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

participating in this new conference today.

66:22

Reminder, this conference will be made available on demand,

66:24

on MRI online.com,

66:25

and addition to all previous news conferences tomorrow.

66:28

Please join us for a new in conference with Dr.

66:30

Steven J pomerance on how to assess

66:32

ligaments on MRI part 2.

66:34

You cannot answer for that and all future.

66:35

And conferences on MRI online.com.

66:38

Thanks and have a wonderful day.

66:40

Bye y'all.