42 Salivary gland disorders

JOHN D. LANGDON

Developmental disorders (Table 42.1) Aplasia/a enesis !on enital absen"e o# one or more o# t$e ma%or salivar& lands "an o""'r b't is ver& rare. ($en it does it is 's'all& t$e parotid land t$at is a##e"ted. D'"t atresia A ain t$is disorder is e)tremel& rare. *s'all& t$e s'bmandib'lar d'"t in t$e #loor o# t$e mo't$ #ails to "an'late d'rin embr&olo i"al development. T$e ne+born in#ant presents +it$in 2 or , da&s o# li#e +it$ s'bmandib'lar s+ellin on t$e a##e"ted side d'e to a retention "&st in t$e s'bmandib'lar salivar& land. !on enital #ist'la -atients +it$ bran"$ial "le#t anomalies present 's'all& +it$ 'nilateral painless s+ellin s in t$e re ion o# t$e parotid. .arel& t$e& are bilateral. T$e& #orm sin's tra"ts eit$er in t$e "rease be$ind t$e pinna or in #ront o# t$e tra 's. T$e& dis"$ar e saliva intermittentl&. Abs"ess #ormation d'e to se"ondar& in#e"tion ma& o""'r. !omplete s'r i"al e)"ision o# t$e sin's tra"t is essential. T$e disse"tion is o#ten ver& e)tensive and #'ll disse"tion o# t$e #a"ial nerve ma& be re/'ired. 0"topi" and aberrant salivar& tiss'e 0"topi" salivar& tiss'e "an develop an&+$ere +it$in t$e territor& o# t$e #irst and se"ond bran"$ial ar"$es in t$e lateral ne"12 p$ar&n) or middle ear. 3alivar& tiss'e is re 'larl& #o'nd in l&mp$ nodes +it$in t$e ne"1 and "an be mista1en #or metastati" disease +$en #o'nd in a ne"1 disse"tion spe"imen. Alt$o' $ rare2 t$e most "ommonl& re"o nised e"topi" salivar& tiss'e is t$e 3ta#ne bone "&st. T$is presents as an as&mptomati" "learl& demar"ated radiol'"en"& at t$e an le o# t$e mandible belo+ t$e in#erior dental "anal. 4t is #ormed b& an inva ination into t$e bone o# t$e lin 'al aspe"t o# t$e mandible b& an e"topi" lobe o# t$e ad%a"ent s'bmandib'lar salivar& land. A""essor& lobes An a""essor& parotid lobe is t$e most "ommon developmental anomal&. 4t o""'rs in as man& as 25 per "ent o# s'b%e"ts. 4ts position is "onstant arisin #rom t$e $ori6ontal "omponent o# t$e parotid d'"t as it"rosses t$e masseter m's"le. 4ts importan"e lies in t$e #a"t t$at an& o# t$e diseases t$at "an a##e"t t$e salivar& lands ma& involve t$e a""essor& lobe and lead to dia nosti" "on#'sion as t$e possibilit& is not "onsidered. T$is is be"a'se t$e s&mptoms and si ns are not +it$in t$e normal anatomi"al territor& o# t$e parotid. 4n#lammator& disorders (Table 42.2) 7iral 8'mps T$e m'mps vir's is a param&)ovir's and is t$e most "ommon "a'se o# a"'te pain#'l parotid s+ellin a##e"tin "$ildren. T$e disease starts +it$ a prodromal period o# 1 or 2 da&s d'rin +$i"$ t$e "$ild e)perien"es #everis$ness2 "$ills2 na'sea2 anore)ia and $eada"$e. T$is is t&pi"all& #ollo+ed b& pain and s+ellin o# one or bot$ parotid lands. T$e parotid pain "an be ver& severe and is e)a"erbated b& eatin or drin1in . 3&mptoms resolve spontaneo'sl& a#ter 9:15 da&s. 4n a "lassi"al "ase o# m'mps t$e dia nosis is based on t$e $istor& and "lini"al e)amination. Ho+ever2 t$e presentation ma& be at&pi"al or sporadi" or $ave

predominantl& 'nilateral or even s'bmandib'lar involvement. 4n t$is sit'ation2 paired blood spe"imens ta1en appro)imatel& 15 da&s apart are 'sed to "on#irm t$e dia nosis. One episode o# in#e"tion "on#ers li#elon imm'nit&. A n'mber o# ot$er viral a ents :!o)sa"1ie A and ;2 parain#l'en6a 1 and ,2 enteri" "&topat$o eni" $'man orp$an vir'ses (0!HO) and l&mp$o"&ti" "$oriomenin itis : "an all "a'se identi"al si ns and s&mptoms. ;a"terial A"'te as"endin ba"terial sialadenitis a##e"ts mostl& t$e parotid lands. Histori"all& it +as des"ribed in de$&drated2 "a"$e"ti" patients o#ten #ollo+in ma%or abdominal s'r er& +$en t$e patient +as on a <nil b& mo't$= re ime. T$e red'"ed salivar& #lo+ and oral sepsis res'lted in ba"teria "olonisin t$e parotid d'"t and s'bse/'entl& involvin t$e parotid paren"$&ma. (it$ "'rrent medi"al pra"ti"e and improved oral $& iene patients are rarel& allo+ed to be"ome de$&drated and t$is "lini"al pattern is 'n"ommon. T$e t&pi"al patient presentin +it$ an a"'te as"endin ba"terial parotitis no+ is an ot$er+ise #it&o'n ad'lt +it$ no obvio's predisposin #a"tors (>i . 42.1). T$e "lini"al presentation is o# t$e onset o# tender2 red2 pain#'l parotid s+ellin over a #e+ $o'rs. T$ere is asso"iated malaise2 p&re)ia and o#ten re ional l&mp$adenopat$&. -ain is e)a"erbated on attemptin to eat or drin1. T$e parotid s+ellin ma& be di##'se b't o#ten itis lo"alised to t$e lo+er pole o# t$e land pres'mabl& be"a'se t$e in#e"tion tends to lo"alise 'nder t$e e##e"t o# ravit&. 4# t$e land is entl& <mil1ed= b& massa in t$e "$ee12 "lo'd& t'rbid saliva "an be e)pressed #rom t$e parotid d'"t and t$is s$o'ld be "'lt'red. T$e in#e"tin or anism is 's'all& 3tap$&lo"o""'s a're's or 3trepto"o""'s viridans. 3ialo rap$& m'st never be 'nderta1en d'rin t$e a"'te p$ase o# in#e"tion as t$e retro rade in%e"tion o# in#e"ted material into t$e d'"t s&stem +ill res'lt in ba"teraemia. *ltraso'nd ima in s$o+s t$e "$ara"teristi" dilatation o# t$e a"inae (>i . 42.2). 4# t$e patient presents at an earl& sta e be#ore abs"ess #ormation2 t$e in#e"tion "an 's'all& be "ontrolled +it$ antibioti"s. 4n a patient not aller i" to peni"illin a "ombination o# a broad?spe"tr'm peni"illin and a peni"illinase?resistant a ent is 's'all& e##e"tive. 4# t$e land be"omes #l'"t'ant indi"atin abs"ess #ormation2 t$e p's m'st be drained. O""asionall& it is possible to drain t$e abs"ess b& aspiratin t$e p's t$ro' $ a lar e?bore $&podermi" needle b't 's'all& it is ne"essar& to 'nderta1e #ormal s'r i"al draina e 'nder eneral anaest$esia (Table 42.,). !$roni" ba"terial sialadenitis is #ar more "ommon in t$e s'bmandib'lar salivar& land and it 's'all& o""'rs se"ondar& to "$roni" obstr'"tion. *n#ort'natel& t$e s'bmandib'lar land $as a poor "apa"it& #or re"over& #ollo+in in#e"tionand2 in most "ases #ollo+in "ontrol o# an& a"'te s&mptoms +it$ antibioti"s2 t$e land itsel# m'st be removed. D'rin t$e operation reat "are m'st be ta1en not to dama e t$e mandib'lar bran"$ o# t$e #a"ial nerve +$en ma1in t$e in"ision2 t$e lin 'al nerve +$en mobilisin t$e land and "lampin t$e d'"t and t$e $&po lossal nerve +$en separatin t$e land #rom t$e #loor o# t$e s'bmandib'lar trian le. .e"'rrent sialadenitis o# "$ild$ood .e"'rrent sialadenitis o# "$ild$ood e)ists as a distin"t "lini"al entit& b't little is 1no+n re ardin its aetiolo & and pro nosis. 4t is "$ara"terised b& t$e rapid s+ellin o# 's'all& one parotid land a""ompanied b& pain and di##i"'lt& in "$e+in as +ell as s&stemi" s&mptoms s'"$ as #ever and malaise. Alt$o' $ ea"$ episode o# parotid s+ellin is normall& 'nilateral t$e opposite side ma& be involved in s'bse/'ent episodes. 0a"$ episode o# pain and s+ellin lasts #or ,:@ da&s and is #ollo+ed b& a /'ies"ent period o# a #e+ +ee1s to several mont$s. O""asionall& episodes are so #re/'ent t$at t$e "$ild loses a "onsiderable amo'nt o# s"$oolin . T$e onset is 's'all&

