Management of

Salivary Gland Tumours

Prof. Dr Ummar Mangalath

Oral & Maxillofacial Surgeon
BDS, MDS, FIBOMS
Prof. Emritus PMS Dental College, Trivandrum
 INTRODUCTION
The investigation and management of salivary swellings have advanced
considerably in the past decade with an emphasis on less invasive
techniques and increased preservation of the salivary gland and
adjacent structures.
 HISTORY OF SURGERY

Salivary gland surgery-16th century

Concept of surgical excision of parotid tumour- by Bertrandi (1802)
(extensive approach-resulted in disfiguration & disability)
1850’s-dissection focused on relation of facial nerve.
1892- Codreanu( Romanian native)- 1st total parotidectomy with facial N
preservation
 HISTORY

THOMAS WHARTON NIELS STENSEN ALDRED SCOTT

( 1614 – 1673) (1638 – 1686) WARTHIN
(1866 – 1931)
Anatomical Considerations

Two submandibular
Two Parotid
Two sublingual
> 400 minor salivary glands
 Parotid Gland

largest salivary gland

FACIAL NERVE divides it into 2 surgical zones (the superficial and deep
lobes).
 The Subamandibular Salivary Gland

It is wedged between the mandible & the floor of the mouth

It has large superficial part & small deep part
Its duct opens in the floor of the mouth at the tip of the sublingual papilla
Sublingual Salivary Glands

Smallest of the major salivary glands.

Almond shaped
Deep to the floor of oral mucosa.
It is drained by approximately
10 small ducts (Ducts of Rivinus)
Minor Salivary Glands

These lie just under oral mucosa.

Distributed over lips, cheeks, palate
and floor of mouth.
Contribute 10% of total salivary
volume.
 Epidemology

Salivary gland tumours consistute– 3-5% of all H+N tumours and 0.5%
of all cancers
Smaller the gland greater the chance of malignancy
Incidence
Etiology
• Environmental(alcohol and smoking)
• Viral(EBV,HIV,HPV16 and 18)
• Genetic
• Radiation
• Nuclear plant exposure
• Ultraviolet light
• Dietary
• High intake of polyunsaturated fats
• Silica dust
• Oncogenes
 Clinical Features
Features of Benign tumours:
➢Slow growing
➢Painless
Features of Malignancy:
➢Sudden increase in size
➢Facial nerve palsy
➢Numbness of tongue
➢Weakness of tongue
➢Pain
➢Fixity to adjacent structures
➢Fixity of nodes
 Investigation
IMAGING TECHNIQUES

❑Ultrasound
❑CT
❑MRI
❑PET Scan
❑MRI Sialography
Colour Doppler ultrasound image of a large pleomorphic
adenoma in superficial lobe of parotid gland.
MRI of deep lobe of the parotid gland in a case of
pleomorphic adenoma
Axial contrast CT of a male patient with a right parotid
mass.
Histopatological Study

❑FNAC
❑Biopsy
❑Immunohistochemistry
❑Frozen section
Fine Needle Aspiration Biopsy

Efficacy is well established

❑ Accuracy = 84-97%

❑ Sensitivity = 54-95%

❑ Specificity = 86-100%

❑ Safe, well tolerated

Algorithm for Management of
Salivary Gland swelling
 Differential Diagnosis

• UNILATERAL PAROTIDOMEGALY
– hypertrophy of the masseter muscle
– dental or brachial cysts
– neuroma of the facial nerve
– temporal artery aneurysm
– sebaceous cysts
– lymphadenopathy
 Differential Diagnosis

• BILATERAL PAROTIDOMEGALY
– Drugs(OCP or thiouracil)
– endocrine disease (Diabetes, Cushings,
Myxoedema)
– bulimia
– alcoholism
– cirrhosis
Classification of Salivary Gland Tumors
 Staging System
• T N M:
• T0 no clinical evidence of primary tumour
• T1 0.1 – 2.0 cms diameter without significant local
extension
• T2 2.1 – 4 cms without local extension
• T3 4.1 – 6.0 cms without local extension
• T4
• a >6 cms without local extension
• b tumour of any size with significant extension
 Staging System

T N M:
❑NX: Lymph nodes (LN) not evaluated
❑N0: Without lymph nodes affection
❑N1: metastasis in only one LN ipsilateral to the tumor with up to 3 cm
❑N2a: LN of 3 to 6 cm, ipsilateral
❑N2b: multiple ipsilateral LNs
❑N2c: bilateral or contralateral LN’s
❑N3: LN’s larger than 6 cm
 TNM STAGING

✓M0 no distant mets

✓M1 distant mets eg., bone, lung

 Staging
❑ Stage I T1N0M0
❑ Stage II T2N0M0
❑ Stage III T3N0M0 or T1-3N1M0
❑ Stage IVA T4aN0-1M0 or T1-4aN2M0
❑ Stage IVB T4bNxM0 or TxN2-3M0
❑ Stage IVC TxNxM1
Common Salivary
Gland Tumors
 Pleomorphic Adenoma

