Head and Neck

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Head and Neck

Iain Nixon, Pradip K Datta
FRCS (Gen Surgery): A Road to Success.
1
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Edition, Doctors Academy Publications, Cardiff, UK, December 2013
The following conditions are discussed. You are expected to match the diagnosis with the clinical features.
01. Branchial cyst
02. Carcinoma of tongue
03. Carotid body tumour
04. Cirsoid aneurysm
05. Cold abscess
06. Cystic hygroma
07. Infective lymphadenopathy
08. Lymphoma
09. Pleomorphic adenoma of parotid
10. Ranula
11. Submandibular salivary duct stone
12. Submandibular salivary gland carcinoma
13. Submandibular sialadenitis
Match the above diagnoses with the clinical features of the various conditions below.
Diagnoses
Conditions of the head and neck are most often encountered in the clinical examination. You will be shown intra-oral pathology and
conditions arising from the lymph nodes, salivary glands and embryological remnants. You must be thorough in your clinical examination,
giving a running commentary as you go along. A systematic list of investigations should be given to come to a diagnosis. In relevant
cases do not forget to examine the abdomen or other parts of the body; for example, when lymphoma is suspected, abdominal
examination for hepatosplenomegaly is paramount; in secondary cervical lymph nodal metastasis a primary should be sought by full
head and neck examination. Postoperative patients may be encountered, some of whom with complications you will need to guess
the operation carried out.
In the oral examination questions relating to pathology affecting the reticuloendothelial system, salivary glands and tongue will be
asked. You must know the principles of certain operations and their complications.
An algorithm for the diagnosis of the various head and neck conditions (excluding salivary glands) are shown in Figure 19.1.
HEAD AND NECK
Synopsis
History
Local symptoms
General: Temperature
Weight loss
Cough & SOB
Abdominal
symptoms
Clinical Examination
Site, Surface, Size
Surrounding area
Consistency
Tenderness
Intra-oral exam
Breast
Abdomen
Investigations
Haematological
Biochemical
Inflammatory
markers
Radioloy
US
CXR
CT scan
Other special
Midline Thyroglossal cyst
Tender Infected lymph nodes
Moving upward with swallowing
Thyroid FNAC
Supraclavicular Lymph nodes
Examine: Breast, Abdomen,
Investigations: CXR, OGD, CT, FNAC
Upper deep
cervical nodes Primary found
Primary not found
ENT referral, OGD, CT, neck & chest,

FNAC
DD=Carotid
body
tumour
Multiple nodes Investigate as
above + biopsy
Cystic Transillumination +ve =
Cystic hygroma
Transillumination ve = Branchial cyst
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Clinical features
A. A 23-year-old woman complains of a swelling below her tongue on the right side, bluish in colour and painless. When she closes
her mouth a part of the swelling is also seen below the mandible.
B. A 70-year-old man, a heavy smoker, complains of a dull aching pain in his right ear and has noticed blood-stained saliva for several
months. On examination he has a fixed hard mass on the right side of the neck and a painful ulcer on the right lateral edge of his
tongue.
C. A 60-year-old woman complains of a swelling, the size of a plum, on the right side of her neck of three years duration. This is
painless and gradually growing in size and would like it removed for cosmetic reasons.
D. A 65-year-old man presents with a painless swelling of eight months duration on his preauricular region. The swelling is firm, non-
tender, lobulated and fixed.
E. A 50-year-old woman complains of colicky pain in her left submandibular region when she eats. This is associated with a painful
swelling which subsides after eating. On examination she has a hard 5 mm swelling impacted in her left sublingual region.
F. A 42-year-old woman presents with a swelling on the left side of her forehead which she has had for as long as she can remember.
The patient is concerned about the unsightly appearance and complains of aching pain. On examination the swelling exhibits to-
and fro-thrill and a machinery murmur.
G. A 55-year-old man presents acutely with a very painful, red, tender, swelling in his right submandibular region. He is unable to
open his mouth because of the pain and he is toxic. He has had this swelling for over a year that gave rise to intermittent pain
particularly during eating.
H. A 60-year-old man complains of a gradually enlarging swelling on the right side of his neck over the last six months. He has been
feeling out of sorts, has lost some weight and has felt feverish. On examination he has an irregular nodular mass on the right side
of his neck which feels rubbery.
