Salivary gland tumours

1. DISORDERS OF SALIVARY GLAND
DR.K.SENTHILKUMAR
SENIOR ASST PROFESSOR
MMC & RGGGH.CHENNAI.

2. PAROTID GLAND
• Between mandible, mastoid and base of skull
• Present over the masseter muscle , over carotid sheath , 11th and 12th
nerve.
STRUCTURES RELATED :
• Facial nerve
• Maxillary artery
• Retromandibular vein
• Lymph nodes

3. CONGENITAL DISORDERS OF PAROTID:
• Agenesis
• Duct ectasia
• Parotid fistula
INFLAMMATORY :
VIRAL :
• Mumps caused by paramyxo virus
• Acute painful swelling
• m/c in children
• Spreads through air droplet
• Prodrome is seen for 1-2 days with fever, nausea, headache
• Resolves in 5-10 days
COMPLICATIONS :
• Seen in adults
• Orchitis, oophritis, pancreatitis, sensorineural deafness, meningoencephalitis
• Also caused by cocksackie A/B virus, parainfluenza 1/3 virus

4. BACTERIAL INFECTION :
Seen in old / dehydrated / post surgical patients
Decreased salivary secretion
Ascending infection from duct into parenchyma of gland
Tender , painful parotid swelling
FEATURES:
Pain more during food intake
INTRA ORAL : pus pointing at the papillae
ORGANISM : Staph aureus, streptococcus virdans
Treatment : antibiotics , adequate hydration and oral hygiene

5. PAROTID ABCESS :
• Result of acute bacterial sialadenitis
• Predisposing factors include Reduced salivary flow, dehydration,
starvation, sepsis, major surgery, radiotherapy, poor oral hygiene
• Due to thick faacia fluctuation presents very late.
• Most common organism – Staphylococcus aureus
• Symptoms- Fever, Malaise, Pain, Trismus.
• O/E: Red, tender, warm, firm swelling with brawny induration and
palpable ,tender cervical lymph nodes
• Pus/cloudy turbid saliva from the duct opening.
• Patient may present with septicemia, severe trismus, rupture into
EAC

6. TREATMENT :
• Antibiotic therapy according to culture report
• Incision and drainage under general anaesthesia
• BLAIR’S incision ( vertical skin incision in front of tragus) , sheath is
opened horizontally and pus is drained using sinus forceps
• Proper hydration, mouth wash using povidone iodine, good nutrition
helps in recovery.

7. PAROTID FISTULA :
• From parotid gland or duct or ductules
• Open inside the mouth as internal fistula or onto skin as external
fistula
• Fistula from duct has profuse discharge , from the gland has minimal
discharge
CAUSES :
• After superficial parotidectomy
• After rupture or drainage of parotid abcess
• After biopsy
• Trauma
• Recurrance of malignant tumor

8. From gland :
• After parotidectomy, arises from the raw area
• Mild and symtoms subside in 1month with anti cholinergic drugs
• Jacobsons tympanic neurectomy completely stops the secretion
From duct :
• Profuse and persistent
• After parotidectomy
• Hence duct has to be ligated as far as possible anteriorly
• If common duct is ligated , deep lobe atrophies but doesn’t form
a fistula
CLINICAL FEATURES:
• Discharging fistula in the parotid region of the face, more on
eating
• Tenderness, induration
• Trismus

9. DIAGNOSIS: Sialography
CT fistulogram
MRI
TREATMENT
• Anticholinergics
• Radiotherapy
• Exploration
• NEWMAN SEABROCKS OPERATION – probe inserted into duct and
fistula, fistulous tract removed, stent placed, duct sutured, stent
removed after 3 weeks
• Total conservation parotidectomy done in intractable cases

10. RECURRENT PAROTITIS OF CHILDHOOD:
• In children of 3-6 years age
• Clinically : sudden swelling, fever, malaise lasting for 3-7 days
• Repeating in intervals of months to years
CAUSE :
• Incompetent punctum leading to soiling of parenchyma with oral fluids
• Characteristic punctate sialectasis on sialography – snow storm appearance
TREATMENT :
• regular endoscopic washouts and long term antibiotics
HIV RELATED PAROTITIS:
• Recurrent parotitis in children
• Histologically similar to sjogrens in adults
• Doesn’t have auto antibodies
• Presents with painless multiple cysts
• SWISS CHEESE PATTERN
CLINICALLY : gross facial swelling & disfigurement
TREATMENT : aspiration / antiviral therapy

