Salivary gland disorders

SALIVARY GLAND
DISORDERS
DR. SALEH BAKRY
ASSISTANT PROFESSOR OF ORAL AND MAXILLOFACIAL SURGERY

 Definition: exocrine glands secreting saliva.
 Classifications:
 According to size:

Major SG
Minor SG

• Parotid gland.
• 600-1000 minor SG.

• Submandibular
SG
• 1- 5 mm in diameter.

• Sublingual SG
• Each gland has a single duct.
• Present all over the oral cavity and oropharynx except:
1. Ant 1/3 of the palate.
2. Ant 1/3 of the dorsum of the tongue.
1. Attached gingiva.

SALIVA
 Saliva contain electrolytes as Na+
, K+
, Cl, Bicarbonate, Ca+
, Phosphate,
magnesium, urea, ammonia, uric acid, glucose and cholesterol.
 The electrolytes composition/ concentration in saliva secreted from the
parotid G. is higher than that of the submandibular G. except Ca+
.
 Calcium concentration in the submandibular G is double that of the
parotid G Õ an important factor considering the salivary stone.
Functions:
 Digestion - Serous - Ptyalin (a-amylase- hydrolysis of starch)
 Lubrication › Mucus secretions (mucin = glycoprotein) - lubricant.
 Antimicrobial.

PAROTID GLAND SUBMANDIBULAR
GLAND
SUBLINGUAL GLAND
Size Largest intermediate Smallest major SG
Parts • Superficial part.
• Deep part.
• Accessory part
(20% of
individuals): above
stensen's duct and
opens into it.
• Superficial part:
Superficial to
mylohyoid Hilum:
behind mylohyoid
ms
• Deep part: deep to
mylohyoid ms Just
beneath the floor of
the mouth

Location Retromandibular
fossa
(between ramus and
sternomastoid
muscle)
• Superficial part:
submandibular
(digastric) triangle
Deep part: sublingual
space.
Sublingual space

PAROTID GLAND SUBMANDIBULAR GLAND SUBLINGUAL GLAND
Duct Stensen's duct opens
in parotid papillae
opposite to upper 7.
Wharton's duct opens
in S.L caruncle.
Ducts of rivinus (8- 20
ducts) opens
Into:
a.Bartholin's duct
b.plica sublingualis
Bartholin's duct: opens
into wharton's duct or
in the floor of the
mouth.
Secretions Serous Mucus Mixed
Structures
within
External carotid A
Retromandibular Vein
Facial Nerve

PAROTID GLAND SUBMANDIBULAR
GLAND
SUBLINGUAL GLAND
Blood supply • Arterial
Branches of Ext.
Carotid A
• Venous
Into Ext. Jugular Vein
• Arteries
Branches of facial and
lingual arteries
• Veins
Drains to the
corresponding veins

• Arterial from
sublingual and
submental arteries
• Venous drainage
corresponds to the
arteries
Nerve in
close relation

• Marginal
mandibular N.
• Hypoglossal N.
• Lingual N.
Lingual N.

I. Clinical history
A. PAST AND PRESENT MEDICAL HISTORY
To determine any medical conditions or medications that is known to be
associated with salivary gland dysfunction.
Examples: patient who received radiotherapy for a head and neck
malignancy or patient who taking a tricyclic antidepressant.
These two examples associated with salivary hypofunction.

I. Clinical history
B. SWELLING
Intermittent swelling
If associated with eating, it suggests an obstruction and the swelling will subside between
meals if the gland is not infected.
Persistent swelling
Caused by tumors or a generalized process such as sjeogren’s syndrome, diabetes,
alcoholism…. etc.
Unilateral swelling
Results from localized processes such as infections, tumors or mechanical obstruction.
Bilateral swelling
Associated with a systemic condition such as mumps or an endocrine dysfunction.

I. Clinical history
C. PAIN
Pain and fullness of the gland, related only to eating suggest
obstruction.
Infection and inflammation produce a more persistent pain not related
to eating.

