Oral and maxillofacial surgery

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Salivary gland tumors
Dr Mirza Muqeem Baig

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3. z Classification of salivary gland tumors
 EPITHELIAL TUMOURS
 A. Adenoma
 1.Pleomorphic adenoma
 2.Monomorphic adenomas
 Adenolympoma(warthin’s tumour)
 Oxyphilic adenoma (Oncocytoma)
 3. Mucoepidermoid carcinoma
 4. Acinic cell tumour

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 5. Carcinoma
 a) Carcinoma in pleomorphic adenoma
 b) Adenoid cystic carcinoma
 c) undiffrentiated carcinoma
 d) Adeocarcinoma
 e) Epidermoid carcinoma
 f) Acinic cell tumours
 g) Mucoepidermoid carcinoma
 h) Malignant mixed tumour

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NON -EPITHELIAL TUMOURS
 1. LIPOMA
 2. LYMPHOMA
 3. NEUROFIBROMA
 4 . LYMPHANGIOMA
 5. SARCOMA

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Difference between Benign and
malignant salivary gland
tumors
BENIGN MALIGNANT
slow growing -usually affects the parotid
gland
Fast growing-usually affects minor salivary
glands
soft and rubbery in consistancy Hard in consistancy
Usually encapsulated Not encapsulated
No ulceration Ulcerations seen with bone invasions
No associated with nerves palsies may cause cranial nerve palsies depending
upon side of involvement

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PAROTID GLAND
 PAROTID GLAND IS PRESENT ON THE LATERAL ASPECT OF FACE
 DEVIDED BY FACIAL NERVE INTO SUPERFICIAL LOBE AND DEEP
LOBE
 SUPERFICIAL LOBE OVERLIES THE MASSATER AND MANDIBLE
 DEEP LOBE IS WEDGED BETWEEN THE MASTOID PROCESS AND
THE STYLOID PROCESS ,RAMUS OF THE MANDIBLE ,MEDIAL
PTERYGOID MUSCLE
 SUPERFICIAL LOBE ALSO RECEIVES A DUCT FROM ACCESSORY
LOBE WHICH IS IN THE REGION OF ZYGOMATIC ARCH

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 THE DUCT OF PAROTID THAT IS STENSON’DUCT ,2-3 mm
IN DIAMETER ,RECIVES A TRIBUTARIES FROM
SUPERFICIAL,DEEP,AND ACCESSORY LOBES PASSING
THROUGH BUCCINATOR MUSCLE AND OPENS IN THE
MUCOSA ON THE CHEECK OPPOSITE THE UPPER 2nd
MOLAR TOOTH
 PAROTID GLAND IS COVERED BY TRUE CAPSULE WHICH
IS CONDONSATION OF FIBROUS STROMA OF THE GLAND
 A FALSE CAPSULE AND AND PAROTID FASCIA WHICH IS A
PART OF THE DEEP CERVICAL FASCIA

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 Constitues more than 50% of all tumours
 90% of all benign tumors of salivary glands
 It can affect both the major and minor salivary glands, commonly
affected by parotid gland, most often present in the lower pole
of superficial lobe 90%
 The different type of both tissue epithelial and connective tissue
elements are seen in tumor giving the name “mixed tumor or
“Endothelioma”
PLEOMORPHIC ADENOMA

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Clinical features
 Plemorphic adenoma most commonly affects parotid gland, followed by minor salivary glands of lip
and palate
 Submandibular salivary galnd is seldom affected
 Majority is seen between 4th -6th decades
 Most commonly females
 Tumor starts painless nodule, either at the angle of mandible or beneath the ear lobe.
 The nodule slowly increase in size, which may characteristically show intermittent growth.
 The tumor is well – circumsribed, encapsulated, firm in consistency, and may show areas of cysic
degeneration.
 It is readily moveable without fixity to the deeper tissue or to the overlying skin.
 The tumor can grow to a very large size, but does not ulcerate. Tissue destruction, pain or facial
parysis is not seen.

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 The intraoral pleomorphic Adenomas, which affect the minor
salivary galnd of the palate, are noticed early because of the
difficulties in mastication, taking etc.
 The palatal pleomorphic Adenomas may show fixity to the
underlying bone but does not ivadee the bone.
 Pleomorphic Adenomas should be differentiated frot other
benign tumor and hyperplastic lymp nodes,. Thought a painless
nodules, firm growth with no ulceration of the overlying skin is
suggestive O of this tumor, pleomorphic Adenomas can become
extremely larger in size, if neglected.

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 Excisional biopsy is advocated for tumor invloing the minor
salivary galnd, which are usually not more than 2cm in daimeter.
 Diffrentntial diagnosis:-
1. Other Adenomas, such as warthins tumor.
2. Lipoma.
3. Hyperplastic lymph node
4. Neurilemmoma of of the facial nerve.

