Volume 68 May 1975
7
283
Section of Surgery President George Qvist FRCS
.
Meeting 19 June 1974 at the Royal Free Hospital, Gray's Inn Road, London WC] (continuedfrom March 'Proceedings' page 180)
Papers Some Aspects of Salivary Gland Disorders by J S Kenefick Mch FRCS
(Royal Free Hospital, London NW3) At the Royal Free Hospital during the period 1960-73 the annual average general surgical admission rate was 5500 per annum. During the same period 252 patients were admitted with disorders of the salivary glands, approximately 20 patients per annum and I in every 250 admissions. The records of these patients have been reviewed and the following paper presents some of their surgical aspects. I have divided the patients into the following six groups, and have described some of these groups, concentrating on the aspects of treatment rather than the clinical features and diagnosis: (1) Sialolithiasis, 87 cases. (2) Sialoadenitis+stricture, 15 cases. (3) Infection, 44 cases. (4) Malignant lesions, 32 cases. (5) Cysts, 21 cases. (6) Pleomorphic adenoma, 53 cases.
only 2 patients in this small series were found to have stones in the parotid gland. Excision of the submandibular gland was the treatment of choice in 35 patients; 6 of these developed a postoperative paresis of the mandibular division of the facial nerve, 3 being permanent. Removal of the calculus was attempted on 70 occasions and the subsequent progress of these patients is shown in Table 1. In this group, 13 patients (20%) who presented initially with duct stones ended up by having their submandibar gglan d as a secondary procedure.
Malignant neoplasms accounted for more than one-quarter of all tumours seen during the period of this study and 75% of these were situated in the parotid gland (Table 2). The 3 cylindromas were all in the parotid gland; this is unusual, as this type of tumour is more common in the minor salivary glands and the submandibular gland. The 3 secondary deposits Table 2 Maignat eoplas of salivary glands
Sialolithiasis: Stoneformationwas thecommonest disorder affecting the salivary glands, accounting for 35% of the total number of patients. Most stones occurred in the submandibular gland; Table
Type Parotid Submandibular All cases 3 Cylindroma 3 Mucoepidermoid carcinoma 1 2 3 Serous carcinoma 1 I 2 Adenocarcinoma 8 8 2 1 Secondary carcinoma 3 Reticuloses 6 3 9 Total
Duct stones 68 cases (70 operations)
21
7
No. of
Subsequent complications Failure: No stone Stone removed at second operation Excision submandibular gland Recurrent stones: Removed Excision submandibular gland Recurrent infection (stricture): Excision submandibular gland Lingual nerve palsy
cases
Table 3
3 ) 2 57 2 J
Cysts of salivary glands
2 6 I
7
Type Adenolymphoma Retention cysts Branchial cysts Idiopathic cysts
Parotid Submandibular 0 9 1 2 5 2 2 0
Total
17
4
28
284
Proc. roy. Soc. Med. Volume 68 May 1975
Table 4
I 4Z
..J
8
l.-".,l
------
Treatment of pleomorphic adenoma of parotid gland (48 cases) Operation
Total cases Complications: Recurrences VII nerve palsy Fistula Gustatory sweating
Parotidectomy Enucleation Superficial Total 3 27 18 12 2 I 0
2 12 I 2
1 3 0 0
Ectopic salivary gland tissue is extremely rare. Micheau (1969) recorded 30 cases from a survey of the world literature; these were situated in the external ear, the mandible, the upper third of the neck and the lower third of the neck adjacent to the stemoclavicular joints. Fig I Dermoid cyst ofsubmandibular gland One patient in our series presented, in 1971, in the salivary glands were from primary carci- with a swelling of the right lobe of the thyroid nomas of the breast, bronchus and pharynx. gland, which had been present for ten years. At Nine patients with reticuloses presented with operation the right lobe of the gland was replaced swellings of the salivary glands. All these patients by a lobulated tumour which was a pleomorphic gave a history of rapid enlargement of the affected adenoma. This case has been reported elsewhere gland and 5 of the 9 patients succumbed within (Lange 1974) and is the only recorded case of a tumour in this situation. It is believed that this five years of the onset of the disease. tumour developed from ectopic salivary gland Cysts: Salivary gland cysts were found most tissue, which can occur in the capsule of the frequently in the parotid gland (Table 3). All the parathyroid gland, as a result of heteroplasia of adenolymphomas occurred in male patients, one remnants of the branchial apparatus. Including recurrences, two-thirds of all pleohaving bilateral lesions. These lesions tend to lie in the superficial part of the gland and at morphic adenomata were in the parotid gland. operation it is tempting to enucleate the swelling, Table 4 summarizes the treatment of these lesions. During the initial years of this study, but recurrence after local excision is common. Branchial cysts of the salivary glands are local excision, or enucleation, usually followed very rare. Three patients had cleft-like spaces in by a course of radiation, was performed on 18 the upper part of the parotid gland. These were cases. Two-thirds of these developed recurrent lined with squamous epithelium and were con- lesions requiring further surgery. Superficial sidered to be remnants of the first branchial cleft. parotidectomy, which is now recognized as the The other 4 had typical dermoid cysts and Fig 1 operation of choice, has a much lower recurrence shows one such lesion of the submandibular rate, but neurological complications were more gland. The 2 idiopathic cysts were very extensive, frequent. Twelve patients in this series developed involving the deep portion of the parotid gland and both recurred after excision.
