HEAD AND NECK

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The parotids and the submandibular salivary glands are in contact with the lower jaw, and they are large glands which produce the saliva.  Often, they may be affected by various diseases, of inflammatory (viral or microbial), autoimmune, lithiasic, or even neoplastic origin.

The usual cause for which a patient visits the doctor is a swelling of the salivary gland.  This swelling may be observed in one or more salivary glands, or it can appear in the whole, or just a part, of the gland.  In addition, it may present fluctuations, most commonly related to food intake, or be permanent and progressively increasing.

Another symptom, which many times accompanies the swelling, is pain.   In certain cases, we may also witness some participation of the skin above (as in cases of inflammation or neoplasia) and, fortunately, more rarely participation of the facial nerve. In other cases, the observed swellings may be connected with the regional lymph nodes, due to spread of the inflammation, or, more rarely, of a metastatic origin.

The taking of the patient’s history will help identifying mainly the time sequence of the symptoms, the way they appear and their connection with events, such as viruses, food intake etc.

The clinical examination is very important.  Firstly, palpation will confirm that the given swelling represents the salivary gland and we will study its characteristics as far as its mobility is concerned, its sensitivity etc.  In addition, we will examine the caruncles of the glands in the oral cavity and their excretion.  From the clinical examination, we will also establish the involvement of the skin and the facial nerve with the pathology of the salivary glands.

In many cases, blood tests will be required, especially if we suspect swelling of viral or immune origin.  In the second case in particular, we will have to refer our patient to a colleague rheumatologist.

The main imaging examination is the ultrasound of the salivary glands. A fast, safe and perfectly tolerable by the patient, it may provide, in capable hands, all the information which is necessary for, both, the completion of the diagnosis and the design of a possible surgery.  In special cases only, a CT or MRI will be required, like in the case of tumors which are spreading to the parapharyngeal space, on the inner side of the jaw.

Sialography is an old examination which has been replaced today, to a large extent, by other imaging examinations and by salivary endoscopy which enjoys an increasing number of applications.

The aforementioned examinations picture and describe the pathology and its connection with the near tissues.  The only diagnostic test which can inform us about the tissue identity of the bulge is a cell exam, after an FNA, done with a thin needle.  The taking of the sample is slightly painful, similar to the placement of a vain caterer.  But it is a safe examination and without the fear of neoplasm spreading.  It cannot be considered as a routine examination, neither is it necessary for all cases.  It is logical, however, that the more information we collect preoperatively, the better we will prepare for a possible surgery.

After the completion of the diagnostic tests, decisions are made on the method of treatment and then our patient is informed.  The discussion should be rather extensive, if the suggested therapy is surgery and it has to do with the parotid gland.

The peculiarity of the parotid is due to the fact that inside it contains all the branches of the facial nerve.  This nerve is responsible for the movements and expressions of the face.  Beginning under the ear, it spreads like a fan and it ends in all the muscles of the face, from the forehead to the lips, in each side.

The correct surgical practice for the removal of the tumors in the parotid, first requires the recognition and dissection of the facial nerve and then the removal of the tumor, surrounded by healthy parotid tissue, in order to avoid any danger of relapse.  For this, the incision of the parotidectomy is disproportionally large in comparison to the tumor under removal.

The incision of the parotidectomy is the specific in all international surgical practice, with very slight variations.  Even if a colleague without sufficient experience chooses the wrong method of enucleation, he/she has to place his/her incision along the traditional incision.

The recognition and dissection of the facial nerve presupposes sufficient experience and systematic dealing with the specific anatomic area.  Today, nevertheless, regardless of our experience, we also possess the necessary equipment for nerve monitoring which warn us when some branch of the facial nerve is under certain strain.

In cases of relapse, the operation gets much harder.  And this because in the area in which we look for the facial nerve, there may be symphyses from a previous operation.  In these cases, in addition to the required use of nerve observation, we may have to look at another part along the nerve which is free from any symphyses.

Another difficult case is when the tumor develops in the parapharyngeal space on the inner side of the jaw and it extensively spreads towards the base of the head.  For such cases, the patient has to be informed about the possibility to access and continue the operation through mandibulotomy.

In general, the surgery of the parotid is quite demanding.  The surgeon should, before the operation, study and analyze all possible scenarios and inform the patient about them.  In addition, he/she has to have enough experience, in order to alter the course of the operation depending on the surgical findings.  Finally, he/she has to be familiar with the methods of rehabilitation of the facial nerve when its continuation has been interrupted