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HEAD AND NECK SURGERY

Gerardo R. Wenceslao, MD, FPCS


Diplomate, Philippine Board of Surgery
CONGENITAL LESIONS
Thyroglossal Duct Cyst

Congenital anomaly in the development of the


thyroid gland
th
As a result of persistent Thyroglossal duct after 10
week
Thyroid gland from the pharyngeal wall at
th
the foramen cecum at 4 week of gestation
It enlarges,descends ventrally to the midline
close to the hyoid bone
During descent, a patent diverticulum is
formed and called Thyroglossal Duct,
th
normally resorbs by the 10 week
Clinical Manifestations
Midline masses in childhood
80% occur at or just below the hyoid bone
Movement or elevation of the cyst during
protrusion of the tongue
May be infected
Approximately 5% contain functional
thyroid tissue. Rare case of Thyroid
Carcinoma is reported
Sistrunk Procedure
Intraoperative picture of the patient in undergoing a
Sistrunk procedure. The central portion of the hyoid
bone is being resected along with the cyst, overlying
skin, and cuff of the base of the tongue muscle

Fetal Branchial Arches and Cleft


Foetus, 25th day (after His). Showing branchial
(visceral) arches and clefts or furrows.
Branchial Cleft Anomalies
Incomplete fusion of the branchial arches
st
Usually in the 1 decade of life
Branchial Cleft Cyst
Appearing in week 4 of embryonic life and normally
th
involuting fully by 7 weeks, contribute to the
formation of various head and neck structures in the
developing embryo
st
Usually present in the 1 decade of life but may do
undetected until childhood
Cysts and sinuses are usually lined by squamous
epithelium
Branchial Cleft Carcinomas occur rarely
May also contain lymphoid tissues and may enlarge
in response to infection
Second Branchial Cleft Anomaly
Most common type of branchial cleft anomaly
Cystic mass along the midline and lower
thirds(anterior border) of the sternocleidomastoid
muscle
With fistulous tract opening into the
pharynx/tonsillar area
Fistulous tract course along the carotid sheath and
then medially over the hypoglossal nerve between
the internal and external carotid arteries to end at
the pharynx adjacent to the tonsillar fossa
Management: Complete Surgical Excision of the cyst
and tract (Stair-step incision)

Note the two skin openings, on either side of the


midline, above the heads of the clavicles.

Second branchial cleft cyst presented with a cystic


mass at the lower one-third of the anterior border of
the sternocleidomastoid muscle
Second branchial cleft cyst

Surgical Excision

Branchial Cleft Cyst

Enoi Bartolome

This branchial cleft cyst was followed superiorly to


the region of the oropharynx, but no communication
was found. The picture below shows the anatomy of
the carotid triangle after removal of the cyst.

Otitis externa-(swimmers ear)


Infection of the skin of the external auditory canal
Pseudomonas aeruginosa-most common organism
Signs/symptoms
Itching initially then pain and swelling.
Treatment:
Removal of debri
Topical neomycin/polymyxin w/ steroids

First Branchial Cleft Cyst

Excision of First Branchial Cleft Cyst

Third Branchial Cleft Cyst


Otitis media
Most common ear infection of childhood
Most cases appear before 2years secondary to
immature Eustachian tube
Contributing factors are:
Upper respiratory viral infection
Cleft palate

Branchial Cleft Anomalies


First Branchial Cleft Anomaly
Subcutaneous mass below the body of the
mandible
Extend through the parotid, ends up at the
membranous ext auditory canal
Third Branchial Cleft Anomaly
Rare
nd
Cyst or mass present like 2 cleft anomaly
Course in the neck is different
Internal opening at the pyriform sinus (Laryngeal
area)
* Course behind the carotid artery to end at the pyriform
sinus
Ear Infections