Pleomorphic adenoma accounted for more than half the tumours in this series. Of 72 cases, 35 were located in the parotid gland, 13 in the submandibular gland, 4 in the minor salivary glands (in buccal mucosa, junction of hard 5nd soft palate, upper lip, and lower lip); 2 were ectopic and 18 were recurrences. The majority of these cases occurred in the third, fourth or fifth decade. The 13 patients with pleomorphic adenoma of the submandibular gland were treated by excision; 2 of these, both in their teens, developed recurrences within five years, each of which showed invasive tendencies and was considered to be malignant. Fig 2 Tumour displacing soft palate
9
Fig 3 Arteriogram showing vascular carotid body tumour
Sectionof Surgery
285
a guide to the position of the VII nerve. This tragal pointer lies 1 cm above the trunk of the nerve. The posterior and inferior borders of the gland are exposed and the external carotid artery is seen on retraction of the posterior belly of the digastric muscle. This artery may or may not be ligated, depending on the surgeon's preference. The posterior facial vein should not be ligated at this stage as the venous congestion makes the dissection of the facial nerve more difficult. The posterior border of the gland is now followed upwards until the main trunk of the facial nerve is found. The supetficial lobe of the gland is removed by dissecting it away -from the nerve and its branches. Some tumours of the superficial lobe of the parotid gland extend medially and protrude into the pharynx. These dumb-bell tumours displace the facial nerve superficially and extend medially between the mandible anteriorly and the styloid process and stylomandibular ligament posteriorly. This space, called the stylomandibular tunnel by Patey & Thackray (1957), must be enlarged before these tumours can be delivered. This is achieved by dividing the stylomandibular ligament and, if necessary, fracturing the styloid process. In this series the majority of operations on the submandibular gland were performed through the standard approach, using an incision in the neck below the mandible. The gland was removed through the mouth in 11 patients, using the technique described by Downton & Qvist (1960). With this approach the gland is exposed through a curved incision along the mucoperiostium of the alveolus. The mylohyoid muscle is separated from the mandible and on retraction of this muscle the gland is seen. Digital pressure beneath the mandible renders the gland more prominent. The facial artery is seen anteriorly and the lingual nerve crosses the duct posteriorly.
postoperative facial palsy, 3 involved the mandibular division of the VII nerve alone and the other 9 were complete lesions. Eleven of these nerve lesions recovered completely, most within three months, the longest taking nine months. The two recurrent lesions had both undergone malignant change. Twenty-eight cases were misdiagnosed as tumours of the salivary glands: 9 reticuloses, 4 tuberculosis, 4 sialolithiasis, 3 sialoadenitis, 3 secondary carcinoma, 1 carotid body tumour, 1 Mikulicz's disease, and 1 normal gland. The patient with the carotid body tumour presented with a pulsatile swelling in the left parotid region. This swelling extended medially into the naso- Acknowledgments: I am grateful to the consultant pharynx (Fig 2) displacing the soft palate; an surgeons at the Royal Free Hospital for permisarteriogram (Fig 3) showed a very vascular sion to examine their cases; to Mr George Qvist tumour extending up to the base of the skull. At and Mr D Downton for instruction in the techoperation this turned out to be a carotid body niques of parotid surgery and of transoral excision of the submandibular gland; and to tumour displacing the parotid gland laterally. Mr M J Lange for permiss on to quote his case of ectopic salivary gland tumour. Operative Procedures The incision we favour for superficial parotidecREFERENCES tomy is that described by Patey (1968). We do not Downton D & QYist G dissect the anterior skin flap to the border of the (1960) Proceedings of the Royal Society of Medicine 53, 543 M J (1974) International Surgery 59, 178 gland until the VII nerve has been identified and Lange Micheau C traced to this area. The first step in the dissection (1969) Archives d'anatomie pathologique 17, 179 is to expose the cartilaginous external auditory Patey D H (1968) In: Operative Surgery. Ed. C Rob & R Smith. 2nd edn. Butterworths, London; p 174 canal. Traction on the ear reveals a ridge on the Patey D H & Thackray A C the which acts as cartilage, called tragal pointer, (1957) British Journal of Surgery 44, 352
7
283
Section of Surgery President George Qvist FRCS
.