I. A 56-year-old man presents with a mass over his left submandibular region of four months duration. This is painless. On examination
the mass is 8 cm x 6 cm, firm in consistency, non-tender and bimanually palpable. There are a few smaller lumps felt in the
periphery of this lump.
J. A 25-year-old man complains of a lump on the right side of his neck of 10 days duration. It is red, tender, warm and cystic. He
feels unwell and feverish. This came on after he had piercing of his earlobe; three days later the affected earlobe became red and
discharged pus.
K. A 42-year-old man complains of a swelling on the left side of his neck of two years duration. It is smooth, non-tender, at the level
of the hyoid bone showing transmitted and expansile pulsations and is mobile transversely but not in the cranio-caudal axis.
L. A 28-year-old man from the Indian subcontinent complains of a lump on the right side of his neck of six months duration. It is
painless and gradually increasing in size. It is fluctuant. He has suffered from cough on and off for several months with low grade
evening temperature.
M. A 3-year-old male child has been brought in with a 10 cm painless swelling over the left supraclavicular area. The lump is cystic
and brilliantly transilluminant.
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Questions
1. What is a branchial cyst and how do you confirm the diagnosis?
2. How do you treat it? Describe the operation detailing which cranial nerves are in danger during the procedure.
3. If left untreated what might happen and how would you treat that problem?
Answers
1. A branchial cyst is a remnant of an embrylogical placode usually from the 2nd branchial cleft. It is of ectodermal origin and is initially
an empty sac. Subsequently over many years the sac fills with debris becoming a full blown cyst; hence its appearance in later life. It
is situated between the carotid sheath and sternomastoid muscle protruding at its anterior border at the junction between the
upper one-third and lower two-thirds. It is cystic, painless and does not usually transilluminate because the fluid inside is turbid and
rich in cholesterol. Confirmation of diagnosis is by ultrasound, MRI to identify any related tracts, and fine needle aspiration biopsy,
although the latter may cause infection resulting in a fistula (see below). Branchial cysts represent one of a number of embryological
remnants of the branchial arch system which may present with cysts, sinuses or fistulae between the mucosal surface of the upper
aerodigestive tract and skin of the head and neck. Care should be taken in assuming a benign diagnosis in older patients who present
with a cystic neck mass and squamous cells on aspiration, as these patients may in fact have a cystic metastasis, traditionally from an
oropharyngeal primary squamous cell carcinoma.
Diagnoses matched with clinical features and images
Answer to question 1 : C
Branchial cyst
Figure 19.2a: A branchial cyst.
Figure 19.2b: A completely excised branchial cyst: same patient as in figure 19.2a.
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2. Treatment is by excision. With the patients neck extended and the head turned to the opposite side, a skin crease incison is made
at least 2 cm below the angle of the mandible. This is to prevent damage to the marginal mandibular branch of the facial nerve. The
platysma is incised with the skin and the deep cervical fascia incised along the anterior border of the sternomatoid. The cyst is
dissected; a part of it may be found to communicate postero-superiorly between the internal and external carotid arteries deep to
the posterior belly of the digastric muscle. Care is taken to identify the hypoglossal and spinal accesssory nerves which are
vulnerable to iatrogenic damage. The wound is closed in layers, after leaving a drain.
3. If left untreated the cyst might get infected and form an abscess. Once the abscess bursts, it will result in a branchial fistula that will
discharge lower down at the junction of the upper two-thirds and lower one-third of the anterior border of the sternomastoid. To
treat it, the infection is controlled and the fistulous tract is visualised by a fistulogram to delineate the upper end which often extends
to the tonsillar fossa. The treatment is surgical excison. The tract which will pass between the two branches of the common carotid
artery, must be excised completely. This will require two separate transverse incisons. The procedure is done under antibiotic
cover.
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Answer to question 2 : B
Carcinoma of tongue
Questions
1. Explain the causes of this patients clinical presentation.
2. What are the various clinical methods of presentation of cancer of tongue?
3. How do you go about investigating this patient?
4. What is the definitive management?
Answers
1. This man presents with otalgia and blood stained saliva. The blood staining is related to ulceration of the tumour, with fragile
capillaries which intermittently bleed on contact. The otalgia is due to referred pain. The most commonly implicated cranial
nerves are the glossopharyngeal (CNIX) and vagus (CNX). Otalgia is an ominous sign, which suggests advanced disease. The
symptom can be related to primary or nodal disease, and the proximity of the vagus and glossopharyngeal nerves to the major
vessels within the neck should alert the clinician to the possibility of unresectable disease.
