Neoplasms of salivary glands

Dr. Ramesh Parajuli, MS

Chitwan Medical College Teaching Hospital,
Chitwan, Nepal

Salivary gland anatomy

Major salivary glands: paired
1. Parotid
2. Submandibular
3. Sublingual
Minor salivary glands:
multiple, submucosal, upper
aerodigestive tract eg. from
nasal cavity and lips down to
the esophagus and trachea

Salivary gland microanatomy

Neoplams of salivary glands

Tumors of salivary glands
uncommon
3% to 6% of all tumors of
head & neck region
Proportion of malignant and
benign varies with gland of
origin

Larger the size of salivary

gland, more the chance of
tumor being benign

Distribution
Parotid: 80% overall; 80% benign (80% pleomorphic
adeoma) i.e. Rule of 80
Submandibular: 15% overall; 50% benign
Sublingual/Minor salivary gland: 5% overall; 40%
benign

Incidence of malignancy is higher in neoplasm of

minor salivary glands. i.e.
Parotid- 25%
Submandibular- 50%
Minor salivary gland- 75%

Risk factors for salivary

neoplasms
Low dose radiation exposure
Wood dust
Chemicals (leather tanning
industry)
Rubber industry
Nickel compound/alloy

Benign tumors
Pleomorphic adenoma
Warthins tumor
Oncocytoma
Lymphangioma
Haemangioma

Pleomorphic adenoma(mixed
tumor)
Mixed tumor: contains both
epithelial and mesenchymal
elements
Most common benign tumor of
salivary glands
Can arise from parotid,
submandibular
Parotid: usually arises superficial
lobe, tail
Encapsulated
Slow growing tumor

 Signs:
Swelling in front, below & behind ear
Raises ear lobule
Retromandibular groove is obliterated
Any swelling which raises ear lobule is due
to parotid gland neoplasm unless proved
otherwise
It sends pseudopods into surrounding gland
surgical excision of the tumor should
include normal tissue around it
Superficial parotidectomy

Oncocytoma (oxyphil adenoma)

Rare: 2.3% of benign salivary tumors
6th decade
Usually benign; malignant oncocytoma- less common

Major salivary glands: Parotid,Submandibular gland

Minor salivary glands: palate, buccal mucosa, tongue
Superficial parotidectomy

Warthins tumor(adenolymphoma)

Encapsulated
Exclusively in parotid gland
Parotid tail
Commonly seen btw 5th 7th
decade
Male: female (7:1)
About 7% of salivary gland
tumor
Usually Fluctuant, slow growing
10% bilateral
Histologically: epithelial &
lymphoid elements
Never malignant
Wide local excision

Hemangioma & lymphangioma

Haemangioma: Most common benign tumors
of the parotid in children
May involute spontaneously
Soft, painless and increase in size with crying
or straining
Surgical excision if do not regress
Lymphangioma:
Less common
Soft, cystic on palpation
Do not regress spontaneously surgical
excision

Malignant neoplasms
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Carinoma ex- pleomorphic adenoma
Adenocarcinoma
Squamous cell carcinoma
Non-hodgkins lymphoma

Mucoepidermoid carcinoma
Most common salivary gland malignancy
Not encapsulated
Commonly in parotid gland
Clinical features:
Slow growing
Facial nerve palsy
Presentation Low-grade: Slow growing, painless mass
High-grade: Rapidly enlarging, +/- pain
Treatment:
Total conservative parotidectomy

Adenoid cystic carcinoma(Cylindroma)

2nd most common salivary gland
malignancy
Slow growing
Infiltrates widely into the tissue
planes & muscles
Perineural spread
Commonly in submandibular
gland, sublingual or minor
salivary glands
Less commonly in parotid gland
Occasionally lymph node
metastasis
Local recurrence after surgical
excision(perineural and lymphatic
spread)

Adenoid Cystic Carcinoma of right hard

palate
Treatment
Radical parotidectomy
Post-operative radiotherapy
Wide local excision of palate: for tumors of
palate

Carcinoma ex-pleomorphic adenoma

Usually from preexisting pleomorphic
adenoma (only 1%
arise ab-initio)
Malignancy takes about
10 years to develop in
an adenoma

 Malignancy should be suspected when:-Rapid growth

-Facial nerve palsy
-Painful
-Skin infiltration
-Get fixed to massester muscletrismus
-Feels stony hard
-Presence of lymph nodes in neck

Adenocarcinoma & Squamous cell

carcinoma

Rare
Highly aggressive
Rapidly growing tumors
Local and distant metastases
Prognosis- very poor

Squamous cell ca (SCC): Rule out metastasis in

the parotid gland from neighbouring skin
cancer or other head and neck tumor

Parotid gland surgery

Landmarks for facial nerve during parotid surgery

1.Tympano-mastoid suture:
6-8 mm deep to this suture
2.Groove between mastoid & bony
EAC: bisected by facial nerve
3.Tragal pointer: 1 cm anteroinferomedial is facial nerve
3.Styloid process: lateral lies facial
nerve
4.Posterior belly of digastric:
superior & parallel lies facial
nerve

Complications of parotid surgery (5 Fs)

1. Flap necrosis: avoid acute bending(angle) of the
incision & use gentle retraction
2. Facial nerve palsy: nerve identification
3. Fluid collection: blood or seromadrain should
be kept
4. Fistula (salivary): duct should be ligated
5. Freys syndrome (gustatory sweating): in 10%
cases

Freys syndrome

Several months after parotid surgery

Sweating and flushing of the preauricular skin during
mastication
Auriculotemporal nerve provides both
-Parasympathetic innervation to Parotid gland
-Sympathetic innervation to Sweat glands & Subcutaneous
blood vessels
Neurotransmitter to both fibers: Acetylcholine
Freys syndrome is due to regrowth of parasympathetic
secretomotor fibers into distal cut ends of the
sympathetic fibers of skin
Whenever patients eats reflex salivation occurs, the skin
blood vessels dilate and sweat gland secretes

Management:
Reassurance
Aluminium chloride-antiperspirant, useful
astringent
Anticholenergics-topical eg glycopyrolate
Botulinum toxin A- injection into affected skin
Surgical:
Tympanic neurectomy: dennervation

Submandibular gland excision

Nerves likely to be injured during SMG
excision:1. Marginal mandibular nerve
2. Lingual nerve
3. Hypoglossal nerve

Thank you