bet+een , and A &ears alt$o' $ it $as been reported in in#ants as &o'n as 4 mont$s. T$e dia nosis is based on t$e "$ara"teristi" $istor& and is "on#irmed b& sialo rap$& +$i"$ s$o+s a ver& "$ara"teristi" p'n"tate siale"tasis o#ten li1ened to a sno+ storm a ainst a dar1 ni $t s1& (>i . 42.,). Traditionall& t$e episodes o# parotitis $ave been treated +it$ antibioti" and s&mptoms settle +it$in ,:9 da&s on s'"$ a re ime. O""asionall& re"'rrent episodes are so #re/'ent t$at prop$&la"ti" antibioti"s are re/'ired #or a period o# mont$s or &ears. 3pontaneo's resol'tion o# s&mptoms seems to o""'r at p'bert&. 3pe"i#i" <in#e"tions= ( ran'lomato's sialadenitis) 8&"oba"terial in#e"tions T'ber"'losis and nont'ber"'lo's parotitis t&pi"all& presents as a t'mo'r?li1e s+ellin o# t$e land. 3&mptoms are 's'all& minimal +it$ little pain and no p&re)ia. O#ten t$e dia nosis is not s'spe"ted and t$e mass is e)"ised b& #ormal parotide"tom&. !at?s"rat"$ disease !at?s"rat"$ disease is "a'sed b& ;artonella $enselae. 4t is a "ommon disease in t$e *3A b't is not o#ten seen in t$e *B. !$ildren are 's'all& a##e"ted. 3&mptoms #ollo+ a s"rat"$ b& a "at +$en a small p'st'le #orms at t$e site o# t$e s"rat"$. T$ere is an asso"iated l&mp$adenitis 's'all& a##e"tin t$e "ervi"al nodes and mild p&re)ia and en"ep$alopat$& +it$ o""asional transient "ranial nerve palsies. T$e parotid lands are s+ollen in , per "ent o# "ases. T$e "ondition is sel#?limitin and resolves +it$o't treatment. 3&p$ilis 3&p$ilis parotitis is no+ rare in t$e *B as t$e disease itsel# is 'n"ommon. T$e lands "an be involved in t$e a"'te earl& sta es b't are more o#ten involved in tertiar& s&p$ilis +it$ 'mma #ormation2 land destr'"tion and dense #ibrosis. To)oplasmosis To)oplasmosis is d'e to t$e proto6oan or anism To)oplasma ondii. 4n most "ases in#e"tion is not re"o nised and is as&mptomati". ($en s&mptoms do o""'r t$e patient 's'all& presents +it$ l&mp$adenopat$& and malaise sometimes a""ompanied b& a $eada"$e and sore t$roat. T$e enlar ed l&mp$ nodes are r'bber& and are not tender. On o""asion t$e patient presents +it$ isolated 'nilateral parotid s+ellin some +ee1s be#ore t$e l&mp$adenopat$& develops. 4n t$is sit'ation a parotide"tom& is o#ten per#ormed +$i"$ leads to t$e dia nosis. Dia nosis is #'rt$er "on#irmed b& t$e dete"tion o# a positive 3abin:>eldman d&e test on t$e ser'm. T$e disease #ollo+s a sel#?limitin "o'rse and resolves spontaneo'sl& a#ter +ee1s or mont$s. 4# s&mptoms are severe t$e patient is treated +it$ a ,? or 4?+ee1 "o'rse o# p&rimet$amine and s'lp$adia6ine. Deep m&"oses >'n al in#e"tions o# t$e salivar& lands o""'r onl& in imm'no"ompromised patients and are most "ommonl& seen in $'man imm'node#i"ien"& vir's (H47)?positive patients. 3alivar& landinvolvement is 's'all& %'st one mani#estation o# a more eneralised in#e"tion. T$e patient presents +it$ a t'mo'r?li1e s+ellin o# t$e a##e"ted land. O#ten t$ere is e)tensive "entral ne"rosis. >res$ material is needed #or "'lt're and identi#i"ation o# t$e or anism. Treatment is b& appropriate s&stemi" anti#'n al "$emot$erap&. 3ar"oid 3ar"oidosis $as a predeli"tion #or salivar& tiss'e2 $'t onl& rarel& is salivar& s+ellin t$e presentin #eat're. -arotid land involvement o""'rs in 15 per "ent o# "ases "lassi"all& as part o# Heer#ordt=s s&ndrome +$i"$ "omprises parotid s+ellin 2 anterior 'veitis2 #a"ial pals& and #ever. Cerostomia ma& be a prominent #eat're. A less 's'al

presentation is +it$ bilateral parotid and s'bmandib'lar s+ellin +$i"$ is one o# t$e "a'ses o# 8i1'li"6= s&ndrome. 4n ea"$ o# t$ese presentations salivar& involvement is +idespread and representative $istolo & "an be obtained #rom a minor salivar& land biops&. .arel& t$e patient +ill present +it$ a lo"alised t'mo'r?li1e s+ellin in one parotid land : t$e so?"alled sar"oid pse'dot'mo'r. 4n t$e absen"e o# ot$er si ns or s&mptoms t$e dia nosis is onl& li1el& to be made #ollo+in parotid s'r er& #or a pres'med neoplasm. (e ener=s ran'lomatosis Alt$o' $ t$e t&pi"al presentation is "$roni" ran'lomato's 'l"eration and destr'"tion in t$e nasop$ar&n) or sometimes t$e oral "avit&2 (e ener=s ran'lomatosis "an involve t$e ma%or salivar& lands. Dia nosis is based on t$e $istolo i"al #indin o# ne"rotisin arteritis o#ten asso"iated +it$ n'mero's iant "ells and ran'lomas. -'lmonar& and renal involvement is ver& "ommon. Treatment is b& "&toto)i" "$emot$erap& s'"$ as "&"lop$osp$amide or a6at$ioprine. T$e pro nosis is poor. Gran'lomato's disease o# minor salivar& lands Gran'lomato's "$eilitis2 8el1ersson:.osent$al s&ndrome (re"'rrent #a"ial pals&/#a"ial s+ellin /#iss'red ton 'e) and !ro$n=s disease all a##e"t t$e minor salivar& lands o# t$e lips. !$eilitis land'laris is a rare disorder mainl& o# ad'lt males in +$om t$e lo+er lip be"omes s+ollen and $ard. T$e labial salivar& lands be"ome nod'lar and t$eir ori#i"es are in#lamed and s+ollen. Aller i" sialadenitis A variet& o# potential aller ens "a'sin a"'te parotid s+ellin $as been identi#ied. 3ome #oods2 dr' s (most #re/'entl& "$loramp$eni"ol and tetra"&"line)2 metals s'"$ as ni"1el and pollens $ave been in"riminated. .adiation sialadenitis >ollo+in t$e start o# t$erape'ti" irradiation +$en t$e parotid lands are +it$in t$e radiation #ield t$e patient develops an a"'te parotitis 's'all& a#ter 24 $o'rs. T$e lands are s+ollen and tender and t$ere is a mar1ed rise in salivar& am&lase and t$e salivar& #lo+ rate is red'"ed. T$e rea"tion is sel#?limitin and resolves a#ter 2 or , da&s even t$o' $ t$e radiot$erap& "ontin'es. T$is rea"tion is /'ite distin"t #rom t$e permanent radiation atrop$& t$at o""'rs +it$ t$erape'ti" doses above 95 G&2 +$i"$ develops pro ressivel& some +ee1s a#ter t$e radiation $as been "ompleted. H'man imm'node#i"ien"& vir's?asso"iated sialadenitis !$roni" parotitis in "$ildren is almost pat$o nomoni" o# H47 in#e"tion. 4n ad'lts a si""a s&ndrome and l&mp$o"&ti" in#iltration o# t$e salivar& lands are more 's'al. T$e presentation o# H47?asso"iated sialadenitis is ver& similar to "lassi"al 3%o ren=s s&ndrome. Dr& mo't$2 dr& e&es and s+ellin o# t$e salivar& lands to et$er +it$ l&mp$adenopat$& s' est t$e dia nosis. Histolo i"all& t$e "ondition "losel& resembles 3%o ren=s s&ndrome and di##erentiation ma& be di##i"'lt. Ho+ever2 a'toantibodies in"l'din antin'"lear2 r$e'matoid #a"tor2 33?A and 33?; are absent 'nless t$e patient "oin"identall& $as a "onne"tive tiss'e disorder. A"/'ired imm'node#i"ien"& s&ndrome (A4D3)?asso"iated l&mp$oma presentin as salivar& land s+ellin $as also been des"ribed. Anot$er presentation o# salivar& land disease in H47?positive patients is m'ltiple parotid "&sts "a'sin ross parotid s+ellin and si ni#i"ant #a"ial dis#i 'rement. On ima in +it$ "omp'terised tomo rap$& (!T) or ma neti" resonan"e ima in (8.4) t$e parotids $ave t$e appearan"e o# 3+iss "$eese +it$ m'ltiple lar e "&sti" lesions. T$e lands are not pain#'l and t$ere is no red'"tion in salivar& #lo+ rates. 3'r er& ma& be indi"ated to improve t$e appearan"e (>i . 42.4). 3ialadenitis o# minor salivar& lands