I. Clinical history
D. SALIVARY FLOW
1. Xerostomia
Commonly caused by:
 Drugs.
 Systemic diseases (Sjeogren’s syndrome).
 Secondary to radiation therapy.
2. Sialorrhea (increased salivation)
Commonly caused by:
 Secondary to an inability to swallow normal secretions.
 Emotional or psychogenic factors.
 Chronic neurological disorders (Parkinson’s disease, cerebral palsy, mental
retardation ... etc.)

II. Physical examination
A. INSPECTION
1) Size
Diffuse enlargement of a single gland suggests inflammatory process or
a tumor.
Enlargement of multiple glands suggests:
 Sjeogren’s syndrome.
 Metabolic disorder (alcoholic cirrhosis).

A. INSPECTION
2) Site.
In the preauricular and Submandibular regions parenchymal glandular
involvement must be distinguished from regional lymph node involvement.
Intra-oral minor salivary gland lesions usually appear on the posterior palate.
3) Shape.
4) Symmetry.
5) Overlying skin / mucosa.
6) Surrounding edge → well/ ill defined.
7) Inspection of the duct orifices for pus or calculus.

B. PALPATIONS
Palpation of the gland
Parotid gland: E.0 Bidigital palpation.
Submandibular S. G: bimanual palpation I.0 and E. 0 (submd L.N felt
E.0 only while S.Md S. G swelling felt E0 and I0)
Sublingual S.G: I.O only.

B. PALPATIONS
Palpation for:
Gland
Consistency.
Massaging the gland and looking at the duct orifice → duct purulence & flow of
saliva.
Duct
Palpable stone, Site, size.

CHECK THE INTEGRITY OF THE NERVES:
Facial nerve assessment (suspicious malignancy in parotid)
Temporal branch → ask the patient to elevate his eyebrows.
Zygomatic branch→ ask the patient to close his eye tightly.
Buccal branch → ask the patient to whistle.
Marginal mandibular branch-ask patient to smile and show his teeth
Lingual nerve assessment → test sensation of ant 2/3 of tongue.
Hypoglossal nerve assessment → check tongue movement.
Any defect of nerve function → malignant infiltration of the nerve.

III. Preoperative diagnostic screening
1. PLAIN RADIOGRAPHS:
Advantages:
 Used to demonstrate the presence of calculi.
 Used as comparative documentation after removal of the stone.
Disadvantages:
No information about ductal system and soft tissue.
1- Occlusal view
It is used for detection of calculi in the floor of mouth (Wharton’s duct).
2- Periapical film
Detect a stone in the parotid duct by placement against the inside of the cheek.
3- Puffed cheek view
For calculi of the parotid duct.
1. PLAIN RADIOGRAPHS:
Advantages:
Used to demonstrate the presence of calculi.
Used as comparative documentation after removal of the stone.
Disadvantages:
No information about ductal system and soft tissue.
1- Occlusal view
It is used for detection of calculi in the floor of mouth (Wharton’s duct).
2- Periapical film
Detect a stone in the parotid duct by placement against the inside of the cheek.
3- Puffed cheek view
For calculi of the parotid duct.

2. COMPUTERIZED TOMOGRAPHY (CT) SCANNING:
Indication
The best choice for examination of masses of the salivary glands.
Study the diffuse non-inflammatory enlargement of the salivary glands.
3. MAGNETIC RESONANCE IMAGING (MRI):
Equal or better than CT in:
No contrast medium.
Less radiation.
No need for ductal cannulation.
Can be used in acute inflammation.
Detection of a lesion or mass.

4. RADIONUCLIDE SCANS (SCINTIGRAPHY):
Radioactive isotope as technetium 99 is injected and traced by gamma camera.
Uptake of the isotope by the gland increase in case of acute inflammation and
decrease in case of chronic inflammation.
Indication:
 Determination of space occupying lesions
 Evaluate the salivary function of the glands.
 Evaluation of patients when sialography is contraindicated or cannot be
performed (such as in cases of acute gland infection or iodine allergy).

5. ULTRASONOGRAPHY:
Advantages:
Fast.
Economical.
Non-invasive.
Simple.
Indication:
Detect stone ≥ 2mm.
Detecting space occupying lesions.
Differentiate a cystic lesion from a solid mass.
Differentiate intrinsic lesion from extrinsic mass.