2. Tongue cancer may present with a spectrum of symptoms and signs. The most common is a non-healing ulcer, and any ulcer that
does not heal for three weeks is amongst the red-flag symptoms and should be referred for an urgent expert opinion. Other
symptoms for urgent referral are: persistent hoarseness, intra-oral discoloured mucosal patches, unresolved neck masses and
cranial nerve palsies. Early lesions may present as a white or red patch (leukoplakia/erythroplakia). More advanced lesions
present with oral bleeding or difficulty in swallowing. Advanced lesions may present with signs related to invasion of the
hypoglossal or lingual nerve or, as previously discussed, referred pain. Disseminated disease presents with classic weight loss and
cachexia.
3. This man requires a tissue diagnosis. The tongue, the neck or both can be targeted for biopsy. Punch biopsy of an oral lesion is
sufficient to confirm histology. FNA of a neck node can be used to confirm metastasis. Imaging should also be ordered. Most
centres would advocate a CT scan of the neck and chest. This allows accurate staging of the primary disease, and screens for
regional and distant metastases. In addition, smokers are at risk of synchronous primaries in the lung, and CT chest is a good way
to screen for these. MRI or ultrasound are also used in neck staging, but the convenience of combining a CT chest with the neck
has led to widespread adoption in the UK.
4. The cornerstone of management of oral cancer remains surgery. Situations where surgery is preferred to radiation in squamous
cancers of the head and neck include: large lymph nodal metastasis and cases where there is evidence of bone and/or cartilage
destruction. Resection of the primary disease with negative margins, along with neck dissection which removes all gross disease
and all lymph node groups at risk of metastasis (defined by the site of the lesion and findings on imaging) should be performed.
Neck dissections are classified as radical neck dissection, modified neck dissection, selective neck dissection and extended node
dissection. In radical neck dissection, all nodes from levels I-V are removed in addition to the accessory nerve, jugular vein and
sternocleidomastoid muscle. Modification of the radical neck dissection involves preservation of the accessory nerve, internal
jugular vein and sternocleidomastoid muscle. In selective neck dissection, only nodes are resected, and at least 1 lymph node level
is preserved (i.e. levels I-IV or II-IV). Following resection of oral cancers, most patients will require some form of reconstruction.
Partial glossectomy and neck dissection results in a communication between the mouth and neck, which will develop in to a
salivary oro-cutaneous fistula. Although primary closure can be performed, larger defects often require a rotation (pectoralis
major) or free (radial) flap. Histological assessment of the specimen will confirm the diagnosis and stage. Indications for adjuvant
radiation therapy include advanced stage (III/IV), close margins which cannot be re-resected, or worrying features such as
invasive islands of carcinoma in the specimen. Those patients with positive margins or with nodal disease and extracapsular
spread are also currently considered for adjuvant chemotherapy. The involvement of multiple professionals from different
specialties has led to the formation of multidisciplinary teams (MDT) to provide effective treatment planning, follow up and
support. In head and neck cancer the MDT is much larger than for other cancers. This is because speech therapist,
prosthodontist and restorative dentist and dietician in addition to the usual members, play a major role in the patients
recovery.
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Answer to question 3 : K
Carotid body tumour
Questions
1. What is a carotid body tumour?
2. Describe the management of a carotid body tumour
Answers
1. A carotid body tumour is a paraganglioma arising from neural crest tissue, the chemoreceptors at the carotid bifurcation. Hence it
is also called a chemodectoma. Because the tumour macroscopically resembles a potato, Hutchison called it a potato tumour. The
tumour is ten times more common in those living in high altitudes. This is because prolonged hypoxaemia stimulates the chemoreceptor
cells to become hyperplastic causing to form a tumour which is slow growing. The physiological mechanism is shown in Figure 19.3b.
One in ten of these tumours are bilateral and in a similar proportion they are familial; a similar number may cause pressure on the
neighbouring cranial nerves 7th, 9th, 10th, 11th, 12th causing palsy. Pain in the neck or ear, headache, dizziness and syncopal
attacks are rare symptoms. They metastasise very rarely.