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Acute Otitis media


Fever
Otalgia
Bulging opaque TM
Symptoms less than 3 weeks
Chronic otitis media
Infection of the middle ear lasting > 8 weeks after
resolution of the acute phase
Chronic inflammation and hypersecretion of the
middle ear mucosa due to:
Viral infection
Eustachian tube and ciliary dysfunction
allergy
P.E.-opaque ,retracted TM w/ bubbles and air fluid
level
Treatment:
Oral antibiotics-for uncomplicated OM
Recurrent and with complication
Myringotomy and tube placement Mastoidectomy

Complications:
Otologic:
TM perforation acute OM- heal spontaneously
after the infection has resolved

chronic OM non-healing with


persistent otorrhea
Treatment
tympanoplasty
Cholesteatoma
Mastoiditis
Facial nerve paralysis
Labyrinthitis
Inflammation of the inner ear
Hallmark of impending Meningitis

Intracranial:
Meningitis Most common intracranial
complication
H. Influenza B-most common org.
in children
Brain abcess
Otitic hydrocephalus
Pharyngeal and Adenotonsillar Disease
Waldeyers Ring

Waldeyers tonsillar ring


Palatine tonsil
Lingual tonsil
adenoids
Chronic or recurrent adenotonsillitis
Infectious
Viral most common etiology
Bacterial
B-hemolytic strep (Strep.
Pyogenes)

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Strep pneumoniae
Anerobes
Cornybacterium diptheriae
Fungal : candida
Non infectious
Reflux
Radiotherapy
Immune mediated
Erythema multiforme

Obstructive Adenotonsillar Hyperplasia


Nasal obstruction
Rhinorrhea
Voice changes
Dysphagia
Complications
Rheumatic fever
Poststreptococcal glomerulonephritis
Sleep disordered breathing or OSA
Treatment
Tonsillectomy and adenoidectomy
3 or more infections/year despite
adequate medical therapy
Miss two or more weeks of
school/year
Adenoidectomy
Chronic sinusitis in children
In children with chronic or
recurrent otitis media
Obstructive Sleep Apnea
Snoring
Excessive daytime somnolence
Frequent sleep arousal
fatigue
Polysomnogram
10 or more episodes of apnea or hypopnea /hr
of sleep
Collapse of the pharyngeal soft tissue
Enlarge tonsil
Tongue size
Obese neck
BMI-> 35 kg/m
Treatment: Non-surgical
Weight loss
Use of oral appliance to open the airway
Elimination of alcohol
CPAP
Thorton Adjustable Positioner

Obstructive sleep apnea


Treatment
Surgery Children-tonsillectomy/adenoidectomy
Adults Uvulopalatoplasty-most common
procedure
Removes redundant tissue from
the uvula and soft palate
Tracheotomy-for severe OSA
MANDIBULAR FRACTURE

Fracture of the Maxilla


Midface fracture
Signs

Most fractures involve the angle,body or condyle


Most mandibular fractures involved two or more
sites
Classified into:
Favorable-undisplaced fractures
Unfavorable-displaced or misaligned
fractures
Signs of mandibular fracture
Point tenderness
Malocclusion
Intraoral mucosal ecchymosis
Instability on bi-manual palpation
Numbness of the lower lip due to inferior
alveolar nerve damage
Diagnosis:
Careful clinical examination
radiograph (panorex) confirms and
identifies the site of fracture
Ct-scan in selected cases only

Treatment:
Antibiotic-for open fractures
Closed reduction and 6 week intermaxillary
fixation (IMF) with arch bar applied via
circumferential wiring

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Open reduction and wire fixation + IMF


For comminuted , displaced
fractures

Classification:

Subconjunctival hemorrhage
Malocclusion
Facial ecchymosis and hematoma
Widening or inner canthi and bridge of the
nose
Midface numbness due to injury of the
maxillary division of the trigeminal nerve
Ocular signs/symptoms
Mobility of the maxillary complex

Le Fort I (transverse fracture)


Upper teeth,palate, mobile palatal
vault
Le Fort II (pyramidal)
Nasal bones, medial wall of the
orbit, infraorbital rim,zygomaticomaxillary articulation
Le Fort III (craniofacial dissociation)
Entire face is mobile from the
cranium
Frontozygomaticomaxillary,
frontomaxillary, frontonasal suture
lines are disrupted
Treatment:
Open reduction
Internal fixation with miniplates and
micropolates