6. BIOPSY
Helpful in the diagnosis of Sjeogren’s syndrome.
The most common suggested procedures are:
Excision biopsy → should be done if the diagnosis remains inconclusive after the
investigation → from the intra-oral minor salivary gland (lower lip).
Incisional biopsy → should not be done because it will seed tumor cells into the
surrounding tissues.
Fine needle aspiration biopsy (FNAB).

7. LABORATORY INVESTIGATION:
Laboratory blood studies are helpful in the evaluation of dry mouth, particularly in
suspected cases of Sjögren’s syndrome.
The presence of nonspecific markers of autoimmunity, such as antinuclear
antibodies, rheumatoid factors, elevated immunoglobulins, and erythrocyte
sedimentation rate → the definitive diagnosis of Sjögren’s syndrome.
↑ Serum amylase → salivary gland inflammation.

8. SIALOGRAPHY:
Definition:
Sialography is the radiographic visualization of the salivary gland following retrograde
instillation of soluble contrast material into the ducts.
Contrast medium: (both contains high percentage of iodine)
Oil based Water soluble
• High viscosity.
• Difficult to inject  discomfort.
• Long time for elimination.
• E.g. lipiadol.
• Low viscosity.
• Easy to inject  discomfort
• Shorter elimination time.
• E.g. (Hypaque and renografin).

8. SIALOGRAPHY:
Appearance
The normal ductal architecture has a “leafless tree” appearance.
Non-opaque sialoliths appear as voids.
Sialectasis is the appearance of focal collections of contrast medium within the
gland, seen in cases of sialadenitis and Sjögren’s syndrome.
Indications:
 Detection of ductal obstruction, stenosis &stricture
 The presence and the size of the tumors
 Detection of salivary fistula

8. SIALOGRAPHY:
Therapeutics uses:
 CM contains Iodine (bacteriostatic effect).
 Drainage of ductal debris & mucus plug.

8. SIALOGRAPHY:
Advantages
Detection of radiolucent sialoliths.
Functional evaluation of the gland.
Detection of the position and size of a neoplasm.
Fistulae and abscess cavities can be displayed.
Disadvantages:
Invasive.
Requires iodine dye.

9. SIALOENDOSCOPE
Indications:
Diagnosis of S.G pathosis either in duct or parenchyma.
Used to dilate small stricture.
Limitations:
Acute infection (Painful and may perforate the duct lumen).
Too narrow duct.

10. SIALOCHEMISTRY:
Saliva can be collected from the parotid and Submandibular glands by cannulation
of their ducts.
If ↑ Na+
and ↓K+
Ô Sialadenitis.
The saliva can be analyzed for:
Electrolytes (Sodium, potassium, chloride, phosphate).
Flow rate.
Total salivary proteins (Amylase, glycoprotein, and albumin).
Immunoglobulin.

CLASSIFICATION OF THE
SALIVARY GLANDS
DISEASES

1. DEVELOPMENTAL
Aplasia (agenesis), atresia.
Aberrancy (Latent bone cyst).
2. INFLAMMATORY
A. Viral (Viral sialdenitis)
Mumps.
Coxachie A.
B. Bacterial
Non-specific
 Acute bacterial sialdenitis.
 Chronic bacterial sialdenitis.
 Necrotizing sialometaplasia.
 Radiation sialadenitis

3. CYSTIC
 Retention cyst.
 Extravasation cyst.
 Ranula.
 Latent bone cyst
4. OBSTRUCTION
Sialolithiasis.
Stenosis & stricture.
5. AUTOIMMUNE
Sjeogren’s syndrome.

6.FUNCTIONAL DISORDERS:
xerostomia
sialorrhoea (ptyalism)
7. METABOLIC
Malnutrition (kwashiorkor).
Alcoholic cirrhosis.
Endocrine (Diabetes mellitus.)

8. NEOPLASTIC
A. Benign
Mixed tumor (pleomorphic adenoma).
Monomorphic adenoma.
warthin's tumor (cystadenolymphoma, papillary cystaenoma
lymphatosum).
B. Malignant
 Mucoepidermoid carcinoma.
 Adenocystic carcinoma.
 Polymorphous low –grade Adenocarcinoma.

