Interactive Transcript
1:58
So we're going to start with anatomy and discuss some of
2:01
the neoplasms and then deal with little bit with salivary
2:04
gland stones and then some inflammatory disease
2:06
and hopefully, we'll get to the cyst as well.
2:09
So,
2:10
first question for the audience
2:13
and is interesting one,
2:15
how much saliva do we make in a day? Is it 1 - 2L,
2:21
3 - 5L,
2:23
5 - 10L, rare than 10 liters,
2:26
or that's a HIPAA violating question,
2:29
you shouldn't be asking me about my saliva production.
2:31
So what do you think?
2:33
How much saliva in a day does the average human create?
2:38
Is it 1 - 2L, 3 - 5L, 5 - 10L, more than 10 liters,
2:44
or no answer?
2:47
So Ashley, when we're ready,
2:49
let me see what the audience is
2:50
thinking about the amount of...
2:53
Okay, so people are kind of hovering in the middle there.
2:56
The answer actually is 1 - 2 liters of saliva per day.
3:01
So that's, that's the production.
3:03
And the predominant portion of that,
3:06
is from the parotid glands,
3:10
the parotid account for 50% of the saliva.
3:14
Submandibular glands, 40%. Sublingual glands, much less.
3:17
minor salivary glands, despite the fact there are a lot,
3:20
a lot of
3:22
minor salivary glands, only about 5% of flow.
3:25
And the importance of this is with regard to xerostomia.
3:29
As some of you who deal with head
3:31
and neck cancer are aware,
3:32
when the patient has irradiated or some
3:34
of the medications are given,
3:36
they can have absence or decrease in the saliva
3:39
flow and that is really uncomfortable. There's...
3:43
you get cracking and bleeding of around the lips and all.
3:47
So saliva is very important.
3:48
The average human produces 25,000
3:51
quarts of saliva in life time.
3:53
Enough to fill two swimming pools,
3:56
depending upon how big your swimming pools are.
3:59
So, let's talk a little about the parotid gland.
4:01
So the parotid gland has tubuloalveolar cells
4:04
and it is a more serous or thin saliva.
4:08
The glands weight about 25 grams.
4:11
You see that the supply are truly is
4:14
from the external carotid artery,
4:16
draining to retromandibular vein.
4:19
You have lymphatics that go through the parotid gland.
4:20
In fact,
4:21
that's one of the unique features of the parotid gland,
4:23
is the prominence of the lymphatics
4:26
within the gland itself.
4:27
And then there are different nerves which will affect
4:31
salivary gland function and the parotid gland,
4:34
including the third division of the fifth cranial
4:37
nerve mandibular nerve branch,
4:38
which is the auriculotemporal branch,
4:41
and you have some from the ninth tympanic plexus,
4:45
as well as the greater superficial petrosal
4:47
nerve from cranial nerve seven.
4:50
So you get contributions from 5, 9 and 7 for salivation.
4:56
So quick picture on MRI scan of the parotid gland.
5:01
And what's nice about this particular case is that the
5:04
facial nerve was thickened on this image to the to,
5:07
the left,
5:08
and what you see is the facial nerve coming
5:10
out from the stylomastoid foramen,
5:13
around the retromandibular vein,
5:14
and it's the facial nerve that separates the superficial
5:18
portion of the parotid gland from the
5:21
deep portion of the parotid gland.
5:23
And these are not really lobes.
5:24
Sometimes we say the superficial
5:26
lobe or the deep lobe,
5:27
but these are just portions not really separated
5:30
by fascia into different lobes.
5:32
And there is a portion of the gland,
5:34
which also courses over the masseter muscle.
5:38
And then we have salivary tissue which
5:40
also is all around the duct. So,
5:43
this is stensen's duct inserting at the second molar
5:47
tooth and you can have salivary
5:51
gland or tissue around there.
5:53
This, for example,
5:54
is a pre amorphic adenoma in salivary gland tissue,
5:58
superficial to the masseter muscle. This is masseter.
6:01
This is pterygoid musculature and within
6:04
the portion of the parotid gland,
6:06
which is superficial to the masseter muscle.
6:11
Stensen's duct, which is the duct for the parotid gland,
6:15
is quite long.
6:16
It runs along that masseter muscle before piercing
6:19
into the cheek opposite the second molar,
6:22
and it may have a secondary accessory
6:24
lobe duct that enters it.
6:27
Here, for example,
6:28
is a patient to head trauma to the left side of the face.
6:32
And I did a sialogram,
6:34
which is inserting the catheter
6:37
into the salivary gland...
6:38
salivary gland duct orifice at the second molar tooth,
6:42
and then injected contrast.
6:43
And what you see is the salivary gland
6:46
or ductal system of stensen's duct,
6:49
as well as what's called a sialocele,
6:52
which is a secondary traumatic cyst associated
6:55
with trauma to stensen's duct in this case.
7:00
Next game, we're talking about it. This submandibular gland.
7:03
This is the second largest of the salivary
7:05
glands weighs about 10 to 15 grams.
7:08
And this has more of a mucinous saliva than
7:12
the Cirrus saliva of the parotid gland.
7:16
It has Arturo Supply by facial, and lingual arteries.
7:19
It's innovated in part by Court attempt.
7:21
Any branch of the seventh cranial nerve as well as
7:24
lingual nerve of the fifth cranial nerve as well as
7:27
portions of this sympathetic nervous system.
7:30
So here we see the submandibular gland on a CT
7:33
scan. You notice that there is a mast within the right?
7:37
Submandibular gland here's the left some and tubular glands
7:40
and this was a benign tumor of the right Samantha Berglund,
7:46
a plea amorphic adenoma.
7:50
Wardens duct is the duct of the submandibular gland.
7:55
Now this is this is an area of confusion with wording.
8:00
So there is a tumor in the parotid gland called.
8:03
The war things tumor,
8:05
that is almost exclusive to the parotid gland,
8:09
but the duct of the submandibular
8:11
gland is Wharton's duct.
8:14
And this runs between the mylohyoid muscle and the
8:17
high-gloss is muscle and along the sublingual
8:20
gland takes up some accessory.
8:23
Ductal system from the sublingual gland
8:25
and this will open under the tongue lat.
8:30
Cyril, to the frenulum.
8:32
Wardens duct here. For example,
8:34
is a calcification on CT within that.
8:38
Submandibular grand, duct Wharton's doctor,
8:41
you see the dilation or select Asia of the main duct
8:45
of the submandibular gland with a large Stone.
8:49
So there's the reductant along the floor of the mouth here.
8:54
You will also see some lingual glandular tissue.
8:58
And what did you think? So,
9:00
We'll go and say to the prodded.
9:01
Why are you so serious?
9:03
So serious saliva in the parotid gland,
9:08
serum, mucinous and mucinous,
9:11
saliva in the submandibular, and sublingual gotta greens.
9:17
And as I mentioned,
9:18
here is the main duct of the sublingual
9:23
duct and that may or may not
9:26
enter into the submandibular duct.
9:28
So you have little ductal system here and then
9:32
there are these tiny little ducks called.
9:33
The Ducks of ribbon has that go from the sublingual gland
9:37
and may also enter the major sublingual
9:40
duct or the submandibular duct.
9:44
Though it was possible that Wade's dog. Had eaten,
9:47
his homework mrs. Berkley tested,
9:49
the remnants for traces of, dog saliva on his homework.
9:55
So as I mentioned the sublingual ducks have
9:57
a main duct, which is the bar When duck,
10:00
that will join Wharton's duct of the submandibular gland.
10:05
And then you have these tiny little ducks of ribbon has
10:08
that open separately into the floor of the mouth or may
10:11
enter the main duct of the submandibular
10:14
gland weren't stuck.
