Salivary glands diseases


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Oral & Maxillofacial Surgery
Fifth Year

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Salivary glands diseases

  1. 1. SALIVARY GLAND DISEASES Dr. Adel I. Abdelhady Assistant Professor College of Dentistry, Dammam University, KSA
  2. 2. Objectives n  n  n  n  n  n  By the end of 2 session the student will be able to: Know the applied anatomy of the SG Autonomic innervations of the SG and its effect function Inflammatory disorder of the SG Obstructive disorders SG neoplasm's . Clinical presentation, investigations. n  n  n  n  n  Epithelial tumors adenomas Carcinomas , adenoid cystic carcinoma , adenocarcinoma Non epithelial tumors , hemangioma and lymphangioma Potential complications during surgery or trauma Gustatory sweating
  3. 3. Major Salivary Gland
  4. 4. Parotid gland Largest salivary gland n  It is located in a compartment anterior to the ear and is invested by fascia that suspends the gland from the zygomatic arch. The parotid compartment contains the parotid gland, nerves, blood vessels, and lymphatic vessels, along with the gland itself Facial nerve bisects gland §  Superficial lobe , Deep lobe §  Superior to mandible anterior to angle of jaw and auricle §  Between SCM muscle and mandibular ramus
  5. 5. Parotid gland n  n  n  n  n  Relations Above: external auditory meats and TMJ Below: post belly digastric Anteriorly: mandible and masseter ms. Medially: styloid process and its muscles separate the gland from the internal jugular vein, internal carotid artery ,the last four cranial nerves, lateral wall of the pharynx
  6. 6. Deep Relations
  7. 7. Anatomy: Parotid Duct n  n  It is located approximately 1 cm below the zygoma and runs horizontally. It passes anteriorly and lie superficial to the masseter muscle and then penetrates the buccinator muscle to open intraorally n  It is 3 mm in diameter n  6cm in length
  8. 8. Submandibular Gland n  n  Large superficial lobe and a small deep lobe, that connect around the mylohyoid ms. Superficial lobe lies at the angle of the jaw, wedged bet the mandible and mylohyoid and overlapping the digastric ms.
  9. 9. Submandibular gland relations n  Superficially: n  The skin, the platysma, the capsule (deep fascia), the cervical branch of Facial Nerve, and the Facial Vein Deeply: the deep aspect lies against the mylohyoid for the most part. But posteriorly lies on the hyoglossus and comes in contact with the lingual and hypoglossal nerves. n  n  Both nerves lie on the hyoglossus as they pass forward to the tongue
  10. 10. Submandibular Duct n  n  n  n  Wharton’s duct passes forward along the superior surface of the mylohyoid adjacent to the lingual nerve. 2-4mm in diameter & about 5cm in length. It opens into the floor of the mouth thru a punctum. The punctum is a constricted portion of the duct to limit retrograde flow of bacterialaden oral fluids.
  11. 11. Sublingual glands The ducts of the sublingual glands are called Bartholin’s ducts. n  In most cases, Bartholin’s ducts consists of 8-20 smaller ducts of Rivinus. These ducts are short and small in diameter n 
  12. 12. Sublingual glands n  The ducts either open… n  individually into the FOM near the punctum of Wharton’s duct n  on a crest of sublingual mucosa called the plica sublingualis n  open directly into Wharton’s duct
  13. 13. Physiology& Saliva content n  Normal daily production is 1-1.5L n  Water 99,5% n  Organic compounds – mucin, amylase, lysozym, immunoglobulin A n  Anorganic compounds – HCO3-, I, K, Cl, Na, Ca, phosphates and others.
  14. 14. Physiology and Function n  n  About 45% is produced by the parotid gland, 45% by the submandibular glands, and 5% each by the sublingual and minor salivary glands. Saliva is produced at a low basal rate throughout the day, with flow increasing 10-fold during meals. Saliva functions to maintain lubrication of the mucous membranes and to clear food, cellular debris, and bacteria from the oral cavity.
  15. 15. Autonomic Innervations Parasympathetic Stimulation results in abundant, watery saliva with a decrease in amylase in saliva and an increase in amylase in the serum. n  Parasympathetic Interruption to salivary glands results in atrophy, while sympathetic interruption doesn’t cause a signifiant change. n 
  16. 16. Parasympathetic Innervation In the case of the parotid, parasympathetic fibers originate from CN IX n  In the case of the Submandibular and Sublingual glands, the parasympathetic fibers originate in CN VII n 
  17. 17. Sympathetic Innervation n  Stimulation by the sympathetic nervous system results in a scant, viscous saliva rich in solutes with an increase in amylase in the saliva and no change in amylase in the serum. n  n  n  n  For all of the salivary glands, these fibers originate in the Superior Cervical ganglion and travel with arteries to reach the glands: 1) External Carotid artery for the Parotid 2) Lingual artery for the Submandibular, and 3) Facial artery in the case of the Sublingual.