I. CYSTIC CONDITIONS
MINOR SALIVARY GLANDS
THE MUCOCELE
Swelling caused by the accumulation of saliva at the site of a traumatized or
obstructed minor salivary gland duct.
Classified into:
Extravasation Mucocele: traumatic injury → salivary leakage into the surrounding
tissue → granulation tissue “encapsulation”
Retention Mucocele: Represents dilatation of salivary excretory duct due to
obstruction by a mucous plug or sialolith formation (FOM, palate)
The site: the lower lip in young people, buccal mucosa.

THE MUCOCELE
Etiology: minor trauma.
Clinically:
Superficial lesion: small bluish translucent, smooth, fluctuant vesicle.
Deep lesion: a firmer vesicle with the same color of normal mucosa.
Diagnosis
History of painless swelling
Clinical examination: fluctuant swelling mainly in lower lip
X-ray –ve.
Aspiration → mucus.

THE MUCOCELE
Treatment:
Simple removal of the “cyst” leads to recurrence of the mucocele 15-30%.
A vertical incision over the lesion with removal of the underlying minor salivary
gland.
In recurrent cases, a CO2 laser is used.

SUBLINGUAL GLAND
THE RANULA
It’s the accumulation of saliva beneath the thin mucous membrane of the floor of
the mouth due to obliteration of sublingual gland duct.
Clinically:
Soft, compressible, painless bluish mass enlarge slowly.
May raise the tongue and interfere with the speech.
Etiology: Extravasations of saliva secondary to trauma.

SUBLINGUAL GLAND
THE RANULA
“Plunging” ranula:
The mylohyoid muscle does not always form a complete diaphragm for the floor
of the mouth, and leakage of saliva below the mylohyoid can allow the lesion to
present in the upper neck.
Diagnosis
History of painless swelling
Clinical examination: fluctuant swelling at one side of floor of mouth or cervical
ranula
X-ray –ve.
Aspiration → mucus.

SUBLINGUAL GLAND
THE RANULA
Treatment
Marsupialization.
The excision of the sublingual gland.

II. INFLAMMATORY/REACTIVE
CONDITIONS
A. NON-SPECIFIC
1. ACUTE BACTERIAL (SUPPURATIVE) SIALADENITIS
(POSTSURGICAL PAROTITIS)
• A suppurative process affecting the major glands more often than the minor glands.
• More common in parotid
Predilection for Parotid:
1. The parotid is more prone to bacterial infection due to its secretions are serous and thus lack the protective
constituents (IgA, lysozomes) seen in mucinous secretions of the other salivary glands.
2. The submandibular glands may be protected by the high level of mucin in the saliva, which has potent antimicrobial
activity.

CONDITIONS
A. NON-SPECIFIC
Etiology
1.Salivary stasis → retrograde contamination of the salivary ducto-acinar units by oral flora (Bacterial ascending
infection).
2.Causes of salivary stasis include postsurgical setting, dehydration, medical illness, radiation, aging and sialolithiasis.
3.Postoperative sialadenitis is due to decrease in salivary flow during anesthesia + administration of anticholinergic
drugs.

CONDITIONS
A. NON-SPECIFIC
Clinical presentation
1.General symptoms; fever….
2.Sudden onset of unilateral or bilateral salivary gland enlargement.
3.The involved gland is painful, indurated, and tender to palpation.
4.The overlying skin may be erythematous.
5.Purulent discharge from Stensen’s duct

CONDITIONS
A. NON-SPECIFIC
Diagnosis:
1.History: swelling and pain
2.Clinical examination
• E.0 examination → Redness, hotness, tenderness, and swelling. Fistulous tract.
• IO examination → Pus oozing through duct on milking the gland.
3.Imaging: CT, MRI, Ultrasound and scintigraphy
4.Needle aspiration → pus.

