoma

--Primary Lymphoma accounts for 1.7% of all Salivary NeoplasmsPrimary Lymphoma accounts for 1.7% of all Salivary Neoplasms..

--Parotid Gland is the most common site of originParotid Gland is the most common site of origin..

--Most Salivary lymphomas are of B-Cell origin,although T-Cell,MALTMost Salivary lymphomas are of B-Cell origin,although T-Cell,MALT& &

Hodgkin’s Lymphomas have also been reportedHodgkin’s Lymphomas have also been reported..

Diagnostic CriteriaDiagnostic Criteria::

11..There is no evidence of extrasalivary lymphomaThere is no evidence of extrasalivary lymphoma..

22..Lymphoma must involve salivary Parenchyma not Periparotid lymph Lymphoma must involve salivary Parenchyma not Periparotid lymph nodesnodes..

33..Lymphoreticular Infiltrate must demonstrate architectural & cytologicLymphoreticular Infiltrate must demonstrate architectural & cytologic

features suggestive of Malignancyfeatures suggestive of Malignancy..

--Patients with SjPatients with Sjöögren’s disease have a 40 times greater risk for thegren’s disease have a 40 times greater risk for the

development of this tumor than the normal populationdevelopment of this tumor than the normal population . .

Clinical PresentationClinical Presentation::

11..Painless enlarging mass:90%Painless enlarging mass:90%

22..Facial Nerve dysfunction:15%Facial Nerve dysfunction:15%

33..Cervical Adenopathy:9%Cervical Adenopathy:9%

--55 years survival rate for primary salivary Hodgkin’s years survival rate for primary salivary Hodgkin’s lymphomalymphoma

is better than primary salivary Non- Hodgkin’s is better than primary salivary Non- Hodgkin’s lymphomalymphoma..

RxRx::

Consist of Chemotherapy and/or radiation.Surgical Consist of Chemotherapy and/or radiation.Surgical Excision isExcision is

Recommended only For MALT lymphomaRecommended only For MALT lymphoma . .

Metastatic CancerMetastatic Cancer

--The Parotid Gland is at risk for metastasis from cutaneous malignanciesThe Parotid Gland is at risk for metastasis from cutaneous malignancies

((SCCSCC ) )of the Scalp,Face & External Auditory Canalof the Scalp,Face & External Auditory Canal..

--Direct extension through Direct extension through fusion planesfusion planes or or perineural spreadperineural spread is likely the is likely the

mechanism used by BCCmechanism used by BCC..

--Positive margins were the principal prognostic factor predicting poor Positive margins were the principal prognostic factor predicting poor outcomeoutcome..

--Facial Nerve weakness at initial presentation was reported in 30% but Facial Nerve weakness at initial presentation was reported in 30% but requiredrequired

partial or complete facial nerve sacrifice in nearly 48% of patientspartial or complete facial nerve sacrifice in nearly 48% of patients..

--Kidney,Lung & Breast are the most common infraclavicular malignanciesKidney,Lung & Breast are the most common infraclavicular malignancies

metastasizing to the parotid & submandibular glandmetastasizing to the parotid & submandibular gland..

--Although Surgery & Adjunctive radiation therapy locoregional recurrenceAlthough Surgery & Adjunctive radiation therapy locoregional recurrence

remains highremains high . .

SarcomaSarcoma

--Malignant Schwannoma & Fibrosarcoma are the Malignant Schwannoma & Fibrosarcoma are the mostmost

common hostologic findingscommon hostologic findings..

--The average time from treatment to death is 2.4 The average time from treatment to death is 2.4 yrsyrs..

--The most common site of metastasis is the LUNGThe most common site of metastasis is the LUNG..

RxRx::

Radical Resection & Postoperative RadiationRadical Resection & Postoperative Radiation..

Elective Dissection seems unnecessaryElective Dissection seems unnecessary..

Surgical Management of Salivary Gland Surgical Management of Salivary Gland NeoplasmsNeoplasms

--Superficial ParotidectomySuperficial Parotidectomy has become the widely accepted form has become the widely accepted form of intervention for most parotid tumors & has been touted of intervention for most parotid tumors & has been touted as the minimal surgery of parotid gland.(Figure1)as the minimal surgery of parotid gland.(Figure1)

--Higher risk of Facial Nerve injury & the potential for Higher risk of Facial Nerve injury & the potential for intraoperative seeding of tumor resulting in recurrence of intraoperative seeding of tumor resulting in recurrence of the tumor has been associated with the use of lesser the tumor has been associated with the use of lesser procedureprocedure . .