  18. 18. Investigation of the Salivary Glands
  19. 19. 1-Ultrasonography n  n  Non-invasive is most useful in the evaluation of deeply seated masses and is often helpful in distinguishing a solid mass from one that is cystic. This technique relies on the fact that different tissue densities result in different degrees of reflection or echo production of a beam of high-frequency sound waves.
  20. 20. 2-Sialography This technique relies on retrograde injection of a water soluble radioopaque fluid, also known as contrast medium, into the duct system of either the parotid or submandibular salivary gland. n  A plain radiograph is made, and the pattern of distribution of the contrast medium is assessed n 
  21. 21. Sialography “Sausage like” appearance of enlarged duct
  22. 22. 3-CT SCAN CT is a cross-sectional radiologic imaging technique that is particularly useful in the evaluation of bone lesions. n  Not only can the density and margins of the lesion in question be evaluated with this technique but cortical expansion and fine internal details can often be more readily appreciated compared with plain film images. Use of contrast media has extended the utility of this technique in areas of soft tissue pathology. n 
  23. 23. n Needle biopsy guided by CT scan can be employed for difficult-to-reach tumors such as parapharyngeal space neoplasms. n CT sialography, while often employed in the past, does not offer superior imaging to high-resolution CT scan or MRI alone and will rarely alter management.
  24. 24. 4-MRI & CT n  CT scan or MRI is useful for determining the extent of large tumors and for evaluating extraglandular extension. Additionally, CT scan or MRI is helpful in distinguishing an intraparotid deep-lobe tumor from a parapharyngeal space tumor and for evaluation of cervical lymph nodes for metastasis.
  25. 25. MRI Appearance of enlarged duct
  26. 26. Minor salivary gland neoplasm's, alternatively, often are more difficult to assess on examination, and use of preoperative CT scan or MRI is important for determining the extent of tumor, which otherwise is not clinically appreciable. n  This is particularly apparent for paranasal sinus salivary gland neoplasms, where skull base or intracranial extension may impact resectability. n 
  27. 27. 5-Radionuclide Imaging n  n  Radionuclide imaging relies on the specific uptake of any one of several isotopes by various types of tissues or cells. Localization of the isotope is determined by examining the patient with a gamma scintillation camera. The most commonly used isotope, technetium 99m pretechnetate, can demonstrate areas of high metabolic activity.
  28. 28. Radionuclide Studies Technetium 99m pretechnetate, is a radioisotope that decays and emits a gamma ray. Half life of 6 hours. n  It is useful in identifying inflammatory conditions such as osteomyelitis, areas of active skeletal lesions of fibrous dysplasia or metastatic disease
  29. 29. 6-Fine needle aspiration biopsy n  FNAB is performed using a syringe with a 20-gauge and after LA ,the needle is advanced into the mass , the plunger is activated to create a vacuum in the syringe the needle is moved back and forth throughout the mass with pressure maintained in the plunger , then pressure released the needle withdrawn , the cellular material was histologically examined
  30. 30. 7-SIALOCHEMISTRY n  Principally the concentration of Na and K which is normally change with salivary flow rate , any changes in the concentration of electrolyte is indicative of SG disease e.g. elevated Na concentration with a decreased K concentration is indicated of SG Sialadenitis
  31. 31. 8-Sialoendoscopy n  n  The SG endoscopic technique opens new horizons in the field of salivary gland diseases. Salivary gland stones and sialadenitis no longer are absolute indications for sialoadenectomy.