A"'te ne"rotisin sialometaplasia is an 'n's'al "ondition +$i"$ +as #irst des"ribed in 1D@,. 4t o""'rs onl& on t$e $ard palate in t$e molar re ion in t$e va'lt o# t$e palate mid+a& bet+een t$e midline and t$e in ival mar in. 4t is onl& seen in $eav& smo1ers. 4t $as a "$ara"teristi" appearan"e +$i"$ resembles a "ar"inoma +it$ "entral 'l"eration and raised er&t$emato's mar ins. T$e 'l"er ma& be as m'"$ as , "m in diameter. As itso "losel& resembles a "ar"inoma t$e dia nosis is o#ten made on t$e basis o# a s'r i"al biops&. T$e lesions are sel#?$ealin b't o#ten ta1e 15:12 +ee1s to resolve (>i . 42.9). Obstr'"tion and tra'ma (Table 42.4) -apillar& obstr'"tion O""asionall& a ro' $ 'pper molar toot$ or an overe)tended dent're #lan e +ill irritate t$e parotid papilla. 4# t$is is s'##i"ient to "a'se 'l"eration +it$ "onse/'ent in#lammation and oedema t$is ma& obstr'"t salivar& #lo+2 parti"'larl& at meal times +$en t$e #lo+ rate is in"reased. 4n t$is sit'ation t$e patient $as "lassi"al rapid onset pain and s+ellin at meal times. 4# t$e tra'ma to t$e parotid papilla "ontin'es t$ere +ill be pro ressive s"arrin and #ibrosis in t$e so#t tiss'es and permanent stenosis o# t$e papilla "an o""'r. A papillotom& +ill be re/'ired. T$is is a simple pro"ed're per#ormed 'nder lo"al anaest$esia. A probe is inserted into t$e ori#i"e o# t$e papilla and +it$ a s"alpel blade t$e papilla is split open b& in"isin do+n on to t$e probe. T$is la&s open t$e papilla and divides t$e stenosis allo+in #ree draina e o# saliva. 3tone #ormation (sialolit$iasis) 0i $t& per "ent o# all salivar& stones o""'r in t$e s'bmandib'lar land2 15 per "ent o""'r in t$e parotid2 @ per "ent in t$e s'blin 'al land and t$e remainder o""'rs in t$e minor salivar& lands. 4t is believed t$at t$e ma%orit& o# stones o""'rs in t$e s'bmandib'lar lands be"a'se t$eir se"retions "ontain m'"'s and t$e vis"osit& is $i $er. 0i $t& per "ent o# s'bmandib'lar stones are radio?opa/'e and "an be identi#ied 'sin plane radio rap$s. ;& "ontrast t$e ma%orit& o# parotid stones are radiol'"ent and "annot be dete"ted on plane radio rap$& (>i . 42.A). T$e "lassi"al presentation is o# a"'te pain and s+ellin at meal times. Onset is rapid : +it$in a min'te o# startin t$e meal : and t$e s+ellin resolves over a period o# abo't 1 $o'r a#ter t$e meal is "ompleted. Ho+ever2 t$is "lassi"al pi"t're onl& o""'rs +$en t$e stone "a'ses almost "omplete obstr'"tion o#ten +$en it is impa"ted at t$e openin o# ($arton=s d'"t. 8ore o#ten t$e stone "a'ses onl& partial obstr'"tion and is l&in eit$er +it$in t$e $il'm o# t$e land or +it$in t$e d'"t in t$e #loor o# t$e mo't$. 4n t$is sit'ation t$e patient ma& "omplain o# o""asional s+ellin o#ten +it$ minimal dis"om#ort or o# a "$roni"all& enlar ed mass in t$e s'bmandib'lar trian le +it$ episodes o# d'll a"$in pain. T$is res'lts #rom "$roni" ba"terial in#e"tionarisin in an obstr'"ted land +it$ salivar& stasis and poor empt&in . O#ten a salivar& stone is totall& as&mptomati" and is dis"overed "oin"identall& d'rin radio rap$& #or ot$er reasons. 4# a stone is identi#ied on plane radio rap$s2 no ot$er investi ation is ne"essar&. -arotid stones o#ten impa"t at t$e parotid papilla or alternativel& ta1e on a <sta ?$orn= s$ape and #orm at t$e %'n"tion o# t$e t+o main "olle"tin d'"ts and t$e 3tenson=s d'"t (>i . 42.@). 4# t$e stone is trapped at t$e d'"t papilla it "an o#ten be released b& entl& probin and "arr&in o't dilatation o# t$e papilla. 4t ma& $e ne"essar& to slit t$e d'"t in order to release t$e stone. 4# t$e stone is l&in in t$e s'bmandib'lar d'"t in t$e #loor o# t$e mo't$ anterior to t$e point at +$i"$ t$e d'"t "rosses t$e lin 'al nerve (se"ond molar re ion) t$e stone "an

be released b& openin t$e d'"t lon it'dinall& (>i . 42.E). 4t is important to pass a lar e s't're aro'nd t$e d'"t pro)imal to t$e stone so t$at d'rin t$e operative pro"ed're t$e stone "annot be displa"ed ba"1+ards in t$e d'"t. On"e t$e stone $as been released t$e +all o# t$e d'"t s$o'ld be s't'red to t$e m'"osa o# t$e #loor o# t$e mo't$ to maintain an openin #or t$e #ree draina e o# saliva. No attempt s$o'ld be made to repair t$e d'"t +all as t$is +ill lead to stri"t're #ormation. A parotid stone lo"ated at t$e "on#l'en"e o# t$e "olle"tin d'"ts "an be released s'r i"all& b& raisin a prea'ri"'lar #lap2 e)posin t$e parotid d'"t and a ain in"isin it lon it'dinall& to release t$e stone. Obstr'"tion in and aro'nd t$e d'"t +all 3"arrin and #ibrosis in t$e d'"t +all stri"t're #ormation +ill also res'lt in obstr'"tion to salivar& #lo+. 4t o#ten res'lts as a "ompli"ation o# lon ?standin sialolit$iasis $'t it ma& o""'r as a res'lt o# tra'ma parti"'larl& to t$e #loor o# t$e mo't$. 3'bse/'ent $ealin and s"arrin "an res'lt in a stenosis o# t$e d'"t. 4n patients +it$ masseteri" $&pertrop$& t$e parotid d'"t ma& be stret"$ed aro'nd t$e anterior border o# t$e m's"le and t$is ma& "a'se obstr'"tion o# salivar& #lo+ at meal times. 8'"o"eles 8'"'s retention "&sts and m'"'s e)travasation "&sts arise in t$e minor salivar& lands as a res'lt o# me"$ani"al dama e to t$e land or its d'"t. T$e "ommon sites are on t$e m'"osal aspe"t o# t$e lo+er lip parti"'larl& in patients +it$ a deep overbite and in t$e b'""al m'"osa posteriorl& +$ere an 'pper +isdom toot$ is er'ptin b'""all&. T&pi"all& t$e patient presents +it$ a $istor& o# re"'rrent s+ellin s t$at develop over da&s or +ee1s2 r'pt're and t$en re"'r a#ter a #e+ +ee1s. T$e "&sts rarel& e)"eed 1 "m in diameter and are tense bl'is$ sessile s+ellin s. T$e treatment is not to t$e "&st itsel# b't to t$e 'nderl&in minor land +$i"$ s$o'ld be e)"ised 'nder lo"al anaest$esia. A ran'la is no more t$an a lar e m'"o"ele arisin #rom t$e s'blin 'al land. !lassi"all& t$e ran'la presents as a lar e tense bl'is$ s+ellin in t$e #loor o# t$e mo't$ anteriorl& o#ten displa"in t$e ton 'e (>i . 42.D). Ho+ever2 t$e ran'la ma& p's$ its +a& t$o' $ t$e midline m&lo$&oid de$is"en"e in t$e #loor o# t$e mo't$ and enter t$e s'bmental spa"e presentin as a midline s+ellin in t$e 'pper ne"1. T$is is t$e <pl'n in ran'la=. T$e treatment o# a ran'la is e)"ision o# t$e s'blin 'al land. 3alivar& neoplasms (Table 42.9) 3alivar& neoplasms "omprise 1.2 per "ent o# all neoplasti" disease.Nearl& all salivar& neoplasms present as slo+l& ro+in masses +$i"$ $ave o#ten been present #or several &ears. 0ven mali nant salivar& t'mo'rs 's'all& ro+ slo+l&. *n#ort'natel& pain is not a reliable indi"ation o# mali nan"&. !ertainl& i# a mali nant salivar& neoplasm is invadin a sensor& nerve pain or paraest$esia "an o""'r b't #re/'entl& at s'r er& one sees a nerve ma"ros"opi"all& invaded b& t'mo'r b't +$i"$ $as been #'n"tionin normall& preoperativel&. >'rt$ermore beni n t'mo'rs o#ten present +it$ pain and a"$in in t$e a##e"ted land pres'mabl& d'e to "aps'lar distension and possibl& also d'e to an element o# o't#lo+ obstr'"tion. T$ere#ore t$e onl& reliable "lini"al indi"ation o# mali nan"& is #a"ial nerve pals& in t$e "ase o# t$e parotid2 ind'ration and/or 'l"eration o# t$e overl&in s1in or m'"osa and re ional l&mp$ati" metastasis. T$e investi ation o# salivar& neoplasms >or parotid and s'bmandib'lar t'mo'rs !T and 8.4 s"annin are t$e most $elp#'l ima in te"$ni/'es (>i s 42.15 and 42.11). T$e& +ill "on#irm t$at t$e mass bein investi ated is indeed intrinsi" to t$e land2 t$e& a""'ratel& ima e t$e borders o# t$e t'mo'r and s$o+ +$et$er it is +ell "ir"'ms"ribed and beni n or di##'se2 invasive and

