Oral and Salivary Gland tumors, Cleft Lip and Cleft Palate😍

Salivary Gland Tumors

General Points

• Benign tumour frequency: 
• Parotid > Submandibular > Sublingual > minor.

• Malignant tumour frequency: 
• minor > Sublingual > Submandibular > Parotid.

Milan System for Cytopathology

Parotid Gland

• Major salivary gland

• Purely serous in nature
• Contains serous acini
• No serous demilunes
• unlike submandibular gland

• Dark staining cells in histology

• Ectodermal origin

Capsules

• True capsule: From fibrous stroma

• False capsule: From investing layer of deep cervical fascia

Parotid Duct (Stensen’s Duct)

• Runs over masseter (superficial) → Turns medially

• Pierces:

• Buccal fat

• Buccopharyngeal fascia

• Buccinator muscle

• Opens at parotid papilla
• opposite upper 2nd molar - maxillary molar
• NOTE: Koplik → Lower 2nd molar

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Structures Piercing Buccinator

1. Stenson's Duct / Parotid duct

2. Buccal br. Of Mandibular (V3) NV

3. Mucus glands of buccopharyngeal Fascia

NOTE

• Facial N supplies but does not pierce

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Clinical points:

• Parotitis

• Koplik's spots

• Duct can be cannulated for imaging

Salivary gland swelling D/Ds

• Sialosis → Salivary gland swelling in alocoholics

ㅤ	ㅤ
HIV Infection ↳ BLEL / ↳ Benign Lymphoepithelial lesions	• CD8+ T lymphocytes infiltrate • HLA-DR5 • Positive serologic test
Sjogren’s Syndrome	• CD4 + T lymphocytes infiltrate • HLA-DR3, DRw52 • Ro La antibodies
Sarcoidosis	• Granulomas in salivary glands • CD4/CD8 ratio > 3.5 : 1

Nerve Supply

• Origin: Inferior salivatory nucleus

• Path:



• CN IX → Tympanic nerve → Tympanic plexus → Lesser petrosal nerve → Otic ganglion
• Postganglionic fibers via auriculotemporal nerve (V3)

• Function: Stimulates secretion

• From carotid plexus

• Function: Inhibits secretion

• Auriculotemporal nerve
• parotid gland
• Referred otalgia

• Great auricular nerve
• skin over gland

Structures Passing Through Parotid Gland

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Superficial → Deep

1. Facial nerve (CN VII) through Patey’s plane
• Does not innervate the gland
• Divides into:



• Temporal
• Zygomatic
• Marginal mandibular
• Buccal
• Cervical

2. Retromandibular vein

3. External carotid artery

Mnemonic: Avnu (artery → vein → nerve from Deep → Sup) Pattiye (Patey)

Note

• Parotid nodes present on superficial surface

Parotid Tumors

• MILAN Staging

• MARSH → Celiac disease

• BETHESDA → Thyroid FNAC staging

• 90% benign

• Clinical Features:
• Lateral facial swelling → Lifts ear lobule.
• If deep lobe enlarged → Tonsillar fossa pushed medially.

• M/C benign tumour:
• Pleomorphic adenoma.

• M/C malignant tumour:
• Mucoepidermoid carcinoma.

Benign Parotid Tumours

Pleomorphic adenoma:

• Features:
• Benign, slow growing.
• A/W PLAG-1 mutation.

• Lobe involved: Superficial lobe.

• Investigations:
• IOC: FNAC.
• Imaging: CT/MRI.

• Treatment: Superficial parotidectomy.

• HPE: Triphasic tumour with epithelial cells in myxoid backgrounds.

• Complication: Carcinoma ex pleomorphic adenoma (malignant transformation).

Warthin's tumor:

• Features:
• 2nd M/C tumour ???
• Mostly bilateral.
• M > F.

• Lobe involved: Superficial lobe.

• Investigations: IOC: FNAC.