--Total ParotidectomyTotal Parotidectomy may be necessary for tumor extension into may be necessary for tumor extension into thethe

deep parotid lobe or when the tumor primarily arises in the deep deep parotid lobe or when the tumor primarily arises in the deep lobelobe..

this can be performed with preservation of the Facial nerve.this can be performed with preservation of the Facial nerve.(Figure2)(Figure2)

((Figure1Figure1))Superficial ParotidectomySuperficial Parotidectomy

((Figure2Figure2))Total Parotidectomy with Facial Nerve Total Parotidectomy with Facial Nerve PreservationPreservation

--Patients Exhibiting with Trismus,decreased masseteric contraction orPatients Exhibiting with Trismus,decreased masseteric contraction or

Jaw shift to the affected side are likely to required Jaw shift to the affected side are likely to required Extended ParotidectomyExtended Parotidectomy

which includes:Resection of Masseter muscle or ascending portion ofwhich includes:Resection of Masseter muscle or ascending portion of

mandible with the Transzygomatic aproach to the Infratemporal fossamandible with the Transzygomatic aproach to the Infratemporal fossa& &

cranial base to clear Perineural spread of tumor along V3 and involvementcranial base to clear Perineural spread of tumor along V3 and involvement

of the pterygoid muscle & infratemporal fossaof the pterygoid muscle & infratemporal fossa..

--Facial Nerve sacrifice is not routinely advocated,but if is performed Facial Nerve sacrifice is not routinely advocated,but if is performed complete removal of parotid is recommendedcomplete removal of parotid is recommended..

--If tumor is completely encasing the nerve branches,neural sacrifice isIf tumor is completely encasing the nerve branches,neural sacrifice is

limited to involved brancheslimited to involved branches..

--Nerve Grafting with the Sural Nerve or Greater Auricular nerve is Nerve Grafting with the Sural Nerve or Greater Auricular nerve is recommended recommended . .

--The use of postoperative radiation does not prevent neural regenerationThe use of postoperative radiation does not prevent neural regeneration

and is not contraindicated for graftingand is not contraindicated for grafting . .

Submandibular GlandSubmandibular Gland::Tumors of Submandibular Gland require complete excision

Of the gland.

Minor Salivary Glands:These Tumors are managed by Transoral Excision.

For High-Grade tumors or tumors that erode bone,

Partial or Total Maxillectomy may be required.

LymphadenectomyLymphadenectomy

--Patients should be stratified into those with or without Clinical Patients should be stratified into those with or without Clinical AdenopathyAdenopathy::

Elective vs Therapeutic DissectionElective vs Therapeutic Dissection..

--Comprehensive neck Dissection is advocated for clinically Positive Comprehensive neck Dissection is advocated for clinically Positive diseasedisease..

--Elective neck Dissection of levels 1 to 3 is advocated for tumors Elective neck Dissection of levels 1 to 3 is advocated for tumors > 4 cm> 4 cm,,

SCC,Adenocarcinoma,Undiffrentiated carcinoma & High-GradeSCC,Adenocarcinoma,Undiffrentiated carcinoma & High-Grade

Mucoepidermoid CarcinomaMucoepidermoid Carcinoma..

Radiation TherapyRadiation Therapy--Salivary cancers were believed to be relatively radioresistant Salivary cancers were believed to be relatively radioresistant

andand

postoperative use of radiation therapy was not routinely postoperative use of radiation therapy was not routinely advocatedadvocated..

--Even if the overal survival is unchanged by postoperative Even if the overal survival is unchanged by postoperative radiationradiation , ,

the resulting improvement in locoregional control confers the resulting improvement in locoregional control confers improved Quality of lifeimproved Quality of life..

--5%5% of Patients experienced severe toxicityof Patients experienced severe toxicity::

11..DeafnessDeafness

22..OsteoradionecrosisOsteoradionecrosis..

33..Optic NeuritisOptic Neuritis..

44..Cervical MyelopathyCervical Myelopathy..

55..Cerebral NecrosisCerebral Necrosis& &

66..Trigeminal NumbnessTrigeminal Numbness..

ChemotherapyChemotherapy

--There is relatively little experience with the use ofThere is relatively little experience with the use of

Chemotherapy for Salivary MalignanciesChemotherapy for Salivary Malignancies..

--The combined use of chemotherapy and radiation in The combined use of chemotherapy and radiation in patients with High-Risk feature is though to patients with High-Risk feature is though to result in improved disease-free survival result in improved disease-free survival compared with radiation alone. -Immunotherapy may compared with radiation alone. -Immunotherapy may soon be used to suppress soon be used to suppress EGFREGFR in in

ADENOID CYSTIC CARCINOMAADENOID CYSTIC CARCINOMA..

Metastatic DiseaseMetastatic Disease

- -Treatment Of Treatment Of Cervical Metastasis Metastasis: :

Comprehensive Neck Dissection + PostOp. Comprehensive Neck Dissection + PostOp. RadiationRadiation..

---Treatment Of Distant Metastasis to Lung or BrainTreatment Of Distant Metastasis to Lung or Brain::

Should be Surgically removed when feasible + Should be Surgically removed when feasible + Chemotherapy & Radiation Chemotherapy & Radiation . .

SurveillanceSurveillance

--Visits every 6 to 8 weeks for the 1Visits every 6 to 8 weeks for the 1stst year year,,

--Every 8 to 12 weeks for the 2Every 8 to 12 weeks for the 2ndnd year year,,

--Every 4 Months the 3Every 4 Months the 3rdrd year,followed by every 6 months year,followed by every 6 months..