mali nant. 4n addition t$e& s$o+ t$e relations$ip o# t$e t'mo'r to ot$er anatomi" str'"t'res and $elp +it$ t$e plannin o# s'bse/'ent s'r er&. Open s'r i"al biops& o# intrinsi" neoplasms o# t$e ma%or lands is absol'tel& "ontraindi"ated. At least @9 per "ent o# all parotid t'mo'rs and more t$an 95 per "ent o# all s'bmandib'lar land t'mo'rs +ill prove to be beni n pleomorp$i" adenomas. T$is t'mo'r +$i"$ is onl& poorl& en"aps'lated is ver& tense and i# an in"ision is made into it t$e "ontents o# t$e t'mo'r b'rst into t$e s'rro'ndin tiss'e planes and it is impossible to eradi"ate t$e mi"ros"opi" spilla e o# t'mo'r "ells. 4# t$is $appens t$e patient +ill develop m'ltiple lo"al t'mo'r re"'rren"es over man& &ears 'nless t$e& are s'b%e"ted to radi"al postoperative radiot$erap&2 +$i"$ is best avoided in t$e mana ement o# beni n disease. !learl& i# t$ere is s1in in#iltration or 'l"eration an open biops& is essential to establis$ a preoperative dia nosis 'pon +$i"$ to plan s'r er&. >or t'mo'rs o# t$e minor salivar& lands parti"'larl& in t$e palate t$ere is a m'"$ $i $er "$an"e o# t$e t'mo'r bein mali nant and as it is not ne"essar& to open 'p ot$er tiss'e planes to ain a""ess to t$e t'mo'r as open in"isional biops& is important. >ine needle aspiration (>NA) biops& is a sa#e alternative to open biops& o# a ma%or land. 0viden"e s' ests t$at provided t$e needle a' e does not e)"eed 1E G t$ere is no ris1 o# seedin viable t'mo'r "ells. Alt$o' $ advo"ates o# t$is te"$ni/'e "laim $i $ a""'ra"& and spe"i#i"it&2 t$ere is inevitabl& a $i $ ris1 o# samplin error. 0pit$elial t'mo'rs 3event&?#ive per "ent o# all salivar& epit$elial t'mo'rs arise in t$e parotid lands and2 o# t$ese2 onl& 19 per "ent are mali nant. J'st over 15 per "ent o""'r in t$e s'bmandib'lar lands and2 o# t$ese2 appro)imatel& one?t$ird are mali nant. Abo't 19 per "ent o# t'mo'rs o""'r in t$e minor salivar& lands and nearl& $al# o# t$ese +ill be mali nant. T'mo'rs arisin in t$e s'blin 'al lands are rare (5., per "ent) b't nearl& all o# t$em +ill be mali nant. ;ot$ beni n t'mo'rs : adenomas : and mali nant t'mo'rs : "ar"inomas : o""'r. Adenomas O# t$e variet& o# beni n adenomas t$at $as been des"ribed onl& t+o : t$e pleomorp$i" adenoma and (art$in=s t'mo'r:arise +it$ an& #re/'en"&. T$e pleomorp$i" adenoma o""'rs at an& a e (mean 42 &ears) and $as an e/'al se) in"iden"e. 4t a""o'nts #or at least @9 per "ent o# parotid t'mo'rs and more t$an 95 per "ent o# s'bmandib'lar t'mo'rs. 4t a""o'nts #or rat$er less t$an 95 per "ent o# minor land t'mo'rs. !lini"all& t$e t'mo'r $as t$e te)t're o# "artila e and $as an irre 'lar and bosselated s'r#a"e. 4n t$e palate2 t$e overl&in m'"osa is rarel& 'l"erated. 7er& rarel& a#ter a n'mber o# &ears t$e t'mo'r ma& 'nder o mali nant "$an e and #or t$is reason all patients presentin +it$ pleomorp$i" adenomas s$o'ld be advised to 'nder o s'r i"al removal o# t$e t'mo'r (>i . 42.12). T$e (art$in=s t'mo'r o""'rs onl& in t$e parotid land +$ere it a""o'nts #or appro)imatel& 19 per "ent o# all neoplasms. 4t is a disease o# t$e elderl& +it$ a mean a e o# presentation o# A5 &ears. Histori"all& it $ad a maleF#emale ratio o# 4F1 b't it is no+ be"omin in"reasin l& "ommon in #emales. .e"ent eviden"e s' ests t$at t$is t'mo'r is related to "i arette smo1in . 4t is also 'n's'al in t$at in 15 per "ent o# "ases it arises eit$er bilaterall& or is m'lti"entri" in t$e one land. 4t does not 'nder o mali nant "$an e.

!ar"inomas T$e a"ini" "ell "ar"inoma and t$e m'"oepidermoid "ar"inoma2 alt$o' $ 'ndo'btedl& mali nant t'mo'rs +it$ a potential #or lo"al invasion and metastati" spread2 are #re/'entl& ver& lo+ rade $istolo i"all& and do not re/'ire t$e radi"al treatment needed #or more a ressive t'mo'rs. To et$er t$e& a""o'nt #or onl& 9 per "ent o# all t'mo'rs at an& sire. T$e m'"oepidermoid t'mo'r is m'"$ more "ommon in t$e *3A +$ere it #orms 15 per "ent o# all salivar& neoplasms. T$e adenoid "&sti" "ar"inoma2 adeno"ar"inoma2 s/'amo's "ell "ar"inoma and 'ndi##erentiated "ar"inoma are all a ressive mali nant t'mo'rs t$at "arr& a poor pro nosis re ardless o# treatment. T$e adenoid "&sti" "ar"inoma is "$ara"terised b& relentless perine'ral spread alon t$e "ranial nerves and into t$e brain. Ho+ever2 it ro+s e)tremel& slo+l& and alt$o' $ inevitabl& #atal t$e 9? and 15?&ear s'rvival #i 'res are @5 per "ent and 45 per "ent2 respe"tivel&. 4t is also 'n's'al in $avin a predile"tion #or distant metastasis to t$e l'n s +$ere it prod'"es o#ten m'ltiple "annon ball t'mo'rs +$i"$ remain s&mptomless #or man& &ears. T$e ot$er "ar"inomas mentioned above $ave 9?&ear s'rvival #i 'res o# aro'nd 29:,9 per "ent. 8ana ement o# epit$elial t'mo'rs ;ot$ beni n and mali nant t'mo'rs arisin in t$e parotid or s'bmandib'lar lands are treated s'r i"all& b& e)"ision +it$ s'r i"al "learan"e. 4n t$e parotid land t$is is b& eit$er s'per#i"ial or total parotide"tom& a""ordin to t$e lo"ation o# t$e t'mo'r. *nless t$e patient presents +it$ #a"ial nerve pals& (indi"atin a mali nant t'mo'r) t$e #a"ial nerve is al+a&s preserved. 4n t$e s'bmandib'lar land treatment is al+a&s b& e)"ision o# t$e land. 4# +$en a de#initive pat$olo i"al dia nosis is re"eived t$e t'mo'r is mali nant t$en t$e patient s$o'ld re"eive radi"al postoperative radiot$erap&. 4n t$ose "ases +$en t$e t'mo'r involves s1in or ot$er ad%a"ent str'"t'res or +$ere t$ere is l&mp$ati" metastasis t$e patient s$o'ld 'nder o radi"al e)"ision2 in"l'din a ne"1 disse"tion and sa"ri#i"in an& str'"t'res invaded b& t'mo'r2 and a ain treated +it$ postoperative radiot$erap&. -leomorp$i" adenomas arisin in t$e minor salivar& lands "an be treated b& lo"al e)"ision +it$ a 9?mm mar in. T$e& do not invade perioste'm and so in t$e palate t$e& s$o'ld be e)"ised s'bperiosteall&. 8'"oepidermoid "ar"inomas and a"ini" "ell "ar"inomas re/'ire rat$er more radi"al e)"ision +it$ a 15?mm mar in and2 +$en t$e& are sit'ated in t$e palate2 palatal #enestration s$o'ld be 'nderta1en. -ostoperative radiot$erap& is onl& indi"ated #or $i $? rade t'mo'rs or i# t$e mar ins are not "lear. >or t$e remainin "ar"inomas arisin in t$e minor salivar& lands radi"al s'r i"al e)"ision and postoperative radiot$erap& are indi"ated. 4n t$e palate t$is +ill be b& ma)ille"tom&. Nonepit$elial t'mo'rs A variet& o# nonepit$elial t'mo'rs "an arise in t$e salivar& lands. Haeman iomas and l&mp$an iomas ("&sti" $& romas) o""'r in "$ild$ood. Haeman iomas o""'r mostl& in t$e parotid and appear s$ortl& a#ter birt$ and ro+ pro ressivel& #or several mont$s. T$e ma%orit& 'nder oes spontaneo's re ression b& 2 &ears o# a e. >emales are more #re/'entl& a##e"ted. L&mp$an iomas are less "ommon. T$e& ma& a##e"t an& o# t$e salivar& lands. T$e& #orm spon e?li1e m'lti"&sti" lesions. >i#t& per "ent are mani#est b& 12 mont$s and D5 per "ent +ill be evident b& t$e end o# t$e se"ond &ear.

T$e& do not 'nder o spontaneo's invol'tion. T$e& #re/'entl& e)tend into t$e ne"1 and mediastin'm2 and "an 'nder o dramati"all& rapid ro+t$ "a'sin respirator& obstr'"tion. Treatment is b& "omplete s'r i"al e)"ision b't t$is ma& be te"$ni"all& ver& di##i"'lt. Ne'ro#ibromas and ne'rilemmomas are t$e "ommonest nonepit$elial t'mo'rs arisin in ad'lts. !lini"all& t$e& are nor distin 'is$able #rom ot$er salivar& t'mo'rs and are onl& dia nosed #ollo+in s'r er& #or a pres'med epit$elial t'mo'r. Lipomas o""'r in t$e parotids parti"'larl& in ad'lt males. T$e& are treated b& s'r i"al e)"ision. Malignant lymphomas Tr'e e)tranodal l&rnp$oma arisin in t$e salivar& lands :'s'all& t$e parotids : is rare. 8ore "ommon is l&mp$oma arisin #rom t$e l&mp$ nodes eit$er on t$e s'r#a"e o# t$e lands or +it$in t$e paren"$&ma o# t$e land. L&mp$oma also arises in t$e salivar& lands2 as a "ompli"ation o# H47 disease2 and also in beni n l&mp$oepit$elial lesion and 3%o ren=s s&ndrome. T$e pea1 in"iden"e #or nonHod 1in=s l&mp$oma is t$e si)t$ and sevent$ de"ades and #emales are t+i"e as li1el& as males to be a##e"ted. 3alivar& land l&mp$omas 's'all& present as #irm painless s+ellin s and more t$an D5 per "ent o""'r in t$e parotids. 4# t$e l&mp$oma is "on#ined to t$e parotid2 treatment is b& parotide"tom& +it$ postoperative radiot$erap&. 4# t$ere is eviden"e o# spread be&ond t$e salivar& land2 treatment is b& pol&"$emot$erap& a""ordin to t$e a""epted proto"ols based on $istolo i"al "$ara"terisation. Unclassified and allied conditions 3ialosis is an 'n"ommon nonin#lammator& "a'se o# salivar& s+ellin 's'all& a##e"tin t$e parotid lands s&mmetri"all&. 4t is 's'all& asso"iated +it$ metaboli" and endo"rine "onditions s'"$ as al"o$ol ab'se2 diabetes mellit's2 pre nan"&2 maln'trition and some dr' s ('s'all& s&mpat$omimeti"s). 4t 's'all& a##e"ts middle a ed and elderl& ad'lts +$o present +it$ bilateral so#t parotid s+ellin s. ;iops& o# t$e lands reveals e)tensive #att& repla"ement b't ot$er+ise normal tiss'es. No treatment is 1no+n to be e##e"tive b't sometimes parotide"tom& is re/'ired to "orre"t t$e dis#i 'rement. Ne"rotisin sialometaplasia2 beni n l&mp$oepit$elial lesion2 salivar& d'"t "&sts2 B'ttner t'mo'r and "&sti" l&mp$oid $&perplasia o# H47 disease "an all mimi" salivar& land neoplasia. 3imilarl&2 bran"$ial "&sts and dermoids "an present dia nosti" "on#'sion on o""asion. As $as alread& been dis"'ssed bot$ sar"oid and to)oplasmosis "an present as parotid pse'dot'mo'rs. Degenerative conditions (Table 42.A) Sjogrens syndrome 3%o ren=s s&ndrome is an a'toimm'ne "ondition "a'sin pro ressive destr'"tion o# t$e salivar& and la"$r&mal lands. 4n 1D,, 3%o ren #irst des"ribed t$e asso"iation o# 1erato"on%'n"tivitis si""a (dr& e&es) and Cerostomia (dr& mo't$). 3$ortl& t$erea#ter $e noted t$at t$ese s&mptoms #re/'entl& o""'rred in patients +it$ r$e'matoid art$ritis (.A). 4t $as sin"e been realised t$at 3%o ren=s s&ndrome "an o""'r in asso"iation +it$ an& "onne"tive tiss'e disorder. 4ndeed t$e asso"iation is ver& m'"$ "ommoner in man& "onne"tive tiss'e disorders t$an it is +it$ r$e'matoid art$ritis. Onl& 19 per "ent o# patients +it$ .A develop 3%o ren=s s&ndrome +$ereas ,5 per "ent o# patients +it$ s&stemi" l'p's er&t$ematos's and nearl& all patients +it$ primar& biliar& "irr$osis do