Temporal bone fracture

BENIGN LESIONS
Benign Lesion: LIP
Clinical Manifestation
Visible or palpable lesion
Thickening of the lip and vermillion junction
Lip scaling
Scaling/Thickeningof the Lips

Patterns of temporal bone fracture


Longitudinal
constitutes 80%
Lateral trauma of the skull
Facial nerve is injured in 20%
Bloody otorrhea
Conductive hearing loss
Labyrinthine concussion

Leukoplakia

TEMPORAL BONE FRACTURE: FACIAL PARALYSIS

This 7 year old boy developed an immediate left


sided facial nerve paralysis when a television set fell
on the side of his head.

Transverse
Occurs secondary to fronto-occipital trauma
Facial nerve is injured in 50% of cases
Involves the otic capsule
Sensory neural hearing loss
Loss of vestibular function
hemotypanum
Facial nerve injury
Treatment:
Conservative treatment
Delayed or partial paralysis
Nerve decompression
Immediate paralysis that doesnt
resolve after 7 days
Electroneuromyography/EMG
90% degeneration 72 hrs
after the onset of
complete paralyssis

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Dyskeratosis, the proliferation and abnormal


orientation of epithelial cells leading to development
of Carcinoma in Situ. With penetration of the
basement membrane, Invasive Squamous Cell
Carcinoma develops
Treatment:
Wide excision and reconstruction

Benign lesions of the Oral Cavity

Mucous Retention Cysts


Submucosal accumulation of mucous
most often caused by rupture of the duct system
with extravasation of mucus
Common in the labial mucosa of the lower lip
Typically less than 1 cm in diameter, smooth,
rounded and with bluish hue

Treatment:
Excision
Marsupialization for extensive

lesions
Central Giant Cell Reparative Granulomas
Of bony origin: less common than the peripheral
type
Expansile endosteal lesion typically within the
mandible
May also arise from the paranasal sinuses, orbit,
cranial vault and temporal bone

Ranula

Type of mucus retention cyst from major salivary


gland, most commonly the sublingual gland
Treatment: Excision

Epulis
Granulomatous lesion of the gingiva
Exaggerated inflammatory response
Two subtypes:
1. Congenital Epulis: typically in anterior
maxilla of newborn
2. Epulis gravidarum: occurs in approximate 1% of
pregnant women
Resolves spontaneously
Excision for symptomatic epulides
Congenital Epulis

Treatment:: Thorough curettage is generally curative

ULCERATIVE LESIONS
Idiopathic Aphthous Ulcer
Most common ulcerative lesion of the oral cavity
Cycle of painful ulceration and spontaneous healing
(several times a year for many years)
nutritional deficiencies including vitamin B, folate or
iron and emotional stress
Treatment:
Topical steroids
Necrotizing Sialometaplasia

Congenital epulis of the newborn. A wellcircumscribed soft tissue enlargement is present on


the maxillary alveolar ridge of a newborn.

Peripheral Giant Cell Reparative Granulomas


Common in gingiva
Soft tissue in origin
May be polypoid, submucosal and fibrous
Can ulcerate and bleed
Radiographs may reveal underlying bone erosion
Complete excision to prevent recurrence

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Benign inflammatory disease of minor salivary glands


usually in the hard palate
Discrete, painful ulcers
Local trauma and progressive local ischemia and
ulceration
Spontaneously heal in 6 10 weeks
May need to be biopsied if differentiation with
Squamous Cell Carcinoma is unclear

White Sponge Nevus


Benign lesion of the Larynx

Lichen Planus

Oral Hairy Leukoplakia

White plaque-like lesions


White sponge nevus-benign familial self limiting dse.
, affects the entire oral cavity.
Lichen planus-an autoimmune degenerative
mucocutaneous dse..may degenerate into
squamous cell ca.
Oral hairy leukoplakia-form of parakeratosis in pts.w/
AIDS or other form of immunosuppresion.
Benign Lesions of the Nose

