Facial and Parotid Tumors

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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

    • 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


    • 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 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


    • 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

candida (thrush) –> topical nystatin/clomitrazole

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

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

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

ACAPS inservice exams 2013-2020

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