Glands and palate

• salivary glands
• parotid – innervated by parasympathetic auriculotemporal nerve (CNV) and glossopharyngeal nerve, but CNVII passes through
• submandibular glands produce the most saliva > parotid > sublingual

 
Head & Neck Neoplasms
Benign

• Thyroglossal duct cyst – presents as a mobile, midline neck mass. caused by failure of the duct to atrophy. treat with excision of the cyst along with portion of hyoid bone. 
• Pharyngeal fistula – presents as a lateral neck draining sinus over the SCM, and tracks deep to stylohyoid & digastric, superficial to ICA & stylopharyngeus
• Myxoma – presents as a slow growing benign tumor. treat with WLE
• Bruxism – presents with hypertrophy of the masseters. treatment is botox -> muscle relaxants -> resection masseter
• mucocele – cyst caused by minor salivary gland mucin seepage on lower lip or in oral mucosa. –> treat by excisional biopsy
• xanthelasmata – localized lipid deposits often located on eyelids. tx surgical excision.
• spiradenoma – painful raised bluish lesion. dense basophils, eosinophil hyaline deposits, and lymphocytes. –> excision
• congenital epulis – oral granular cell tumor in newborns. can cause mechanical obstruction. F>M, maxilla>mandible. –> excision
• leukoplakia – white patch that cannot be wiped off (evolves into SCC in a small percentage of cases)
• Nasopharyngeal angiofibromas – presents with epistaxis. these are benign but are locally invasive. treat with resection & radiation if there is intracranial extension.
• Benign lymphatic malformations – CO2 laser vs resection if symptomatic
• Fibrous dysplasia – ground glass appearance on imaging à treat by shaving and recontouring bone
• Divided into zones on the face – zone 1 (midface and upper face) you can shave/recontour, zones 2&4 (hear bearing scalp and teeth bearing bones) you can do a conservative resection to improve contour, and zone 3 (base of skull) don’t resect

 
Tumors of the mandible/teeth:

• Aneurysmal bone cyst – multinucleated giant cells –> treat w/ resection and curettage
• Osteoradionecrosis of the Jaw
• ORN occurs after 6500 gray and increased risk with dental caries, periodontal disease
• Bisphosphonate related osteonecrosis: related to bisphosphonate therapy (alendronate)
• Can develop nonvital bone (remember suffix -onate)
• Stage 1: exposed alveolar bone without pathologic fracture –> responds to local debridement, oral hygiene, and HBO
• Stage 2: needing major bony debridement or non-responsive to HBO
• Stage 3: failed treatment, pathologic fracture, orocutaneous fistula, evidence of lytic involvement in the mandibular border -> treatment of mandibular segmental resection and reconstruction (free fibular graft if >6cm)
• Bilateral pathologic fractures- debridement and free fibular graft 
• Gingival cyst – keratin containing cysts found on alveolar ridges of infants.
• Dentigerous cyst / follicular cyst – develop around an unerupted tooth when it degenerates and becomes unilocular cyst of nonkeratinizing stratified squamous epithelium
• Most common around the mandibular third molar (tooth will be at bottom of cyst and cyst will surround unerupted tooth, at an acute angle of the tooth)
• Radicular/periapical cysts – inflammatory cysts which develop from the periodontal ligament at the apex of nonviable erupted tooth (often after infection)

• Fibrous shell with inflammation and non-keratinizing epithelium
• Primordial cysts/odontogenic keratocysts – keratinizing squamous lined cysts that develop from basal cell hamartomas à treat with enucleation and chemoablation

• Gorlin syndrome – calcifying odontogenic cysts (along with BCC + medulloblastoma etc discussed later) – biopsy shows epithelium undergoing keratinization with rete ridges and ameloblastic proliferations with some calcifications
• Ameloblastoma – presents as a mass/swelling on tooth bearing segments of the mandible. looks like a soap bubble on imaging with a radiolucent, multicystic, unilocular lesion. 
• Benign but locally invasive àE&C (high recurrence)/complete segmental resection w/ reconstruction
• Pathology: odontogenic epithelial islands with palisading cells (odontogenic epithelium)
• Typically present in 4th and 5th decade of life  
• Neurofibroma – 
• Bilateral expansile lesions along inferior alveolar nerve is pathognomonic for neurofibromatosis
• mast cell in mixoid stroma, absence of sphenoid greater wing and macrocephaly

 
 
Malignant

• Nasopharyngeal carcinoma – associated with EBV and burkitts lymphoma
• usually treated with chemo/radiation instead of resection
• Osteosarcoma – 
• aggressive expanding mass in maxilla or mandible, needs radical excision with adjuvant chemo/rads (risk factors are fibrous dysplasia and retinoblastoma or previous radiation)
• looks like lamellar ossification and cortical destruction with poorly defined borders on XR