• Treatment: Superficial parotidectomy.

• HPE:
• Two layers of cells (mitochondria rich).
• Lymphocytic infiltration.

• Show hot spot on 99mTc scan

Malignant Parotid Tumours

1. Mucoepidermoid carcinoma.

2. Adenoid cystic carcinoma:

• 2nd M/C parotid tumour.

• PNI ⊕.
• Extremely painful.

• ↑ Recurrence rate.

• HPE: Swiss cheese appearance.

• Mnemonic: Swiss cheese () moshtichapo adi (Adenoid cystic) kitti → Extreme Pain () ayi

3. Carcinoma ex pleomorphic adenoma/
Mixed malignant tumor:

• Malignant transformation of pleomorphic adenoma.

• Signs of malignant change:
• Rapid ↑ in size.
• Painless → painful (d/t capsular stretching)
• Ulceration.
• Facial nerve involvement.
• Lymph node enlargement.

• IOC: FNAC.

• Mx: Surgery f/b radiotherapy.

Parotid Tumour Treatment Principles

• Margin: 0.5 cm (PARA → ARA cm)

• Elective SOHND:
• T3/T4 tumours.
• High-grade tumours.

• Adjuvant Radiotherapy indicated if:
• Stage 3 and 4.
• High grade tumours.
• Positive margins.
• PNI ⊕/LVI ⊕.
• ENE ⊕.

Parotidectomy

• Incision: Lazy S incision/modified Blair's incision.
• 2 cm below mandible to prevent marginal mandibular N injury

Types of Parotidectomy

1. Superficial.

2. Total (superficial + deep lobe removed).
1. Conservative (Facial nerve spared).
2. Radical (Facial nerve removed).
• Cable graft (Sural nerve > Greater auricular nerve for facial nerve repair).

Complications of Parotidectomy

• Haemorrhage.

• Nerve injury:
• Greater auricular nerve: 
• Anaesthesia over beard region.
• Carries sensory fibers from angle of mandible
• Marginal mandibular branch > Cervical branch of facial nerve:
• Both cause Drooping of angle of mouth.
• Marginal mandibular branch → Paralysis of lower lip

• Parotid fistula.

Frey’s Syndrome:

• Gustatory sweating.

• Parasympathetic fibers of Parotid gland (ATN)
• communicates with GAN (most common)

• Stimulus to ATN → sweating in parotid region

• Investigation: Starch iodine test.
• Sprinkle starch and Paint iodine

• ATN fuses with:
• Ettan (Atn) likes gan
• GAN > Buccal nerve > Lesser occipital nerve

• Mx:
• First line: Botox and anti-perspirants
• TOC: Tympanic neurectomy.

• Prevention: 
• SCM flap/digastric muscle flap to cover parotid bed.

Facial Synkinesis

• Facial nerve anomalous regeneration

• Examples
• Crocodile tears (Bogorad syndrome):
• Facial N Injury before geniculate ganglion.
• Fibers anastomose with chorda tympani.
• Lacrimation when patient eats.
• Mouth retraction on eye closure
• orbicularis oculi aberrantly innervate orbicularis oris

Submandibular Tumors

• M/C tumour:
• Pleomorphic adenoma.

• M/C malignant tumour:
• Adenoid cystic carcinoma.

• O/E: 
• Bimanual palpation



• Submandibular gland: Palpable.
• Submandibular LN: Not palpable.

• Diagnosis: FNAC (IOC).

• Mx: Submandibular excision.

Complications:

• Haemorrhage.

• Nerve injury:
• Marginal mandibular nerve
• M/C injured
• Lingual nerve
• If duct or stone is given
• Hypoglossal nerve.

• Injury to other structures: 
• Anterior facial vein,
• facial artery.

Sublingual Tumour

• M/C tumour of sublingual gland:
• Adenoid cystic carcinoma.

Minor Salivary Gland Tumors

• M/C tumour:
• Adenoid cystic carcinoma.