Polyps:

Common in nasal cavity and paranasal cavities


Equal male:female ratio
Often multiple and bilateral
Allergy- those arising in the region of turbinates and
ethmoids
Infectious- those arising from the posterior nasal
cavity
Treatment
Medical for allergic cause; empiric
antimicrobial and steroids
Polypectomy
May need to be biopsied if differentiation with
Squamous Cell Carcinoma is unclear

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Recurrent Respiratory Papillomatosis


Etiology-human papilloma virus subtypes 6 and 11
Early childhood
Acquired during vaginal delivery
Adult onset
rd
th
3 to 4 decade
Manifestation is less severe
Treatment
No cure
Excision or laser ablation
Intralesional Cidofovir
HPV vaccines
Benign lesions of the larynx

Laryngeal granuloma
Occurs in the posterior larynx
Pain on swallowing-most common complaint
Etiology:
Acid reflux
Voice abuse
Chronic throat clearing
Endotracheal intubation
Vocal cord paralysis
Diagnostic work up
Fiberoptic laryngoscopy
Voice analysis
EMG
PH probe testing
Treatment
Voice rest
Voice retraining therapy
Anti-reflux therapy
Surgery
If carcinoma is considered
Airway obstruction
Vocal Cord paralysis
Iatrogenic
Surgery of the thyroid ,parathyroid
, cardiothoracic procedures
Malignancy

Idiopathic
A presenting sign of malignancy of
the thyroid, lungs and esophagus
Treatment
Bilateral: Tracheotomy,
arytenoidectomy
Unilateral: Speech therapy
Surgery: Injection laryngoplasty,
Laryngeal framework surgery, implantation of
cartilage, silicone, etc

Laryngocele
Herniation of the laryngeal ventricles
Three forms categorized by site presentation:
o Internal Laryngocele:
confined to the larynx
presents as enlargement of the false
vocal cord
o External Laryngocele:
protrudes through the thyrohyoid
membrane causing swelling in the
anterior neck
o Mixed Laryngocele:
combination of the above types
Pathogenesis related to chronic increases in intralaryngeal pressure
Propensity to singers and musician
Treatment:
o Ligation of stalk or the Laryngocoele and
repair of the ventricular weakness
Odontogenic Tumors
Tumors arising from progenitors cells of tooth
development
Usually involving the mandible and the maxilla
Most are benign

Calcifying odontogenic cysts


Gorlins cyst
Cementomas

NON-ODONTOGENIC TUMORS
Torus

Torus Palatinus

Lobular torus palatinus with a denture situated


round the torus
Torus-Mandibularis

Ameloblastoma/adamantinoma
Arise from dental lamina
Associated with impacted teeth in young patients
Painless jaw mass
Common in the mandible

slow growing low grade malignancy


May erode adjacent bone
X-ray-Soap Bubbles appearance
Calcifying epithelial odontogenic
Pinborg tumors
myxomas

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Benign slow growing projection from the surface of


bone
TORUS-PALATINUS (midline of the hard palate)
TORUS-MANDIBULARIS (develops in the lingual
surface of the mandible opposite the premolars,
often bilaterally)
Often begin at puberty and slow-growing
May cause ulceration of overlying mucosa,
mimicking a mucosal neoplasm
No treatment is needed unless they interfere with
speech, mastication or the use of dentures (simple
excision)

Multinodular mandibular tori

Exostoses
Localized bone overgrowths in the jaw, can be
multiple, flat or pedunculated
Common in the maxilla at the canine fossa
Treatment:
Excision if symptomatic

Osteomas
Slow-growing tumors of mature bone that arise
within (intraosseous) or at the periphery of the
involved bone
Peripheral lesions often attached to the cortical bone
by a dense pedicle; most commonly in the mandible
at the lingual aspect of the ramus or angle of the
mandible
May also involve the paranasal sinuses
Excision advised when continues growth encroaches
upon vital structures