11. OBSTRUCTIVE PAROTITIS:
CAUSES : Stones
• Less common (20%)
• Radioleucent
• Frequent location – confluence of collecting ducts, over masseter,
distal most part of duct
• Treatment : < 4mm -basket removal
4-8mm – lithotripsy
> 8 mm – endoscopic assisted removal with gland
STRICTURES :
• Causes 20% of all obstructions
• Due to mucus plugs that form because of stagnation
• Patients presents with meal time syndrome starting at the breakfast ,
with increasing swelling
• Swelling is relieved by massage with a gush of salty saliva
• Treatment : dilatation and endoscopic washouts

12. PAPILLARY OBSTRUCTION:
• Trauma to papilla with subsequent edema and inflammation
• Leads to formation of mega duct , with its course visible on patients cheek
• Treatment : progressive dilatation of papillae with stent placement
TUMOURS OF PAROTID GLAND:
ETIOLOGY :
• Genetic – 1q, 8q, 17q
• Infective – mumps, EBV, recurrent inflammation can cause duct
dysplasia and carcinoma
• Radiation – mucoepidermoid carcinoma
• Smoking – adenolymphoma of warthins
• Sex – more common in females

13. CLASSIFICATION

14. PLEOMORPHIC ADENOMA OF PAROTID GLAND
• Pleomorphic adenoma- m/c salivary gland tumor in adults (80%)
• It involves parotid frequently ( 80%)
• More common in females , 4th and 5th decade
• Usually unilateral
• ORIGIN : mesenchymal, myoepithelial and duct reserve cell
• Microscopically it has epithelial and stromal components
• Encapsulated but has pseudopods extension beyond margin of tumor
• Mostly involves superficial lobe, if deep lobe is involved presents as
parapharyngeal swelling called DUMB-BELL TUMOR
• CLINICAL FEATURES :single, smooth, firm, lobulated swelling,
painless, ulceration and dysphagia (when deep fascia is involved)
• Raised ear lobule, curtain sign, obliteration of retromandibular
groove

15. ADENOMA TO CARCINOMA?
• Longstanding pleomorphic adenoma can turn into
carcinoma
• Early PA – 2-3% , long standing – 15%
SYMPTOMS :
• Recent increase in size
• Pain and nodularity
• Involvement of skin , ulceration
• Involvement of masseter, facial nerve, neck nodes
• Restricted jaw movements

16. INVESTIGATIONS :
• FNAC ( incisional biopsy contraindicated)
• CT -status of deeplobe, local extension and spread
• MRI – better
TREATMENT :
• Superficial lobe involved – superficial parotidectomy
• Both lobes involved – total conservative parotidectomy
with retaining facial nerve
•
• Enucleation avoided – recurrance due to pseudopods
• RT may be given ( controversial)

17. ADENOLYMPHOMA
(Warthin’s, papillary cystadenoma lymphomatosum)
CLINICAL FEATURES
• Not malignant, not lymphoma
• Benign tumour in lower pole parotid
• Due to trapping of lymph sacs in developmental period
• Involves superficial lobe, multicentric, often bilateral
• Smoking and radiation have been strongly associated
• Incidence : males, 6th decade, smokers
• Presents as slow growing, smooth, soft, bilateral swelling
INVESTIGATIONS :
• Technetium pertechnetate scan – hot spot – DIAGNOSTIC
• FNAC
TREATMENT :
• superficial parotidectomy

18. ONCOCYTOMA :
• From oxyphil cells
• Common in parotid as small , tan coloured well circumscribed
encapsulated solid tumour
• INVESTIGATIONS : Tc99 scan – hotspot, fnac
BASAL CELL ADENOMA :
• Isomorphic basaloid cells with basal layer and basement
membrane
• More common in minor salivary glands

19. MUCOEPIDERMOID TUMOUR
• Commonest malignant tumour in parotid
CAUSE – radiation
• Slowly progressing and spreads to neck nodes
• Hard, nodular swelling
TYPES :
• Low grade- mucous cells, spreads to regional nodes
• Intermediate – clear cell variety
• High grade – epidermoid cells only, distant spread
• Facial nerve & skin involvement, pain -late stages

