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Approximately 80% of salivary gland tumors occur in the parotid gland In adults, about 80% of these are benign In the submandibular triangle, it is sometimes difficult to distinguish a primary submandibular gland tumor from a metastatic submandibular space node Only 50 60% of primary submandibular tumors are benign Tumors of the minor salivary glands are most likely to be malignant, with adenoid cystic carcinoma predominating Most parotid tumors present as an asymptomatic mass in the superficial part of the gland Their presence may have been noted by the patient for months or years Facial nerve involvement correlates strongly with malignancy Tumors may extend deep to the plane of the facial nerve or may originate in the parapharyngeal space In such cases, medial deviation of the soft palate is visible on intraoral examination MRI and CT scans have largely replaced sialography in defining the extent of tumor When the clinician encounters a patient with an otherwise asymptomatic salivary gland mass where tumor is the most likely diagnosis, the choice is whether to simply excise the mass via a parotidectomy with facial nerve dissection or submandibular gland excision or to obtain an FNA biopsy first Although the accuracy of FNA biopsy for malignancy has been reported to be quite high, results vary among institutions If a negative FNA biopsy would lead to a decision not to proceed to surgery, then it should be considered Poor overall health of the patient and the possibility of inflammatory disease as the cause of the mass are situations where FNA biopsy might be helpful In otherwise straightforward nonrecurrent cases, excision is indicated In benign and small lowgrade malignant tumors, no additional treatment is needed Postoperative irradiation is indicated for larger and highgrade cancers

Bajaj Y et al Critical clinical appraisal of the role of ultrasound guided fine needle aspiration cytology in the management of parotid tumours J Laryngol Otol 2005 Apr;119(4):289 92 [PMID: 15949083] Bhattacharyya N et al Determinants of survival in parotid gland carcinoma: a population-based study Am J Otolaryngol 2005 Jan Feb;26(1):39 44 [PMID: 15635580] Luna MA Salivary mucoepidermoid carcinoma: revisited Adv Anat Pathol 2006 Nov;13(6):293 307 [PMID: 17075295] Wahlberg P et al Carcinoma of the parotid and submandibular glands a study of survival in 2465 patients Oral Oncol 2002 Oct;38(7):706 13 [PMID: 12167424]

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air passes incompletely apposed vocal cords, as in unilateral vocal cord paralysis The voice is harsh when the vocal cords are stiff and vibrate irregularly, as is the case in laryngitis or malignancy Stridor, a high-pitched sound, is the result of turbulent airflow from a narrowed glottis Airway narrowing at or above the vocal cords produces inspiratory stridor Airway narrowing below the vocal cord level produces either expiratory or biphasic stridor The timing and rapidity of onset of stridor are critically important in determining the seriousness of the airway problem All cases of stridor should be evaluated by a specialist and rapid-onset stridor should be evaluated emergently Evaluation of an abnormal voice begins with obtaining a history of the circumstances preceding its onset and an examination of the airway Any patient with hoarseness that has persisted beyond 2 weeks should be evaluated by indirect laryngoscopy Especially when the patient has a history of tobacco use, laryngeal cancer or lung cancer (leading to paralysis of a recurrent laryngeal nerve) must be strongly considered In addition to structural causes of dysphonia, laryngoscopy can help identify functional problems with the voice, including vocal fold paralysis, muscle tension dysphonia, and spasmodic dysphonia

Grillone GA et al Laryngeal dystonia Otolaryngol Clin North Am 2006 Feb;39(1):87 100 [PMID: 16469657] Merati AL et al Common movement disorders affecting the larynx: a report from the neurolaryngology committee of the AAO-HNS Otolaryngol Head Neck Surg 2005 Nov;133(5): 654 65 [PMID: 16274788] Richardson BE et al Clinical evaluation of vocal fold paralysis Otolaryngol Clin North Am 2004 Feb;37(1):45 58 [PMID: 15062686]

Any of the complications of the underlying disease (eg, tuberculosis) are more likely to occur, and the patient is susceptible to intercurrent infections that may precipitate crisis Associated autoimmune diseases are common (see above)

There was a time when people thought of computers as manipulating numeric values exclusively. Among the first uses of computers was to calculate missile trajectories during World War II, and for a very long time programming was taught in the math department of major universities. Today, most programs are concerned more with manipulating and displaying strings of characters in addition to strings of numbers. Typically, these strings are used for word processing, document manipulation, and the creation of web pages. C# provides built-in support for a fully functional string type. More importantly, C# treats strings as objects that encapsulate all the manipulation, sorting, and searching methods normally applied to strings of characters.

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