  32. 32. New technique Sialoendoscopy n  Diagnostic Sialendoscopy n  Interventional Sialendoscopy
  33. 33. Diagnostic Sialendoscopy
  34. 34. Intraductal instruments Endoscope
  35. 35. 8-Sialendoscopy Dilation Sialography Stenosis Endoscopy
  36. 36. Differentiating diagnosis n  Chronic recurrent parotitis n  SjÖgren syndrome
  37. 37. Salivary Gland Diseases
  38. 38. Salivary Gland Diseases n Functional disorders n Obstructive disorders n Non-neoplastic disorders n Neoplastic disorders
  39. 39. Functional Disorders n  Sialorrhea (Increase in saliva flow) n  Psychosis, mental retardation, certain neurological diseases, rabies, n  mercury poisoning n  Xerostomia (Decrease in saliva flow) n  Mumps, Sjogrens, syndrome, lupus, postirradiation n  Post surgical
  40. 40. Functional Disorders n  Mucocele n  Secondary to trauma n  70% occur in lower lip n  Excisional biopsy usually curative n  Ranula n  Sublingual salivary gland mucocele n  Treatment should include removal of sublingual gland
  41. 41. Mucocele n  n  Mucus is the exclusive secretory product of the accessory minor salivary glands and the most prominent product of the sublingual gland. The mechanism for mucus cavity development is extravasation or retention n  n  Secondary to trauma 70% occur in lower lip
  42. 42. Mucocele " " " " Extravasation is the leakage of fluid from the ducts or acini into the surrounding tissue. Extra: outside, vasa: vessel Retention: narrowed ductal opening that cannot adequately accommodate the exit of saliva produced, leading to ductal dilation and surface swelling, less common phenomenon. Lacks a true epithelial lining
  43. 43. Treatment of Mucocele Excision with strict removal of associated minor salivary glands n  Avoid injury to other glands during primary wound closure n 
  44. 44. Mucocele
  45. 45. Ranula n  Is a term used for mucoceles that occur in the floor of the mouth. n  The name is derived form the word rana, because the swelling may resemble the translucent underbelly of the frog.
  46. 46. Ranula n  n  n  Presents as a blue dome shaped swelling in the floor of mouth (FOM). They tend to be larger than mucocele & can fill the FOM & elevate tongue. Located lateral to the midline, helping to distinguish it from a midline dermoid cyst.
  47. 47. Plunging or Cervical Ranula Occurs when spilled mucin dissects through the mylohyoid muscle and produces swelling in the neck. n  Concomitant FOM swelling may or may not be visible. n  MRI of plunging ranula
  49. 49. Treatment of Ranula Marsupialization ( deroofing ) has fallen into disfavor due to the excessive recurrence rate of 60-90% n  Sublingual gland removal via intraoral approach n 
  50. 50. Obstructive SG Disorders Sialolithiasis /stone Sialolithiasis results in a mechanical obstuction of the salivary duct n  Is the major cause of unilateral diffuse parotid or submandibular gland swelling n 
  51. 51. Sialolithiasis Salivary calculi ( Stone ) The exact pathogenesis of sialolithiasis remains unknown. n  Thought to form via…. n  an initial organic nidus that progressively grows by deposition of layers of inorganic and organic substances. n  May eventually obstruct flow of saliva from the gland to the oral cavity.
  52. 52. Etiology Hypercalcemia…in rats only n  Xerostomic meds n  Tobacco smoking, positive correlation n  Smoking has an increased cytotoxic effect on saliva, decreases PMN phagocytic ability and reduces salivary proteins n 
  53. 53. Sialolithiasis Reasons of arising 1. Anatomy 2.Components of saliva Upwarding route n  Mucus protein n Longer duct n  Calcium content n Curve duct n 
  54. 54. Reasons sialolithiasis may occur more often in the SMG n  n  n  n  n  Saliva more alkaline Higher concentration of calcium and phosphate in the saliva Higher mucus content Longer curved duct Anti-gravity flow
  55. 55. Sialolithiasis " " " Obstruction Phenomenon :Acute ductal obstruction may occur at meal time when saliva producing is at its maximum, the resultant swelling is sudden and can be painful. Gradually reduction of the swelling can result but it recurs repeatedly when flow is stimulated. This process may continue until complete obstruction and/or infection occurs.
  56. 56. Sialolithiasis n  n  The higher frequency of sialolithiasis in the submandibular gland is associated with several factors: the pH of saliva (alkaline in the submandibular gland, acidic in the parotid gland); the viscosity of saliva (more mucous in the submandibular gland); and the anatomy of the Wharton’s duct (the duct of the submandibular salivary gland opening into the mouth at the side of the lingual frenum is an uphill course .Stones are rarely found in the sublingual gland.
