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 

• 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 

• 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 

  

Tumors of the mandible/teeth: 

• Aneurysmal bone cyst – multinucleated giant cells –> resection and curettage 
• Osteonecrosis 
• ORN occurs after 6500 gray and increased risk with dental caries, peridontal disease 
• Bisphosphonate related osteonecorsis: related to bisphosphonate therapy (alendronate) 

• Can develop nonvital bone (remember suffix onate) 

• Stage 1: exposed alveolar bone without pathologic fracture –> responds to local debridment, oral care, 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 unerputed 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 
• path shows 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 parotidectomy 
• 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 
• Parotid: tympanomastoid suture as landmark to avoid facial nerve injury during parotidectomy, can use midpoint between fascial covering and tragus 

• 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) 
• 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 

• 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, perioorbital regions in middle aged patients, perineural invasion –> mohs resection 
• Mucoepidermoid carcinoma – 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: aggressive, head and neck in elderly women, dark deep purple, dense oval sheets with indistinct borders that invade deep dermis, sq fat, muscle –> wide local excision of at least 3cm, ipsilateral neck dissection (parotid as well if in preauricular areas) 
• 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 
• 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 postg 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 idodine 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 
•  
• HPV- staging (p16+), better prognosis for chemoradiation therapy 

• tumor size is T, N = nodes, M = mets 
• P16 (HPV) downgrades it because lethality is less 
• HPV 16, 18 common in oropharyngeal cancers 
• recommendations 
• 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 
• 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 hypo/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 
• Gastric pull up flap has high morbidity and poor perfusion 

  

  

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