Meeting 19 June 1974 at the Royal Free Hospital, Gray's Inn Road, London WC] (continuedfrom March 'Proceedings' page 180)
Papers Some Aspects of Salivary Gland Disorders by J S Kenefick Mch FRCS
(Royal Free Hospital, London NW3) At the Royal Free Hospital during the period 1960-73 the annual average general surgical admission rate was 5500 per annum. During the same period 252 patients were admitted with disorders of the salivary glands, approximately 20 patients per annum and I in every 250 admissions. The records of these patients have been reviewed and the following paper presents some of their surgical aspects. I have divided the patients into the following six groups, and have described some of these groups, concentrating on the aspects of treatment rather than the clinical features and diagnosis: (1) Sialolithiasis, 87 cases. (2) Sialoadenitis+stricture, 15 cases. (3) Infection, 44 cases. (4) Malignant lesions, 32 cases. (5) Cysts, 21 cases. (6) Pleomorphic adenoma, 53 cases.
only 2 patients in this small series were found to have stones in the parotid gland. Excision of the submandibular gland was the treatment of choice in 35 patients; 6 of these developed a postoperative paresis of the mandibular division of the facial nerve, 3 being permanent. Removal of the calculus was attempted on 70 occasions and the subsequent progress of these patients is shown in Table 1. In this group, 13 patients (20%) who presented initially with duct stones ended up by having their submandibar gglan d as a secondary procedure.
Malignant neoplasms accounted for more than one-quarter of all tumours seen during the period of this study and 75% of these were situated in the parotid gland (Table 2). The 3 cylindromas were all in the parotid gland; this is unusual, as this type of tumour is more common in the minor salivary glands and the submandibular gland. The 3 secondary deposits Table 2 Maignat eoplas of salivary glands
Sialolithiasis: Stoneformationwas thecommonest disorder affecting the salivary glands, accounting for 35% of the total number of patients. Most stones occurred in the submandibular gland; Table
Type Parotid Submandibular All cases 3 Cylindroma 3 Mucoepidermoid carcinoma 1 2 3 Serous carcinoma 1 I 2 Adenocarcinoma 8 8 2 1 Secondary carcinoma 3 Reticuloses 6 3 9 Total
Duct stones 68 cases (70 operations)
21
7
No. of
Subsequent complications Failure: No stone Stone removed at second operation Excision submandibular gland Recurrent stones: Removed Excision submandibular gland Recurrent infection (stricture): Excision submandibular gland Lingual nerve palsy
cases
Table 3
3 ) 2 57 2 J
Cysts of salivary glands
2 6 I
7
Type Adenolymphoma Retention cysts Branchial cysts Idiopathic cysts
Parotid Submandibular 0 9 1 2 5 2 2 0
Total
17
4
28
284
Proc. roy. Soc. Med. Volume 68 May 1975
Table 4
I 4Z
..J
8
l.-".,l
------
Treatment of pleomorphic adenoma of parotid gland (48 cases) Operation
Total cases Complications: Recurrences VII nerve palsy Fistula Gustatory sweating
Parotidectomy Enucleation Superficial Total 3 27 18 12 2 I 0
2 12 I 2
1 3 0 0
Ectopic salivary gland tissue is extremely rare. Micheau (1969) recorded 30 cases from a survey of the world literature; these were situated in the external ear, the mandible, the upper third of the neck and the lower third of the neck adjacent to the stemoclavicular joints. Fig I Dermoid cyst ofsubmandibular gland One patient in our series presented, in 1971, in the salivary glands were from primary carci- with a swelling of the right lobe of the thyroid nomas of the breast, bronchus and pharynx. gland, which had been present for ten years. At Nine patients with reticuloses presented with operation the right lobe of the gland was replaced swellings of the salivary glands. All these patients by a lobulated tumour which was a pleomorphic gave a history of rapid enlargement of the affected adenoma. This case has been reported elsewhere gland and 5 of the 9 patients succumbed within (Lange 1974) and is the only recorded case of a tumour in this situation. It is believed that this five years of the onset of the disease. tumour developed from ectopic salivary gland Cysts: Salivary gland cysts were found most tissue, which can occur in the capsule of the frequently in the parotid gland (Table 3). All the parathyroid gland, as a result of heteroplasia of adenolymphomas occurred in male patients, one remnants of the branchial apparatus. Including recurrences, two-thirds of all pleohaving bilateral lesions. These lesions tend to lie in the superficial part of the gland and at morphic adenomata were in the parotid gland. operation it is tempting to enucleate the swelling, Table 4 summarizes the treatment of these lesions. During the initial years of this study, but recurrence after local excision is common. Branchial cysts of the salivary glands are local excision, or enucleation, usually followed very rare. Three patients had cleft-like spaces in by a course of radiation, was performed on 18 the upper part of the parotid gland. These were cases. Two-thirds of these developed recurrent lined with squamous epithelium and were con- lesions requiring further surgery. Superficial sidered to be remnants of the first branchial cleft. parotidectomy, which is now recognized as the The other 4 had typical dermoid cysts and Fig 1 operation of choice, has a much lower recurrence shows one such lesion of the submandibular rate, but neurological complications were more gland. The 2 idiopathic cysts were very extensive, frequent. Twelve patients in this series developed involving the deep portion of the parotid gland and both recurred after excision.