Carotid body tumour
Figure 19.3a: Carotid body tumour.
erythropoietin
production
from kidney
Polycythaemia
Figure 19.3b: Algorithm explaining the aetiology of carotid body tumour.
Mountain dwellers low O
2
level
Chronic hypoxia stimulates carotid sinus
respiratory rate, heart rate and blood pressure
Hypertrophy of carotid body Chaemodectoma
2. The initial diagnosis is established by duplex ultrasonography. The patient is referred to a vascular surgeon. Surgery is only contemplated
after considerable thought because of the complication of hemiplegia (1-2%) and cranial nerve damage (12-40%). After informed
consent, if surgery is contemplated, further investigations are done. These are: magnetic resonance angiography and/or digital
subtraction CT angiography. Catecholamine screening is done to exclude a phaeochromocytoma.
Imaging will confirm the degree of involvement of the internal carotid artery (ICA). This is referred to as the Shamblin calssification:
group 1 minimal involvement (25%); group 2 partial involvement (50%); group 3 encirclement and invasion (75%). A
combined team of vascular and head and neck surgeons should be involved. Surgery entails dissection of the tumour away from the
carotid bifurcation. Rarely resection and vein graft with the use of an intra-operative bypass may be necessary.
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Answer to question 4 : F
Cirsoid aneurysm
Figure 19.4: Cirsoid aneurysm.
Questions
1. What is a cirsoid aneurysm?
2. Describe the management.
Answers
1. A cirsoid aneurysm (will be shown as a clinical case) is an arteriovenous fistula, usually found in the head and neck, particularly
in the scalp. It is uaually of congenital origin although some are said to occur as a result of birth injury to the superficial temporal
vessels or a blow to the head in later life. Pressure may result in erosion of the underlying bone. Most patients complain about
cosmesis; however, as the swelling enlarges it causes an ache. The swelling is warm, pulsatile, with a to-and-fro thrill and a
machinery murmur; there are dilated cutaneous vessels giving the feel of a bag of worms. If the swelling is large, on occluding
the feeding vessel with a finger, the pulsation disappears resulting in bradycardia; this is called Barnhams test.
2. If on clinical grounds, intervention is contemplated, imaging by arteriography, MRI and CT scan will delineate the anatomical
details of the lesion. Although the clinical diagnosis is obvious, it should be differentiated from a bony secondary from a follicular
thyroid carcinoma or a renal cell carcinoma which are characteristically vascular and therefore present as a pulsatile painful mass.
Any treatment must be embarked upon after careful assessment of the risks by an experienced vascular surgeon and radiologist.
This is because there may be inadvertent cerebral ischaemia resulting in serious vascular deficiency. Treatment consists of
therapeutic embolisation or occlusion of the feeding vessel with excision of the mass.
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Figure 19.5b: Tuberculous sinus.
Courtesy of Professor Ahmad Fahal, Professor of surgery, Khartoum, Sudan
Answer to question 5 : L
Cold abscess
Figure 19.5a: Cold abscess.
Questions
1. Describe the pathology including microbiology.
2. Describe the management.
Answers
1. The underlying pathology is tuberculosis which forms a matted lymph nodal mass; this later becomes cystic due to caseation and
liquefaction necrosis resulting in an abscess. Features of inflammation - heat and redness - are conspicuous by their absence, hence
the name cold abscess. The abscess which initially is deep to the fascia bursts into the space beneath the superficial fascia
producing a bi-locular mass called a collar-stud abscess. Left untreated, the abscess ruptures into the skin forming a tuberculous
sinus (Figure 19.5b). The latter has typical watery discharge with overhanging edges. The responsible organism is the acid fast
bacillus Mycobacterium tuberculosis.
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2. The first stage in the management is to establish the diagnosis and then exclude other sites. Pus from the abscess is aspirated and
sent for culture and sensitivity. Raised inflammatory markers and anaemia are common. Blood is also sent for interferon gamma
(IFN- ) release assays. This is an in vitro blood test of cellular immune response. Sputum is sent for culture and sensitivity; a CXR
is done. The treatment is manily medical and carried out by the chest physician. Incision and drainage produces a discharging
abscess which is unpleasant for the patient and should be avoided.