so. T$is "ombination o# dr& e&es2 dr& mo't$ and a "onne"tive tiss'e disorder : most o#ten .A as t$is is b& #ar t$e most #re/'ent "onne"tive tiss'e disorder : is "alled se"ondar& 3%o ren=s s&ndrome. T$e same "ombination o# dr& e&es and dr& mo't$ b't +it$o't asso"iation +it$ a "onne"tive tiss'e disorder is 1no+n as -rimar& 3%o ren=s s&ndrome. -rimar& 3%o ren=s s&ndrome also di##ers #rom se"ondar& 3%o ren=s s&ndrome b& virt'e o# more severe )erostomia and )erop$t$almia2 more +idespread d&s#'n"tion o# ot$er e)o"rine lands2 a $i $er in"iden"e o# developin l&mp$oma and a di##erent antibod& pro#ile. >emales are a##e"ted more o#ten t$an males in t$e ratio o# 15F1. T&pi"all& t$e& are middle a ed. T$e presentin "omplaint is 's'all& o# t$e 'nderl&in "onne"tive tiss'e disorder and onl& later does t$e patient be"ome a+are o# a ritt& #eelin in t$e e&es d'e to dr& e&es or o# dr& mo't$. O""asionall& t$ere is enlar ement o# t$e parotid lands bilaterall& and even more rarel& t$e enlar ed parotids are pain#'l (>i . 42.1,). 3'perin#e"tion o# t$e mo't$ +it$ !andida albi"ans is #re/'ent. Less #re/'entl& t$e patient develops ba"terial sialadenitis d'e to as"endin in#e"tion #rom t$e mo't$. T$e "ondition does not invariabl& pro ress to total )erostomia and #or an& individ'al patient it is nor possible to predi"t t$e o't"ome. T$e "$ara"teristi" #eat'res o# t$e "ondition are pro ressive l&mp$o"&ti" in#iltration2 a"inar destr'"tion and proli#eration o# d'"t epit$eli'm o# all salivar& and la"$r&mal tiss'e. T$e dia nosis is o#ten based on t$e "$ara"teristi" $istor&. No laborator& investi ation is pat$o nomoni" o# eit$er primar& or se"ondar& 3%o ren=s s&ndrome. Ho+ever2 t$e #ollo+in investi ations are 's'all& 'nderta1enF 1. 3ialo rap$& reveals t$e pro ressive dama e #rom p'n"tate siale"tasis to total paren"$&mal destr'"tion leavin no more t$an a rossl& dilated d'"t (>i . 42.14). 2. Labial salivar& land biops& "an be misleadin parti"'larl& i# onl& one minor land is $arvested. T$e "$ara"teristi" l&mp$o"&ti" in#iltration is #o"al and a sin le land ma& not s$o+ t$e "$an es. A minim'm o# t$ree lands s$o'ld be s'bmitted to t$e pat$olo ist. ,. 0stimation o# salivar& #lo+ ma& be 'n$elp#'l as t$e normal variation in #lo+ rates ma1es t$e interpretation o# t$e res'lts di##i"'lt. 4. 7iral stainin o# t$e "ornea +it$ rose ;en al and e)amination o# t$e "ornea +it$ a slit?lamp is a ver& sensitive assessment o# a dr& e&e. 9. A'toantibod& s"reen. 3ee Table 42.@. A. ;lood tests 's'all& s$o+ a moderatel& raised er&t$ro"&te sedimentation rate (03.) and a mild mi"ro"&ti" anaemia (t$e anaemia o# "$roni" disease). T$e mana ement o# 3%o ren=s s&ndrome m'st be s&mptomati". No 1no+n treatment modi#ies or reverses t$e )erostomia and 1erato"on%'n"tivitis si""a. Arti#i"ial tears are essential to prote"t t$e "ornea. >or t$e dr& mo't$ vario's arti#i"ial saliva preparations are available b't o#ten t$e patient pre#ers to 'se #re/'ent drin1s and learns to "arr& a bottle o# +ater +it$ t$em at all times. 4# patients are to 'se saliva s'bstit'tes it is important t$at2 i# t$e& are dentate2 t$e prod'"t s$o'ld not $ave a lo+ pH and s$o'ld "ontain #l'oride as rampant dental "aries are a #re/'ent "ompli"ation. T$ere is also in"reased in"iden"e o# developin l&mp$oma in patients +it$ 3%o ren=s s&ndrome. T$e ris1 is $i $est in t$ose +it$ primar& 3%o ren=s s&ndrome. 8ono"&toid ;?"ell l&mp$oma is t$e 's'al "ompli"ation. 4ts onset is o#ten $eralded b& imm'nolo i"al "$an es (#allin imm'no lob'lin levels2 #allin titre o# r$e'matoid #a"tor2 risin ;2? mi"ro lob'lin titre2 risin ser'm ma"ro lob'lin titre and t$e appearan"e o# mono"lonal li $t "$ains in t$e ser'm and 'rine)2 l&mp$adenopat$& and +ei $t loss. Benign lymphoepithelial lesion

T$e term <beni n l&mp$oepit$elial lesion= +as "oined b& God+in in 1D92.*se o# t$e +ord <beni n= to des"ribe t$e lesion is misleadin as appro)imatel& 25 per "ent o# patients +it$ beni n l&m$oepit$elial lesion or 3%o ren=s s&ndrome 'ltimatel& develop l&mp$orna. Histolo i"all& it is not possible to distin 'is$ beni n epit$elial lesions #rom 3%o renGs s&ndrome. ;ot$ are "$ara"terised b& l&mp$o"&ti" in#iltration2 a"inar atrop$& and d'"tal epit$elial proli#eration. 4ndeed t$e& ma& +ell be mani#estations o# t$e same "ondition. !lini"all& beni n l&mp$oepit$elial lesion presents as di##'se s+ellin o# t$e parotid. T$e s+ellin is #irm and o#ten pain#'l. 4n 25 per "ent o# "ases t$e parotid s+ellin is bilateral. 0i $t& per "ent o# patients are #emale and most are over 95 &ears old at presentation. O#ten t$ere is an asso"iated "onne"tive tiss'e disorder and t$e ris1 o# developin l&mp$oma is parti"'larl& $i $ in t$ose +it$ r$e'matoid art$ritis. 8ost patients +ill be treated b& parotide"tom& in order to establis$ t$e dia nosis b't i# an& parotid remnants are le#t2 t$e s+ellin ma& re"'r a ain +it$ t$e ris1 o# l&mp$omato's "$an e. -rolon ed #ollo+?'p is essential. Mikulicz syndrome 4n 1EEE 8i1'li"6 des"ribed beni n2 as&mptomati"2 s&mmetri"al enlar ement o# t$e la"rimal and salivar& lands. His ori inal p'bli"ation des"ribed a series o# patients +$o "learl& $ad a variet& o# di##erent "onditions. ;eni n l&mp$oepit$elial lesion2 3%o ren=s s&ndrome2 l&mp$oma2 l&mp$o"&ti" le'1emia2 sar"oid and 3ialosis "an all present in t$is +a&. T$e term 8i1'li"6= s&ndrome is nor $elp#'l and s$o'ld nor be 'sed (>i . 42.19). Xerostomia A "omplaint o# dr& mo't$ is "ommon. 4t seems to be parti"'larl& #re/'ent in postmenopa'sal +omen +$o also "omplain o# a b'rnin ton 'e or mo't$. Normal salivar& #lo+ de"reases +it$ a e in bot$ men and +omen. T$e sit'ation is #'rt$er "on#'sed as patients +it$ 3%o ren=s s&ndrome are #re/'entl& 'na+are o# $avin a dr& mo't$ and patients +$o "omplain o# dr& mo't$ #re/'entl& $ave normal salivar& #lo+ rates. T$e most "ommon "a'ses o# )erostomia in order o# #re/'en"& areF H "$roni" an)iet& states and depressionI H de$&drationI H dr' s : man& dr' s $ave been impli"ated in "a'sin )erostomia as an 'ndesirable side e##e"t (Table 42.E)I H salivar& land diseases as des"ribed earlier. Cerostomia "an be di##i"'lt to treat. Treatment is aimed at t$e relie# o# s&mptoms and t$e avoidan"e or "ontrol o# "ompli"ations. >re/'ent sips o# +ater $elp most patients. Arti#i"ial salvias are nor +ell a""epted b't t$eir l'bri"ant properties ma& be parti"'larl& 'se#'l at meal times. !$oliner i" dr' s s'"$ as pilo"arpine "an be tried b't t$eir side e##e"ts : diarr$oea and p'pillar& dilatation o#ten o't+ei $ an& bene#it. .ampant "aries and destr'"tive periodontal disease are ma%or "ompli"ations d'e to oral in#e"tion. 8eti"'lo's oral $& iene and t$e +ee1l& 'se o# topi"al #l'oride are essential. T$ere is a $i $ in"iden"e o# oral "andidiasis and anti#'n al dr' s are ne"essar&. Sialorrhoea (Table 42.D) 3ome dr' s and pain#'l lesions in t$e mo't$ in"rease salivar& #lo+ rates. 4n normal $ealt$ t$is is rarel& noti"ed as t$e e)"ess saliva is s+allo+ed spontaneo'sl&. <>alse pt&lism= is more "ommon and is a +ell?re"o nised del'sional s&mptom or o""'rs d'e to #a'lt& ne'rom's"'lar "ontrol leadin to droolin despite normal saliva prod'"tion. *n"ontrollable droolin is 's'all& treated s'r i"all&. As t$e s'bmandib'lar land "ontrib'tes most restin saliva2 attention is dire"ted at t$ese lands bilaterall&. T$e