--CXRCXR::

Yearly screening CXR are normally used for the the Yearly screening CXR are normally used for the the Surveillance ofSurveillance of

Malignant NeoplasmsMalignant Neoplasms . .

--CT Scan or MRICT Scan or MRI::

Is reserved for new onset of symptoms or new physical Is reserved for new onset of symptoms or new physical findingsfindings . .

Complications/MorbidityComplications/Morbidity

--Facial Nerve ParalysisFacial Nerve Paralysis..

--Greater Auricular Nerve DefectGreater Auricular Nerve Defect..

--TrismusTrismus..

--HematomaHematoma..

--Frey’s SyndromeFrey’s Syndrome..

Facial Nerve ParalysisFacial Nerve Paralysis

--Patients with Patients with large tumorlarge tumor, , chronic Sialadenitischronic Sialadenitis or or previous parotid previous parotid surgerysurgery

are at higher risk of facial nerve injuryare at higher risk of facial nerve injury..

--Performing parotid surgery during Non-paralytic Performing parotid surgery during Non-paralytic anesthesia,permitting stimulation & identification of motor anesthesia,permitting stimulation & identification of motor nerve branchesnerve branches . .

--Bleeding that Obscure the field immediately procedes facial nerve Bleeding that Obscure the field immediately procedes facial nerve injuryinjury..

therfore blinde clamping of vessles should be avoidedtherfore blinde clamping of vessles should be avoided..

--Dissection anterior to the tragus & EAC should be juxtaposed to the Dissection anterior to the tragus & EAC should be juxtaposed to the cartilage,preventing injury to the facial nerve or superficial cartilage,preventing injury to the facial nerve or superficial temporal Arterytemporal Artery..

--Unipolar Electrocautery is not appropriate in the region of the nerveUnipolar Electrocautery is not appropriate in the region of the nerve..

--Temporary NeurapraxiaTemporary Neurapraxia may result despite normal anatomy & may result despite normal anatomy & electrostimulation at the end of procedure & results in electrostimulation at the end of procedure & results in

Paresis secondary to traction or thermal injuryParesis secondary to traction or thermal injury . .

--Observation should last Observation should last 6 to 9 months6 to 9 months to evaluate recovery to evaluate recovery

before permanent rehabilitative techniques be usedbefore permanent rehabilitative techniques be used..

--If accidental nerve transection occures the ends should beIf accidental nerve transection occures the ends should be

atromatically marked & the parotid tumor should be removed atromatically marked & the parotid tumor should be removed before repair before repair..

--If significant traction exists nerve Grafting should be usedIf significant traction exists nerve Grafting should be used . .

Greater Auricular Nerve DefectGreater Auricular Nerve Defect

SymptomSymptom::

Postoperative Auricular NumbnessPostoperative Auricular Numbness..

--recent reports have shown the routine preservation recent reports have shown the routine preservation ofof

posterior branch of greater auricular nerve duringposterior branch of greater auricular nerve during

parotidectomy is feasible but is more appropriate parotidectomy is feasible but is more appropriate to assureto assure

the patient that this is an expected sequelathe patient that this is an expected sequela..

TrismusTrismus

--Trismus suggests irritation of the pterygomasseteric Trismus suggests irritation of the pterygomasseteric slingsling..

its often may worse when postoperative radiation its often may worse when postoperative radiation addedadded..

RxRx::

NSAIDs and use of oral opening applianceNSAIDs and use of oral opening appliance..

Patients with significant trismus who require generalPatients with significant trismus who require general

anesthesia usually require transnasal fiberoptic anesthesia usually require transnasal fiberoptic intubationintubation

or Tracheotomyor Tracheotomy..

HematomaHematoma

--Hematoma & Seroma are the Hematoma & Seroma are the most commonmost common surgical surgical

complicationcomplication..

they are prevented by good hemostasis and provision they are prevented by good hemostasis and provision ofof

adequate drainageadequate drainage..

--A suction drainage system is prefered + pressure A suction drainage system is prefered + pressure dressingdressing..

--Fluid Collection:should be removed using a 18-guage Fluid Collection:should be removed using a 18-guage needle needle..

--Occasionally,a small portion of the wound may need Occasionally,a small portion of the wound may need to be opened to facilitate the adequate drainageto be opened to facilitate the adequate drainage . .

Frey’s SyndromeFrey’s Syndrome

--Gustatory sweatingGustatory sweating, is belived to occure secondary to , is belived to occure secondary to thethe

denervated postganglionic Parasympathetic fibers denervated postganglionic Parasympathetic fibers growinggrowing

into the dermis & innervating the sweat gland after into the dermis & innervating the sweat gland after removal of parotid gland removal of parotid gland..

--PreventionPrevention::

11..Placement of acellular DermisPlacement of acellular Dermis..

22..PolytetrafluoroethylenePolytetrafluoroethylene..

33..Fat GraftingFat Grafting..

44..Use of interposition flap such as SCM muscle orUse of interposition flap such as SCM muscle or

Temporoparietal fascial flapTemporoparietal fascial flap..