  57. 57. Sialolithiasis
  58. 58. Traditional treatment n  Intraoral route Sialolithotomy n  Sialadenectomy via external approach
  59. 59. Stone Composition n  Organic; often predominate in the center n  Glycoproteins n  Mucopolysaccarides n  Bacteria! n  Cellular n  debris Inorganic; often in the periphery n  Calcium carbonates & calcium phosphates in the form of hydroxyapatite
  60. 60. Other characteristics: Despite a similar chemical make-up, 80-90% of SMG calculi are radio-opaque 50-80% of parotid calculi are radiolucent n  30% of SMG stones are multiple 60% of Parotid stones are multiple n 
  61. 61. Submandibular Gland Lithiasis n  n  Diagnosis Clinical examination , clinial feature and radiographic examination Pain and sudden enlargement of gland while eating n  Palpation of stone submandibular duct n  Occlusal radiograph (80%) n 
  62. 62. Diagnostics: Plain occlusal film Effective for intraductal stones, while…. n  intraglandular, radiolucent or small stones may be missed. n 
  63. 63. Submandibular Gland Lithiasis n  Treatment n  Can be removed transorally if in duct and easily palpable n  If in gland and gland is damaged, then gland should be removed
  64. 64. Plain radiographs One Two Three
  65. 65. Traditional treatment n  Intraoral route n  Sialadenectomy via external approach
  66. 66. Manifestations n  Intermittent swelling of the gland n  Aggravating with taking food n  Acute infection
  67. 67. Transoral vs. Extraoral Removal Indication of Transoral Removal (Sialolithotomy) n  if a stone can be palpated thru the mouth, it can be removed trans-orally (TO) n  Or if it can be visualized on a true central occlusal radiograph, it can be removed TO. n  Finally, if it is no further than 2cm from the punctum, it can be removed TO.
  68. 68. Posterior Stones n  n  n  n  Deeper submandibular stones (~15-20% of stones) may best be removed via sialadenectomy. Some surgeons say can still remove transorally, but should be done via general anesthetic. Floor of mouth (FOM) opened opposite the first premolar, duct dissected out, lingual nerve identified. Duct opened & stone removed, FOM approximated.
  69. 69. Gland excision indicated Very posterior stones n  Intra-glandular stones n  Failed transoral approach n 
  70. 70. Gland excision Sialoadenectomy While some believe that a gland with sialolithiasis is no longer functional, a recent study on SMGs removed due to sialolithiasis found there was no correlation between the degree of gland alteration and the number of infectious episodes. n  50% of the glands were histopathologically normal or close to normal n  A conservative approach to the gland/stone seems to be justified n 
  71. 71. Salivary Gland Infections Acute bacterial sialdenitis n  Chronic bacterial sialdenitis n  Viral infections (Mumps) n 
  72. 72. Sialadenitis " Awareness of salivary gland infections was increased in 1881 when President Garfield died from acute parotitis following abdominal surgery and associated systemic dehydration.
  73. 73. Sialadenitis Acute infection more often affects the major glands than the minor glands
  74. 74. Pathogenesis " " " Causes: 1. Retrograde contamination of the salivary ducts and parenchymal tissues by bacteria inhabiting the oral cavity. 2. Stasis of salivary flow through the ducts and parenchyma promotes acute suppurative infection.
  75. 75. Acute Suppurative More common in parotid gland. n  Suppurative parotitis, surgical parotitis, post-operative parotitis, surgical mumps, and pyogenic parotitis. n  The etiologic factor most associated with this entity is the retrograde infection from the mouth. n  20% cases are bilateral n 
  76. 76. Risk Factors for Sialadenitis Systemic dehydration (salivary stasis) n  Chronic disease and/or immunocompromise n  n  Liver failure n  Renal failure n  DM, hypothyroid n  Elderly, debilitated bed reddened, malnourished, dehydrated patient
  77. 77. Risk Factors continued… n  n  n  n  n  Neoplasms (pressure occlusion of duct) Sialectasis (salivary duct dilation) increases the risk for retrograde contamination. Is associated with cystic fibrosis and pneumoparotitis Extremes of age Poor oral hygiene Calculi, duct stricture
  78. 78. Complex picture n  There must be other factors at work….. n  Sialolithiasis can produce mechanical n  obstruction of the duct resulting in salivary stasis and subsequent gland infection. Calculus formation is more likely to occur in SMG duct (85-90% of salivary calculi are in the SMG duct) However, the parotid gland remains the MC site of acute suppurative infection.