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Answer to question 6 : M
Cystic hygroma
Questions
1. What is a cystic hygroma and in which other anatomical sites can it occur?
2. What is the management?
Answers
1. A cystic hygroma is a congenital malformation of the lymphatics, usually of the head and neck and found in children; some may
occasionally manifest later in life. It consists of thin-walled multiple intercommunicating cysts in the tissues of the root of the
neck. It is cystic, brilliantly transilluminant and varies in size; rarely they may be so large as to cause obstructed labour whilst
others may result in dyspnoea and dysphagia. Most are asymptomatic. The other less common sites of occurrence are: cheek,
axilla, mediastinum and groin.
2. Symptomatic cysts are referred to the paediatric surgeon for excision. This is carried out after thorough delineation of the cyst
by a CT scan or MRI as some may extend into the mediastinum. Aspiration and injection of a sclerosant has been tried. Recurrence
is not uncommon. Therefore a one-stage resection should always be attempted. Lesions may be uni or multi-locular. They may
also be categorised as supra or infra hyoid. Those above the hyoid often involve mucosal surfaces, are multi-loculated and difficult
to treat. Infra hyoid, uniloculated lesions are generally easier to treat, but should be fully assessed with imaging as extension in
to the mediastinum may prevent surgical resection.
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Answer to question 7 : J
Infective lymphadenopathy
Questions
1. What is your management?
2. How do you classify the groups of cervical lymph nodes?
Answers
1. At the outset bloods are sent for culture, full blood count and inflammatory markers. He is given analgesia, broad spectrum
antibiotics and arrangements are made for incision and drainage of the abscess. The pus is sent for culture and sensitivity. The
original site of infection of the ear lobe is allowed to settle down by itself.
2. In the body one-third of lymph nodes are in the neck. Secondary metastases of cervical nodes are common not only from cancer
of the head and neck but also from the abdominal organs such as stomach, and pancreas; testicular cancer is also known to spread
to the supraclavicular nodes. The latter three organs metastasise to the left side, the cancer cells being carried by the thoracic
duct which empties at the confluence of the left internal jugular and subclavian veins.
Cervical lymph nodes are anatomically divided into a superficial group lying along the external jugular vein and a deep group lying
along the internal jugular vein. These are further subdivided and named according to their location. Skin lesions drain into the
superficial nodes some of them being called anterior cervical nodes. At the front of the neck, deep to the investing fascia, lie the
infrahyoid, pre and paratracheal (draining the larynx, trachea and thyroid), prelaryngeal and retropharyngeal nodes. The deep cervical
nodes lying along the internal jugular vein are divided into superior (jugulodigastric) and inferior (jugulo-omohyoid) groups; intra-oral
cancer including the tongue drain into this group of lymph nodes.
The surgeon proposing to do a block dissection of the neck for malignancy classifies cervical nodes as follows:
Level 1 nodes in submental and submandibular triangles
Level 2 - 4 deep cervical nodes which are
Level 2 = nodes from skull base to carotid bifurcation / level of hyoid bone
Level 3 = nodes from carotid bifurcation to cricoid cartilage
Level 4 = nodes from cricoid cartilage to clavicle
Level 5 posterior triangle of neck related to 11
th
cranial nerve
Level 6 pre and paratracheal nodes
Level 7 nodes in superior mediastinum
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Answer to question 8 : H
Lymphoma
Figure 19.6: Lymphoma of neck.
Questions
1. Having made a clinical diagnosis, what is your next step in the management?
2. What are the various types of lymphoma? Briefly describe the pathology and staging.
3. What other anatomical sites can be affected by lymphoma?
Answers
1. Following a clinical diagnosis, a tissue diagnosis is required. Not only will this confirm the clinical suspicion, but immunohistochemical
analysis will allow therapy to be tailored to the specific subtype of malignancy. Individual departments have differing approaches to
obtaining tissue. Classically open incisional or excisional biopsy is performed. Although this is not a surgical disease, there are
some low grade subtypes of lymphoma which may be appropriately managed in elderly patients with resection and observation.
The majority however will require further treatment, so if excision of a node in its entirety puts vital structures at risk an
incisional biopsy is more appropriate. Some departments may be willing to base a diagnosis on core biopsy or even on FNA,
depending on the cellularity of the specimen however, for exam purposes an open biopsy allows tissue architecture to be assessed
and provides ample tissue for advanced staining.