MALIGNANT HEAD AND NECK TUMORS


Most are Squamous Cell Carcinoma
From the respiratory and stratified
squamous epithelium of the upper
aerodigestive tract
Effects on human life mainly due to disruption of
function
Alimentation
Respiration
Death is mainly brought about by malnutrition and
airway obstruction
60% of patients die without distant metastasis but
due invasion of CNS, rupture of great vessels and
infection

Etiology
Carcinogen: agent that initiates cancer
development
1. Ultraviolet Rays (Sunlight)
Lip cancer; skin cancer in head and
neck
2. Tobacco
Lip cancer; oral cavity cancer;
laryngeal cancer; NPCA
3. Alcohol
4. Occupational related
NPCA: In wood workers and shoe
factory workers
5. Race
Chinese: Nasopharyngeal
carcinoma
Genetic and viral (Epstein-Barr
Virus)
6. Radiation Exposure
Thyroid cancer; salivary gland
cancer

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DIAGNOSIS
History
Elicit past history and Family history of cancer
Four (4) most common presenting symptoms
Pain

Bleeding
Mass

Obstruction
Biopsy
To establish definitive diagnosis
Techniques
1. Punch Biopsy
2. Incisional Biopsy
3. Fine Needle Aspiration Biopsy
Exception: Very small lesions that can completely
removed by same biopsy procedure
Additional Studies
1. Radiologic Studies
2. CT Scan
3. MRI
4. Contrast Studies/Barium Swallow
Use to assess the extent of tumor invasion to
adjacent structure
Use for better treatment planning
Levels of cervical lymph nodes

LEVELS of Cervical lymph nodes


LEVEL I
Submental, Submandibular and
Digastric triangle nodes
LEVEL II
Upper Jugular Chain
LEVEL III
Middle Jugular Chain
LEVEL IV
Lower Jugular Chain
LEVEL V
Posterior Triangle Nodes
LEVEL VI
Ventral group, Muscular, Triangle
Nodes (Thyroid, Paratracheal)
LEVEL VII
suprasternal notch, mediastinum
Routes of Lymphatic Spread From Common Head and Neck
Sites
Submental:Lower lip,anterior oral cavity, skin
Submandibular: Lower lip, oral cavity, fascial skin
Subdigastric: Oral cavity, oropharynx, hypopharynx
Midcervical: Hypopharynx, base of tongue,larynx,
thyroid
Lower Cervical: Hypopharynx, thyroid, lung,
gastrointestinal
Occipital: Scalp
Posterior Triangle: Nasopharynx, hypopharynx,
thyroid

Supraomohyoid Neck Dissection


Classical Radical Neck Dissection

Shaded region indicates the region included in a


Supraomohyoid Neck Dissection
Extended Radical Neck Dissection

Extended neck dissection (common carotid artery


resected)

Lateral Neck Dissection

Posterolateral Neck Dissection

Modified Radical Neck Dissection

Types of SND

Supraomohyod neck dissection


Oral cavity malignancy
Removes level 1-3
Lateral neck dissection
Laryngeal malignancy
Removes levels 2-4
Posterolateral neck dissection
Thyroid malignancy
Removes level 2-5

CANCER OF THE ORAL CAVITY

Neck dissection
Selective neck dissection
Preservation of one or more group of lymph
nodes
Internal jugular, spinal accessory nerve and
SCN are preserved

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Carcinoma of the Lip


Etiology:
More common in males
Most are stage I well differentiated
squamous cell ca
More common in the lower lip

Upper lip-usually basal cell ca


Associated with chronic exposure to
sunlight

Treatment:
Resection with clear margins or radiation
Cure rate of 90% for stage I and 50-80% for stage II
If + for lymph node-ipsilateral or bilateral neck
dissection
Resection with primary closure
Involves less than one-third of the
lip
Burrow triangle flap
More than one-third