10:17
When you have obstruction of some of these
10:21
ductal system of the sublingual gland.
10:24
In this case, we're looking at a T2 weighted MRI scan,
10:27
the sublingual gland is seen as this great bright area.
10:31
The mylohyoid muscle, is this darker area? That intrinsic,
10:35
tongue musculature. Here,
10:37
this is all normal.
10:38
Sublingual Grand juror tissue.
10:40
Here we have a cyst nice and bright on the T28.
10:43
Scan within that sublingual range alert issue.
10:47
And this is indeed a rangiroa,
10:49
a simple rangiroa due to obstruction of the ductal
10:53
system of the sublingual gland. In addition,
10:57
we have minor salivary glands now minor salivary
11:00
Are all over the air digestive system,
11:02
including in portions of the trachea, the lungs,
11:05
the bronchi,
11:06
as well as assigning nasal cavity. In fact,
11:09
the mucus retention cyst that we see in the maxillary sinus
11:13
or you thought to be secondary to obstruction
11:16
of ducks of minor salivary gland.
11:19
The highest concentration is in the hard palate and soft
11:22
pound but you can get them all around the lung and the mouth
11:25
and these are mostly mucus mucinous and mucous secreting.
11:30
Not as thin and these have lots of different Innovations
11:33
depending on where they are in the body.
11:37
This is a graph from Justin Shaw's,
11:40
book called head and neck surgery.
11:42
And it shows the incidence of minor salivary gland tissue,
11:48
as well, as minor salivary gland,
11:50
neoplasms and where they occur.
11:53
As you can see,
11:53
the most common site for minor salivary gland.
11:56
Neoplasms is the hard and soft palate, which is also,
12:00
the where there is the highest concentration
12:03
of minor salivary,
12:04
gland tissue
12:07
So let's move from anatomy and talk
12:09
a little bit about benign neoplasms.
12:13
So here's a question, number two,
12:15
for polling and it says that the 80% rule of salivary gland
12:19
says that 80 percent of tumors are in the parotid gland.
12:22
A percent of benign, tumors are pre amorphic. A dome,
12:24
has 80% of pleomorphic,
12:26
adenoma has will never show malignant degeneration,
12:29
80% of salivary gland, tumors are benign,
12:32
none of the above,
12:34
some of the above,
12:36
or all of,
12:36
The above. So again,
12:38
what does the 80% rule of salivary, gland,
12:41
salivary gland? Say,
12:42
does it say that 80 percent of tumors are in the parotid?
12:44
A percent of benign tumors that we amorphic at Nomas,
12:47
80% of Glamorgan domas,
12:48
do not show malignant degeneration,
12:51
80% of salivary gland, tumors are benign.
12:54
None of these are true.
12:55
Some of these are true or all of them are true,
12:59
which You enter.
13:03
80% rule.
13:05
So let's see what the audience is predicting here and
13:12
the correct answer is indeed all of the above that is,
13:16
I guess it can't be already but if some of them are
13:18
not available for some people, but anyway,
13:20
eighty percent of tumors of sound very gland,
13:22
tumors are in the parotid gland.
13:23
80% of benign tumors are polymorphic adenoma 80% of the
13:28
American Home has never shown Malik degeneration.
13:31
In fact,
13:33
if you don't take out the pleomorphic Gad Noma
13:36
it said that over the course of 20 years,
13:39
20 percent,
13:40
fifteen to twenty percent will eventually show malignant
13:43
degeneration and 80% of salivary
13:45
gland tumors are indeed benign.
13:48
So here is again, from this great book,
13:51
it's actually many additions to go 1996 showing that the
13:55
majority of tumors of the salivary
13:58
glands are in the Right again,
14:01
followed by some men Debbie or minor salivary glands.
14:05
And when you look at the benign
14:07
versus malignant breakdown,
14:10
you notice that eighty percent or 75 percent of parotid,
14:13
masses are benign,
14:15
whereas in the minor, salivary gland category,
14:20
80% are malignant and in the submandibular
14:23
sublingual glands were, it's about 50/50.
14:26
So there's an adage.
14:27
And that is that the larger in the salivary gland,
14:33
the lower the rate of malignancy.
14:35
So the smallest of the salivary glands which are the
14:38
miners have events, have the highest rate of malignancy.
14:43
We look at the various malignancies.
14:46
What one sees is that mucosa epidermoid,
14:49
carcinoma kind of predominates in the parotid gland,
14:53
but in the other locations,
14:56
you see that the most common is going to be adenoid cystic.
15:00
Carcinoma.
15:01
So you clap parotid elsewhere, some ended,
15:05
we were minor salivary, glands,
15:07
adenoid cystic and in point of fact,
15:09
we take all comers with salver gland neoplasms.
15:12
I think adenoid cystic just beats out the
15:15
mucus epidermoid adenocarcinoma,
15:17
also possible malignant mix tumor or those pleomorphic
15:22
adenoma is that convert to malignancies?
15:25
That's the malignant mix,
15:27
this in Excel much less common.
15:30
One more in the parotid than anywhere else and
15:32
then you have squamous cell carcinomas,
15:34
which talk about that may derive
15:36
from ductile epithelium.
15:39
So let's talk about the parotid gland and the
15:41
benign neoplasms of the parotid gland.
15:44
Most common is the pleomorphic.
15:46
Adenoma it does represent 80% of the benign neoplasms.
15:50
So, we think of 80% of parotid gland,
15:53
neoplasms are benign,
15:55
and then 80% of the benign ones are P amorphic.
15:59
Adenoma You come up with about 64%, 0.8 times 0.8 of parotid,
16:06
neoplasms or pleomorphic,
16:07
adenoma has
16:09
the second most common are hemangiomas and these are both
16:15
the infantile ones in the the young trailer children as well
16:21
as what we call Hemangioma as but are actually
16:24
being as vascular. Malformations in adults,
16:27
you then have worth ins tumors.
16:30
Which we'll talk about and Uncle side. Tom is another,
16:32
that's commonly are your schwannomas of those nerves.
16:35
That are going through the parotid gland,
16:37
including the fifth cranial nerve,
16:39
and the seventh cranial nerve in the ninth grade.
16:41
And we have lipomas
16:44
within the submandibular glands,
16:47
the sublingual glands in the minor salivary. Glands,
16:49
the benign lesion still are most commonly pleomorphic
16:53
adenoma has you may see more monomorphic at Nomas than
16:57
you do in the parotid gland? However, in the malignancies,
16:59
Yes.
17:00
As I mentioned,
17:01
predominantly adenoid cystic carcinoma
17:03
less commonly new couette,
17:06
so p.m. or forgot. No. Miss the most common benign,
17:08
sub salivary gland tumor usually occurs in
17:12
women who are 30 to 50 years of age.
17:15
Women more than men about 3 to 1 ratio.
17:18
These are really bright on a T2 weighted MRI scan.
17:22
When you see a neoplasm that is really bright
17:24
on T2 and chose contrast enhancement.
17:27
You can go that this is likely a play.
17:30
And more forgot.
17:30
Noma they may have areas of calcification and bad because
17:35
they are the more common benign tumors but in the vast
17:38
majority just light up like a bulb on your T28 scan.
17:41
So for example,
17:42
here we have a neoplasm here that is overlying.
17:47
The masseter muscle.
17:49
This is very similar to the one I showed earlier.
17:51
Look how bright this is Auntie to way. It's can infect.
17:54
You look at the CSF.
17:57
and this tumor and initially you might say, well,
18:00
Could this be a cyst?
18:01
It's so bright.