2. Lymphoma is a malignancy of the B and T cells of the immune system. Although previously described as Hodgkins and non-
Hodgkins lymphoma, this classification was not clinically useful. A number of classifications based upon the histological architecture
have been used, but the current WHO classification is based on the affected cell type (B cell, T cell or Natural killer cell) with
further sub-classification based on the phenotype and molecular or cytogenetic characteristics of the cells.
The classic Ann Arbor staging system classifies patients in to 1 of 4 stages. Stage I represents patients with lymphatic disease
limited to one site. Stage II represents lymphatic disease in 2 sites, both on the same side of the diaphragm. Patients with
lymphatic disease on both sides of the diaphragm are stage III and those with extralymphatic disease are classified in Stage IV.
Additional annotation used includes A for those without systemic symptoms and B for those with symptoms. E is used to denote
extra-nodal disease. X is used to represent deposits over 10 cm in size and S is used to indicate splenic involvement.
3. Sites other than lymph nodes which can be involved with lymphoma include the liver, bone marrow spleen, lungs and gastrointestinal
tract.
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Answer to question 9 : D
Pleomorphic adenoma of parotid
Figure 19.7a: Pleomorhic adenoma of parotid.
Questions
1. On clinical examination what specific physical finding are you going to elict and why?
2. What investigation would you do to confirm the diagnosis? What other investigations would be helpful?
3. What operation would you perform? Briefly describe the steps.
4. Enumerate the possible complications of the operation.
5. Classify salivary gland tumours.
Answers
1. One needs to elicit the integrity of the facial (7
th
cranial) nerve. Involvement of the facial nerve indicates that the parotid tumour
is malignant. The nerve is tested by asking the patient to look upwards creating wrinkles on the forehead (occipitofrontalis),
screwing up the eyes (orbicularis oculi), whistling (orbicularis oris), blowing out the cheeks (buccinator).
2. Fine needle aspiration cytology (FNAC) may be used for diagnostic purposes and can differentiate malignant from a benign
tumour in over 90% of cases. A CT or MRI scan would also be helpful to identify deep lobe involvement. An algorithm for the
diagnostic pathway for a solid parotid swelling is shown in Figure 19.7b. However, imaging procedures should be performed
before doing the FNAC as the latter investigation will distort the images of the scan.
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5. Salivary gland tumours are classified according to the World Health Organisation classification in Figure 19.9.
3. After full informed consent regarding the vulnerability of the facial nerve, this patient should undergo a superficial parotidectomy.
The procedure involves removing the part of the parotid superficial to the facial nerve. The operation may be performed under
hypotensive anaesthesia with the use of a nerve monitor; if the latter is used, the anaesthetist should not paralyse the patient.
The modified Blair incision preauricular-mastoid-cervical - starts in the preauricular area and goes down in front of the ear, in
the pre-auricular crease, and then behind towards the mastoid process where it curves downwards and forwards along a cervical
skin crease over the anterior border of the sternomastoid. The incision is deepened through the platysma in the neck and
following this plane, the the parotid fascia is identified, and the anterior flap is elevated to expose the parotid gland. Inferiorly the
subplatysmal flap is raised with identification of the greater auricular nerve. The posterior branch can sometimes be preserved,
and an attempt to preserve some length of the nerve is made in case the facial nerve is sacrificed, at which point the greater
auricular can be used as a cable graft.
The trunk of the facial nerve is identified as it emerges from the stylomastoid foramen and lies deep to the tragal cartilage before
it enters the gland. A number of markers are available to assist the surgeon including the tragal pointer and the anterior surface
of the posterior belly of the digastric muscle. The most consistent landmark however is the tympanomastoid suture, which leads
to the stylomastoid foramen. The nerve and its branches are followed removing parotid tissue superficial to the avascular
fasciovenous plane.
When the facial nerve is identified and traced forwards, it is seen to divide into two major branches, an upper temporo-zygomatic
and a lower cervico-mandibular branch. The upper division and its branches are dissected first, removing the glandular tissue
between the nerve branches using scissors and fine artery forceps. This method is repeated along the lower division of the nerve
and its branches until the tumour is removed. After leaving a suction drain the platysma is closed separately followed by clips to
skin.
4. The complications of the operation are shown in Figure 19.8.
Complications after parotid surgery
Immediate Intermediate Late
Haematoma
Temporary facial
weakness
Permanent facial palsy
Numbness of ear lobe
Facial numbness
Freys syndrome
gustatory sweating
erythema
Infection
Temporary facial
weakness
Figure 19.8: Complications after parotid surgery.