CONDITIONS
A. NON-SPECIFIC
1. ACUTE BACTERIAL (SUPPURATIVE) SIALADENITIS (POSTSURGICAL PAROTITIS)
Treatment of Acute Sialadenitis/Parotitis
1.Culture and sensitivity testing (for appropriate antibiotics).
2.Supportive measures
Fluid replacement.
Empirical antibiotic and analgesics.
Improved oral hygiene.
Massage of the gland.
Warm compresses.
Sialogogues (salivary stimulants).
3. Failure to respond → incision and drainage.
4. Incisions should be placed parallel to facial nerve branches to avoid injury.

CONDITIONS
A. NON-SPECIFIC
Complications of Acute Parotitis
1.Direct extension.
Into external auditory canal and TMJ.
Into the parapharyngeal space → airway obstruction, mediastinitis, internal jugular thrombosis and carotid artery
erosion.
3. Hematogenous spread
4. Dysfunction of one or more branches of the facial nerve.

CONDITIONS
A. NON-SPECIFIC
2. NECROTIZING SIALOMETAPLASIA
• Benign self-limiting condition of the oral cavity.
• It originates from the minor salivary glands of the hard palate, buccal mucosa, lip
or retro molar area.

CONDITIONS
A. NON-SPECIFIC
2. NECROTIZING SIALOMETAPLASIA
Clinical picture:
Presents as an ulcer.
It is usually painless.
The ulcer may be unilateral or bilateral and appears large, deep
and sharply demarcated.
Etiology: Local ischemia (trauma, L.A injury, smoking).
Treatment: Self-limiting & heals by secondary intention in 6-8 weeks.

CONDITIONS
B. SPECIFIC INFLAMMATION
Non-suppurative bilateral acute sialadenitis of viral origin.
It is a contagious disease (Droplet infection).
Its incubation period is 2-3 weeks.
It affects mostly children at 6-8 years old.
Mumps (epidemic parotitis)

CONDITIONS
The causative virus
1.Mumps paramyxovirus.
2.Coxsackie virus A.
3.Echo virus.
Clinical picture:
1.Painful parotid swelling may last 2 weeks.
2.Usually one gland is affected first then the other.
3.The symptoms subside in 3-7 days and recovery occurs within 2-3 weeks.

CONDITIONS
Complications of mumps:
1.Other organs (e.g., testes, ovaries, breasts, and pancreas) may be affected.
2.In adults, orchitis may lead to sterility.
Diagnosis:
1.Leucocytopeniawith relative lymphcytosis.
2.Increase in serum amylase (normal by 2-3w of disease).
3.Serology reveals:
•Complement fixing antibodies.
•S or soluble antibodies.

CONDITIONS
Treatment
1. It resolves spontaneously in 5-10 days.
2. Symptomatic relief of pain and fever (analgesic antipyretic).
3. Prevention of dehydration is essential by increase fluid uptake.

III. IMMUNOLOGIC DISORDERS
SJEOGREN’S SYNDROME
DEFINITION
Sjögren’s syndrome is an autoimmune disease characterized primarily by
decreased lacrimal and salivary gland secretions.
CLINICAL FEATURES:
Triad of:
1.Xerostomia (mouth).
2.Keratoconunctivitis sicca (eyes).
3.A connective tissue disease (usually rheumatoid arthritis).
Salivary, mucous and lacrimal glands replacement by a lymphocytic infiltrate
causes the classic symptoms of dry eyes, dry mouth and parotid swelling.

TWO FORMS:
Primary: involves the exocrine glands only
Secondary: associated with a definable autoimmune disease, usually rheumatoid
arthritis.
DIAGNOSIS
Diagnostic tests include:
 Schirmer’s tear function
Using two strips of red litmus papers placed at the inner side of the lower eyelid
(area of lacrimal glands). A positive finding is lacrimation of 5 mm.
 Sialography will give “the apple-tree in blossom” appearance.
 Salivary biopsy (either from the lower lip or the tail of the parotid gland.
 Immunologic and hematologic laboratory studies.

TREATMENT
 Dry foods, smoking and alcohol consumption should be avoided.
 Treatment is directed to:
Supportive care with sialogauges to stimulate salivation and salivary
replacement by means of methylcellulose.
Supportive care with artificial tears.
Treatment of the autoimmune connective tissue diseases.