s'bmandib'lar d'"ts "an be mobilised and repositioned in t$e base o# t$e anterior pillars o# t$e #a'"es. Alternativel& t$e t+o lands ma& be e)"ised. Surgery of salivary gland disease T$e most "ommon indi"ation #or removal o# t$e s'blin 'al salivar& land is in t$e mana ement o# a ran'la2 +$i"$ is a m'"o's e)travasation/retention "&st o# t$e land. Neoplasms o# t$e s'blin 'al land o""'r onl& rarel& b't nearl& all t'mo'rs at t$is site +ill be mali nant. 4n t$is sit'ation s'r er& is t$e same as t$at #or an& ot$er mali nan"& in t$e #loor o# t$e mo't$ : rese"tion +it$ a "lear mar in o#ten involvin t$e mandible and +$en ne"essar& en blo" +it$ a ne"1 disse"tion. ;e#ore an in"ision is made it is $elp#'l to in#iltrate t$e #loor o# t$e mo't$ +it$ a lo"al anaest$eti" "ontainin a vaso"onstri"tor. >or simple e)"ision o# t$e s'blin 'al land2 a linear in"ision is made in t$e #loor o# t$e mo't$ parallel to and %'st lateral to t$e s'bmandib'lar d'"t2 +it$ "are ta1en not to e)tend t$e in"ision more posteriorl& t$an t$e #irst molar toot$ so as to avoid dama e to t$e lin 'al nerve (>i . 42.1A). T$e in"ision s$o'ld open t$e "avit& o# t$e ran'la and allo+ t$e m'"ino's "ontents to $e aspirated. T$e s'bmandib'lar d'"t is no+ "are#'ll& identi#ied and retra"ted mediall&. 3ta& s't'res passed t$ro' $ t$e mar ins o# t$e m'"osa are $elp#'l to aid retra"tion. *sin bl'nt disse"tion +it$ s"issors t$e lin 'al nerve is identi#ied. T$e s'blin 'al land +$i"$ lies ad%a"ent to t$e inner "orte) o# t$e mandible is t$en mobilised and its m'ltiple d'"ts +$i"$ drain into t$e s'bmandib'lar d'"t are divided "are#'ll& in order nor to dama e t$e d'"t itsel#. T$e anterolateral part o# t$e s'blin 'al land ma& be atta"$ed to t$e perioste'm o# t$e mandible b& #ibro's tiss'e and t$is m'st be divided "are#'ll&. >ollo+in removal o# t$e land2 t$e m'"osa o# t$e #loor o# t$e mo't$ is loosel& "losed +it$ t+o or t$ree plain 't s't'res. ($en s'blin 'al land e)"ision is ne"essar& #or a t'mo'r2 it s$o'ld be removed +it$ a +ide mar in in"l'din a rim rese"tion o# t$e mandible (>i . 42.1@). !ompli"ations Dama e to t$e lin 'al nerve posteriorl& or t$e s'bmandib'lar d'"t mediall& is avoided b& "are#'l s'r i"al te"$ni/'e. 8eti"'lo's $aemostasis is re/'ired to avoid a postoperative $aematoma in t$e #loor o# t$e mo't$. Submandibular gland excision T$e patient is positioned s'pine on t$e operatin table +it$ moderate ne"1 e)tension and t$e "$in rotated to t$e opposite side. 4t is $elp#'l to $ave $ead?'p tilt on t$e operatin table as t$is red'"es veno's en or ement. >ollo+in ro'tine s1in preparation and drapin t$e in"ision is mapped o't. T$e line s$o'ld r'n +it$in a s1in "rease in t$e ne"1 at least , "m belo+ t$e lo+er border o# t$e mandible in order to avoid ris1 o# dama in t$e mandib'lar bran"$ o# t$e #a"ial nerve as it loops do+n belo+ t$e lo+er border o# t$e mandible. T$e in"ision s$o'ld be appro)imatel& @ "m lon . T$e in"ision line is t$en in#iltrated +it$ "onventional dental lo"al anaest$eti" sol'tion "ontainin 2 per "ent li no"aine and 1FE5 555 adrenaline. T$is res'lts in some vaso"onstri"tion +$i"$ limits "apillar& oo6e and $elps to de#ine tiss'e planes. T$e in"ision is made +it$ eit$er a n'mber 19 blade or a #ine "'ttin diat$erm& +$ilst t$e assistant p'ts tension a"ross t$e in"ision line. T$e in"ision is made dire"tl& do+n to plat&sma. T$e s'b"'taneo's #at is stripped +it$ #irm press're and a s+ab #rom t$e 'nderl&in m's"le #or appro)imatel& 1 "m on ea"$ side o# t$e in"ision as t$is #a"ilitates a la&ered "los're later. T$e 'nderl&in plat&sma is t$en in"ised to t$e #'ll e)tent o# t$e s1in in"ision a ain +it$ eit$er a blade or "'ttin diat$erm&. T$e assistant

"an no+ retra"t t$e +o'nd mar ins 'sin <"at pa+s= or Allis #or"eps applied to t$e "'r ed e o# t$e plat&sma m's"le (never t$e s1in ed esJ). T$e 'nderl&in investin la&er o# t$e deep "ervi"al #as"ia is ne)t divided2 pre#erabl& +it$ s"issors2 a#ter t$e #as"ia is #irst tented o't+ards +it$ toot$ed #or"eps. O#ten t$e #as"ia "onsists o# a series o# separate laminae li1e an onion s1in b't o""asionall& it is "omposed o# a sin le t$i"1er s$eet. A ain t$e #as"ia s$o'ld be divided alon t$e #'ll len t$ o# t$e in"ision to avoid t$e operative #ield be"omin ever smaller. -osteriorl&2 t$e #as"ial in"ision approa"$es t$e an 'lar tra"t +$ere t$e deep "ervi"al #as"ia splits to #orm t$e investin la&er t$at $as %'st been in"ised and t$e deeper la&er t$at #orms t$e #loor o# t$e s'bmandib'lar trian le "ontainin t$e s'bmandib'lar land. T$e mandib'lar bran"$ o# t$e #a"ial nerve normall& r'ns on t$e deep aspe"t o# t$e investin la&er o# #as"ia alt$o' $ o""asionall& it lies bet+een t$e plat&sma and t$e #as"ia. Great "are m'st be ta1en to prote"t t$e mandib'lar bran"$. T$e anterior #a"ial vein +$i"$ lies in t$e "onne"tive tiss'e overl&in t$e s'bmandib'lar land ?is "lamped2 divided and tied. T$e loose "onne"tive tiss'e is separated +it$ s"issors to e)pose t$e s'bmandib'lar land. T$e disse"tion #rom no+ on "ontin'es on t$e "aps'lar s'r#a"e o# t$e land. >or "$roni"all& in#e"ted lands t$ere is #re/'entl& e)tensive #ibrosis2 and "are and patien"e are re/'ired to maintain t$is plane. >or all t'mo'rs "ontained +it$in t$e s'bmandib'lar land "aps'le2 t$is plane is sa#e as it #orms an e##e"tive barrier. >or mali nant t'mo'rs t$at $ave in#iltrated be&ond t$e "aps'le2 a #'ll s'bmandib'lar "learan"e2 's'all& as part o# a ne"1 disse"tion2 and o#ten in"l'din t$e perioste'm o# t$e lo+er and inner aspe"t o# t$e mandible2 is needed. T$e anterior pole o# t$e s'per#i"ial lobe o# t$e s'bmandib'lar land is #irst mobilised and retra"ted 'p+ards +it$ Allis #or"eps (>i . 42.1E). T$is reveals t$e posterior bell& o# t$e di astri" m's"le +$i"$ is t$en entl& retra"ted do+n+ards +it$ a small Lan enbe"1 retra"tor. T$is e)poses t$e #a"ial arter& +$i"$ emer es #rom be$ind t$e st&lo$&oid m's"le and passes 'p+ards and #or+ards to enter t$e deep s'r#a"e o# t$e s'bmandib'lar land. T$e arter& is t$en "lamped2 divided and tied. Great "are m'st be ta1en to se"'re t$e pro)imal li at're. As t$e vessel is divided it retra"ts o't o# si $t and2 i# t$e li at're slips2 t$e bleedin end o# t$e vessel "an be ver& di##i"'lt to identi#&. T$e "o'rse o# t$e #a"ial arter& is variable. O#ten it deepl& penetrates t$e s'bstan"e o# t$e land to emer e a ain at its 'pper border. 3ometimes t$e arter& lies in a roove in t$e deep aspe"t o# t$e land. T$e disse"tion in t$e plane o# t$e s'bmandib'lar land "aps'le "ontin'es to mobilise t$e anterior pole o# t$e s'per#i"ial lobe o# t$e land2 +$i"$ is t$en entl& retra"ted posteriorl&. D'rin t$is disse"tion a n'mber o# small arteries and veins +ill be identi#ied enterin t$e land. T$ese s$o'ld be "are#'ll& "lamped2 divided and tied or diat$ermised a""ordin to t$eir si6e. As t$e disse"tion "ontin'es posteriorl& alon t$e lo+er border o# t$e mandible2 t$e #a"ial arter& and anterior #a"ial vein are en"o'ntered as t$e& $oo1 aro'nd t$e mandible. T$e vessels are a ain "lamped2 divided and li ated at t$is point. At t$is sta e in t$e operation2 t$e anterior pole o# t$e s'per#i"ial lobe o# t$e land "an be retra"ted posteriorl& to reveal t$e roove bet+een t$e s'per#i"ial and deep lobes o# t$e s'bmandib'lar land. T$e posterior border o# t$e m&lo$&oid m's"le lies +it$in t$is roove. 4t is entl& #reed +it$ s"issors and t$en retra"ted #or+ards +it$ a Lan enbe"1 retra"tor. T$e deep lobe o# t$e s'bmandib'lar land "an no+ be mobilised eit$er +it$ a #in er or b& openin t$e blades o# t$e s"issors applied to t$e s'r#a"e o# t$e land. On t$e deep aspe"t o# t$e deep lobe2 one or t+o small veins ma&