Parotid: 80% of parotid tumors originate within the parotid gland 

• Most common location for salivary gland malignancy: pain paresthesia and facial paralysis are signs of neural invasion (usually associated with malignancy)
• Also associated with malignancy is rapid growth, bony fixation, skin ulceration, palpable nodal enlargement 
• Facial nerve divides superficial and deep portions –> superficial parotidectomy involves removal of parotid gland superficial to the plane of the facial nerve
• Indicated for benign parotid tumors (pleomorphic adenoma, mucocele, branchial cleft cysts, lymph nodes)
• Total parotidectomy is removal of superficial and deep parotid
• Radical parotidectomy is indicated for malignant lesion of facial nerve –> total parotidectomy with facial nerve sacrifice
• If tumor invades parotid capsule, will need superficial parotidectomy
• Use the tympanomastoid suture as landmark to avoid facial nerve injury during parotidectomy, look for the midpoint between fascial covering and tragus
• Benign
• Pleomorphic adenoma (benign) and most common tumor of the parotid gland
• biopsy will show stellate/spindle cells with mixoid background. à superficial parotidectomy to avoid local recurrence (preserve nerve)
• recurrence rate is 6 to 15%
• Warthin’s tumor (usually benign) and second most common parotid tumor
• Occur in men 50-70 years of age
• – commonly presents as bilateral tumors in older men who are smokers. biopsy will show papillary cysts, mucoid fluid, and lymphoid nodules. –> superficial parotidectomy vs monitoring
• Submandibular gland duct (wharton duct): can be blocked if cancer invades this area resulting in backup of salivary content, gland enlargement, becomes firm and painful, and can become infected
• Most common cause of hard mass in floor of mouth is salivary origin
• Malignant
• Adenoid cystic carcinoma: second most common malignancy of salivary glands after mucoepidermoid carcinoma
• propensity for neural invasion
• presents with facial paralysis, pain, mets to lung. biopsy will show cribiform/swiss cheese cells with perineural invasion. –> radical surgical excision (high rate of recurrence/mets)
• MRI/CT first to determine neural invasion/plan for surgery
• 1-2cm margins +/- XRT
• Microcystic adnexal carcinomas: flesh-colored nodules of upper lip, nose, perio-orbital regions in middle aged patients, perineural invasion –> mohs resection
• Mucoepidermoid carcinoma – most common. biopsy will show mucus producing and poorly differentiated epithelial cells. Locally invasive. 
• high grade mucoepidermoid (total parotidectomy/ipsi neck dissection/post op radation) radiate if nodes clinically positive; superficial parotidectomy could be performed in low grade tumors
• Merkel cell tumors: extremely aggressive, head and neck, extremities (sun-damaged areas) in elderly women, dark deep purple (murkle purple), dense oval sheets with indistinct borders that invade deep dermis, sq fat, muscle –> wide local excision of at least 1-2cm including fascia, ipsilateral neck dissection (parotid as well if in preauricular areas)
• AEIOU: asymptomatic, expanding, immunosuppressed, older than 50 years, and ultraviolet-exposed fair skin
• Minor salivary gland maligancy: less common, but more likely to be malignant
• Palate most common source of minor salivary tumors 
• most adenoid cystic carcinomas –> requires surgical resection with adequate margins, radiation if high grade, mets, no good resection, etc
• Paresthesias are consistent with perineural invasion
• Remember to stage with CT/MRI prior to any operative intervention

Complications:

• Complications include facial nerve paralysis, gustatory sweating, sialocele
• Chylous fistula: medium chain triglyceride diet, closed suction drain of neck after radical neck dissection; exploration and ligation may be considered in refractory cases, pec flap can help seal the fistula
• Parotid:

• Frey syndrome –gustatory sweating
• Aberrent reinnervation of auriculotemporal nerve following superficial parotidectomy (postganglionic of parasympathetic to postganglionic of dermal plexus) (place SMAS between parotid bed and overlying skin) –> can treat with skin excision or tympanic neurectomy, anticholinergics to abate the symptoms (can identify with iodine or tissue test)
• Can botox
• Bogorad syndrome (crocodile tears) – less common phenomenon gustatory hyperlacrimation after injury to facial nerve (another form of aberrant regeneration) –> lacrimal gland resection, botox, dilating lacrimal tract
• laceration of parotid duct – at risk from penetrating injury in line from the tragus to the mid upper lip

• if identified early, try to explore and re-anastomose. if identified later, manage with drainage, pressure, and antisialogogues
• Last resort superficial parotidectomy for recalcitrant salivary collections
• Salivary fistula is a risk after superficial parotidectomy for recalcitrant sialadenitis

 
 
Neck Dissection and Staging

• SCC staging: T1<2cm, stage III>4cm T4 invades surrounding structures, N2 when contralateral nodes are involved or node >3cm
• SCC most common in maxillary region of paranasal area