18:02
It's so homogeneous and left for that reason we always give
18:06
Gad and with gadolinium on this fat suppress can you see
18:09
that the region is enhancing. So here it is on pre guide,
18:14
post got that set,
18:16
it doesn't hand. So this is not a cyst,
18:18
it is indeed a queer more forgot Noma and some people,
18:24
I was taking the ABR Moc about about month ago
18:28
in this sort of struck me, that they said that,
18:30
That they're often is a hypo intense Rim around the P.
18:34
Amorphic, I'd know,
18:35
my identifying it as being encapsulated sometimes
18:40
you can get forward because this is the fat nearby,
18:42
this could be a chemical shift artifact Another example,
18:47
this one T1 T2 not quite as bright,
18:51
but still a bright lesion.
18:52
Post Gad enhancing its lobulated.
18:55
It's got relatively. Well, defined margins.
18:57
This is going to be a pleomorphic. Adenoma.
19:00
Here's that pleomorphic adenoma 1ct of the
19:04
submandibular gland generally well-defined not infiltrative
19:08
margins no evidence of spread to the petite
19:11
is my muscle or the adjacent fat.
19:15
This is a one that unfortunately I scanned after
19:18
I had after the commission, had done the biopsy.
19:22
So this is a soft palate pleomorphic.
19:26
Adenoma so soft palate.
19:29
Hi High concentration of minor salivary glands,
19:33
minor salivary gland,
19:35
most common, benign tumor still,
19:37
we have more of a guide Noma this one was biopsy and you
19:40
got some bud products within it but this was indeed
19:43
a polymorph. Got no more of the soft palate.
19:47
so clean morphic adenoma is predominant
19:48
in the parotid gland,
19:50
but they can occur as I said in all of the salivary glands,
19:53
and if they are the most common of the benign,
19:55
tumors of all on the salivary glands,
19:58
most of them are in the Superficial portion of the
20:02
parotid gland and is superficial
20:03
to the seventh cranial nerve.
20:05
They may recur in about 125 percent
20:08
and you can have multi centricity.
20:12
Here's to interesting ones.
20:14
This one both of these I biopsy this one
20:18
was in the power for injil space.
20:20
So in the priest I avoid power fringes of space,
20:24
you do have minor,
20:25
salivary gland rests and this was a pre amorphic adenoma
20:30
on the right side. This was a smaller one.
20:33
Again in the power for NGO, space fat here.
20:37
You can see me doing my biopsy.
20:38
This is the technique that I described in.
20:41
Geology back in believe, is 1989 insertion of the needle.
20:47
Through the anterior portion of the fat of the face in this
20:51
kind of retro maxillary space to do the biopsy
20:54
of this power. For in Jewel space,
20:57
we amorphic adenoma.
21:00
So we have a nice question for you.
21:02
Keep you guys awake
21:05
regarding diffusion-weighted Imaging
21:07
and a DC and salivary glands,
21:09
which is true ATC is greater than 80% accurate and
21:12
differentiating, benign versus point of Pride. Tumors,
21:16
ADC values are higher in war,
21:18
things tumors than clamor of got Nomas low-grade mucus.
21:22
Dermoid ADC values are higher than clean morphicon Nomas.
21:28
Worthen's tumors ADC Values fall in the malignant
21:31
range or all of the above. So again,
21:34
regarding diffusion, wait,
21:35
scanning and use of ADC values in salivary gland, tumors,
21:40
which is true,
21:41
ATC is 80% accurate in differentiating,
21:43
but I'm Versa malignant.
21:44
ADC values are higher and more things than clamor can do.
21:47
Miss low grade new co-op ADC values or higher
21:50
than P morphicon Nomas worth. Ins tumors,
21:53
ADC values fall in the morning range, or all of the above.
21:57
So, go ahead and answer that question line.
22:00
Sipping, my LaCroix.
22:04
Okay.
22:06
Let's see how you did on this question.
22:10
So the people are putting all the above and I'm tricky.
22:15
I'm tricky know, all the above,
22:18
in this case,
22:18
the correct answer is worth and tumors ADC values
22:22
fall in the Mileena trained were things.
22:24
Tumors are the ones that kind of overlap and you can't
22:28
really use them for differentiating a benign tumor
22:32
worth and stumer versus malignancy.
22:35
The other thing is that sometimes these
22:38
low-grade milk epidermoid tumors do.
22:40
You have high ADC values but they are not usually higher
22:44
than the plea amorphic adenoma as but
22:45
they're higher than other malignancies.
22:49
So high ATC values are rare in cases of malignant tumors and
22:52
help distinguish geomorphic adenomas versus malignancy
22:55
and there is a cut-off that people
22:57
use of greater than 1.8,
22:59
but Worth ins tumors and malignancies tend to overlap
23:03
and tend to have low ATC values. As one would expect,
23:09
So the other technique that is used to differentiate among
23:13
the various parotid masses in particular is perfusion
23:17
imaging and usually this is the dce dynamic, contrast,
23:22
enhancement technique and pleomorphic.
23:24
Adenoma is are characterized by a slow
23:27
Progressive increased perfusion
23:30
worth and stumer fast. Uptake fast washout.
23:34
Where's my didn't seize our fast update,
23:36
but do
23:37
slower on That wash out so you could potentially use them.
23:42
The other thing that people will use or these mean transit
23:46
times etcetera and you can see that with the blood value
23:52
versus the blood flow that there are some differences
23:55
here between the benign tumors
23:58
versus the Or malignant tumors.
24:01
And so some people will use a dynamic,
24:05
perfusion imaging technique.
24:08
Same thing with magnetization,
24:09
transfer magnetization transfer is effectively a
24:13
method of looking at the protein transfer
24:16
to proton to water protons.
24:19
As one would expect when you
24:21
have higher protein in a tumor,
24:24
you have greater magnetization transfer and the empty ratio
24:28
will be will change on that basis and people have looked
24:32
at magnetization transfer ratios and the applies.
24:35
In fact, I've done it.
24:35
You see my publication on this and that also is useful
24:40
for distinguishing malignancies versus P,
24:43
amorphic adenoma but unfortunately even with mtrs
24:47
were thin streamers is the one that can fool you
24:52
so among them benign. Tumors,
24:53
let's move from pleomorphic adenoma to other tumors
24:57
and they include the monomorphic atom.
24:59
Is these are you?
25:00
Seen me in my experience more commonly in the submandibular
25:04
OR sublingual glands rather than in the parotid glands.
25:07
And then this is an example of monomorphic
25:11
adenoma that was seen in the left,
25:13
submandibular gland low-density well-defined,
25:16
non infiltrative margins.
25:19
There is an adage. However, that is stated by me,
25:24
which is benign lesions of the parotid gland are
25:26
never as benign as typical benign masses.
25:30
Oh, and malignant,
25:31
lesions are never as malignant as typical malignant tumors.
25:35
And so,
25:37
you know, I'm taking credit for this.
25:39
It may be that one of my mentors once said
25:41
this to me and now I'm claiming it.
25:44
But what do I mean by this?
25:46
What I mean by this is that pleomorphic
25:48
adenoma has if they are not removed,
25:52
can act like malignant lesions and if in removing a plea
25:57
amorphic adenoma you cut across its Capsule.
26:01
It has the potential for shedding cells into the
26:04
operative field where you have just tumor,
26:09
You Know,
26:09
Field hybridization into the field with a
26:14
morphic adenoma from the standpoint of malignancies
26:18
low-grade. Epidermic wepa dermoid,
26:21
carcinomas have a 95 percent five-year survival and
26:27
when you look at pre amorphic adna - they have,
26:30
About the same 95 percent five-year survival because of
26:34
this issue about potential Moines and degeneration.
26:37
So because of that,
26:38
we have this saying that benign lesions of the
26:40
broader never has been eyes. Just typical,
26:43
we took it out and patients doing great.
