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Parapharyngeal Tumors

42.1 Prestyloid and Poststyloid Tumors The parapharyngeal space is a potential space in the deep neck, shaped like an inverted pyramid. The fascia, running posteriorly from the styloid process to the tensor veli palatini muscle, divides the parapharyngeal space into the prestyloid and poststyloid compartments. It is difficult to evaluate tumor presence until they grow to at least 2.5–3 cm. The most frequent symptom and sign is…

Parotidectomy: Deformity and Reconstruction

Introduction Parotidectomy is a common treatment for benign or malignant tumors of the parotid gland and for aggressive cutaneous facial tumors. Ablation of the gland with or without adjacent tissues may lead to poor facial contour at the angle of the mandible, at the cheek, zygoma, and temporal region. Associated radical neck dissection, sternocleidomastoid (SCM) muscle and temporal bone ablation may emphasize the deformity. Moreover, facial…

Management of Parotidectomy Complications

Introduction The most devastating complication of parotid surgery is facial paralysis (see Chapter 50 ) and therefore preoperative counseling is generally centered around it. Early postoperative complications include sialoceles/salivary fistula, skin anesthesia, and “wound complications” such as infection, bleeding, hematoma, seroma, and skin flap necrosis. Late complications include adverse scarring, Frey syndrome, local deformity with skin depression (see Chapter 40 ), as well as tumor recurrence…

Minimally Invasive Approaches – Extracapsular Dissection

Introduction Extracapsular dissection (ECD) challenges the need to remove most of the parotid gland to prevent tumor recurrence. The dissection takes place within the parotid tissue, 2–3 mm peripheral to the palpable and visible tumor edge. In traditional parotidectomy, tumor removal with wide surgical margin (>5 mm) is not achieved in most cases because the facial nerve runs in close proximity to the tumor capsule. A partial ECD…

Facial Nerve Monitoring

Introduction Salivary gland surgery requires knowledge of facial nerve anatomy and meticulous dissection technique. In both adults and children, temporary facial weakness following parotid gland surgery is relatively common, with reported rates ranging from 20% to 40%. Permanent facial nerve injury occurs in a much smaller percentage of patients, 0% to 4%, and is more likely to be associated with malignant pathologies. A study of 102…

Surgery for Benign Salivary Gland Tumors: Classic Approaches

35.1A Parotidectomy Surgical excision is the preferred treatment for most benign tumors of the parotid gland. It is of paramount importance to carefully examine the patient and to evaluate the imaging tests for better planning of the surgical approach. Once the decision for surgical excision has been made, a specific procedure will be chosen for each patient, depending on the size and location of the tumor.…

Benign Tumors

34.1 Pleomorphic Adenoma Pleomorphic Adenoma Pleomorphic adenoma (PA) is an enigmatic tumor with a variety of names, including adenoma multiforme and benign mixed tumor. It is one of 15 benign epithelial tumors of the salivary glands as described by the 2017 World Health Organization (WHO) classification, and the most common benign tumor of the salivary glands, comprising 45–60% of all salivary gland tumors. More than 80%…

Sialendoscopy for Stenosis: Complications

Introduction Ductal stenosis produces symptoms of obstruction once luminal diameter is reduced below 1.6 mm (~30% loss of diameter) when fully dilated. Unlike stones, ductal stenosis is more common in the parotid gland (75% of cases) possibly due to the smaller dilated diameter of Stensen's duct compared with Wharton's duct (2.5 mm vs 3.0 mm), and the increased predilection of inflammatory and autoimmune disorders to affect the parotid gland.…

Salivary Stents for Stenosis

Introduction Interventional sialendoscopy has evolved into a range of endoscopic approaches and combined (transoral and external) approaches to manage salivary stones and ductal stenosis in an effort to facilitate gland preservation. Intervention may involve endoscopic therapies like mechanical or balloon dilations, lithotripsy, or open sialodochotomy with or without repair. A constant area of questioning debate around these interventions in the use of a salivary stent –…

Submandibular Gland Duct Strictures

Submandibular Strictures Obstructive submandibular sialadenitis is characterized by recurrent swelling during meal time, reduced or absent saliva secretion from the affected gland, without a concomitant reduction in saliva production, followed by bacterial infection. The main causes of non-stone-based obstructive diseases are stenosis or strictures. Compared with a stricture, which is a short segment of intraluminal scar, with either a complete blockage or a very narrow lumen,…

Parotid Gland Intraoral/External Combined Approaches for Strictures

Introduction Salivary duct stenosis is a relatively rare pathologic condition. Of the stenosis cases, 70–75% are located in the parotid duct system. Salivary duct stenosis is the second most common cause of obstruction in the parotid gland, representing 15–25% of cases and making up 50–90% of cases of unclear duct dilation or gland swelling. Parotid stenosis can be associated with various conditions/diseases; however, chronic (recurrent) parotitis…

Parotid Gland Intraoral Dilation of Strictures

Introduction Salivary ductal stenosis is a common cause of parotid gland obstruction. In the past, parotid strictures had been treated with sialography-guided balloon dilation. A number of case series demonstrated the technical feasibility and favorable intervention outcome. Nevertheless, with the technologic advancements over the past two decades, there has been a paradigm shift towards the use of sialendoscopic dilatation. This new technique does not involve radiation…

Interventional Sialendoscopy: Complications

Introduction The widespread adoption of sialendoscopy is largely due to successful management of patient symptoms (~70–80%) and gland preservation (~95%) that avoids the potential serious complications of gland extirpation. This chapter focuses on complications of sialendoscopy for salivary stones (complications of stenosis [scar] are covered in Chapter 31 ). Stone-Related Complications The complications of sialendoscopy can be divided into disease-specific complications related to the underlying pathology…

Stenting/Marsupialization

Introduction After procedures for stone retrieval, both stent placement and performing a marsupialization reduces the risk of stricture to the duct or papilla. Salivary flow during the healing process is also maintained. Stenting is generally recommended after combined approaches, but is not necessarily the rule after uneventful endoscopic stone removal, except in cases where a complication arises or a case associated with stricture. Material Several salivary…

Extracorporeal Lithotripsy

Background and Indication Treatment of sialolithiasis is currently achieved by a minimally invasive gland-preserving therapy regime. The observation by van den Akker and Busemann-Sokole that salivary gland function completely recovers after stone removal later was confirmed by others. In >80% of stones, fragmentation is necessary because of the size, impaction, and location. Of all stones in the submandibular, 80–85% and 75–80% in the parotid gland can…