WHO Classification of Salivary Gland Tumours
Malignant
lymphoma
Adenoma Carcinoma Non-epithelial
tumours
Secondary
tumours
Tumour-like
lesions
Unclassified
Acinic cell
Mucoepidermoid
Adenoid cystic
Pleomorphic
adenoma
Carcinoma
Pleomorphic
adenoma (80-85%)
Warthins tumour
Oncocytoma
Angioma
Lipoma
Cysts
Figure 19.9: Classification of salivary gland tumours.
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Answer to question 10 : A
Ranula
Questions
1. What is a ranula?
2. What is the treatment? What complications may occur during the operation?
Answers
1. A ranula is a form of a retention cyst arising in the floor of the mouth due to obstruction of one of the ducts of the sublingual
salivary glands. It presents as a slowly enlarging painless mucocoele. As the collection expands, it may extend behind the free
posterior edge of the mylohyoid muscle and into the neck, where it is termed a plunging ranula.
2. Treatment is excision under general anaesthetic. If done under a local anaesthetic, the boundaries of the thin-walled cyst are easily
lost thereby making the chances of recurrence more common. The operation, though regarded as a minor day case procedure,
should be done by an experienced surgeon to prevent the intra-operative complications of damage to the submandibular duct and
lingual nerve.
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Figure 19.10b: Operative procedure for removal of submandibular duct stone.
Answers
1. This orthopantogram shows a stone in the submandibular salivary duct (Whartons duct). This stone needs to be removed. On
occasions while the patient is waiting for the operation, it has been known for the stone to be spontaneously extruded, particularly
when the patient has been instructed to intermittently milk the stone out.
Answer to question 11 : E
Submandibular salivary duct stone
Questions
1. What are you going to do?
2. Describe the operation (Figure 19.10 b).
Figure 19.10a: Orthopantogram showing stone in left submandibular salivary (Whartons) duct.
Stone in left
Whartons
duct
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2. Under a general anaesthetic as a day case (Figure 19.10 b), once the mouth is opened with a gag, a suture is placed underneath the
duct proximally to prevent it from slipping back towards the gland. An incision is made directly over the stone which is removed.
The cut edges of the duct are sutured to the floor of the mouth to marsupilise the duct. The duct is washed out with normal
saline to empty it of any debris. The procedure can be done under a local anaesthetic if the patient is willing and co-operative.
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Answer to question 12 : I
Submandibular salivary gland carcinoma
Questions
1. What are you going to do now?
2. What will be the definitive treatment?
3. In which salivary gland is carcinoma more common?
Answers
1. This patient is at risk of salivary malignancy. There is a palpable mass in the submandibular gland with possible associated regional
lymphadenopathy. A full examination should be performed, with particular attention to the cranial nerves, to identify evidence of
perineural invasion. Investigations should include cross sectional imaging of the neck: MRI scan with multiplanar reconstruction
provides the best soft tissue definition and CT scan of the chest. The need for FNA is controversial. Traditionally, cytology has
been unreliable, particularly in departments who deal with low numbers of salivary biopsies. With the drive to centralization of
services, this is less of an issue and most head and neck surgeons now do use FNA to help guide the process of consent,
particularly in relation to potential sacrifice of the facial nerve. Despite that, it is true that the surgical management is not likely to
be altered by FNA results; a negative FNA does not exclude the possibility of malignancy.
2. Definitive treatment for salivary gland malignancy is surgery. The adenocarcinomas which affect the salivary glands are relatively
radio-resistant, and radiation thereapy is reserved for adjuvant treatment. Investigation may confirm the diagnosis and even point
towards a histological grade however, in this example stage is more important than grade. The presence of regional lymphadenopathy
dictates that treatment will include resection of the involved submandibular gland, and neck dissection. Levels I-V should be
included in order to remove all lymph nodes at risk of metastatic involvement. In the event that preoperative investigation
identifies no regional lymphadenopathy, excision of the submandibular gland alone may be considered adequate. Following
surgery a formal histological diagnosis can be confirmed including sub-type, grade and pathological stage. High grade lesions,
stage III/IV disease and positive histological margins are considered indicators for post operative radiation therapy.
