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📚 Salivary Glands & Head/Neck Surgery - High-Yield Notes

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🔵 SUBMANDIBULAR GLAND TUMORS

• 50% benign, 50% malignant (unlike parotid where 80-90% are benign)
• Red flags for malignancy: Rapid growth, facial nerve involvement, skin ulceration, cervical lymphadenopathy
• Investigation: CT/MRI (best), FNAC (to differentiate). Open biopsy = CONTRAINDICATED (causes tumor seeding)
• Treatment: Surgical excision of gland + capsule; neck dissection if malignant

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🔵 PAROTID GLAND - ANATOMY

• Relations: posterior (ear canal), superior (zygoma), medial (parapharyngeal space), inferior (sternocleidomastoid + posterior belly of digastric)
• Facial nerve exits stylomastoid foramen → splits into 5 branches inside the gland
  • Deep lobe = medial to facial nerve
  • Superficial lobe = lateral to facial nerve
• Stensen's Duct = 2 inches (5 cm), opens opposite 2nd upper molar tooth
• Parasympathetic supply via auriculotemporal nerve

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🔵 PAROTID INFECTIONS

• Unknown etiology, immunologically mediated
• Sialography shows "snowstorm appearance"
• Self-limiting, symptomatic treatment

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🔵 PAROTID TUMORS

• 85% of all salivary tumors arise in parotid; 90% are benign
• 50% of submandibular/sublingual tumors = malignant
• 80% of minor salivary gland tumors = malignant
• Overall: <2% of all head & neck neoplasms

Benign:

1. Pleomorphic Adenoma (most common overall)
   • Mixed cell tumor (epithelial + mesodermal elements)
   • Involves superficial lobe
   • Slow growing, over angle of mandible, raises ear lobule
   • Cannot move above zygomatic bone
   • Facial nerve NOT involved
   • Longstanding → can turn malignant
   • Tx: Superficial parotidectomy (NOT enucleation - causes recurrence)
2. Warthin's Tumor (Monomorphic Adenoma / Adenolymphoma)
   • More common in males
   • Papillary epithelium in lymphoid stroma
   • Shows as "hot spot" on 99mTc scan (other parotid tumors = cold spots)
   • Tx: Superficial parotidectomy

Malignant:

• T1: <2 cm | T2: 2-4 cm | T3: 4-6 cm | T4: invades mandible/skin

• Low-grade: Superficial parotidectomy (if deep lobe uninvolved)
• High-grade: Radical parotidectomy = whole gland + facial nerve + masseter + neck dissection

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🔵 TYPES OF PAROTIDECTOMY

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🔵 FREY'S SYNDROME (Gustatory Sweating)

• Cause: Damaged auriculotemporal nerve (parasympathetic) fibers regenerate into sweat glands of preauricular skin
• Symptom: Sweating/erythema over cheek on smelling or tasting food
• Prevention: Sternomastoid flap / fascial flap / artificial membrane between skin and parotid bed
• Treatment: Anti-perspirants, tympanic neurectomy, botulinum toxin injection (most effective)

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🔵 TUMORS OF ORAL CAVITY

Premalignant Conditions:

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🔵 ORAL CANCER

• Mostly squamous cell carcinoma
• Sites: lips, tongue, floor of mouth, buccal mucosa, alveolus, retromolar trigone, palate
• Spreads to cervical lymph nodes very early
• Causes: Tobacco, pan chewing, alcohol, erythroplakia, candidiasis, ill-fitting denture

Treatment by site:

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🔵 NECK DISSECTION IN ORAL CANCER

• Level I: Submental + submandibular
• Level II: Upper jugular
• Level III: Middle jugular
• Level IV: Lower jugular
• Level V: Posterior triangle
• Level VI: Anterior compartment (pretracheal, paratracheal)

• N0, N1: Selective neck dissection
• N2a, N2b: Radical or modified radical + postop radiotherapy
• N2c: Bilateral neck dissection preserving IJV
• N3: Radiotherapy alone

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🔵 NECK SWELLINGS

• Upper midline: Thyroglossal duct cyst (#1), subhyoid bursa, lymph nodes, skin lesions
• Lower midline: Thyroid
• Lateral: Cysts (cystic hygroma, branchial cyst, pharyngeal diverticulum) or Solid (lymph nodes, sternomastoid tumor, carotid body tumor)

• 50% of neck swellings = from thyroid
• 40% of neck masses = malignancy (80% metastatic, 20% primary)
• 10% = inflammatory
• Multiple swellings = almost always lymph nodes

Branchial Cyst:

• Develops from vestigial remnant of 2nd branchial cleft
• Lined by squamous epithelium, contains turbid fluid with cholesterol crystals
• Forms at anterior border of sternomastoid at junction of upper and middle thirds
• Fluctuant, non-transilluminant
• Diagnosis: Ultrasound; Treatment: excision

Carotid Body Tumor (Chemodectoma / Glomus tumor / Paraganglion tumor):

• Rare tumor in people at high altitude (hypoxia)
• Arises from chemoreceptor cells at carotid bulb
• Presents as painless lump below angle of mandible
• Mass is firm, pulsatile, moves side to side but NOT up and down
• Biopsy/FNAC contraindicated (life-threatening hemorrhage risk)
• MRI = best imaging; Angiography to define/embolize feeder vessels
• 5-10% malignant; Treatment: surgical excision (complications are serious)

Subhyoid Bursitis:

• Space between hyoid bone and thyrohyoid membrane
• Soft, cystic swelling between hyoid and thyroid cartilage
• Moves up on swallowing but NOT on tongue protrusion (distinguishes from thyroglossal cyst)
• Treatment: Excision under GA

Sternomastoid Tumor:

• Due to birth trauma → hematoma → fibrosis in sternomastoid
• Misnomer: not a true tumor (it's fibrosis)
• Common in breach delivery / obstructed labor
• Smooth, hard, non-tender swelling at 3-4 weeks of age
• Causes torticollis (chin points to opposite side)

Metastatic Cervical Lymph Node:

• Asymptomatic cervical lymph node enlargement in adult = 85% chance of malignancy
• 70% are metastases from primary head and neck cancers
• Features suggesting malignancy: node >1.5 cm, hard, painless, rapidly enlarging
• Most common primary sites: nasopharynx, oropharynx, tongue base, hypopharynx, supraglottic larynx, tonsil
• Supraclavicular nodes = primary from below the clavicle (bronchus, stomach)
• Investigations: CT/MRI head + neck, biopsy, tumor markers (CEA, AFP)
• If no head/neck primary found: CT chest/abdomen/pelvis + scrotal ultrasound