Pleomorphic adenoma accounted for more than half the tumours in this series. Of 72 cases, 35 were located in the parotid gland, 13 in the submandibular gland, 4 in the minor salivary glands (in buccal mucosa, junction of hard 5nd soft palate, upper lip, and lower lip); 2 were ectopic and 18 were recurrences. The majority of these cases occurred in the third, fourth or fifth decade. The 13 patients with pleomorphic adenoma of the submandibular gland were treated by excision; 2 of these, both in their teens, developed recurrences within five years, each of which showed invasive tendencies and was considered to be malignant. Fig 2 Tumour displacing soft palate
9
Fig 3 Arteriogram showing vascular carotid body tumour
Sectionof Surgery
285
a guide to the position of the VII nerve. This tragal pointer lies 1 cm above the trunk of the nerve. The posterior and inferior borders of the gland are exposed and the external carotid artery is seen on retraction of the posterior belly of the digastric muscle. This artery may or may not be ligated, depending on the surgeon's preference. The posterior facial vein should not be ligated at this stage as the venous congestion makes the dissection of the facial nerve more difficult. The posterior border of the gland is now followed upwards until the main trunk of the facial nerve is found. The supetficial lobe of the gland is removed by dissecting it away -from the nerve and its branches. Some tumours of the superficial lobe of the parotid gland extend medially and protrude into the pharynx. These dumb-bell tumours displace the facial nerve superficially and extend medially between the mandible anteriorly and the styloid process and stylomandibular ligament posteriorly. This space, called the stylomandibular tunnel by Patey & Thackray (1957), must be enlarged before these tumours can be delivered. This is achieved by dividing the stylomandibular ligament and, if necessary, fracturing the styloid process. In this series the majority of operations on the submandibular gland were performed through the standard approach, using an incision in the neck below the mandible. The gland was removed through the mouth in 11 patients, using the technique described by Downton & Qvist (1960). With this approach the gland is exposed through a curved incision along the mucoperiostium of the alveolus. The mylohyoid muscle is separated from the mandible and on retraction of this muscle the gland is seen. Digital pressure beneath the mandible renders the gland more prominent. The facial artery is seen anteriorly and the lingual nerve crosses the duct posteriorly.
postoperative facial palsy, 3 involved the mandibular division of the VII nerve alone and the other 9 were complete lesions. Eleven of these nerve lesions recovered completely, most within three months, the longest taking nine months. The two recurrent lesions had both undergone malignant change. Twenty-eight cases were misdiagnosed as tumours of the salivary glands: 9 reticuloses, 4 tuberculosis, 4 sialolithiasis, 3 sialoadenitis, 3 secondary carcinoma, 1 carotid body tumour, 1 Mikulicz's disease, and 1 normal gland. The patient with the carotid body tumour presented with a pulsatile swelling in the left parotid region. This swelling extended medially into the naso- Acknowledgments: I am grateful to the consultant pharynx (Fig 2) displacing the soft palate; an surgeons at the Royal Free Hospital for permisarteriogram (Fig 3) showed a very vascular sion to examine their cases; to Mr George Qvist tumour extending up to the base of the skull. At and Mr D Downton for instruction in the techoperation this turned out to be a carotid body niques of parotid surgery and of transoral excision of the submandibular gland; and to tumour displacing the parotid gland laterally. Mr M J Lange for permiss on to quote his case of ectopic salivary gland tumour. Operative Procedures The incision we favour for superficial parotidecREFERENCES tomy is that described by Patey (1968). We do not Downton D & QYist G dissect the anterior skin flap to the border of the (1960) Proceedings of the Royal Society of Medicine 53, 543 M J (1974) International Surgery 59, 178 gland until the VII nerve has been identified and Lange Micheau C traced to this area. The first step in the dissection (1969) Archives d'anatomie pathologique 17, 179 is to expose the cartilaginous external auditory Patey D H (1968) In: Operative Surgery. Ed. C Rob & R Smith. 2nd edn. Butterworths, London; p 174 canal. Traction on the ear reveals a ridge on the Patey D H & Thackray A C the which acts as cartilage, called tragal pointer, (1957) British Journal of Surgery 44, 352
