Knowledge spread

1. Neoplasms of salivary glands
Dr. Ramesh Parajuli, MS
Chitwan Medical College Teaching Hospital,
Chitwan, Nepal

2. • 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 anatomy

3. Salivary gland microanatomy

5. 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

6. • 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%

7. Risk factors for salivary neoplasms
• Low dose radiation exposure
• Wood dust
• Chemicals (leather tanning
industry)
• Rubber industry
• Nickel compound/alloy

8. Benign tumors
• Pleomorphic adenoma
• Warthin’s tumor
• Oncocytoma
• Lymphangioma
• Haemangioma

9. 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

10. • 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

11. 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

12. Warthin’s tumor(adenolymphoma)
• Encapsulated
• Exclusively in parotid gland
• Parotid tail
• Commonly seen btw 5th
– 7th
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

13. 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

14. Malignant neoplasms
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Carinoma ex- pleomorphic adenoma
• Adenocarcinoma
• Squamous cell carcinoma
• Non-hodgkin’s lymphoma

15. 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

16. Adenoid cystic carcinoma(Cylindroma)
• 2nd
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

17. Treatment
• Radical parotidectomy
• Post-operative radiotherapy
• Wide local excision of palate: for tumors of
palate
Adenoid Cystic Carcinoma of right hard
palate

18. 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

19. • 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

20. 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

21. Parotid gland surgery

22. 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

24. 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

25. 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

26. Management:
Reassurance
Aluminium chloride-antiperspirant, useful astringent
Anticholenergics-topical eg glycopyrolate
Botulinum toxin A- injection into affected skin
Surgical:
Tympanic neurectomy: dennervation

27. Submandibular gland excision
Nerves likely to be injured during SMG
excision:-
1. Marginal mandibular nerve
2. Lingual nerve
3. Hypoglossal nerve

28. Thank you