• M/C site:
• Hard palate.

Milan System of grading

Oral Cancers

Features

Risk Factors

• Primary:
• Smoking
• Alcohol
• Betel quid

• Secondary:
• Immunosuppression
• Sharp dentures
• HPV (oropharyngeal > oral SCC)

• Note: EBV linked to Gastric > nasopharyngeal cancer

Pre-Malignant Conditions

• Risk Factors for Malignant Change:
• Females
• Non-smoker
• Lesion size > 200 mm²
• Non-homogenous/multiple lesions
• Sites: Lateral tongue, floor of mouth

Types:

Other High-Risk Conditions

• Chronic hyperplastic candidiasis

• Ulcerative oral lichen planus

• Secondary syphilis

Plummer-Vinson Syndrome:

• aka Patterson Kelly Brown Syndrome/Sideropenic dysphagia

• Perimenopausal women

• Iron deficiency anemia, koilonychia

• Angular stomatitis, glossitis

• Post-cricoid/upper esophageal webs
• ↑↑ SCC esophagus and hypopharyngeal cancer risk
• Postcricoid carcinoma

NOTE:

• Oral candidiasis → White patch can be rubbed off → Least reddish border

Investigations

• Biopsy:
• Edge/wedge (avoid necrotic center)
• Depth of invasion (DOI) predicts prognosis

Staging of Oral Cancer:

• NOTE:
• Clinical extranodal extension → Matting/skin fixity
• M/c site of distant mets → lungs
• LN → Submandibular

Radio

• IOC FOR CA ORAL CAVITY : CECT

• IOC FOR CA TONGUE: MRI

Treatment

• Surgery:
• Commando Operation
• Wide excision (0.5 cm margin)
• Mandibular resection if involved
• Neck dissection for LN clearance
• f/b Reconstruction

• Adjuvant:
• Chemotherapy
• Radiotherapy

Surgical Approaches – Oral Cavity & Mandible

• Lip-split mandibulotomy
• Most common access procedure
• Used for carcinoma at base of tongue

• Marginal mandibulectomy (Rim resection)
• Removes partial mandibular thickness
• Preserves continuity of mandible

Benign Salivary Gland Conditions

Conditions & Management

Submandibular stones

Cleft Lip/Palate

Features

• 1 in 600 live births

• Males > females

• M/c defect: Combined lip plus palate

 

Documentation (LAHSAL System)

• Capital “L”: complete cleft

• Small “l”: partial cleft

• L: Lip

• A: Alveolus

• H: Hard palate

• S: Soft palate

• A: Alveolus

• L: Lip

Management

• Cleft Palate:
• Timing: 
• Soft palate (3-6 months),
• Hard palate (12-15 months)
• Repair techniques: Wardill-Kilner, V-Y plasty

• Cleft Lip:
• Timing: 3-6 months
• Repair techniques: Millard, Tennison

• BOTH:
• CL + SP → AT 5 MON
• HP → AT 15-18 MON

ㅤ	Forms from	Non-fusion
Upper Lip	Maxillary process & Medial Nasal Process/philtrum	ㅤ
Lower Lip	Mandibular process	Midline cleft lower lip

• Midline cleft upper lip:
• Non-fusion of MNP

• U/L cleft upper lip:
• Non-fusion of MNP + maxillary process.

• B/L cleft upper lip:
• Non-fusion of both MNP + maxillary process
• Leads to exposed nasolacrimal duct.
• Results in harelip.

• Oblique facial cleft:
• Occurs when maxillary process cannot reach the lateral nasal process.

Palate Development

• MNP (FNP) forms
• Pre-maxilla
• Incisive fossa of the palate → gives passage to greater palatine artery.

• Maxillary process forms
• Palatine process → forms the remaining part of the palate.

• Muscles of palate:
• Derived from 4th pharyngeal arch
• Exception: Tensor veli palatini (TVP) → from 1st arch.