  79. 79. Acute Suppurative Parotitis - History n  n  n  n  Sudden onset of erythematous swelling of the pre/post auricular areas extend into the angle of the mandible. Male above 60 affected more than female Staphylococcus aureus is the most causative organism hence it is colonizes around ductal orifice Decrease salivary flow
  80. 80. Clinical Presentation Rapid onset of the preauricular swelling n  Erythema n  Pain n  Palpation ( milking ) of the involved gland will reveal no flow or elicit a thick , purulent discharge from the orifice of the duct n 
  81. 81. Bacteriology n  Purulent saliva should be sent for culture. n  Staphylococcus aureus is most common n  Streptococcus pnemoniae and S.pyogenes n  Haemophilus Influenzae also common
  82. 82. Lab Testing n  n  n  n  n  n  Parotitis is generally a clinical diagnosis However, in critically ill patients further diagnostic evaluation may be required Elevated white blood cell count Serum amylase generally within normal If no response to antibiotics in 48 hrs can perform MRI, CT or ultrasound to exclude abscess formation Can perform needle aspiration of abscess
  83. 83. Treatment of Acute Sialadenitis Symptomatic and supportive care n  Intravenous fluid hydration n  Warm compresses, maximize OH, give sialogogues (lemon drops) n  External salivary gland massage if tolerated n 
  84. 84. Treatment of Acute Sialadenitis/Parotitis Antibiotics! n  70% of organisms produce B-lactamase or penicillinase n  Need B-lactamase inhibitor like Augmentin or Unasyn or second generation cephalosporin n  Can also consider adding metronidazole or clindamycin to broaden coverage n 
  85. 85. Differentiating diagnosis n  Tumor in sublingual gland n  Tumor in submandibular gland n  Space infection in submandibular region n  Lymphadenopathy
  86. 86. Thanks for your attention
  87. 87. Minor Salivary Glands n  From 600-1000 minor salivary glands are located throughout the paranasal sinuses, nasal cavity, oral mucosa, hard and soft palate, pharynx, and larynx. Each gland is a discrete unit with its own duct opening into the oral cavity.
  88. 88. SALIVARY GLAND NEOPLASMS 2 Dr. Adel I. Abdelhady BDS, Msc, (Tanta, Egypt), PhD (Egypt,USA) Oral and Maxillofacial Surgery Dept. College of Dentistry, King Faisal University, KSA
  89. 89. Salivary Glands Neoplasms n  n  Neoplasms arising in the salivary glands are relatively rare, yet represent a wide variety of benign and malignant histological subtypes The incidence of salivary gland neoplasms as a whole is approximately 1-2 per 100,000 individuals in the US. An estimated 750 deaths related to salivary gland tumors occur annually. Salivary gland neoplasms make up 1% of all head and neck tumors
  90. 90. n  Salivary gland neoplasms present most commonly in the sixth decade of life. Malignant lesions typically present after age 60, while benign lesions usually present after age 40. Benign neoplasms occur more frequently in women, but malignant tumors are distributed equally between the sexes.
  91. 91. n  n  n  Among salivary gland neoplasms, 80% arise in the parotid glands, 10-15% arise in the submandibular glands, and the remainder occur in the sublingual and minor salivary glands The most common tumor of the parotid gland is the pleomorphic adenoma, which represents about 60% of all parotid neoplasms . Almost half of submandibular gland neoplasms and the majority of sublingual and minor salivary gland tumors are malignant.
  92. 92. n  Salivary gland neoplasms are rare in children. Most tumors (65%) are benign, with hemangiomas being the most common, followed by pleomorphic adenomas. In children, 35% of salivary gland neoplasms are malignant. Mucoepidermoid carcinoma is the most common salivary gland malignancy in children
  93. 93. History of the Mass or Swelling Initial history should focus on n  the presentation of the mass, n  growth rate, n  changes in size or symptoms with meals, n  facial weakness or asymmetry, and n  associated pain. n  A thorough general history will give insight into possible inflammatory, infectious, neoplastic or autoimmune etiologies
  94. 94. History n  A thorough history is important in managing patients with suspected salivary gland neoplasms. A diverse variety of pathologic processes, including infectious, autoimmune, and inflammatory diseases, can affect the salivary glands and may masquerade as neoplasms. While most masses of the parotid gland ultimately will be diagnosed as true neoplasms, submandibular gland enlargement most commonly is secondary to chronic inflammation and calculi.
