HEAD NECK 18 malignant parotid

8.6.1 MALIGNANT MIXED TUMOURS

Malignant mixed tumours arise from a neoplastic transformation of

a  benign mixed tumour.  Patients are generally older,  malignant

lesions  are  usually  larger and any mixed  tumour  may  contain

within  it malignant elements and may result in  adeno-carcinomas,

squamous cell carcinoma or malignant spindle cell alternation.

With  the exception of mixed tumours; benign lesions of  salivary

tissues have no malignant potential.

CLINICAL PRESENTATION

Mixed  tumour may grow for years at a slow pace.   The  malignant

component  suddenly develops and there is a marked change in  its

course.

Fixation  of  glands to skin or underlying  structures,  palpable

nodes and involvement of the VIIth nerve are all diagnostic.

Excision of the mass and histologic examination are indicated  in

every case.

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HEAD NECK 17 Parotid tumors

8.5 TUMOURS

8.5.1 MIXED TUMORS

A  common  lesion  of the salivary gland  is  the  mixed  tumours

(pleomorphic adenoma).

*  Eighty  percent of all benign tumours probably originate  from

   the myoepeithelial cells of the ducts.

*  Microscopic examination shows a network of strands of  spindle

   shaped and stellete cells.

*  In  one-third  of  cases loose  myxoid  pattern  predominates. 

   Half, in addition, have pseudocartilaginous structures.

Treatment  is  superficial  Parotidectomy  with  conservation  of

branches of the facial nerve.

8.5.2 PAILLARY CYSTADENOMA LYMPHOMATOSUM (WHARTHIN'S TUMOUR)

The lesion feels firm on examination and represent parotid tissue

sequestered in a lymphnodes.  It is the second most common benign

tumour of salivary tisse

The Histogenesis is unceertain

Treatment is surgical excision.

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HEAD NECK 16 Sialolithisis sialoadenitis

8.4 SIALOLITHIASIS (STONES)

Calculi  sometimes form within the ducts of salivary  glands  and

this occurs because of poor drainage and change of pH.

The symptoms are those of obstruction and distension of the gland

following  the  taking of food.  The gland may  enlarge  and  may

become palpable.

The  stone may be felt in the cheek in the parotid duct  and  the

floor of the mouth in the case of Submandibular duct symptoms are

of pain and swelling.

Treatment is by removal of the stone .

SIALOADENITIS

This occurs most often with invasion by bacteria.

Acute  parotitis occurs, with the symptoms of pain, swelling  and

fever progress is rapidly in these cases .

Obstruction  of the duct plays a causative role  dehydration  and

malnutrition also contribute.

Treatment  is  removal  of  causitive  factors  and  antibiotics. 

Drainage of abscess may be required.

Recurrent sialoadenitis also occur with repeated episodes of pain

and swelling with fever and its complication of orchitis has been

discussed elsewhere.

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SALIVARY GLANDS 15

8. SALIVARY GLANDS

Besides  the  parotid  glands, salivary tissue is  found  in  the

submaxillary  glands  lingual  glands and  other  minor  salivary

glands in the mouth.

8.1 PAROTID GLAND

The  parotid  gland  is  U-shaped and  wraps  itself  around  the

ascending ramus of the mandible .

The larger portion of the gland is the superficial lobe.

The smaller portion is the deep lobe.

The VIIth nerve divides into its branches in the parotid gland.

Branches eventually leave the parotid gland and course across the

masseter muscle. Tumours commonly occur in the superficial lobe.

8.2 SUBMANDIBULAR GLAND

Submandibular   gland  is  an  avoid  structure,  lying  in   the

submandibular fossa, beneath horizontal ramus of the mandible and

bounded  by  the anterior and posterior belly  of  the  diagstric

muscle.

The lowest branches of the VIIth nerve courses over the gland.

Lingual  nerve is deep to inferior durface of  the  submandibular

gland, both these nerves are at risk during surgery  Fig.14.4a  &

14.4b

8.3 THE LINGUAL GLAND

Lies beneath the mucosa of the anterior part of the floor of  the

mouth on either side of the frenulum of the tongue.

Most of the lesions occur in the parotid glands, the second  most

common being the mandibular gland

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HEAD NECK 14 Mandibe malignant tumors

7.1.3 AMELOBLASTOMA (ADAMANTINOMA)

 

This  is an uncommon solid tumour of the mandible and  occurs  in

the body of mandible at its junction with the ramus.

 

Growth is slow and it expands the bone.

 

Microscopically interlacing strands of odontogenic epithelium  is

enmeshed  in  a  connective tissue stroma.  There  are  areas  of

cystic degeneration.

 

Treatment   is  segmental  resection  of  mandible  followed   by

reconstruction of the mandible.

 

7.2 OSTEOGENIC TUMORS

 

These are malignant tumours like those that affect other bones in

the  body,  e.g. Multiple myeloma,  Ewing 's  sarcoma,  Osteogenci

sarcoma, chondrosarcoma and periosteal fibrosarcoma.

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HEAD NECK 13 mandible

7. MANDIBLE

 

7.1 ODONTOGENIC(ODONTOMA)

 

These lesions arise from odontogenic remnants (tissue involved in

tooth formation) and are invariably benign.

 

7.1.1 FOLLUCULAR CYSTS (DENTIGEROUS CYTS)

 

These  cysts are derived from the dental lamina, the outer  enamel

epithelium  of  developing teeth.  A remnant of  this  tissue  is

sequestered during development. It occurs in women between  30-40

years

 

Clincially, these lesions present with an enlargement of ramus of

the mandible and on absent molar tooth.

 

Microscopically,  these  cysts  have a fibrous  wall  lined  with

squamous epithelium.  Cysts develops at the site of an  un-erupted

tooth. 

 

X-ray  shows  the  cyst  with  unerupted  tooth  in  its  cavity. 

Treatment  is  intraoral  excision of the cyst  with  its  lining

membrane.

 

7.1.2 RADICULAR CYST

 

These  arise  due  to inflammation of  the  epithelial  structure

involved in formation of the root.  It is enclosed within a dense

connective   tissue   lining  covered  internally   by   squamous

epithelium.

 

Treatment  is extraction of the tooth and exicision of  the  cyst

lining.

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HEAD NECK 12 Tongue Cancer

5.3 TONGUE

 

Carcinoma originates at the tip or along the free borders:   Area

of hyperkeratosis develops first.

 

Later  this  develops  into an ulcerated  lesion  with  exophytic

undermined border.

 

Palpation  detects  hardness  and  indicates  that  invasion  has

occurred beyond the ulcer.

 

Spread   cancer  of  the  tip  of  the  tongue  metastasises   to

ipsilateral sub mandibular nodes and later the nodes at the  angle

of  the mandible are involved. 

 Forty percent have nodes  at  the time of presentation.

 

CLINICAL

 

The patient presents with :

-  Pain

-  Salivation

-  Fixation of Tongue

-  Dysphagias

-  Difficulty in speech

-  Foetor

 

Diagnosis

 

Multiple biopsies establish the diagnosis and the extent in large

tumours.

 

TREATMENT

 

T1NoMo lesions can be treated by radiotherapy or surgery as small

lesion  is  removed  with 1.5 cm margin  of  healthy  tissue  all

around.  Lesion of upto 1cm can be treated by interstitial radion

with Iridium192 wire. 

 

Combined  operation  including  wide resection of  a  small  oral

lesion  if  they  have nodes at the time  of  presentation,  they

require radial neck dissection.

 

Treat  all  larger lesions with preoperative  radiation  therapy,

following  this with a radical neck dissection and in  continuity

excision of any residual cancer.

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