3. The majority of salivary gland cancers occur in the parotid gland. However, candidates should remember that the majority of
masses in the parotid are benign. The incidence of malignancy in salivary masses is inversely proportional to the size of the gland
involved; 80% of parotid masses are benign, and 80% of minor salivary gland masses are malignant.
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Answer to question 13 : G
Submandibular sialadenitis
Questions
1. What is your immediate management? What will be your definitive management?
2. During the operation (describe it briefly) of your definitive management, what anatomical structures are in danger?
3. In which salivary gland are stones most common and why?
Answers
1. This patient has come as an emergency with infected calculous submandibular sialadenitis (Figure 19.11a). If this is not treated
promptly it will result in an abscess. The patient is admitted, given adequate analgesia, intravenous rehydration, followed by bloods
being sent for blood cultures, inflammatory markers and full blood count. Intravenous broad spectrum antibiotics with antiseptic
mouth washes are given. With this conservative management, the patient would recover from the acute phase. Once he has
recovered from the acute episode, he is given a course of oral antibiotics.
The condition settles down over the next six to eight weeks. By this time the inflamed gland becomes small, discrete and mobile
and non-tender. It is now ready for the definitive treatment of excision of the submandibular salivary gland. An algorithm for the
diagnostic pathway for a submandibular salivary gland swelling is shown in Figure 19.11b.
Stone
Large soft
tissue
shadow
around the
stone
denoting a
very
enlarged
gland
Figure 19.11a: X-ray showing stone in submandibular salivary gland.
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2. The operation is simple excision of the entire submandibular salivary gland (superficial and deep parts) by intracapsular dissection.
The incision is made 3 to 4 cm below the lower border of the mandible and deepened down to the gland. The upper flap consisting
of skin, platysma and fascia investing the gland is raised up to the ramus of the mandible. This manoeuvre prevents inadvertent
damage to the marginal mandibular branch of the facial nerve which lies between the planes of the platysma and the fascia. Trapped
between these planes, which are elevated from the submandibular gland, the nerve is protected. The facial vein is ligated and
divided as is the facial artery. The artery passes from the external carotid, over digastric up into the gland and on over the
mandible. As such it may be encountered twice during the dissection, and care should be taken to ligate this vessel. The superficial
lobe is mobilized with careful dissection. Thin walled vessels around the gland tend to bleed and retract if damaged so careful
dissection with bipolar diathermy to vessels prevents bleeding complications. When the anterior border is dissected, mobilization
allows visualisation of the mylohyoid muscle. This can be retracted, affording a view of the floor of mouth. The surgeon should
identify the lingual verve at this point, which carries with it parasympathetic nerve fibers to the gland. These pass through the
submandibular ganglion with a small vessel. This should be clamped and ligated to allow the nerve to pass up into the floor of
mouth, as the gland delivers down in to the neck. The hypoglossal nerve should be identified and protected deep and medial to
the lingual. The submandibular duct is also tied off, as the deep lobe is delivered. Following removal, the wound is irrigated,
bleeding points controlled and closed in layers over a suction drain.
To summarise, the anatomical structures in danger of indavertent injury are: marginal mandibular branch of facial nerve, lingual
nerve and the hypoglossal nerve.
3. Stones are much more common in the submandibular salivary gland for two reasons. Firstly, histologically it is a mixed type of
gland which secretes both serous and mucus type of saliva making the secretions more viscid in nature. Secondly, the gland is
anatomically dependent. Therefore the duct has to drain against gravity (Figure 19.11 c) thus encouraging stasis. Salivary calculi are
far more common in the submandibular gland which is responsible for 80% of the stones; a similar number are radio opaque and
hence seen on a plain x-ray.
Solid submandibular salivary gland swelling
with gradual increase in size
Proven stone No stone
Excision or
Follow-up
FNAC
Pleomorphic
adenoma
Benign
tumour
Excision
Carcinoma
Staging CT,
CXR
MRI
MDT discussion
Not helpful
CT, Frozen section
Low-grade Ca

Radical
excision
+
Lymph node
di ssecti on i f
LN
involved
High
grade
Ca
Radical
excision
+
Block
dissection
Radiotherapy
Follow Up
Figure 19.11b: Algorithm for diagnostic pathway for a solid submandibular salivary gland
swelling.
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Submandibular
sialogram
showing the
duct running
uphill and
draining
against
gravity
Figure 19.11c: Submandibular sialogram showing the duct running uphill and draining against
gravity.

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