  95. 95. n  n  The majority of patients with salivary gland neoplasms present with a slowly enlarging painless mass. Parotid neoplasms most commonly occur in the tail of the gland. Submandibular neoplasms often present with diffuse enlargement of the gland, while sublingual tumors will produce a palpable fullness in the floor of the mouth
  96. 96. n  n  n  n  Minor salivary gland tumors will have a varied presentation depending on the site of origin. Painless masses on the palate or floor of mouth are the most common presentation of minor salivary neoplasm. Laryngeal salivary gland neoplasms may produce airway obstruction, dysphagia, or hoarseness. Minor salivary tumors of the nasal cavity or paranasal sinus can present with nasal obstruction or sinusitis. Lateral pharyngeal wall protrusions with resultant dysphagia and muffled voice should raise suspicion of a parapharyngeal space neoplasm.
  97. 97. Clinical Examination n  n  n  n  Physical examination : of salivary gland masses should occur in the setting of a thorough general head and neck examination. Note size, mobility, fixation to surrounding structures, tenderness, and extent of the mass. Perform bimanual palpation of the lateral pharyngeal wall for deep lobe parotid tumors to assess for parapharyngeal space extension. Similarly, bimanual palpation for submandibular and sublingual masses will reveal the extent of the mass and will assess fixation to surrounding structures. Pay attention to surrounding skin and mucosal sites, which drain to the parotid and submandibular lymphatics. Regional metastases from skin or mucosal malignancies may present as salivary gland masses. A careful neurologic examination focusing on the cranial nerves will give clues as to neural infiltration and extent of malignant lesions.
  98. 98. Facial paralysis: n  indicates malignancy. The significance of painful salivary gland masses is not entirely clear. Pain may be a feature associated with both benign and malignant tumors. Pain may arise from suppuration or hemorrhage into a mass or from infiltration of a malignancy into adjacent tissue .Facial paralysis could also occur in non malignant condition such as acute suppurative parotitis
  99. 99. SG EXAM. Bimanual palpation
  100. 100. Salivary glands Benign Tumours n  n  n  n  n  n  n  Comprise 3% - 6% of all head & neck tumours Pleomorphic Adenoma Commonest tumour (53% - 71%) Slowly growing, painless, solitary, firm, smooth, moveable without nerve involvement Both mesenchymal/epithelial elements FNA, CT, MRI Superficial parotidectomy
  101. 101. Classification of Salivary Gland Tumors n  Adenomas (Epithelial) n  Pleomorphic adenoma n  Monomorphic adenoma n  Adenolymphoma n  Oxyphilic adenoma
  102. 102. Salivary Gland Tumors n  n  Mucoepidermoid tumor Acinic cell tumor
  103. 103. Mixed SG tumor
  104. 104. SG Neoplasm
  105. 105. Pleomorphic Adenoma ( BENIGN TUMOUR ) n  Pleomorphic adenoma is the most common n  n  benign salivary tumor at all sites. Approximately 80% of all pleomorphic adenomas occur in the parotid, and despite their slow growth they can become extremely large if neglected. This tumor is thought to arise from both salivary gland ducts and myoepithelial cells and is a true “mixed tumor.” Because of its derivation, can occur, from cellular, glandular, and myxoid types to cartilagenous and histologically, many different patterns even ossified forms. These features can be seen in different areas of the same tumor, accounting for its name, pleomorphic (Greek for many forms).
  106. 106. n  Plemorphic adenoma is one of the very few tumors that can undergo change from benign to malignant . Mixed SG tumors is poorly encapsulated and had a tendency toward local recurrence if only enucleated .