26:45
They still will survey the patient and similarly,
26:48
with if you have a low-grade mucus epidermoid you,
26:50
there's a very tiny,
26:52
very small incidents of nodal spread or any malignant
26:57
spread outside the parotid gland,
27:00
So for example,
27:00
here we have a patient who has this massive lesion
27:06
that is in the Deep lobe of the parotid gland.
27:08
And what one notices is that it's sort of right up against
27:12
the Carotid artery. It's in that power Fringe of space.
27:15
It's narrowing,
27:16
the airway and we see a second little
27:18
nodule of the tumor here. And here,
27:20
this is going to be a really difficult pleomorphic,
27:23
adenoma to resect,
27:26
and it's likely that the capsule will be violated
27:29
and there could be Be tumor shed,
27:31
selling tumor cell shedding into the operative field.
27:36
Here, it is, Auntie to a scant still bright.
27:38
So it's still pretty much forgotten,
27:39
but you've got multiple nodules associated with this.
27:42
And this is not going to be an easy lesion
27:44
to remove and the five-year prognosis.
27:49
In particular,
27:50
may be less than that of a low-grade
27:53
Miko epidermoid carcinoma.
27:55
So let's move from pleomorphic.
27:57
Adenoma is to the next benign tumor, which is worth it.
28:00
Cameron again, not Wharton's duck, but War thins,
28:04
tumor.
28:05
This is a benign tumor that has
28:07
no moving and degeneration.
28:09
This is a tumor that you may remove it.
28:11
You don't have to remove it because it doesn't
28:15
have that malignant potential.
28:18
This is a tumor that has a high rate of by that
28:21
around e and multifocal T and therefore,
28:24
you have to be very careful in looking at both parotid
28:27
glands and multiple sites in the product.
28:30
Now, the,
28:30
the t2-weighted signal intensity of
28:33
a worth Institue Murr is variable.
28:34
It may be bright and maybe dark,
28:37
it's often mixed and I'll show you some examples of it.
28:42
So here we have 81 ways, scan, and T2 weights.
28:44
Can we see the mass relatively easily on the T1 way?
28:48
It's can we see a second Mass over
28:50
here in the left parotid gland?
28:53
You notice that somewhat bright on the T28
28:56
scan on the left side, but on the right side,
28:58
it's kind of a heterogeneous.
29:00
And that's very typical of a worth in Sumer heterogeneity.
29:03
This is also known as limpid. No Matos, mm.
29:08
And that lymph portion of it is accounts for
29:12
the darker signal on the t2-weighted.
29:14
Same scan and the adenoma tosem is
29:18
the more bright portion of the tumor.
29:20
So,
29:20
mix cellular type as well as mixed signal intensity on T28
29:26
scan. And therefore it may look like a malignancy.
29:29
So the what of the other ads is that we
29:31
say about salivary gland tumors,
29:33
is that if it's dark or intermediate on T28 scan,
29:37
it must be biopsy because it's malignant until proven.
29:41
Otherwise, again,
29:43
dark, Auntie to got a biopsy bright,
29:47
Auntie to assume it's a plea amorphic.
29:50
I know I'm gonna make sure it's not a cyst,
29:53
you do that with a ghetto, any of it,
29:54
solidly enhancers it's okay, morphicon Noma,
29:57
if it only enhances on the rim or doesn't enhance it.
30:00
System.
30:01
Another example of a patient with worth and stumer knows
30:04
that there's bilateral disease or maybe multifocal disease.
30:08
Sometimes we even say that were consumer may
30:10
be extra provided. But within the Carotid space,
30:14
this is even heterogeneous on the T1.
30:16
Way it's can but you have darker areas as well as
30:19
brighter areas. This is not going to be a polymorphic.
30:22
Add know my,
30:22
we have to biopsy this or the alternative is
30:25
to do a technetium pertechnetate, scan,
30:29
because Athens tumors take up
30:32
technetium, protect the case.
30:34
So this this case is the spitting
30:37
image of the prior one.
30:43
All right,
30:43
I can't tell whether anyone's laughing but I'll move it.
30:47
So, as I mentioned,
30:48
were consumer has a high rate of
30:50
bilateral and multifocal tumors.
30:54
When you see multiple parotid masses,
30:56
the vast majority of these are going to be benign
30:58
lymph nodes in the product.
31:00
That we just saw.
31:01
Don't even pay attention to often.
31:02
They do have a little fatty hilum,
31:05
eccentrically that tells you that their lymph nodes.
31:09
You can have multiple cysts with talk about that towards
31:11
the end of the talk. If I make it with HIV related lesions,
31:15
you can have multiple local acidic cell carcinoma.
31:19
You can't have lymph node metastasis
31:21
usually from squamous cell.
31:22
Carcinomas are basal cell carcinomas of the skin which
31:26
will metastasize to interpreted lymph nodes.
31:29
And then we have our 9mm for epithelial regions or blouse
31:32
that are associated with both HIV
31:34
as well as Sjogren's syndrome.
31:37
I mentioned that were thin streamers are one of the
31:39
tumors that will take up technetium pertechnetate
31:42
if you don't want to do fine, needle aspiration,
31:45
which is pretty simple here. I mean,
31:47
this is less than an inch deep from the skin surface.
31:50
You could do this can and it would show.
31:53
I technetium pertechnetate update,
31:56
Aqua saitama's are another of the benign,
31:58
tumors of the parotid.
32:00
And this has a characteristic feature of becoming I.
32:05
So intense post contrast T1 way.
32:08
It's can the so called Vanishing tumor that you see
32:11
it on the pre Gad outlined by fatty parotid tissue,
32:16
and then you give Gad and it becomes,
32:18
I so intense the brightest, when you say,
32:20
where the tumor go,
32:21
it's there.
32:22
But it's
32:25
I so intense through the native carotid tissue,
32:28
these tumors also are technetium map.
32:32
And this is an example of a both superficial
32:35
and deep lobe on Gosai Toma.
32:38
21 weights can most broad tumors are really
32:41
easy to see you on a T1 weighted.
32:43
MRI scan most are easy to see on a CT scan
32:47
unless you have dental amalgam,
32:48
spray artifact.
32:51
This is a another benign tumor of the parotid gland.
32:54
In this case,
32:55
we're seeing an oblong lesion on the sagittal scan,
32:58
which is going up these Bible mastoid framing
33:01
identifying it as a schwannoma.
33:04
So it has both a skull base portion.
33:07
This is the descending in mastoid
33:10
portion of the facial nerve.
33:12
This is the style of masculine frame in.
33:13
This is the interpreted portion of the facial nerve.
33:16
You can see this also on the T1,
33:19
post-grad, coronal, scan,
33:21
as well as a portion that even went
33:23
into the internal auditory canal.
33:26
Okay? So we've gotten through the benign. Neoplasms.
33:30
And fortunately, as I said 80% of salivary gland,
33:33
tumors are benign.
33:34
Now we have to get to the negative
33:36
6 and that is the malignancies.
33:39
So let's ask question to introduce this portion
33:42
regarding salivary gland, malignancies.
33:45
Number one, you kept dermoid carcinomas.
33:46
The most common salivary gland,
33:48
malignancy number two and noid.
33:49
Cystic carcinoma has a thirty to forty percent
33:51
rate of paranormal spread number three,
33:54
parotid lymphoma occurs in a five times higher
33:57
rate in patients with Sjogren's disease.
34:00
Number four,
34:01
the rate of Mowing and degeneration worth in tumors
34:03
is 123 percent number five. All of the above number six,
34:08
ninety about. So which of these is true.
34:10
You kept a dermoid carcinomas.
34:11
The most common salary gland militancy,
34:14
number two and white cystic.
34:15
Carcinoma has a thirty to forty percent
34:17
rate of paranormal spread number 3,
34:19
/ I lymphoma occurs in at five times higher in patients
34:22
with Sjogren's disease. Number four,
34:24
right? Of malignant degeneration, more consumers,
34:26
123 percent number five. All the above number six,
34:30
None of the above.