❑ Commonest tumour
❑ Comprise 3 – 6%
❑ Both mesenchymal/epithelial
elements present
❑ Gender: female > male
 Pleomorphic Adenoma

❑Common sites are parotid,

palate, upper lip, buccal mucosa

❑Symptoms: slow growing

painless mass

❑FNAC, CT, MRI

 Pleomorphic Adenoma

Gross specimen-
shows
“ cut potato surface”
 Warthin Tumour (Papillary Cystadeno
Lymphomsatosum)

• Benign salivary gland tumor

• Gender: male > female
• Age: 5-7th decades
• Symptoms: painless mass
• Site: parotid, multi-
focal/bilateral (14%)
• Etiology: smoking (8 fold
risk)
 Mucoepidermoid Carcinoma
TREATMENT:
❑Commonest malignant tumour
❑50% -salivary gland malignancies ❑Surgical resection
❑High Recurrence ❑Neck dissection
❑Metastases to lymph nodes, lung, bone, ❑Radiation therapy
skin
❑Low to intermediate grades
– good prognosis
❑High grade
– poor prognosis
❑Site: submandibular, floor of mouth and
palate
 Adenoid Cystic Carcinoma

❑Common- submandibular (35% - 40%),

❑7% of parotid malignancies
❑Slowly growing
❑Perineural invasion
❑ lymph node mets and distant mets
❑5 year survival 75%
❑10 year survival 30%
❑20 year survival 13%
 Treatment Modalities

•Surgery
•Radiotherapy
•Chemotherapy
•Combined Therapy
Surgeries for the Parotid Gland
Tumors

Superficial parotidectomy
Total conservative parotidectomy
Radical parotidectomy
Radical parotidectomy with neck dissection
 Informed Consent

Facial weakness
Facial anaesthesia
Cosmetic defects
Frey’s syndrome
 Surgical Anatomy of Parotid Gland & Facial
Nerve

Variations in facial nerve anatomy

Double truncated – Katz &
Catalano
6 types – Davis et al (1977)
8 types – Miehlke et al(1979)
5 types - Katz & Catalano(1987)
(Katz & Catalano 1987)
Type I-
25%
No links between main branches
 Approaches to Parotidectomy

Modified Rhytidectomy Lazy ‘S’ Modified Blair

APPROACHES:
1. ANTEROGRADE APPROACH
2. RETROGRADE APPROACH
 Superficial Parotidectomy

It is removal of parotid tissues

lateral to the facial nerve.

It is mostly used for benign

tumors
 Superficial Parotidectomy

•Local anaesthetic infiltration given

•Lazy S incision made
•Skin flap reflected
•Facial nerve identified with the trunk
•Mobilization of gland done
•Closure- with placement of drain
 Total Conservative parotidectomy
with nerve preservation

•Lazy S incision made

•Superficial lobe reflect
•Trunk & branches freed from underlying structures
•External Carotid Artery ligated
•Deep lobe released from lateral pharyngeal wall
 Radical Parotidectomy
Total Parotidectomy with nerve
Transsection & Grafting

Lazy S for parotid

If neck node involvement is noted
Mcfee’s incision for neck dissection
If perineural invasion, nerve
transsection and grafting
Submandibular gland
surgeries
 Surgery of the Submandibular Gland
INFORMED CONSENT:
•Scar
•Marginal branch damage
•Hemi anesthesia – ant 2/3
tongue

APPROACHES
• Transcervical approach
• Transoral approach
•Infiltrate the incision area with 2% lignocaine
•Incision along the skin crease
•Flaps developed – fascial plane
•Superior flap – body of mandible
•Inferior flap – body of hyoid
•Blunt dissection and lingual nerve preservation
•Closure of the incision
 Hayes martin manoeuvre
The Hayes-Martin manoeuvre
involves ligation of the posterior
facial vein and superior
reflection of the investing fascia
below the mandible to preserve
the marginal mandibular nerve.
 Surgery of the Sublingual Gland
APPROACH :
• Transoral

•Incision lateral to Wharton’s duct

•Blunt dissection taking care of lingual
nerve
 Surgery of Palatal Tumors

Incision around the tumour down the periosteum

Margin of normal tissue should be involved in the incision
Defect left open for secondary healing
Palatectomy
Hemimaxillectomy
 Management of the Neck

Patients with ipsilateral +ve neck nodes - ipsilateral radical neck

dissection
If contralateral neck nodes +ve - contralateral modified radical
neck dissection is performed
 Management of the Neck
If neck is negative for nodes
• Management is still controversial
• Some authors recommend resection of the nodes for
– high risk tumours (Undifferentiated mucoepidermoid
carcinoma, SCC, adenocarcinoma and salivary duct
carcinoma)
– T3 and T4 tumours
– Preop facial n. paralysis
– patient age over 54 years
– extraparotid extension of tumour and perilymphatic
invasion
 Complication of Parotidectomy

