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

• Warthin’s 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 from its tail,

deep lobe

• 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
 Warthin’s tumor(adenolymphoma)
• Encapsulated
• Exclusively in parotid gland
• Parotid tail
• Commonly seen btw 5 th – 7 th 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-hodgkin’s 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)
• 2 nd 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
 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 pre-existing
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 muscletrismus
-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 anteroinfero-

medial 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 F’s)
1. Flap necrosis: avoid acute bending(angle) of the
incision & use gentle retraction

2. Facial nerve palsy: nerve identification

3. Fluid collection: blood or seroma drain should be

kept

4. Fistula (salivary): duct should be ligated

5. Frey’s syndrome (gustatory sweating) : in 10% cases

 Frey’s 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

Frey’s 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