34:34
Again, a little drive with my saliva here,
34:36
so I'm just supplementing.
34:41
Okay. Whatever.
34:42
Okay. So people can, I Fortune with that?
34:46
All the above again?
34:47
Hey you some is a tricky guy.
34:51
So here, the egg, the correct answer.
34:54
May I have a drum roll, please.
34:58
The correct answer is actually none.
35:00
The above.
35:01
So I mentioned this new klappa durman.
35:04
Carcinoma is very close to adenoid cystic or it's the
35:09
most common in the parotid but all comers,
35:14
minor salivary gland,
35:15
some linguo some in Timber adenoid
35:18
cystic just beats it out by a little bit.
35:21
Number two adenoid cystic carcinoma has a 50 to 60% rate
35:26
of Colonel spread over half of adenoid cystic carcinoma Emma
35:30
on histology have perineural spread President Obama
35:35
occurs at a 15 to 20 times higher
35:38
rate in patients with Sjogren's.
35:40
So it really increases the rate of lymphoma much higher
35:45
in a patient with Sjogren's disease and million
35:48
degeneration doesn't occur in more than tumors,
35:51
those are benign tumors that don't have malignancy
35:53
generation. So the correct answer was none of the above,
35:56
I congratulate the 4% of you. Who got that, correct.
36:01
Okay, so let's talk about malignancies. We send them,
36:04
you have a dermoid and ascending cell and
36:07
adenocarcinoma but really it's dominated by mucus.
36:11
Epidermoid adenoid,
36:13
cystic carcinoma and in the parotid gland these malignant
36:16
mixed tumors of we amorphic adenoma
36:19
is that have joined in t generation.
36:21
We do have that increased rate of lymphoma in Sjogren's
36:24
patients as well as HIV related disease. So,
36:30
That's with HIV.
36:30
Have a higher rate of parotid lymphoma and we
36:33
talked about metastasis and almost everybody
36:38
knows about the dangers of salivary gland neoplasms and
36:41
how they may spread except for those
36:44
people not wearing the mask.
36:47
Okay, so we've said the smaller, the grand,
36:49
the higher,
36:50
the rate of mine and tumors and we pointed out that the
36:53
rate of malignancy in minor salivary gland tumors is 81
36:56
percent in. This is dominated by adenoid cystic carcinoma.
37:01
He's staging for salivary glands.
37:03
I just want to briefly put up there
37:05
to remind you to measure all
37:09
sounds very Grand masses because the T staging
37:14
has to do in part with the size of the mass,
37:17
as well as whether it's extending outside,
37:20
the confines of the Grand and then if it starts spreading
37:26
into the mandible, the year, the facial nerve or the skin,
37:30
In particular for parotid,
37:31
glands or skull based are good plates,
37:34
you're going to get the tea for a and t 4 B category.
37:39
So Meek epidermoid most common parotid malignancy
37:43
as well as in adults, as well as kids.
37:47
But only represent about six to nine percent of all the
37:50
parotid masses and the t2 signal
37:53
intensity is is variable.
37:55
Sometimes those low-grade new cup dermoid
37:57
carcinomas can be bright on a tee.
38:00
Wait skin.
38:03
This is one where we have the T one way.
38:05
It's can we have a tea to way? It's, can we have the ATC map?
38:09
We have post gadolinium, so infiltrative Mass.
38:13
It is in superficial and deep portions of the parotid gland.
38:17
The facial nerve usually in Long,
38:19
the plane between the Retro mandibular tunnel here,
38:23
dark 22.
38:24
Once you see this dark signal and T2 got to be biopsied,
38:28
do not call the clinician say we've got
38:31
something here in the progress.
38:32
And start going T to this needs biopsy ATC,
38:35
map showing the hyper cellularity
38:37
potentially low ABC.
38:39
Differential, diagnosis might be worth in this tumors.
38:43
But this is, this is pretty much,
38:46
you know,
38:46
were things tumors tend to occur in older men and usually
38:50
at the angle of the mandible or
38:53
the tale of the parotid gland.
38:56
So here you can see this Mass on the Coronavirus.
39:00
And you're seeing the intra mastoid descending portion
39:04
of the facial nerve in this mass
39:05
is growing into the styler
39:08
mastoid framing. We see this here as well,
39:10
and up to facial nerve. So, this is a bad,
39:12
this is a bad tumor.
39:14
Is a tumor that not only will you need the product to me,
39:16
but you're going to need a temporal
39:18
bone resection in this individual.
39:22
Here's another one.
39:23
Coronal scan showing this ill-defined mass
39:27
in the right parotid gland Auntie to way.
39:29
It's can darken signal intensity,
39:33
probably a million. See in this case by Graeme,
39:36
you go up or adenocarcinoma.
39:38
Here's one that's in bobbing the minor salivary glands.
39:42
Only this was not an annoyed cystic,
39:44
this was an adenocarcinoma you have a dark signal intensity
39:48
mass and bobbing the hard palate this is The marrow
39:52
signal of the hard palate on the right hand side,
39:56
infiltration of the marrow signal
39:58
of the hard palate grow.
40:00
Up into the maxillary Antrim and actually,
40:02
lifting a mucous retention system curiously.
40:06
And this is showing contrast enhancement,
40:08
dark signal, and T2.
40:10
Bad enhancing malignancy till proven,
40:13
otherwise in this Arena of the minor salivary glands,
40:16
it's 80% chance of being willing.
40:20
So adenoid. Cystic,
40:21
carcinoma represents about 4% of the salivary gland tumors,
40:25
but 12% of the malignant ones and it has the Anshel
40:30
for nodal spread. What's good about adenoid?
40:32
Cystic is a grows relatively slowly and therefore long-term
40:36
the average survival is somewhere at the 15 to 20 year
40:41
range because it doesn't kill you immediately.
40:44
It's not that aggressive.
40:45
Unfortunately,
40:46
it has that 50 to 60 percent perineural spread. So it,
40:49
it keeps coming back along the cranial nerves either
40:52
the fifth, or the seventh cranial nerve in particular,
40:56
and you,
40:57
you follow it at five years and New little
41:00
nodule along the cranial nerve and,
41:03
you know,
41:04
patient has to get re-radiation or gamma,
41:07
you know,
41:07
radiosurgery, Etc.
41:09
So it's a slowly Progressive tumor.
41:14
Here are two examples of patients with
41:18
adenoid cystic. Carcinoma of the parotid gland,
41:22
here, we have the infiltration at the skull base.
41:24
You see the parotid gland? Superficial,
41:26
and deep portion here.
41:28
It's going right into To style mastoid foramen.
41:31
So this is going to be adenoid cystic.
41:33
Carcinoma growing up the seventh cranial nerve, again,
41:37
2nd gen.
41:38
You of the seventh grade owner of going from
41:40
the tympanic to the intra mastoid portion.
41:43
Here's a different patient with a mass in the parotid
41:46
gland and although we're not at
41:48
the section of the parotid gland,
41:50
we are at foramen ovale.
41:54
And we see the infiltration from the skull base into frame
41:57
Enola Vale and potentially even into the covers.
42:00
So this is Paranormal spread up,
42:04
the auricular temporal nerve,
42:06
which is a branch of the mandibular nerve which
42:11
is the third division of the trigeminal nerve,
42:15
which goes through frame and ovalle.
42:17
So, this is parotid adenoid cystic.
42:20
Carcinoma growing up framing of Valley,
42:22
along the fifth cranial nerves.
42:24
Third division
42:26
is a really fascinating case that presented 15 Years
42:30
after the initial presentation of soft palate.