IV. OBSTRUCTIVE DISORDERS
SIALOLITHIASIS
DEFINITION
The formation of calcific masses (stones) within the ductal system of a major or minor
salivary gland.
CAUSES OF OBSTRUCTION INCLUDE
 Salivary calculi (Sialolithiasis).
Pressure on the duct due to an adjacent mass.
 Invasion of the duct by a malignant neoplasm.
 Mucous retention/extravasation.

SIALOLITHIASIS
CLINICAL FEATURES
It occurs in men twice as often as in women.
The Submandibular gland is the most common site of involvement (80%), followed
by the parotid (19%).
The stones are single, but it may be multiple (more in the parotid in this case).
ETIOLOGY
The exact nature of stone formation is not known, but may be due to:
The calculi are believed to arise from the deposition of ca ++ salt around a nidus of
debris within the duct lumen, these debris include bacteria, ductal epith cells, or
foreign bodies.

SIALOLITHIASIS
FORMATION OF CALCULI IS ALSO FACILITATED BY SEVERAL
SECONDARY FACTORS:
The mucous content of the submandibular gland makes its secretions more
viscous than the parotid.
The duct of the submandibular gland is longer than that of the parotid gland
and runs against gravity in a tortous.
The submandibular duct is situated at a lower level than its orifice.

SIALOLITHIASIS
SIGNS AND SYMPTOMS:
Absence of subjective symptoms (discovered accidental).
Eating initiates intermittent transient swelling accompanied by moderate
discomfort.
The involved gland is enlarged and tender.
Stasis of the saliva → infection, ductal stricture, and ductal dilatation fibrosis, and
gland atrophy.
No salivary flow or purulent discharge.
If the treatment is not beginning: Swelling, redness and tenderness are present
along the course of Wharton’s duct & pus may exude from the duct orifice.

SIALOLITHIASIS
DIAGNOSIS:
History of swelling at mealtime which subside between meals.
Palpation along the course of the duct.
Occlusal view.
C.T, MRI, Ultrasound.
Sialography.

SIALOLITHIASIS
TREATMENT
Treatment Modalities
Removal of the stone:
 Conservative management by:
1. Milking the gland.
2. Shock-wave Lithotripsy (external and intraductal).
3. Electrohydraulic Lithotripsy.
4. Interventional sialendoscopy
 Surgical removal (Sialolithotomy).
Gland excision (Sialadenectomy).

SIALOLITHIASIS
I. CONSERVATIVE MANAGEMENT
1. MILKING THE GLAND.
Stone may be removed by spontaneous exfoliation on stimulation of salivation to flush
the stone out of the duct:
Indication:
 Small, mobile stone at or just behind the duct orifice.
 Stone causing partial obstruction.
Procedures
 Hydration.
 Application of moist warm heat.
 Gland massage.
 The use of sialogogues.

SIALOLITHIASIS
2. SHOCK-WAVE LITHOTRIPSY (EXTERNAL AND INTRADUCTAL).
3. ELECTROHYDRAULIC LITHOTRIPSY.
4. INTERVENTIONAL SIALENDOSCOPY
II.SURGICAL TREATMENT
Extraglandular → removal of the stone (sialolithotomy) → intraoral approach.
Intraglandular → removal of the gland → intraoral approach (sublingual gl) or Extraoral
approach (Parotid, submand. gl).

SIALOLITHIASIS
1. STONE REMOVAL
Surgical removal of submandibular duct sialoliths (sialolithiotomy, sialodochplasty,
marsupialization or 2nd
duct orifice):
Surgical removal of parotid duct sialoliths (sialolithiotomy)
2. GLAND REMOVAL (SIALADENECTOMY):
Indication
Very posterior stones.
Intra-glandular stones.
Irreversible parenchymal damage.

1- MIXED TUMOR (PLEOMORPHIC ADENOMA)
INCIDENCE AND LOCATION
Most common salivary gland tumors.
The majority arise in the parotid (84%).
Mixed tumors account for more than 50% all intra-oral minor salivary gland
tumors.
Male to female is 3:2.
5% malignant transformation.