be en"o'ntered r'nnin #rom t$e land t$ro' $ t$e 'nderl&in $&o loss's into t$e lin 'al veins. 4# t$ese veins are not tied or ade/'atel& diat$ermised2 tro'blesome bleedin ma& be en"o'ntered. T$e s'bmandib'lar salivar& land "an no+ be p'lled do+n+ards revealin t$e 7? s$aped lin 'al nerve. T$e ape) o# t$e 7 is t$e point at +$i"$ paras&mpat$eti" se"reto motor #ibres tet$er t$e lin 'al nerve to t$e salivar& land. 4t is ver& important to identi#& "are#'ll& t$e 7 o# t$e lin 'al nerve and its paras&mpat$eti" #ibres as t$e latter m'st be transe"ted to #ree t$e land (>i . 42.1D). As t$ese #ibres are "'t2 t$e lin 'al nerve sprin s #or+ards. >inall& t$e s'bmandib'lar d'"t is "lamped2 divided and tied as #ar #or+ard as possible +it$ %'st eno' $ le#t to drain t$e ma%or s'blin 'al land +$i"$ empties into t$e d'"t. A t$in la&er o# loose "onne"tive tiss'e remains in t$e land bed overl&in t$e $&po lossal nerve. T$e +o'nd is inspe"ted #or an& bleedin points2 a va"''m drain inserted and t$e +o'nd "losed in la&ers 'sin a s'b"'ti"'lar s't're to "lose t$e s1in. T$e +o'nd ed es are rein#or"ed +it$ s1in "los're tapes. omplications T$ree "ranial nerves are at ris1 d'rin removal o# t$e s'bmandib'lar salivar& land t$e mandib'lar bran"$ o# t$e #a"ial nerve2 t$e lin 'al nerve (a bran"$ o# t$e t$ird division o# t$e tri eminal nerve) and t$e $&po lossal nerve. ($en "$roni" in#e"tion and s'bse/'ent #ibrosis $ave o""'rred2 it is sometimes di##i"'lt to identi#& t$e lin 'al nerve and t$e deep aspe"t o# t$e deep lobe ma& be atta"$ed to t$e $&po lossal nerve. At t$ese sta es o# t$e operation2 t$e s'r eon m'st be "onvin"ed t$at t$ese str'"t'res $ave been identi#ied be#ore 'sin an& s$arp disse"tion. 8eti"'lo's $aemostasis is re/'ired t$ro' $o't t$e operation as man& o# t$e vessels enterin and leavin t$e s'bmandib'lar land are onl& apparent +$en t$e land is 'nder tra"tion and as soon as t$e& are divided t$e vessels retra"t into t$e ad%a"ent m's"le planes. !arotidectomy Treatment o# parotid t'mo'rs is b& s'per#i"ial parotide"tom& #or all beni n t'mo'rs in t$e s'per#i"ial lobe and total parotide"tom& #or all beni n deep lobe and d'mb?bell t'mo'rs. 3'"$ t'mo'rs in"l'din deep lobe t'mo'rs s$o'ld never be approa"$ed #rom t$e p$ar&n eal aspe"t. T$e #a"ial nerve is preserved in all "ases. T$e pro nosis #or mali nant parotid t'mo'rs is poor. T$ere is little eviden"e t$at radi"al parotide"tom&2 +$i"$ in"l'des sa"ri#i"in t$e entire #a"ial nerve2 adds si ni#i"antl& to t$e patient=s s'rvival. 4t does2 $o+ever2 "onsiderabl& in"rease t$e morbidit&. >or t$is reason2 s'per#i"ial or total parotide"tom& #or mali nant t'mo'rs is 'nderta1en +it$ preservation o# t$ose bran"$es o# t$e #a"ial nerve not ma"ros"opi"all& invaded b& t'mo'r. T$is is #ollo+ed in all "ases o# mali nant parotid t'mo'rs b& radi"al radiot$erap&. 3imilarl&2 <s'praradi"al= s'r er& #or adenoid "&sti" "ar"inomas is nor advo"ated. T$is t'mo'r2 alt$o' $ probabl& al+a&s #atal in t$e lon term2 is "ompatible +it$ a 'se#'l 15?&ear s'rvival rate. 4t is di##i"'lt2 t$ere#ore2 to %'sti#& e)tensive m'tilatin s'r er& +it$o't o##erin a "'re. Adenoid "&sti" "ar"inomas +$ose ma"ros"opi" mar ins remain +it$in t$e parotid are treated b& total parotide"tom& #ollo+ed b& radi"al radiot$erap&. >or more e)tensive t'mo'rs2 radi"al disse"tion +it$ as +ide a mar in as is anatomi"all& appropriate +$ilst bein "ompatible +it$ reasonable re$abilitation

#ollo+ed b& radi"al radiot$erap& +ill ens're e)"ellent lo"al "ontrol o# t'mo'r. T$e radiot$erap& #ield s$o'ld in"l'de t$e s1'll base in order to "ontrol t$e perine'ral t'mo'r e)tensions. >or an& mali nant parotid t'mo'rs +it$ s1in involvement2 #a"ial nerve +ea1ness2 mandib'lar invasion2 e)tension into t$e in#ratemporal #ossa or l&mp$ node metastasis2 radi"al rese"tion o#ten in "ontin'it& +it$ radi"al ne"1 disse"tion m'st be 'nderta1en +it$ re"onstr'"tion +it$ t$e 'se o# appropriate #laps and #ollo+ed b& radi"al postoperative radiot$erap&. Surgical techni"ue ($enever t$e #a"ilit& is available and t$e patient #ir2 $&potensive anaest$esia is 'sed2 as t$is "onsiderabl& red'"es oo6in and t$'s ma1es it easier to tra"e t$e #a"ial nerve #ibres. T$e in"ision line is in#iltrated +it$ li no"aine $&dro"$loride and 1FE5 555 adrenaline and t$e in"ision made +it$ a 1ni#e or #ine "'ttin diat$erm&. >ollo+in a prea'ri"'lar in"ision e)tendin do+n+ards to "ontin'e in a s'itable s1in "rease in t$e ne"12 t$e s1in #lap is raised in t$e plane o# t$e pre parotid #as"ia and t$en $eld #or+ard b& s't'rin t$e mar ins #or t$e #lap to t$e ad%a"ent to+els. T$e blood?#ree plane anterior to t$e e)ternal a'ditor& meat's is opened 'p b& bl'nt disse"tion and t$is leads t$e s'r eon do+n to t$e base o# s1'll %'st s'per#i"ial to t$e st&loid pro"ess and t$e st&lomastoid #oramen. T$is plane is t$en entl& opened 'p in an in#erior dire"tion b& bl'nt disse"tion 'ntil t$e tr'n1 o# t$e #a"ial nerve is seen. (it$ lar e posterior t'mo'rs t$is plane ma& be di##i"'lt to open 'p. 4n t$is sit'ation it is $elp#'l to identi#& t$e posterior bell& o# t$e di astri" m's"le in t$e "ervi"al e)tension o# t$e in"ision. T$e anterior border o# t$e sterno"leidomastoid m's"le is mobilised and retra"ted in#eriorl& to displa& t$e di astri" m's"le beneat$ it (>i . 42.25). T$is manoe'vre ne"essitates se"tionin t$e reat a'ri"'lar nerve. T$e posterior bell& o# t$e di astri" is tra"ed 'p+ards and ba"1+ards to its insertion on to t$e mastoid2 +$i"$ lies immediatel& belo+ t$e st&lomastoid #oramen2 t$'s leadin t$e operator to t$e #a"ial nerve #rom belo+. T$ere are #o'r anatomi"al landmar1s leadin to t$e identi#i"ation o# t$e tr'n1 o# t$e #a"ial nerve as it leaves t$e st&lomastoid #oramen (>i . 42.21). 1. T$e "artila ino's e)ternal a'ditor& meat's #orms a pointer= at its anterior2 in#erior border indi"atin t$e dire"tion o# t$e nerve tr'n1. 2. J'st deep to t$e "artila ino's pointer is a reliable bon& landmar1 #ormed b& t$e "'rve o# t$e bon& e)ternal meat's and its ab'tment +it$ t$e mastoid pro"ess. T$is #orms a palpable roove leadin dire"tl& to t$e st&lomastoid #oramen. *n#ort'natel& t$is roove is #illed +it$ #ibro#att& lob'les t$at o#ten mimi" t$e tr'n1 o# t$e #a"ial nerve +$i"$ "an lie as m'"$ as 1 "m deep to t$is landmar1. ,. T$e anterior2 s'perior aspe"t o# t$e posterior bell& o# t$e di astri" m's"le is inserted %'st be$ind t$e st&lomastoid #oramen. 4. T$e st&loid pro"ess itsel# "an be palpated s'per#i"ial to t$e st&lomastoid #oramen and %'st s'perior to it. T$e nerve is al+a&s lateral to t$is plane and passes obli/'el& a"ross t$e st&loid pro"ess. A bran"$ o# t$e posta'ri"'lar arter& is 's'all& en"o'ntered %'st lateral to t$e nerve. On"e t$e #a"ial nerve tr'n1 $as been identi#ied t$e s'per#i"ial lobe o# t$e parotid "an $e e)teriorised b& openin 'p t$e plane in +$i"$ t$e bran"$es o# t$e #a"ial nerve r'n bet+een t$e t+o lobes b& bl'nt disse"tion. 4nitiall&2 as it leaves t$e st&lomastoid #oramen2 t$e tr'n1 o# t$e #a"ial nerve t'rns abr'ptl& to be"ome more s'per#i"ial and