CANCER OF THE OROPHARYNX


Pathology
Mostly Squamous Cell Carcinoma
Minor salivary gland neoplasms and lymphomas
particularly Non-Hodgkins Lymphoma involving the
tonsil and other parts of the Waldeyers Ring arise
in this area
Over all incidence of nodal involvement is 70%
Clinical Features
Ulcerating lesion and nodal involvement in 60%
Muffled hot potato voice in large tumors
Odynophagia or dysphagia is common symptoms
Reffered otalgia
Trismus indicates medial pterygoid muscle
involvement
Treatment
Small Tumors (T1 and T2)
Surgery or radiotherapy with similar results
and treatment must be individualized
Small tonsillar cancer respond well to
radiotherapy
Large Tumors
Surgery + Postoperaive radiotherapy
Preoperative radiotherapy then surgery
Partial glossectomy-involves the base of the tongue
Total Glossectomy- tongue involvement crossing the
midline

may be accompanied by laryngectomy to


prevent subsequent dysphagia and
aspiration
Commando procedure-(jaw-neck resection)-involves
the mandible

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Commando Operation

CA of Tongue
Oral tongue
Primary tumors
Leiyomyomas.leiomyosarcoma,rhebdomyosarcoma,
neurosrcoma
Clinical manifestation
Ulcerations/exophytic masses
Ipsilateral paresthesias and deviation of the
tongue
Submandibular and upper cervical
Lymphadenopathy
Treatment
T1-T2
Wide local excision with primary
closure
Partial glossectomy
Removes large portion of the
lateral oral tongue
Prosthetic augmentation
Faciocunatneous free flaps
MRND or SND
CARCINOMA OF THE NASOPHARYNX

Mostly Squamous cell ca


High incidence in china , africa, alaska
70%-EBV infection, tobacco use
Symptoms:
Painless neck mass on the post. trianglemost common presentation
Respiratory obstruction ,epistaxis
Palsies of CN II, IV, V, VI
Horners Syndrome if cervical sympathetic
chain is compressed

Ohngrens Line
Nasopharyngeal carcinoma
Examinations:
Fiberoptic endoscope
CT w/ contrast-best for determining bone
destruction
MRI- intracranial and soft tissue extension
Treatment:
Stage 1 and 2
Irradiation
For more advanced ca
Irradiation +chemotherapy
CARCINOMA OF THE NASAL CAVITY AND PARANASAL SINUSES

Usually Squamous Cell Carcinoma


Frequently advanced at presentation
Maxillary Sinus most common site
Diagnosis is frequently made after unsuccessful tx
for a recurrent sinusitis
Symptoms:
Nasal obstruction
Fascial pain
Headache
Epistaxis
Loose dentition

Malignant Tumors of Nasal Cavity

st

1 : A nasal cavity tumor has eroded through the


hard palate and is causing difficulty with fitting a
denture
nd
2 : A nasal tumor that has eroded through the nasal
bone and causing deformity of the nasal bridge
Diagnosis
Nasal speculum
CT Scan
MRI
Treatment:
Surgery: En-bloc removal of the involved
sinus and surrounding structures
Total maxillectomy w/ or
w/o orbital exenteration
Radiotherapy

Enoi Bartolome

CARCINOMA OF THE LARYNX


Tobacco (especially when combined with alcohol) is a
recognized etiologic agent
Men:women 10:1
Supraglottic (above true vocal cords) 45%
Glottic (involving vocal cord) 50%
Subglottic (below vocal cord) less than 5%
Symptoms:
Prolonged hoarse voice
Dysphonia
Dysphagia
Neck mass
Glottis Produce symptoms early
Low incidence of spread to regional lymph
nodes (1-4%)
Treatment:
Chemoradio therapy or surgery and post-op radiotx
T3
Limited to larynx with cord fixation
T4
Massive tumor with cartilage
destrurction or extension beyond
the larynx or both
Supraglottic Ca
30-50% incidence of spread to regional LN
Supraglottic laryngectomy
w/o arytenoid or vocal
cord extension
Total laryngectomy + post op
radiotx
w/ cartilage destruction
Extension beyond
endolarynx
Treatment:
Subglottic
Grow a considerable size before producing
symptoms
Regional metastasis common (40%)
usually far advanced when dx
Total laryngectomy +neck
dissection

