Salivary Gland Tumors Tumors of the salivary gland are relatively uncommon and represent less than 2% of all

head and neck neoplasms. The major salivary glands are the parotid, submandibular, and sublingual glands. Minor salivary glands are found throughout the submucosa of the upper aerodigestive tract with the highest density found within the palate. Eighty-five percent of salivary gland neoplasms arise within the parotid gland (Fig. 18-46). The majority of these neoplasms are benign, with the most common histology being pleomorphic adenoma (benign mixed tumor). In contrast, approximately 50% of tumors arising in the submandibular and sublingual glands are malignant. Tumors arising from minor salivary gland tissue carry an even higher risk for malignancy (75%). Fig. 18-46.

Example of a tumor in the parotid with the pattern of the facial nerve and associated anatomy. m. = muscle; n. = nerve; v. = vein. Salivary gland tumors are usually slow growing and well circumscribed. Patients with a mass and findings of rapid growth, pain, paresthesias, and facial nerve weakness are at increased risk of harboring a malignancy. The facial nerve, which separates the superficial and deep lobes of the parotid, may be directly involved by tumors in 10 to 15% of patients. Additional findings ominous for malignancy include skin invasion and fixation to the mastoid tip. Trismus suggests invasion of the masseter or pterygoid muscles.85 Submandibular and sublingual gland tumors present as a neck mass or floor of mouth swelling, respectively. Malignant tumors of the sublingual or submandibular gland may invade the lingual or hypoglossal nerves, causing paresthesias or paralysis.86 Bimanual examination is important for determining the size of the tumor and possible fixation to the mandible or involvement of the tongue. Minor salivary gland tumors present as painless submucosal masses and are most frequently seen at the junction of the hard and soft palate. Minor salivary gland tumors arising in the prestyloid parapharyngeal space may produce medial displacement of the lateral oropharyngeal wall and tonsil. The incidence of metastatic spread to cervical lymphatics is variable and depends on the histology, primary site, and stage of the tumor. Parotid gland malignancies can metastasize to the intra- and periglandular nodes. The next echelon of lymphatics for the parotid is the upper jugular nodal chain. Although the risk of lymphatic metastasis is low for most salivary gland malignancies, lesions that are considered high grade or that demonstrate perineural invasion have a higher propensity for regional spread. Tumors arising in patients of advanced age also tend to have more aggressive behavior. Initial nodal drainage for the submandibular gland is the level Ia

and Ib lymph nodes and submental nodes followed by the upper and midjugular nodes. Extraglandular extension of tumor and lymph node metastases are adverse prognostic factors for submandibular gland tumors. Diagnostic imaging is standard for the evaluation of salivary gland tumors. MRI is the most sensitive study to determine soft-tissue extension and involvement of adjacent structures. Unfortunately, imaging studies lack the specificity for differentiating benign and malignant neoplasms. Diagnosis of salivary gland tumors is frequently aided by the use of FNA. In the hands of an experienced cytologist familiar with salivary gland pathology, FNA can provide an accurate preoperative diagnosis in 70 to 80% of cases. This can help the operative surgeon with treatment planning and patient counseling, but should be viewed in the context that a more extensive procedure may be ultimately required. The final histopathologic diagnosis is confirmed by surgical excision. Benign and malignant tumors of the salivary glands are divided into epithelial, nonepithelial, and metastatic neoplasms. Benign epithelial tumors include pleomorphic adenoma (80%), monomorphic adenoma, Warthin's tumor, oncocytoma, or sebaceous neoplasm. Nonepithelial benign lesions include hemangioma, neural sheath tumor, and lipoma. Treatment of benign neoplasms is surgical excision of the affected gland or, in the case of the parotid, excision of the superficial lobe with facial nerve dissection and preservation. The minimal surgical procedure for neoplasms of the parotid is superficial parotidectomy with preservation of the facial nerve. Enucleation of the tumor mass is not recommended because of the risk of incomplete excision and tumor spillage. Tumor spillage of a pleomorphic adenoma during removal can lead to problematic recurrences. Malignant epithelial tumors range in aggressiveness from low to high grade. Their behavior depends on tumor histology, degree of invasiveness, and the presence of regional metastasis. The most common malignant epithelial neoplasm of the salivary glands is mucoepidermoid carcinoma. The low-grade mucoepidermoid carcinoma is composed of largely mucin-secreting cells, whereas in high-grade tumors, the epidermoid cells predominate. High-grade mucoepidermoid carcinomas resemble nonkeratinizing squamous cell carcinoma in their histologic features and clinical behavior. Adenoid cystic carcinoma, which has a propensity for neural invasion, is the second most common malignancy in adults. Skip lesions along nerves are common and can lead to treatment failures because of the difficulty in treating the full extent of invasion. Adenoid cystic carcinomas have a high incidence of distant metastasis, but display indolent growth. It is not uncommon for patients to experience lengthy survival despite the presence of disseminated disease. The most common malignancies in the pediatric population are mucoepidermoid carcinoma and acinic cell carcinoma. For minor salivary glands, the most common malignancies are adenoid cystic carcinoma, mucoepidermoid carcinoma, and low-grade polymorphous adenocarcinoma. Carcinoma ex pleomorphic adenoma is an aggressive malignancy that arises from a pre-existing benign mixed tumor. The primary treatment of salivary malignancies is surgical excision. In this setting, basic surgical principles include the en bloc removal of the involved gland with preservation of all nerves unless directly invaded by tumor. For parotid tumors that arise in the lateral lobe, superficial parotidectomy with preservation of CN VII is indicated. If the tumor extends into the deep lobe