42:35
Adenoid cystic, carcinoma with proptosis.
42:38
So the patient has had the soft palate
42:41
and hard palate resected.
42:43
And what you see is soft tissue that's
42:45
growing into the left orbit.
42:48
So here's the normal optic nerve and extraocular muscles
42:51
and orbital fat here. We have infiltration of that orbit.
42:55
You can see the infiltration via the inferior.
42:59
Orbital.
43:00
Sure into the orbit.
43:02
So this tumor that was at the soft palate when up the
43:06
Greater and lesser pouting for aminah into the terror
43:09
group outing. Fossa from there in entered,
43:12
the inferior orbital fissure and grew into
43:15
the orbit and presented with proptosis,
43:19
50 15 years after the thought that
43:25
it was cured from the soft palate.
43:27
So this is the problem or the danger of adenoids.
43:30
Has a carcinoma now,
43:31
basins already 15 years survival. So done. Well,
43:35
but it comes back along those cranial nerves Perrineau
43:39
spread is not exclusive to adenoid cystic. Carcinoma,
43:43
you do see it in other tumors,
43:44
including squamous cell carcinoma,
43:46
and the problem with squamous cell carcinoma
43:48
in the parotid gland. For example is,
43:50
is it from the ductile epithelium or is it from a
43:54
nodal metastasis from a skin squamous cell carcinoma,
43:59
both of them can Trade The Prodigal,
44:01
it you can have direct infiltration from the ear
44:04
cancers into the parotid gland may be squamous
44:07
cell or it may be a primary product with itself.
44:11
Usually thought to be from squamous,
44:12
metaplasia of the acinar cells,
44:16
or the ductile cells of the parotid gland lymphoma
44:20
also can cause paranoia spread,
44:22
but these are uncommon compared to the 50 to
44:25
60 percent rate of adenoid cystic carcinoma.
44:28
And we all know that Imaging findings of perineural spread.
44:32
Here's another one. This was a sublingual gland or mass.
44:35
You see it on the post Gad scan.
44:39
This is T 2.
44:40
This is sorry.
44:41
This is post Gat T to this is pre get T to intermediate
44:46
signal intensity better biopsy.
44:48
This this was another adenoid cystic
44:51
carcinoma and from here,
44:53
it can spread on the lingual nerve of the fifth cranial
44:56
nerve or the seventh grade in order of chorda.
44:59
Tympani Or even the hypoglossal nerve going back
45:03
to the hypoglossal. Canal from the 12 cranial nerve.
45:08
So squamous cell, carcinoma and mentioned,
45:10
they are usually Dark One T28 scan, like most malignancies.
45:14
They may cause seventh cranial nerve paralysis.
45:17
Here's a patient with a squamous cell. Carcinoma,
45:20
a T28 skin darkens signal intensity.
45:23
Is this a node metastasis or is this
45:25
a primary periodic tumor?
45:28
We do the biopsy and we send it to pathology,
45:30
maybe they can make that distinction.
45:33
So with regard to nodal metastasis,
45:36
the parotid gland is the only Only gland that encapsulates
45:40
lymphoid tissue as part of its embryology.
45:43
So you don't see no disease within submandibular gland or
45:48
sublingual gland or obviously minor salivary glands
45:50
but the program because of late encapsulation has
45:53
the potential for being a source where metastatic
45:56
disease can go to interpreted lymph nodes.
46:00
And no carcinoma
46:02
may have portions with squamous cell carcinoma,
46:06
they tend to have a worse prognosis and this is another
46:09
adenocarcinoma of the soft palate. Here's another and,
46:13
of course them in the parotid gland again.
46:15
Darken single intensity, Auntie to get that biopsy.
46:19
Let me segue to lymphoma and check my climbing
46:23
segue to lymphoma. So lymphomas,
46:25
do occur both within the nodes in the parotid
46:29
gland from systemic Oklahoma,
46:31
as well as primarily in the parotid gland as this mucosal
46:36
Associated lymphoid, type or malt lymphoma.
46:39
As I mentioned the rate of lymphoma is much much
46:43
higher in patients with Sjogren's syndrome,
46:45
it is also higher in patients with HIV AIDS.
46:50
And these are usually Non-Hodgkins Lymphoma here,
46:53
is a patient who has the typical features of Sjogren's
46:56
syndrome with lots of little micro cysts,
46:59
but in addition,
47:00
Is darker area among the normal, the normal,
47:04
the BBC micro. Cystic portion of the Sjogren's.
47:08
It was this darker area on T28 scam biopsied lymphoma.
47:12
Here's another patient with lymphoma in the parotid
47:15
gland primary parotid lymphoma
47:19
Okay, we may have to say Alan with is this.
47:21
I've got about eight minutes to go,
47:23
so let's try get through these last three categories.
47:26
So stones in the in the, some salivary glands.
47:30
So, the terms we use,
47:31
I held with Isis for stone sale at nights.
47:35
I'll add a nice for inflammation of the grand.
47:37
Silo joke. Itís name ductile information,
47:41
select Asia,
47:42
dr. Dilatation,
47:44
Silo sucess is a benign condition of the
47:47
product and where that's enlarged.
47:49
And puffy cheeked big glans, not inflamed.
47:53
This can occur with diabetes hypothyroidism, obesity,
47:56
alcohol, use liver disease Etc.
47:58
These are the patients who kind of Look like a chipmunk.
48:02
So Silas is no masses in, they're not inflamed.
48:06
So let's talk about Siam Lo-Fi assist,
48:09
the ratio of submandibular gland to burrata.
48:13
Green stones is what is it? 1 2 1 2, 2 1, 1 2 2 4 2, 1,
48:19
1, 2 for the ratio of some ended. If you have the stones,
48:24
they occur more commonly in submandibular glands than
48:27
parades and if so at what Rate is it 1 2 1, 2, 2, 1, 1 2 2 4,
48:33
2, 1,
48:34
1 2 4 or none of the above
48:38
so which which has more and by, what?
48:41
Right?
48:43
Some individual glands or parotid gland Stones.
48:47
So let's hit it actually because
48:48
I'm running out of time.
48:51
Good for to one is the correct answer.
48:52
Yes 80% of stones are in the submandibular gland and that's
48:57
because the submandibular gland has
48:59
the more Useless thick secretions.
49:02
It also has to run uphill.
49:05
It has a
49:07
pH that is more likely to precipitate calcium,
49:11
oxalate calcium. Phosphate Stones.
49:12
It's got tighter orifice.
49:14
So there's more stasis in these submandibular gland.
49:17
Remember that 25% of stones are multiple here.
49:21
We have a submandibular gland stone.
49:25
That is in the ductal system with select Asia,
49:28
as well as soil.
49:30
How do kindness and the gland is also enlarged in a little
49:34
bit less dense. Oh, they're Silent Night is as well.
49:38
There's also information in the form of the mouth.
49:40
So some interior Style with ice.
49:43
As you can see these on MRI scan as dark signal,
49:46
intensity Stones,
49:48
here's one stone. Here's the other Stone.
49:49
Here's the enlarged.
49:51
Wharton's duct.
49:54
Here's a little joke. I'm sorry kids. But last night,
49:57
your father passed a difficult day.
50:00
For the cell, very Stone family.
50:02
Pass a stone.
50:04
No humor.
50:07
Okay,
50:08
Doctor,
50:10
dr.
50:10
Graham saligram
50:13
given to me by Ruth eliyahu from Israel or filling defect
50:17
here. Here's a tiny little one, right at the frenulum.
50:20
And you see the enlarged gland here.
50:24
You can see this Stone and DuckDuckGo dilatation.
50:28
You do get stones in the parotid gland.
50:31
Again, about 20% of all the stones here.
50:34
You see that big rock in the stenson's duct with dr.