• tumor size is T, N = nodes, M = mets
• P16+ (HPV) downgrades it because lethality is less
• HPV 16, 18 common in oropharyngeal cancers
• Recommendations for extent of dissection
• n0 and N1 of oral cavity –> levels I-III
• clinically palpable mets –> modified neck dissection
• involvement of nerve, vein, or muscle –> radical resection/ neck dissection
• selective neck dissection in low grade oropharyngeal cancers (stage I/II) with negative palpable nodes- leads to decreased nodal recurrence, increased postop complications, and higher rates of survival compared to therapeutic surgery only

Epidemiology and specific treatments based on extent of invasion

• Cortical invasion of SCC Is indication for segmental mandibulectomy; marginal mandibulectomy indicated for tumors that abut the mandible but do not invade
• SCC of lip –> excision, neck dissection (if nodes involved) and marginal mandibulectomy (if not invaded mandible), segmental if invasion present

• Radiation for T4 lesions
• Chronic exposure to nickel associated with development of SCC of nasal sinuses

 
Node Drainage

• Level 1a and1b –> lie within the submental region with the mandibular body being the superior border and the hyoid bone being the inferior margin (submental and submandibular): drained teeth gums lips and anterior hard palate
• Level 2: upper jugular group (upper third internal jugular drain) drains naso/oro/hypopharynx and parotid
• Level 3 (middle third of the internal jugular) drains naso/oro/hypopharynx and larynx
• Level 4 (lower jugular with the cricoid cartilage as the superior border, clavicle of inferior border) drains hypopharynx/larynx/ cervical esophagus
• Level 5 posterior triangle (naso and oro pharynx)
• Level 6 anterior central (between hyoid and sternum) and drains thyroids/esophagus/larynx

 
 Reconstruction

• Mandible (need free vascularized transfer for defects >6cm)
• free fib-peroneal artery and vein (long pedicle, good skin island, able to accept dental implants to cortical bone)
• Free fibula dental implants initial depend on thickness of cortical bone (better initial stability)
• free iliac crest (better vertical height): Deep circumflex iliac 
• free scapula: based on circumflex scapular artery (branch of subscapular artery)
• Can be harvested as a chimeric flap (latiss, seratus, scapular and parascapular skin 
• free radius
• Maxilla
• small defect <5cm – bone grafting
• soft tissue only – temporalis muscle flaps
• posterior maxillary defects – ALT/rectus abdominis
• large bony defect – free fib, iliac crest, scapula 
• Reconstruction of anterior mandible reconstructed with free fibula flap –> can perform multiple osteotomies
• Scalp
• In long standing scalp wounds with necrosis –> obtain biopsy first to rule out cancer recurrence, CT scan –> resection –. Reconstruction (in cases of presumed ORN)
• hx XRT – consider free vascularized tissue transfer particularly full thickness defects
• nonradiated, partial thickness – skin grafts
• defect <8cm and no radiation – scalp rotational flap
• Remember radial forearm has a long pedicle for cases with no local vessels
• tongue
• ideally thin, pliable, minimal morbidity (muscle flaps less desirable)
• Workhorse has been the RFFF, which requires STSG for closure of the donor site
• MSAP- medial artery sural perforator flap (medial sural artery)
• If patients fail swallow study, need to ensure enteral feeding via tube so patient may meet caloric needs
• Ideally radiation begins within 4-6 weeks of glossectomy for effectiveness
• Lower face/chin: can rely on submental flap based on facial vessels (myofascial or myocutaneous) -> is adjacent to defect and provides similar skin color and texture
• facial nerve: best outcomes are obtained by direct repair or cable nerve grafting 
• <2cm –> direct repair
• 3-5cm –> conduit
• >5-7cm –> autologous cable graft
• If the nerve is resected very proximally to intracranial portion can perform cross facial nerve grafting
• Masseteric nerve transfer can provide facial reanimation as well as free innervated muscle graft
• Pharynx:
• Circumferential defects can be reconstructed with a tubularized ALT for single stage reconstruction to re-establish alimentary track

• Reduced donor site morbidity, higher rate of feeding tube independence, equivalent/lower flap loss rates to gastric pull up, superior use of TEP(tracheoesophageal puncture) for voice production 

• Gastric pull up flap has high morbidity and poor perfusion, but advantage is more straightfoward inset

 
 
Infection
candida (thrush) –> topical nystatin/clomitrazole

• The most ubiquitous and common flora –> can be seen in immunocompromised patients. Presents as white papules of oral mucosa

 
Miscellaneous: 
Hypocalcemia- can cause perioral tingling and numbness (particularly after thyroidectomy if parathyroids are inadvertently removed)
 
 
 
Sources:

• https://www.sciencedirect.com/science/article/pii/S2211568414003350

ACAPS inservice exams 2013-2020