CLINICAL FEATURES
In the parotid gland, these neoplasms are slow growing and usually occur in the
posterior inferior aspect of the superficial lobe.
In the submandibular glands, these neoplasms are well-defined palpable masses.
Intraorally, the mixed tumor most often occurs on the palate, followed by the
upper lip and buccal mucosa.
Mobile, except when they occur in the hard palate, where they are adhering firmly
to the underlying tissue.

TREATMENT
Complete excision with 1 cm margins of clinically uninvolved normal tissue.
For the parotid gland, superficial parotidectomy with preservation of the facial
nerve.
For the Submandibular gland, complete excision of the gland is indicated.
For intraoral tumors, extracapsular excision is indicated including the overlying
mucosa and saucerization of any bony margins of resection.

2- MONOMORPHIC ADENOMA
Benign salivary gland tumors composed predominantly of epithelium with no
evidence of mesenchymal tissue.
Rare tumor the parotid and minor salivary glands.
CLINICAL FEATURES
A submucosal nodular mass.
Freely mobile firm to slightly compressible.
Normal color of overlying mucosa.
TREATMENT
Extracapsular surgical excision

3-WARTHIN'S TUMOR (CYSTADENOLYMPHOMA,
PAPILLARY CYSTAENOMA LYMPHATOSUM)
6% of epithelial tumors of the salivary glands.
Almost in the parotid gland.
3-4% of all minor salivary gland tumors
Intraorally, most commonly in the palate and buccal mucosa.
CLINICAL FEATURES
Soft to firm, It grows slowly.
Asymptomatic mass in the parotid.
Arise from salivary gland tissue sequestered in lymph nodes.
TREATMENT
Surgical excision with safety margins and superficial parotidectomy.

1- MUCOEPIDERMOID CARCINOMA
INCIDENCE AND LOCATION:
70 % in the parotid.
20 % minor salivary glands.
10 % submandibular gland.
RADIOGRAPHIC FEATURES: Multilocular radiolucency.

CLINICAL FEATURES:
The low-grade tumor in the palate
 Grow very slowly
 Not ulcerated until after very long time
 Appear bluish in color
 Don't invade the bone
The low-grade tumor in parotid
Freely movable
Firm
Circumscribed mass

CLINICAL FEATURES:
The high-grade tumor in the palate
Faster growing
Diffuse
Ulcerate early
Destruct underlying bone
Painful
The high-grade tumor in parotid
Diffuse mass
Fixed
Facial nerve affection

TREATMENT
The low-grade tumor in the palate
Tumor excision with 1 cm of soft tissues margin.
The high-grade tumor in the palate
Hemimaxillectomy + postoperative radiotherapy.
 Bilateral neck dissection.

TREATMENT
The low-grade tumor in parotid
 Involve superficial lobe and without facial nerve involvement→ superficial
parotidectomy + nerve preservation.
 If it extends to deep lobe or involve facial nerve → total parotidectomy + nerve
resection, then nerve grafting.
The high-grade tumor in parotid
 Total parotidectomy + nerve resection.
 Ispilateral neck dissection + radiotherapy postoperative.

2- ADENOCYSTIC CARCINOMA
 Most common in the palate.
 Most common malignant tumor of Submandibular S.G and parotid G.
 Age: 53 years.
 Male to female 3:2.
CLINICAL FEATURES:
Slowly growing, non-ulcerated mass, Unilocular mass.
Firm on palpation.
Bone invasion occurs.
Lung metastasis.
Chronic dull pain.

2- ADENOCYSTIC CARCINOMA
TREATMENT
Because of the ability of this lesion to spread along the nerve sheaths, radical surgical
excision of the lesion is the treatment.
1. FOR PALATE:
 Hemi-maxillectomy with 3 cm safely margin
 Complete extirpation of pterygomaxillary space till skull base
 Extirpation of greater palatine nervous bundle to skull base
2. FOR PAROTID G:
 Total parotidectomy + nerve preservation if facial nerve not involved
 If it involves facial nerve → total parotidectomy + nerve resection, then nerve
grafting.
3. FOR SUMANDIBULAR S.G AND TONGUE:
 Radical excision & post surgical radiotherapy and chemotherapy.

Salivary gland disorders

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