50:40
Dilatation proximally. Here you have big inflamed,
50:43
soft tissue,
50:44
sayago doke itís with cellulitis with silent night,
50:49
has with sayago with biases.
50:51
As that Stone is coming to the second mole region of the
50:55
buccal membrane again with contrast you Macy that.
51:00
Asymmetric enhancement of the gland. That is inflamed.
51:05
And right there is the stone in the
51:10
distal most portion of the duct,
51:12
as it inserts on the buccal mucosa there.
51:16
Here we go.
51:18
There was an entity called Kutner summation.
51:20
The Kutner lesion is usually in the submandibular gland,
51:23
I'm showing you an example of it in the parotid gland.
51:26
This is chronic silent night.
51:28
Is that is mass like and feels I'm even palpate a mass in the
51:33
submandibular gland thought to mimic them a neoplasm.
51:37
But this hard mass is really just chronic
51:40
style and itís with chronic sclerosing.
51:43
Sometimes from a stone usually in children.
51:46
So made to Sis, let's keep going with this,
51:48
the most common salivary gland sister's,
51:50
your mucus retention sister. As I said,
51:52
it's obstruction of the minor salivary gland that can
51:55
occur just de novo or after structures
51:57
or trauma or tumors.
52:00
Cirrhosis is,
52:01
if you have a duct that ruptures and then you have
52:04
fibrous tissue encapsulating assist, that's a pseudocyst.
52:08
If the duct communicates with Asus, we call it a cyano seal.
52:15
You can have all kinds of cysts,
52:16
you're going to have an input.
52:16
The theosis you can have first Franco Cliffs has dermoid
52:20
cyst cystic. Read the opossums or in the HIV your back.
52:25
20 years ago,
52:25
we sold lots and lots of cysts in the
52:27
parotid glands and then we'll talk.
52:30
A little bit about rang on. So let's go to question.
52:32
Number 6,
52:32
the importance of distinguishing a simple from a
52:35
plunging rang and it has to do with
52:37
what the likely site of obstruction,
52:40
the potential for neoplasm is the ideology.
52:42
But weakness in the my Ohio and musculature the surgical
52:46
approach or whether it's coming from the submandibular
52:50
gland versus a sublingual gland,
52:52
two minutes ago,
52:53
let's make a quick answer quickly the importance of
52:56
distinguishing simple from plunging Rana has to do with
52:58
likely site of Potential for neoplasm weakness in
53:02
the mylohyoid musculature surgical
53:04
approach or one is a ra.
53:08
So CA with the submandibular gland the other with
53:10
the sublingual gland. What's the correct answer?
53:12
Simple versus plunging ring. So good.
53:15
The correct answer is surgical approach because the simple
53:17
Wranglers is approached intro orally with marsupial
53:21
ization into orally, whereas the plunging one,
53:24
they take out by a neck approach a cervical approach,
53:28
so let's quickly look at With this system,
53:31
the parotid gland well-defined we want to give Gad to
53:34
make sure that this is not a plan worked at NoMa.
53:36
This was a first branchial cleft cyst and there's
53:40
two different types, the are no classification.
53:43
Type 1 versus type to the type,
53:45
to is the one that has the potential for a
53:47
fistula to the external auditory canal.
53:50
And this is a couple examples of our no classification with
53:56
thickening and growing into the external auditory canal,
53:58
your are no type
54:00
Thank you to Santosh for this first branko clip sis HIV.
54:05
Sis diffuse multiple often with nodules and what
54:10
we call benign limb for epithelial region.
54:12
So sis and nodules bilaterally in the product.
54:15
And with lymph nodes we think about HIV or we think
54:20
about Sjogren's syndrome and let me just get quickly,
54:23
this is that Sjogren's syndrome.
54:25
Patient I showed previously with the lymphoma within it.
54:30
Let's just remember,
54:32
just takes a quick look at the regulus
54:33
and then we'll call it a day.
54:35
Simple, regular lies above. The mylohyoid,
54:37
has not pierced through the mylohyoid,
54:39
we're just the plunging goes into the submandibular.
54:41
Space plunging through the mylohyoid musculature,
54:45
and here you have it confined by the mylohyoid here.
54:49
It's through the mylohyoid spit happens.
54:52
Here's the simple.
54:54
Here are two different ones. This one mylohyoid is intact.
54:58
Simple R Angela.
55:00
Mylohyoid has been broached plunging regular
55:03
that they take out via a cervical approach.
55:06
This one by intraoral approach.
55:08
Plunging Romulan down into the sub mandibular,
55:11
space cervical approach and we talked about the cyano SEO.
55:16
So we made it,
55:19
albeit rapid ending.
55:21
Hopefully,
55:22
you've gotten a good sense of the salivary gland,
55:26
pathology the anatomy,
55:28
benign and malignant.
55:30
Murmurs ductile and Grand River Stones
55:33
inflammatory disease and sis.
55:36
So with that, I will pass it over for the Q&A.
55:40
All right? Thank you dr.
55:41
You some if you open up that Q&A feature,
55:43
there are some questions in there for you.
55:45
All right.
55:46
You and me can we actually distinguish between benign or
55:49
malignant Minor 7 based on Imaging is biopsy necessary,
55:52
risk of seeding, polymorphic items after biopsy.
55:55
So as long as you're using a 20 gauge needle or less,
56:00
By and large. There's no risk of doing biopsies.
56:03
And in most cases, if it's bright on T2 and enhancing,
56:08
they assume it's actually more of a God moment.
56:10
Take the patient to the or anything, dark on T28 Scan,
56:14
they will do a aspiration biopsy up there.
56:17
That's palpable or they will ask us to do it ourselves.
56:21
So seating is really, really not an issue.
56:26
When you're talking about the needles that we currently use,
56:29
how do we differentiate I hate from Hemangioma.
56:31
So you can do Dynamic Imaging which case Hemangioma has
56:34
will light up like a bulb and will
56:37
persist them and
56:37
have fast uptake.
56:40
But most of the time there is a clinical skin lesion in
56:45
patients who have infantile hemangiomas schwannoma
56:48
versus pleomorphic. Adenoma.
56:49
So some schwannomas are cystic some schwannomas or darker,
56:53
Auntie to weights,
56:54
can
56:57
I?
56:58
You know,
56:58
I make the Assumption and Really bright on the t2,
57:01
it's a poem or forgotten them.
57:02
It's uncommon for schwannomas to be really bright
57:06
because of the Antony a and intimately beat tissue.
57:09
The Antony
57:11
be tissue having more cellular and strand,
57:14
e and therefore less bright Auntie to AIDS can if it's
57:18
more heterogeneous I may go
57:19
extra Noma if it's a long night,
57:21
you know the course of the fifth
57:23
or seventh cranial nerve,
57:24
you can go which one Doma what should be our recommendation
57:27
impression on the report. So I, you know,
57:29
I would say Say you know
57:31
lesion that is bright on T28 scan showing contrast
57:34
enhancement. Most likely a p.m.
57:36
or pretend Noma lesion and His Dark One T28
57:39
scan could represent a Worthen stumer.
57:42
If it's a two tailed a broad grin or multiple but
57:45
malignancy is concerned concerning
57:47
recommend aspiration, cytology,
57:50
interesting background, any relation to the subject today.
57:53
I'm at my brother's home and he's
57:56
into kind of abstract art to me,
57:58
this kind of looks like the Of a
58:02
butterfly.
58:03
So I put my head they're just that we have a good contrast
58:06
please elaborate elaborate on magnetization
58:08
transferring its applications.
58:10
So Mac transfer is very easy to perform,
58:12
you just have to use a suppressor post about 2,000
58:16
Hertz away from the water post and that is
58:21
goes into the protein molecular protein,
58:24
macromolecular
58:28
area of the spectrum.