20. ADENOID CYSTIC CARCINOMA:
• Most common in submandibular and sublingual glands
• 50% cases in minor salivary glands
• Common in females, 5th 6th decade
• slow growing but highly malignant
• High affinity for perineural spread
• Spread to lungs can occur but does not affect the prognosis as they remain
dormant
• Treatment : wide or radical excision of gland with neck dissection and postop RT
ACINIC CELL TUMOR :
• Almost always in parotid gland
• Soft and cystic – characteristic variable consistency
• More common in woman, elderly

21. MALIGNANT MIXED TUMOURS:
• 10% of salivary tumors with epithelial and mesenchymal component
• Worst prognosis
• Types :
• Carcinoma ex pleomorphic adenoma
• Primary mixed malignant tumour
• Metastatizing mixed tumors
ADENOCARCINOMA :
• 3% of parotid, 10% of submandibular tumours
• More common in children
SQUAMOUS CELL CARCINOMA:
• Rare , parotid is the commonest site
• High grade tumour, grows rapidly, non encapsulated tumour from ductal system
• Men , 6th or 7th decade
• Causes pain, facial palsy, skin fixity and ulceration, neck nodes- poor prognosis
• Treatment : radical parotidectomy with RT

22. STAGING:
• T1- <2cm, without extra parenchymal spread
• T2- 2-4cm, without extra parenchymal spread
• T3- >4cm or with extra parenchymal spread
• T4- 4a :facial nerve involvement
4b :base of skull, pterygoid plates, external carotid artery
• N1- regional node <3cm without ENE
• N2- ipsilateral 3-6cm node with ENE/ >6cm without ENE
• N3- Ipsilateral / contralateral >6cm with ENE
• M0 – no distant metastasis
• cM1- distant metastasis present
• pM1- microscopically confirmed distant metastasis

23. TREATMENT :
• T1, T2, T3 , Low grade tumours – Total conservative parotidectomy
• T4, high grade tumours , SCC – radical parotidectomy
• Radical : sacrifice facial nerve mandibular ramus , skin, massester muscle,
petrosectomy, infratemporal fossa dissection.
FACIAL NERVE SACRIFICE:
• Nerve involved pre operatively
• Intra op gross involvement
• Margin positive on frozen section
• Tumours transgressing through nerve
COMPLICATIONS :
• Hemorrhage, infection, flap necrosis, fistula
• Frey’s syndrome, facial nerve palsy
• Numb ear lobe – great auricular nerve palsy
• Sialocele

24. POST OP RADIOTHERAPY :
• Prevents relapse
• T3, T4, high grade
• Adenoid cystic , SCC
• Peri neural, deep lobe , vascular involvement
• Close/ inadequate clearance margin, spillage
• Recurrent pleomorphic adenoma
COMPLICATIONS OF RT:
• Xerostomia
• Osteoradionecrosis of temporal bone
• Skin ulcers, mucositis
• Trismus

25. PAROTIDECTOMY:
• SUPERFICIAL/ PATEY’S/ LATERAL :removal of superficial lobe in
front of faciovenous plane of patey
• TOTAL CONSERVATIVE: Both lobes removed, facial nerve intact
• RADICAL : removal of both lobes, facial nerve, fat, fascia, masseter,
pterygoid, buccinator, lymph nodes
• INCISION : modified blair’s/ lazy s incision, sistrunk approach
• Facial nerve trunk is identified and gland separated from the nerve
• Irrigation of distilled water to kill spilled tumour cells

26. FREYS SYNDROME / GUSTATORY SWEATING/
AURICULOTEMPORAL SYNDROME
• Post ganglionic parasympathetic fibres synapses with sympathetic
fibres of superior cervical ganglion
• Inappropriate regeneration of secretory parasympathetic fibres to
overlying skin
FEATURES: flushing, sweating, erythema, pain, hyperaesthesia over
the skin supplied by ATN , On mastication
• Minor starch iodine test – BLUE (due to sweat)
TREATMENT : antiperspirants, anticholinergics
• Surgical division of jacobsons nerve (parasympathetic)
• Dermal/ fat graft, interposition of temporal fascia, fascia lata, scm
muscle can be done.