Total Laryngectomy

Papillary Cystadenoma Lymphomatosus (Warthins Tumor)

Hemangioma Salivary Gland

SALIVARY GLAND TUMORS


Major Salivary Glands

Incidence of Malignancy
Parotid tumors - 25%
Submandibular tumors 40%
Sublingual and Minor Gland tumors 70%
Since 70% of salivary gland tumors occur in the
parotid and three-fourth of these are benign, the
majority of salivary gland neoplasms are benign
Pathology
Benign:
Plemorphic Adenoma (Benign mixed tumor)
Most frequent, most in females middle
aged
10% recurrence with surgery
Papillary Cystadenoma Lymphomatosum(Warthins
Tumor)
Mostly in males
10 15% bilateral
Hemangioma
Most common salivary tumor in children
Pleomorphic Adenoma

Mucoepidermoid Carcinoma

Carcinoma of the minor salivary gland. Note the


swelling on the right side of the floor of the mouth
which, on histopathological examination, proved to
be mucoepidermoid carcinoma
Adenoid Cystic Carcinoma

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Malignant tumors
Mucoepidermoid carcinoma-most common
Low grade-composed of mucin
secreting cells
High grade-epidermoid cells
predominate
Adenoid cystic
second most common in adults
Propensity for neural invasion
High incidence of distant
metastasis
Display an indolent growth

Most common malignant salivary gland tumors in


pediatric populations
Acinic cell carcinoma
Mucoepidermoid carcinoma
Minor salivary gland

Adenoid cystic carcinoma


Mucoepidermoid carcinoma
Low grade polymorphous adenocarcinoma
Diagnostic modalities
MRI- most sensitive study for soft tissue
extension and involvement of adjacent
structures.
FNA 70-80% -accuracy rate

Parotid Tumors
Approximately 2/3 of malignant salivary tumor occur
in the parotid
Most Parotid tumor are benign
Tumors more common in the superficial lobe
Cranial Nerve VII (Facial Nerve)
Courses along the substance of the gland
If patient with CN VII palsy, probably
malignant
Treatment
Superficial parotidectomy-those that arise from the
lateral lobe
Total parotidectomy-involves the deep lobe
CN VII preservation is mandatory unless grossly
involved by a malignant lesion
Ispsilateral neck dissection must be
performed for clinically palpable nodes
Superficial Parotidectomy

80% of malignant masses are metastatic


80% of primary tumors are located above
the clavicle

History
Physical Examination
Panendoscopy
Nasopharyngoscopy
Laryngoscopy
Bronchoscopy
Esophagoscopy
Suspicious lesions are biopsied
Fine needle aspiration cytology
Excision:
Should not be the initial step
Can be done with concomitant neck
dissection

Nasopharyngoscopy

Video-Laryngoscopy

st

1 : Defect After Gland and Tumor Removal


(Superficial Lobe) Note Facial Nerve (Black arrow)
nd
2 : Surgical defect after superficial parotidectomy
note facial depression or dent
Total Parotidectomy
Tumor under facial nerve requiring Total
Parotidectomy
(Black arrow points to facial nerve overlying benign
tumor of the deep lobe)
Postoperative radiation
Indications:
Extraglandular dse.
Perineural invasion
Direct invasion of regional
structures
High grade histology
UNKNOWN PRIMARY CANCER OF THE HEAD AND NECK
Work-up of Cervical Mass
Most midline masses will relate to thyroid gland
especially if the mass moves with deglutition
Rules of 80s:
80% of non-thyroid masses are neoplastic
80% of neoplastic lesions are malignant

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Direct Laryngoscopy

Bronchoscopy

Esophagoscopy

Unknown primary Ca
Treatment:
Neck Dissection ( levels 1-5) + chemoRdx
N1 (single ipsilateral 3cm or less)
w/o extracapsular spread
w/o hx of incision or excision
biopsy
Radiotherapy /chemotherapy
N2 or greater
w/extracapsular spread
w/ hx of previous biopsy

Enoi Bartolome