58:30
And then you're able to look at whether there's transfer
58:33
from that protein to the water molecules.
58:37
And if you have something that has higher protein,
58:40
it will transfer a greater amount. Therefore,
58:43
is more likely to be a higher grade,
58:45
Emily neoplasm or hypercellular Nimbuzz.
58:49
How do you work up? Incidentally,
58:50
detective small Pariah masses on head. CT.
58:52
So this is a problem because you know we see a lot of
58:56
parotid nodes and you know you're doing
58:59
your I've were patients multiple sclerosis.
59:02
And you see these not nodules in the parotid gland?
59:07
I tend to just ignore them particularly,
59:10
if their kidney bean shaped, or if they have a hilum,
59:13
or if they're multiple and assume that their lymph nodes.
59:17
Could we be wrong? We could be wrong. It's a potential.
59:21
Usually they have a little bit of chemical shift
59:24
artifact associate with them or they
59:27
they kind of Shimmer in a way.
59:30
That makes me feel better about them.
59:32
How do we know if it's adenoid cystic,
59:33
carcinoma with paranormal spreader,
59:35
or schwannoma from the seventh cranial nerve?
59:37
So,
59:38
usually the masses away from the seventh cranial nerve and
59:42
then you have this tale of thickening
59:44
along the seventh cranial nerve,
59:46
whereas we do think of sausage shape more with
59:50
a true schwannoma of the seventh cranial nerve.
59:53
So
59:55
if it's just the nerve that seems
59:58
to be where the tumor is,
60:00
Will more likely called a schwannoma?
60:02
If I see a mass in the pride,
60:03
but I see a large nerve emanating from it,
60:06
I'm more likely to call it annoyed cystic,
60:08
carcinoma converted lesions less than 1,
60:10
cm be followed up and not biopsied.
60:14
That's a good question.
60:18
I would say if it's dark 1 T 2,
60:20
it should be aspirated.
60:24
What I be comfortable with just saying,
60:25
I get a three or four month follow
60:27
up to see whether it grows,
60:28
yes, because most of them are Mugo epidermoid,
60:31
and they don't have as bad, a prognosis,
60:33
but I'm in my report, if it's dark 22, I'm saying,
60:38
you know, recommend aspiration psychology.
60:41
Let's see.
60:42
How do we confidently? Distinguish?
60:44
Were things from P Morgan Dome,
60:46
apart from contrast enhancement. And bilaterally.
60:48
Look at the t2.
60:49
Were things are not going to be that bright and
60:51
where things are heterogeneous on the tee?
60:53
To Wade, Singleton,
60:54
see if you really don't are uncomfortable,
60:57
recommend that technetium pertechnetate scam.
61:00
It was the wardens are going to take it up
61:03
and usually you're talking about the difference
61:06
between a 75 year old man,
61:09
with a tale of the parotid Mass versus a 45 year
61:12
old woman with a superficial carotid mess.
61:17
Do we have to biopsy each patient with
61:19
Sjogren's to rule out lymphoma
61:22
if there's a dominant mass that
61:23
has dark signal and T28 scan,
61:26
you probably have to biopsy or
61:30
You know, a pet scan or something along those lines.
61:33
Would you recommend the use of mucus?
61:34
We tend to insist phenomenon versus pseudocyst
61:37
since it's not a cyst. Anyway,
61:41
I called him because we tend to insist.
61:44
Maybe I'm Wrong.
61:45
I assume that it's obstruction of the tiny
61:47
little ducks of the minor salivary gland.
61:49
So
61:51
if I start saying mucus retention phenomenon
61:53
to my clinician, for go, go.
61:55
What are you doing?
61:58
Why are you not worried about seating with fur?
62:00
Thanks pops.
62:00
It's been shown that unless you're
62:02
using hi Gage biopsy needles.
62:06
You don't have any risk of seating and I'm usually
62:11
using a twenty two or Twenty gauge needle.
62:13
The needle is that have been shown to see door like these,
62:17
14 gauge and 12-gauge needle so and I don't use them.
62:20
I may use the 10 Mo of biopsy gun,
62:23
usually just 20 gauge on that.
62:26
What's my secret to happiness?
62:28
Positive attitude.
62:31
Do you recommend you some diffusion sequences in your?
62:33
Yes.
62:34
So my colleague,
62:36
not the eigen who is our Premier head and neck
62:39
radiologist is a big advocate of using diffusion weighted
62:42
sequences both for lymph nodes as well as primary tumors.
62:45
It's definitely shown some value in the parotid
62:48
glands and so it is a part of our protocol,
62:52
you know,
62:53
diffusion doesn't take that long.
62:55
Let me see how we're doing on time,
62:56
okay? I'm still one more minute of 20 questions,
63:00
So diffusion doesn't take that long so it's an easy sequence
63:04
to do and you get some information that may suggest
63:09
malignancy that you would not otherwise get different points
63:12
between malignant neoplasms versus Kutner region.
63:15
So a lot of those Kutner Masons get biopsy because they
63:19
feel hard and they're dark and Signal intensity it's only
63:23
if I saw that the patient had Stones Etc or long history.
63:30
Etc.
63:30
That it probably would obviate the need for a biopsy.
63:36
Is there any risk of some individual who sailed with
63:38
Isis in the long term on those babies who their
63:40
frenulum was cut due to tongue-tied?
63:44
Sorry? Yeah, no. Yeah,
63:46
I have no knowledge about that.
63:48
That's one of my fellows. The Googling,
63:52
let's see,
63:53
screening of rotted and Sjogren's syndrome,
63:57
you know, Sjogren's is uncommon.
64:00
Is its involvement in the product and is
64:03
known to with the sickle syndrome.
64:06
I would probably recommend ultrasound as follow up just
64:10
because you don't want to keep putting the patient through
64:13
a lot of advanced technology Imaging that's expensive.
64:19
All right,
64:21
how am I doing, Ashley, it's 105.
64:23
What's going? One more down at the very bottom here.
64:26
Can multi parametric MRI predict salivary gland.
64:30
Her histology.
64:31
Yes. In addition to the, you know,
64:33
I'm still t2-weighted dark.
64:36
I'm recommending biopsy DWI.
64:38
Yes.
64:40
Low ATC more likely to be malignancy overlap
64:43
with were things tumor mag transfer.
64:46
Yes,
64:47
the higher, the mag transfer ratio the higher.
64:50
The likelihood of it being a neoplasm.
64:55
There probably has been Mr.
64:56
Spectroscopy of sovereign lands.
64:58
I don't know the literature on.
65:01
And do I perform FNA or true cut biopsy.
65:04
I usually do with a 20-gauge spinal needle into the
65:11
parotid masses or sub or
65:15
or the para Fringe of space. Masses,
65:17
I go coaxially to a 16-gauge injection,
65:20
needle and put in as the introduced me to go coax me
65:23
with a 20 gauge through the 16 gauge and do my FNA.
65:27
And if and Hopkins for Actually we have one site.
65:31
Cytology if they're hedging or say,
65:35
it's not a good enough specimen.
65:37
I'll usually then go with the ten Mo 20-gauge,
65:41
you know, snap and get a histologic specimen.
65:45
Asking them to do a touch prep on the cytology so times up,
65:50
it's been fun.
65:52
Hope you enjoyed the talk.
65:54
Hope to see you again if I'm invited.
65:58
You know, MRI online offers a Good quality material.
66:01
For those of you who would like access to a lot more than
66:05
that. I've done nine Mastery courses on MRI online,
66:09
and it's a good place for educational material.
66:13
Perfect. Is it bring this to a close on to thank you? Dr.
66:15
You some for your time,
66:16
expertise and dance moves there.
66:17
At the beginning want to, thank all of you for
66:19
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