also divides into t$e lar er 6& omati"o#a"ial tr'n1 and smaller "ervi"o#a"ial tr'n1. T$e #ive main bran"$es o# t$e nerve are t$en #ollo+ed perip$erall& t$ro' $ t$e parotid 'ntil t$e s'per#i"ial lobe is "ompletel& #reed. T$is part o# t$e operation is per#ormed 'sin #ine s"issors2 opened 'p in t$e plane o# t$e #a"ial nerve bran"$es2 +it$ "are al+a&s ta1en to identi#& t$e nerve #ibre be#ore dividin parotid tiss'e (>i . 42.22). D'rin t$e lo+er part o# t$e disse"tion2 bran"$es o# t$e posterior #a"ial vein +ill be en"o'ntered immediatel& deep to t$e mar inal mandib'lar bran"$. Great "are m'st be ta1en +$en vas"'lar "lamps are applied to t$ese bran"$es to avoid dama in t$e #a"ial nerve. 4# t$e s'per#i"ial partotide"tom& is bein per#ormed #or "$roni" in#e"tion2 t$e d'"t s$o'ld be tied o## as #ar #or+ard as possible to prevent re"'rrent as"endin in#e"tion #rom t$e oral "avit&. 4# t$e t'mo'r lies in t$e deep lobe o# t$e land a "onventional s'per#i"ial parotide"tom& is per#ormed as des"ribed. Ne)t2 t$e bran"$es o# t$e #a"ial nerve are mobilised and li#ted on n&lon tapes to enable t$e deep lobe to be #reed aro'nd its mar ins and removed +$en t$e mass is dropped do+n+ards (>i . 42.2,). As t$is spa"e is +ed e s$aped +it$ its ape) s'perior2 it is almost invariabl& possible to do t$is. T$e deep lobe is "overed b& a "aps'le (t$e deep la&er o# t$e deep "ervi"al #as"ia +$i"$ splits to envelope t$e parotid) and is s'rro'nded b& t$e parap$ar&n eal #at. T$'s2 it is relativel& eas& to mobilise t$e deep lobe b& bl'nt disse"tion +it$ eit$er s"issors or a #in er. Onl& ver& rarel& is it ne"essar& to per#orm a mandib'lotom& to ain a""ess to t$e deep lobe. 7er& rarel& most o#ten a#ter re"'rrent in#e"tion +it$ #ibrosis or previo's radiot$erap& : t$e tr'n1 o# t$e #a"ial nerve "annot be "on#identl& identi#ied. 4n t$is sit'ation t$e perip$eral bran"$es o# t$e nerve are identi#ied at t$e anterior border o# t$e parotid and tra"ed "entrall& to+ards t$e st&lomastoid #oramen. >ollo+in removal o# t$e parotid land t$e blood press'reis ret'rned to normal2 all bleedin points are "ontrolled2 ava"''m drain is pla"ed and t$e +o'nd "losed in la&ers. Apress're dressin is t$en applied #or 4E $o'rs. omplications -ermanent #a"ial nerve paral&sis #ollo+in s'per#i"ial or total parotide"tom& is rare e)"ept +$en bran"$es o# t$e #a"ial nerve $ave been deliberatel& sa"ri#i"ed. ($en t$e #a"ial nerve or its bran"$es are sa"ri#i"ed as a res'lt o# ma"ros"opi" t'mo'r involvement2 an immediate nerve ra#t ma& be 'nderta1en 'sin "onventional mi"rone'ral te"$ni/'es. Temporar& +ea1ness d'e to ne'ropra)ia o""'rs in appro)imatel& ,5 per "ent o# operations b't re"overs rapidl&2 's'all& +it$in A +ee1s. Anaest$esia o# t$e s1in #lap slo+l& resolves as t$e sensor& nerves re enerate #rom t$e perip$er&. Anaest$esia o# t$e ear lobe d'e to se"tionin o# t$e reat a'ri"'lar nerve "an be tro'blesome2 ?parti"'larl& in #emales +$o #ind it di##i"'lt to +ear earrin s. .e"over& "an ra1e 'p to 1E mont$s and sometimes is never "omplete. G'stator& s+earin (>re&=s s&ndrome) is a re 'lar se/'el to parotide"tom& o""'rrin in 'p to 94 per "ent o# "ases. 3'r i"al manoe'vres to treat it on"e establis$ed are not s'""ess#'l and most patients eit$er learn to live +it$ it or alternativel& 'se an antiperspirant "ontainin al'mini'm "$loride.

3pilla e o# a beni n pleomorp$i" adenoma s$o'ld not o""'r i# a #ormal s'per#i"ial parotide"tom& is 'nderta1en. Ho+ever2 t$ere are #o'r "ir"'mstan"es +$ere even +it$ meti"'lo's s'r i"al te"$ni/'e t$is "an $appenF H e)tremel& lar e pleomorp$i" adenomas o""'p&in t$e entire s'per#i"ial lobe ma1in mobilisation o# t$e land di##i"'ltI H t'mo'rs t$at are intimatel& asso"iated +it$ bran"$es o# t$e #a"ial nerve re/'irin ver& deli"ate disse"tion alon t$e "aps'le o# t$e t'mo'r to release t$e nerveI H t'mo'rs +it$ lob'lar e)tensions e)tendin beneat$ t$e mastoid2 6& omari" ar"$ or mandibleI H some t'mo'rs t$at are abnormall& #riable +it$ even ro'tine retra"tion o# t$e s'per#i"ial lobe res'ltin in r'pt're.4# r'pt're o""'rs an e)tremel& "are#'l inspe"tion o# t$e +o'nd m'st be 'nderta1en and t$e area t$oro' $l& irri ated. 4n all s'"$ "ases postoperative radiot$erap& s$o'ld be 'nderta1en in order to avoid m'ltiple re"'rren"es d'e to t'mo'r seedin . Ot$er tare "ompli"ations s'"$ as sialo"ele or salivar& #ist'4a o""asionall& #ollo+ parotide"tom&. ;ot$ "ompli"ations are mana ed "onservativel& and resolve spontaneo'sl& a#ter da&s or +ee1s. 7er& rarel& a parotid #ist'la persists despite attempts at s'r i"al "los're. 4n t$is sit'ation postoperative radiot$erap& +ill destro& t$e resid'al #'n"tionin a"inar tiss'e and allo+ t$e #lst'la to "lose. .adiot$erap& -arotid t'mo'rs are o#ten "onsidered to be <radioresistant=. T$is is not tr'eF re ression a#ter radiot$erap& is 's'all& slo+2 b't t$is re#le"ts t$e slo+ "ell t'rnover time o# t$e ma%orit& o# t$ese t'mo'rs2 rat$er t$an t$e inabilit& o# radiation to e##e"t a "'re. T$ere are man& reports o# lon ?term lo"al "ontrol o# lar e inoperable t'mo'rs b& radiot$erap&. Nevert$eless2 t$e "$an"e o# s'""ess#'l radiot$erap& does seem lo+er t$an in t$e "ase o# s/'amo's "ell "ar"inoma2 and t$ere#ore t$e primar& treatment s$o'ld be s'r i"al +$erever possible. .adiot$erap& is o# val'e #or t$e inoperable t'mo'r2 and also s$o'ld be 'sed postoperativel& +$enever t$ere is a ris1 o# in"omplete e)"ision s'"$ as r'pt're o# a pleomorp$i" adenoma. 4t s$o'ld also be 'sed prop$&la"ti"all& to radi"al dosa e #ollo+in e)"ision o# an& mali nant parotid t'mo'r. 4n "ases +$ere reoperation is re/'ired #or re"'rren"e or +$ere t$ere is ross resid'al t'mo'r2 radiation in $i $ doses in"reases s'rvival si ni#i"antl&. Adenoid "&sti" "ar"inoma $as been reported to be t$e most2 "onsistentl& radio responsive t'mo'r t&pe. 4n vie+ o# t$e propensit& o# t$is t'mo'r #or later re"'rren"e2 it is do'bt#'l +$et$er $i $ lo"al "ontrol rates at , or 9&ears reall& indi"ate radio "'rabilit&. A +ide vol'me aro'nd t$e t'mo'r s$o'ld be irradiated2 espe"iall& in t$e "ase o# adenoid "&sti" "ar"inoma. A dose "lose to t$e limits o# normal tiss'e toleran"e is ne"essar&. >'rt$er readin !a+son2 ..A.2 Gleeson2 8.J. and 0veson2 J.( (1DD@) -at $o?lo & and 3'r er& o# t$e 3alivar& Glands2 4sis 8edi"al 8edia2 O)#ord. !lini"al anatom& and p$&siolo &