1. FACIAL NERVE PALSY

2. INJURY TO THE GREATER AURICULAR NERVE –
NUMBNESS EAR
3. SALIVARY FISTULA
4. FREY’S SYMDROME
5. SCARS
 Complication of Submandibular Gland
Excision

1. DAMAGE TO MARGINAL MANDIBULAR NERVE

2. DAMAGE TO LINGUAL NERVE
3. DAMAGE TO HYPOGLOSSAL NERVE

1. DAMAGE TO LINGUAL NERVE

2. DAMAGE TO WHARTON’S DUCT
 Rehabilitation

Facial nerve reconstruction

Using:
• Greater auricular nerve (opposite
side)
• Sural nerve – C.T, large diameter
• Nylon suture is used
• 4 epineural sutures are placed
• Return of function- within 6-9
months
 Radiotherapy
• Great value in controlling loco-regional disease and
improving survival
• Indications
– high grade malignancy/unfavorable histology
– advanced clinical stage with facial n. involvement
– + margins of resection
– Recurrent disease
– + neck nodes following dissection
– Tumour spillage during surgery
 Chemotherapy
• Role is limited to treatment of metastatic
disease and palliation of loco-regional disease
not amenable to salvage surgery or radiation
therapy
• Cisplatin : most studied single agent
– A study of 25 pts = 18 % showed response to locoregional
disease and 7% response rate in
metastatic disease with mean survival 14 months
 Prognosis

The incidence of local recurrence & regional metastasis

are lowest in patient with stage I
 FREQUENTLY ASKED QUESTIONS
1.Classify salivary gland tumors..Write in detail about pleomorphic adenoma
2. Classify salivary gland tumours. How will you diagnose and manage a female
patient with ACC of hard palate. Briefly describe the reconstruction modalities to
restore the defect.
3. Surgical anatomy of facial nerve and techniques of superficial parotidectomy.
4 Various approaches to treatment of parotid gland tumor and factors affecting
choice of treatment.
Short notes:
1.. Warthins tumour
2. Adenoid cystic carcinoma
3. superficial parotidectomy
4.Mucoepidermoid carcinoma
5. Total parotidectomy
6. Hayes Martin maneouvre
 Books For References

1. Salivary Gland tumors ,Myers,Ferris,3rd edition

2. Principles of Oral and maxillofacial Surgery ,2nd edition,vol1 ,LJ Peterson
3. Marx RE ,Stern D Oral and maxillofacial pathology ,a rationale for
diagnosis and treatment ,Hanover Park ,IL,2012
4. Jatin Shah et al Head and surgery oncology, 4th edition
5. Surgical pathology of the salivary glands, Gary L Ellis, Paul L Auclair.
6. Management of salivary gland lesions by Mark S. Granick and Dwight
7. Oral and maxillofacial pathology, 3rd edition, Neville.
8. Color/Atlas text of salivary gland tumor pathology, Irving Dardick.
9. Gnepp, diagnostic surgical pathology of the head and neck
10. Salivary gland surgery – Langdon 2nd edition
 Articles

1. Impact of dysfunction of the facial nerve after superficial parotidectomy: a prospective study ,V
E Prats-Golczer 1, E Gonzalez-Cardero 1, J A Exposito-Tirado 2, E Montes-Latorre 3, L M
Gonzalez-Perez 1, P Infante-Cossio DOI: 10.1016/j.bjoms.2017.07.0062017 Oct;55(8):798-
802,british journal of oral and maxillofacial surgery
2. Superficial parotidectomy: technical modifications based on tumour characteristic .Nikolaos
Papadogeorgakis 1, Chris A Skouteris, Anastassios I Mylonas, Angelos P 2004 Dec;32(6):350-
3. doi: 10.1016/j.jcms.2004.05.004,journal of craniomaxillofacial surgery.
3. Improving esthetic results in benign parotid surgery: statistical evaluation of facelift approach,
sternocleidomastoid flap, and superficial musculoaponeurotic system flap application ,Bernardo
Bianchi 1, Andrea Ferri, Silvano Ferrari, Chiara Copelli, Enrico Sesenna2011 Apr;69(4):1235-
41. doi: 10.1016/j.joms.2010.03.005. Epub 2010 Aug 12.
4. Oral and maxillofacial Clinics of North America ,’The comprehensive management of Salivary
gland pathology7(3) 1995 the otolaryngyology clinics of north America ,salivary gland diseases
32(5),1999
 Conclusion

SURGICAL MANAGEMENT OF SALIVARY GLAND TUMOURS ARE

TECHNIQUE SENSITIVE AND CHALLENGING.SO PROPER
DIAGNOSIS, GOOD SURGICAL SKILL, ADEQUATE
EXPERIENCE AND SOUND KNOWLEDGE OF HEAD AND NECK
ANATOMY IS MANDATORY TO GET GOOD SURGICAL
RESULTS.
THANK YOU