  107. 107. MIXED TUMORS
  108. 108. Salivary Glands Tumours Warthin’s tumour(adenolymphoma, papillary cystadenoma lymphomatosum) n  6% - 10% n  Benign, bilateral, parotid gland only, n  Older age group n  Superficial location n  Malignant potential non existent n 
  109. 109. Warthin’s Tumors (Adenolymphoma ) This benign tumor is almost exclusively found in the parotid. It occurs mostly in men and is more common in smokers. It is thought to derive from salivary duct cells that are entrapped in lymph nodes during embryonic development. n  The tumor consists of large cystic spaces with a surrounding columnar epithelium and a stroma of lymphocytes. Surgically these tumors may be multiple in one parotid gland or bilateral, or involve lymph nodes adjacent to the parotid gland. n 
  110. 110. Salivary Glands n  Mixed malignant tumour Long standing pleomorphic adenoma n  Older age group n  Worse prognosis n  Lymph node mets 15% n  Distant mets 30% n  5 year survival 40% - 50% n  15% year survival 20% n 
  111. 111. Salivary Glands MalignantTumours Locally aggressive n  Grow along neural pathways, may access skull base and brain eventually adenoid cystic carcinoma n  Also lymphatic and haematogenous spread n 
  112. 112. Salivary Galnds Malignant Tumours n  n  n  n  n  n  n  n  Mucoepidermoid Carcinoma Commonest malignant tumour 50% of all salivary gland malignancies Parotid involved in 40% - 50% 75% are low grade & have good prognosis 1 – 5 year survival 85% High grade mucoepidermoid carcinomas invade locally, spread regionally & distant metastasizes 5 year survival drops 30%
  113. 113. Salivary Gland Tumors n  Carcinomas n  Adenoid cystic carcinoma n  Adenocarcinoma n  Mucoepidermoid carcinoma n  Carcinoma in EXpleomorphic adenoma Adenocarcinoma
  114. 114. Malignant Tumors Mucoepidermoid carcinoma (MEC) is the most common malignant salivary gland neoplasm in both adults and children, and the most common salivary gland cancer of the parotid and minor salivary glands. This tumor can be of low grade or high grade depending on its histology. Low-grade MECs have multiple macrocysts and abundant mucus-producing cells. n  High-grade varieties have multiple squamous cells and very few mucus-producing cells or cysts, n 
  115. 115. n  The respective ratio of mucus producing cells to squamous cells will determine the clinical aggressiveness of the tumor . Lowgrade MECs can be very slow growing and nonmetastasizing, and can generally behave like a benign tumor. n  High-grade MECs can exhibit aggressive growth and invasion resulting in widespread metastasis and death. Highgrade tumors usually show increased pleomorphism and meiotic figures. High-grade lesions may metastasize to cervical lymph nodes or spread hematogenously to the lung, liver, and bone.
  116. 116. n  n  The infiltrative nature of this lesion and the frequency of perineural involvement with spread along the nerve mandate wide resection margins. Perineural spread is a bad prognostic sign for both local recurrence and distant metastasis. Clinical and radiologic examination of this tumor frequently underestimate its true extent, and follow-up of 15 to 20 years is required as late recurrences occur
  117. 117. Low-Grade Adenocarcinoma n  Low-grade adenocarcinoma occurs almost exclusively in the minor salivary glands and is second only to mucoepidermoid carcinoma at these sites. It arises from terminal duct cells n  local recurrence will occur with inadequate excision due to perineural involvement .
  118. 118. Salivary Glands n  Adenocystic carcinoma (Cylindroma) n  Commonly involves submandibular (35% - 40%), only 7% of parotid malignancies Slowly growing Perineural invasion 30% lymph node mets, 50% distant mets 5 year survival 75% 10 year survival 30% 20 year survival 13% n  n  n  n  n  n 
  119. 119. Salivary Glands n  Acinic cell carcinoma Low grade n  Slow growing n  10% of malignant parotid tumour n  Lymph node mets 10% n  Aggressive tumours n  Radical parotidectomy n 
  120. 120. Salivary Glands n  Squamous cell carcinomas Infrequent occurrence 1% - 5% n  May have skin infiltration n  Total radical parotidectomy n 
  121. 121. Carcinosarcoma n  Gross pathology n  n  n  n  n  Poorly circumscribed Infiltrative Cystic areas Hemorrhage, necrosis Calcification
  122. 122. Squamous Cell Carcinoma n  n  Gross pathology n  Unencapsulated n  Ulcerated fixed
  123. 123. Incidence of Malignancy According to Site Sublingual 70% n  Submandibular 40% n  Parotid 20 % n 
  124. 124. Parotid Gland n  n  Site of Tumor The surgical principles of treating parotid tumors are dictated by the histopathology of the tumor and the need to preserve the facial nerve. Diagnostic imaging with computed tomography (CT) or magnetic resonance (MR) is desirable for superficial lobe tumors but is essential for suspected deep-lobe neoplasms, especially those with a parapharyngeal component. Since 80% of parotid tumors are benign and 80% of these are pleomorphic adenomas, a solitary mass in the parotid with no features of malignancy is most likely . Open biopsy of such a mass is therefore contraindicated as this will rupture the “capsule” and increasing the complexity of subsequent surgery and chances of recurrence.
  125. 125. Fine-needle aspiration biopsy (FNAB) for cytology is the preferred method of diagnosis. Clinically only one-third of malignant tumors will have symptoms or signs of malignancy, such as pain, ulceration of skin, facial nerve palsy, or metastatic cervical nodes.