27. SUBMANDIBULAR GLAND
SIALADENITIS :
Inflammation of the gland
Acute / chronic/ acute on chronic
ACUTE :
• Viral – mumps
• Caused by paramyxoma virus
• Occurs along with parotitis
• Bacterial : is due to obstruction caused by stones
• Trauma : over the duct causing oedema/ stricture and stasis
• Clinically : Pain, swelling, tenderness
• Dysphagia, trismus , fever
• Double chin appearance due to spreading oedema downwards
• Treatment : antibiotics and anti inflammatory

28. CHRONIC :
• Acute bacterial sialadenitis often progresses to chronic sialadenitis
• Common with partial obstruction of gland
• Clinically, pain more during mastication due to stimulation – salivary colic
• During salivation size of the swelling increases and decreases after 2 hours
• Firm, rubbery tender swelling
• Requires excision of the gland
• KUTTNER TUMOR – CHRONIC SCLEROSING SIALADENITIS OF
SUBMANDIBULAR GLAND
ECTOPIC / ABBERENT SALIVARY GLAND:
• Most common – stafnes bone cyst
• Invagination of salivary gland into lingual aspect of mandible
• Seen as well defined radioleucency at the angle of mandible
• Asymptomatic
• No treatment required

29. OBSTRUCTION:
• Due to stones ( sialolithiasis)
• 80% salivary gland stones arise from submandibular gland
• BECAUSE THE SECRETION IS MORE VISCOUS AND HAS NON DEPENDENT
DRAINAGE
• 80% stones are radio opaque and can be seen on plain radiograph
CLINICAL FEATURES :
With complete obstruction With incomplete obstruction
Acute painful swelling on eating minimal discomfort
not associated with mealtime
clinically : firm tender swelling
Pain remains for 2-3 hours
Relieved

30. TREATMENT:
• Obstruction anterior to lingual nerve
Exploration and longitudinal incision of duct
• Posterior to lingual nerve :
Intraoral approach removal of stone
Failure to retrieve : Gland excision with stone and ligation of duct
• Latest approach :
Sialadenoscope and endoscopic removal
Lithotripsy

31. SUBMANDIBULAR GLAND EXCISON
INDICATIONS : Chronic sialadenitis , Tumours
APPROACH : Submandibular region on the outside
INCISION : 5-8 cm in length, 2-3 cms below mandible
MOBILISATION OF GLAND: Intracapsular in sialadenitis,
extracapsular in tumours
COMPLICATIONS :
• Hemorrhage, Infection
• Injury to marginal mandibular, hypoglossal, lingual nerve

32. SUBLINGUAL GLAND
• Numerous ducts from the head drain into oral cavity (Ducts of Rivinus)
• Largest of these ducts called Bartholin duct joins the submandibular gland
• ALL TUMORS – MALIGNANT
CYSTS :
Ranula –mucous extravasation cyst
Transluecent- frogs belly
Treatment : excision of cyst along with the gland/ spontaneous resolution
I&D - Recurrence
PLUNGING RANULA:
Mucous Retention cyst
Mucus perforates through the mylohyoid muscle (diaphgram of the neck)
Dumb bell shaped swelling with a intraoral portion and portion in the neck region
Soft, fluctuant and painless
Diagnosis : USG / MRI
Treatment : remove gland and aspirate

33. TUMOURS OF SUBLINGUAL GLAND:
• Rare
• 90% malignant
• Rubbery in consistency
• Presenting in the floor of the mouth
• With pain or paraesthesia –indicates high grade
• Treatment : en block wide excision with simultaneous neck
dissection
• Intraoral reconstruction after surgery can be dine with : radial
artery forearm free flap, anterolateral thigh flap , pedicled
pectoralis major flap

34. MINOR SALIVARY GLANDS
• Around 800 salivary glands are present
• Contribute to 10% of salivary secretion
• Present in the lips, cheeks, floor of mouth, palate, retro molar trigone,
• Also in aero digestive tract – oropharynx, larynx, trachea
CYSTS :
• Extravasation cyst are common
• Due to trauma to overlying mucosa
• Areas : lower lip / floor of the mouth
• Painless and translucent swelling
• Rx: Spontaneous resolution /excision.

35. TUMORS :
• 90% of tumours in minor salivary glands are MALIGNANT
• Seen in palate and upper lip
• Well defined, rubbery lump
• Slow growing, painless and firm swelling
TREATMENT :
BENIGN - Excisional biopsy
MALIGNANT – Excision with burring of bone and reconstruction

36. THANK YOU