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Treatment:-
 Pleomorphic Adenomas are treated by surgical excision. The
parotid tumor are removed with adequate margin- superficial or
total parotidectomy, whereas the intraoral lesion can be treated little
more consevatively. In case of submandibular tumor, the gland is
excised along with the tumor. Wide local excision of minor salivary
galnd tumor.
 The removal of pleomorphic adenoma should be perfomed with
careful dissection and preservating the facial nerve in case of the
parotid tumor. Also, one should take care not to spill any tumor
tissue, as they are highly implantable.
 Irradiation is contraindicated as the tumor is radioresistant

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 THE MAIN LINE OF TREATMENT OF SALIVARY GLAND TUMOURS IS WELL-
PLANNED SURGICAL EXCISION
 PAROTIDECTOMY CAN BE OF
 1 -PARTIAL SUPERFICIAL: EXCISION OF SUPERFICIAL PORTION OF GLAND
,WHICH HAS PATHOLOGY WITH A SAFE MARGIN OF PAROTID TISSUE AND LEAVING
BEHIND THE PORTION OF THE GLAND UNAFFECTED BY PATHOLOGY
 ONLY SOME BRANCHES OF FACIAL NERVES ARE DISSECTED
2 -SUPERFICIAL OR LATERAL :RESECTION OF THE ENTIRE GLAND SUPERFICIAL
LOBE OF PAROTID GLAND ABOVE THE FACIAL NERVE (EXICISING ALL THE PARTS OF
GLANDS SUPERFICIAL OR LATERAL TO THE FACIAL NERVE )
INDICATION: mainly use for benign (PLEOMORPHIC ADENOMA) or low
grade small size malignant tumors of superficial lobe of the parotid
gland or for metastasis to parotid lymphnodes ,e.g,from skin
cancer/melanoma or high grade malignant tumour of parotid gland

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 TOTAL PAROTIDECTOMY : resection of entire parotid gland
both superficial as well as deep lobes,with preservation of facial
nerve
 Indication: primary parotid malignancies originating in deep
lobe or primary malignancies that extend outside parotid gland
or multifocal tumours of oncocytomas
 RADICAL/ EXTENDED TOTAL PAROTIDECTOMY : resection of
entire parotid gland with facial nerve and adjacent involved
structures in pathology Eg tumours showing perinural invasion (
adenoid cystic carcinoma)

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PROCEDURE
1 .GENERAL ANESTHESIA
2.skin incision marking ,LA infilteration,wait
3. incise skin along the margin
4. Raise the skin flap along marking
5. raise skin flap, parotid exposure
6. Free the tail of parotid
7.Identification of main trunk of CN VII
8.NERVE DISSECTION and removal of salivary tissue superficial to
ligate the parotid gland

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 9.deep lobe removal
 10.hemostasis and drain placement
 11.Two layer closure
 complications: hematoma
 infections
 facial nerve palsy- neurpraxia ,streching and devascularisation
 salivary fistula
 Gustatory sweating
 cosmetic deformity


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Complications:-
 Incomplete excision of the tumor may lead to recurrence.
 Long standing untereated begin pleomorphic adenomas may
undergo malignant transformation. Malignant transformation
should be suspected when the tumor is hard in consistency,
show ulceration, facial paralysis or lymph nodes involvement.

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SUPERFICIAL PARATIDECTOMY
APPROACHES
 PREAURICULAR
 SUBMANDIBULAR
 COMBINATION OF TWO APPROACHES

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Warthins tumor
 This slow growing benign tumor affects the parotid galnd. Involvement
of the submandibular Or the minor salivary gland is very rare. Usually,
male are affected more commenly in the 5th decade of life, male to
female 5:1 ratio, 6-10% Of parotid gland.
 Recently, some investing have highlighted the association of
smocking in the pathogenesis of this tumor.
 The tumor present as a firm, nontender, circumcribed mass in the
region of angle or ramus of the mandible or beneath the ear lobe.
 TREATMENT: it has well defined capsule ,hence
enucliation can be done

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 Treatment:- The tumor surgically excised.

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Mucoepidermoid carcinoma:-
 This most common type of malignant tumor of the salivary galnd
is famous for varied bilogical behavior and has created
difference of Opinion among research workers.
 Based on its behavior, it has been gradede into low grade tumor
behaves almost like a benign tumor with very good Prognosis,

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Clinical features:-
 Depends upon the grade of the tumor. Thus, it may grow Slowly or
rapidly, usually as a painless swelling of the parotid or other major
salivary grand 10%, or in the minor salivary galnd-20%.
 Intraorally, it may affect the minor gland of the palate, buccal
mucosa, tongue And retromolar area. The highgrade tumor may
produce pain, ulceration, facial paraysis, local destruction and
mestasis to regional lymph nodes and distant metastasis tobthe
lung, bone And tobthe brain in later stages poor prognosis.
 It is common for intraoral mucoepidermoid carcinoma to undergo
cystic degeneration thus mimicing a mucocele clinically dignosis
should be confirmed by biopsy

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INTRAOSSEOUS MUCOEPIDERMOID
CARCINOMA
 Mucoepidermoid carcinoma can occur intraosseously within the
jaw bone commonly in the mandible
 The entrapped mucous glands the epithelial cell of odontogenic
cysts or aberrant salivary glands present intraosseously may
undergo neoplastic transforamtion
 These tumors are similar in the behaviour to the extraosseous
varity

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Treatment
 The stage 1 and 2 tumors should be treated wide local surgical
excise. The excision she be more radical than for pleomorpic
adenoma.
 Radiotherapy can be added to improve local control, Stages 3
and 4 radical excision, plus neck dissection and postoperative
radiator therapy

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Adenoid cystic carcinoma:-
 It is also called as cylindroma, because Of it’s histological
appearance. It may arise as a slow growing Swelling, sometimes
may mimic a benign tumors Clinically and histology, but has
greater potential for the destruction and invasiveness, commenly
perineural invasion
 Treatment- patients may srevive for years with metastasis, due
to the fact that the tumors is well diffntited and radical excision
and postoperative radiation is mainly utilized for locoregional
control for early stage disease.

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THANK YOU