  126. 126. n  n  n  Thus virtually all parotid tumors will initially be treated as benign unless FNAB shows definite malignancy or there is clinical evidence of malignancy The majority of tumors occur in the superficial lobe, and superficial lobectomy with preservation of the facial nerve has been the standard operation for many years. . Superficial lobectomy is suitable for benign and lowgrade malignant tumors, and even in high-grade malignancies only branches of the nerve that are actually infiltrated will be sacrificed. If the nerve or portions of it have to be resected, immediate grafting is recommended. In deep-lobe tumors a total parotidectomy is performed, with the superficial lobe being dissected first to expose the nerve
  127. 127. Good margins with surrounding normal salivary gland tissue are more difficult to obtain on deep-lobe tumors, which tend to be large as they are often detected late. In highgrade tumors, surrounding tissues such as skin, masseter, and mandible may require sacrifice, as dictated by the need to obtain clear margins. n  In these instances consideration should be given to neck dissection.Where clinically positive nodes are present, a modified radical neck dissection is usually the operation of n  In high-grade tumors postoperative radiation therapy is usually indicated. Chemotherapy has not been shown to convey a survival benefit for these lesions. n 
  128. 128. n  A, Large neglected pleomorphic adenoma of the left parotid gland. B, Axial computed tomography scan showing tumor in the superficial lobe. C, Operative photograph showing superficial parotidectomy with initial dissection of the upper and lower branches of the facial nerve trunk.
  129. 129. Submandibular Gland n  n  50% of tumors will be malignant, adenoid cystic carcinoma being the most common. In benign neoplasms removal of the submandibular gland with an extracapsula dissection of the tumor and 2 to 3 mm of surrounding soft tissue is sufficient. If indicated the overlying platysma superficially and the mylohyoid muscle deeply will be excised. In most malignant tumors with N0 necks, the cervical incision necessary for removal of level I will dictate extending levels I to III.
  130. 130. n  n  The adenoid cystic carcinoma does not usually metastasize via the lymphatics; this to a supraomohyoid neck removing instead it spreads hematogenously and neck dissection may not be indicated. The mandibular branches of the facial, lingual, and hypoglossal nerves are all in close relation to the submandibular gland. If these nerves appear to be involved by cancer, they should be traced until the nerve appears normal.After resection, frozen sections should be sent from the cut nerve trunk to confirm clearance, although “skip” lesions do occur. Radiation may be useful postoperatively.
  131. 131. n  Larg pleomorphic adenoma of the right palate.
  132. 132. The Retromolar Fossa n  Although this is a relatively unusual site for minor salivary gland tumors, virtually 100% are malignant and are low-grade mucoepidermoid carcinomas. The surgeon should be aware that a cystic soft tissue mass distal to the third molar, with or without radiographic mandibular involvement, is unlikely to be a mucocele, and incisional biopsy should be undertaken to confirm the diagnosis. .
  133. 133. Intrabony Tumors n  Although intrabony (central) salivary gland tumors are rare, the vast majority are malignant lowgrade mucoepidermoid carcinomas.13 These are mostly seen in the third molar region of the mandible and are frequently multilocular. n  The tumors are often diagnosed radiologically as ameloblastomas, or odontogenic keratocysts. Resection with a 1 cm margin and sacrifice of the inferior alveolar nerve and overlying soft tissue in areas of perforation are required.
  134. 134. n  Neck dissection is usually not necessary, but if the neck has been opened widely for mandibular resection a supraomohyoid neck dissection can be undertaken. A reconstruction plate is placed and either primary reconstruction with a fibular or deep circumflex iliac artery microvascular flap or secondary posterior iliac crest corticocancellous reconstruction may be used
  135. 135. The Sublingual Gland n  n  . Less than 1% of all salivary gland tumors occur in the sublingual gland but almost 100% are malignant. Surgical approach will be dictated by the histology and required access for margins. In most cases we have preferred a lip split and mandibulectomy to allow good visualization of the tumor, direct examination of the mandibular lingual cortical plate, and the ability to trace back the lingual nerve when necessary Other Intraoral Sites n  Interestingly, the proportion of benign to malignant tumors varies according to site, with virtually all upper lip tumors being benign and a higher proportion of lower lip tumors being malignant. Salivary gland neoplasms of the tongue and buccal mucosa tend to be malignant and require wide soft
  136. 136. n  Recurrent lowgrade adenocarcinoma of the palate postmaxillectomy with invasion of the orbital floor and orbital fat.
  137. 137. Smooth mucosal covarge Ulcerated mucosal coverage
  138. 138. Carcinoma of ex-plemorphic adenoma Carcinoma of ex-plemorphic adenoma