of the parotid, a total parotidectomy with nerve preservation is performed. Although malignant tumors may abut the facial nerve, if a plane of dissection can be developed without leaving gross tumor, it is preferable to preserve the nerve. If the nerve is encased by tumor (or is noted to be nonfunctional preoperatively) and preservation would result leaving gross residual disease, nerve sacrifice should be considered. The removal of submandibular malignancies includes en bloc resection of the gland and submental and submandibular lymph nodes. Radical resection is indicated with tumors that invade the mandible, tongue, or floor of mouth. Therapeutic removal of the regional lymphatics is indicated for clinical adenopathy or when the risk of occult regional metastasis exceeds 20%. High-grade mucoepidermoid carcinomas, for example, have a high risk of regional disease and require elective treatment of the regional lymphatics. When gross nerve invasion is found (lingual or hypoglossal), sacrifice of the nerve is indicated with retrograde frozen section biopsies to determine the extent of involvement. If the nerve is invaded at the level of the skull base foramina, a surgical clip may be left in place to mark the area for inclusion in postoperative radiation fields. The presence of skip metastases in the nerve with adenoid cystic carcinoma makes recurrence common with this pathology. Postoperative radiation treatment plays an important role in the treatment of salivary malignancies. The presence of extraglandular disease, perineural invasion, direct invasion of regional structures, regional metastasis, and high-grade histology are all indications for radiation treatment. Reconstruction in Head and Neck Surgery Defects of soft tissue and bony anatomy of the head and neck can occur after oncologic resection. Tumor surgery frequently necessitates removal of structures related to speech and swallowing. Loss of sensation and motor function can produce dysphagia through impairment of food bolus formation, manipulation, and propulsion. Removal of laryngeal, tongue base, and hypopharyngeal tumors can lead to impairment in airway protective reflexes and predispose to aspiration. Cosmetic deformities that result from surgery can also significantly impact the quality of life of a patient. Current surgical management of head and neck tumors requires restoration of form and function through application of contemporary reconstruction techniques. Basic principles of reconstruction include attempting to replace resected tissue components (bone, skin, soft tissue) with tissue with similar qualities. However, restoring a patient's functional capacity does not always require strict observation of this rule. The head and neck reconstructive surgeon must consider a patient's preoperative comorbidities and anatomy when constructing a care plan. A stepladder analogy has been used to describe the escalation in complexity of reconstructive options in the repair of head and neck defects. It is important to remember that the most complex procedure is not always the most appropriate. Progression for closure by secondary intention, primary closure, skin grafts, local flaps, regional flaps, and free-tissue transfer flaps (free flaps) run the gamut of options available. The most appropriate reconstructive technique used is based on the medical condition of the patient, the location and size of the defect to be repaired, and the

functional impairment associated with the defect. Small defects of the skin of the medial canthus, scalp, and nose may be allowed to heal by secondary intention with excellent cosmetic and functional results. When considering primary closure, the excision should be placed in the lines of relaxed skin tension and should attempt to not distort surrounding anatomy such as the hairline, eyelids, or lips.