CASE PRESENTATION

CASE HISTORY
• A 34 years old female patient reported to the Dept. of OMFS, SDC on 14th
feb, 2019 with a chief complaint of:
• Swelling on right back region of palate since 4 years.

• Patient further revealed that she was apparently well 4 years ago, since then
she noticed swelling on right posterior region of palate. Earlier swelling
was small in size (peanut size) which increased gradually to attain its
present size. Patient also gives history of pain in the same region since 2-3
months. Pain is dull aching and continuous in nature which relieves on
taking medication.
• Patient also gives a history of the following:
• No difficulty in swallowing or respiration.
• No history of fever.
• Absence of any other same swelling
• No secondary changes like softening, ulceration, fungation,
inflammation
• No weight loss
• Past medical history – non relevant history
• Past dental history- patient underwent extraction with 46 one year ago
without any complication
• Family history-non relevant history
• Personal history-vegetarian, brush once daily with paste and a toothbrush
• No Deleterious habit
• Drug history-not known allergic to any drug
• Patient is moderately- built with weight 47 kg, came walking on her own
with a normal gait and posture and was well oriented to time place and
person.
GENERAL PHYSICAL EXAMINATION
• Temp. - 98.40 f
• Pulse - 78 bpm
• BP - 110/70 mm/Hg
• Pallor - Absent
• Icterus - Absent
• Cyanosis - ABSENT
• Koilonychia - ABSENT
• Lymphadenopathy - NON PALPABLE
• Edema - ABSENT
EXTRA ORAL EXAMINATION
• Facial symmetry – No gross facial asymmetry present

• TMJ – Bilateral synchronous movements

No abnormal sounds on opening or closing of mouth
No deviation on opening and closing of mouth
Normal protrusive or lateral movements

• LYMPHNODE – Non tender ,non palpable bilaterally

 INTRA ORAL EXAMINATION
• Mouth opening: 37 mm irt 11&41
• Teeth present : 1-7 on upper right quadrant
1-7 on upper left quadrant
1,2,3,4,5,7,8 on lower right quadrant
1-8 on lower left quadrant
• Missing teeth -46
• Carious – 15
• Occlusion: Class I canine relationship
on both right and left side
 Swelling examination
• Inspection – single ovoid shaped swelling around 6.5x 5.5 cm in
dimension present on right side of hard palate extending from 15 to
posterior part of palate i.e soft palate excluding uvula without crossing
the midline.
• Pale pink in color, firm in consistency ,smooth surface, margins are well
defined.
• Non-pulsatile, non-fluctuant, afebrile, slightly tender swelling.
• Fluid thrill absent, non-translucent, non-reducible, non- compressible,
fixed to the overlying mucosa and underlying structures, no secondary
changes seen.
• Provisional diagnosis- Benign tumour of the minor salivary
gland
Differential diagnosis –
• Warthin’s tumor -usually seen in
elderly males with a history of
smoking, does not cause eversion
of the ear lobe
• located in the lower portion of the
parotid (near angle of mandible),
and 10-15% cases show bilateral
involvement.
• H/P shows cyst formation with
papillary projections into the
cystic spaces and lymphoid
matrix showing germinal layers.
• Myoepitheliomas - uncommon, and H/P composed of spindle shaped or
plasmacytoid cells or combination of two cell types. These cells may be
set in myxomatous background which may vary from scanty to copious
• Mucoepidermoid carcinoma - 6-9% of salivary gland tumours-H/P shows
mucus secreting cells, epidermoid type cells and intermediate cells.It also
shows sheets or nests of epidermoid cells and similar nests of mucus
cells arranged in a glandular pattern.
• Adenoid cystic carcinoma - 5th or 6th decade of life, H/P shows basal cells
arranged in anastomosing cords or may contain a mucoid material
producing the typical ‘honeycomb’ or ‘swiss-cheese pattern’. The stromal
connective becomes hyalinized and surrounds the tumor cells, forming a
structural pattern of cylinder- hence the name ‘cylindroma’
 RADIOGRAPHIC INVESTIGATION

OPG
• CT PNS (without contrast)reveled well defined lytic lesion of size approximately
21x15 mm seen in right posterior hard palate involving posterior maxillary sinus
wall.
• Lesion is bulging into inferior nasal cavity and in oral cavity.
PA chest
 Systemic investigation
• Plasma glucose random – 94 mg/dl
• Viral serology( HBsAG, HCV, HIV ) – negative
• Blood urea nitrogen – 10.1mg/dl
• Blood urea – 21.7mg/dl
• Serum creatinine – 0.9 mg/dl
• Serum uric acid – 4.1mg/dl
• Serum sodium – 140.7mEq/l
• Serum potassium – 3.96 mEq/l
 Hematology

• Hb -9.3g/dl
• TLC- 8600cells/mm3
• DLC- 50/42/04/04/0 %
• Platelet count- 4.50 lac cells/mm3
• RBC count-4.2 millions cells/ul
• BT-2.54 min
• CT- 5.16min
• P.C.V-27.9cc%
• MCV-76 fl
• MCH-18.7 pg
• MCHC-24.5g/dl
• PT-16.5 sec
• PC 81.7 %
• INR – 1.2
• ABO-BLOOD GROUP – ‘O’
• RH(ANTI D ) – positive

• Urine examination – normal

ECG
• Normal

• LFT
• Serum bilirubin-0.83mg/dl
• Serum GPT – 10.4 IU/L
• Serum GOT – 18.7 IU/L
• Serum alk. Phosphatase – 175.2 IU/L
Histopathology
• Sections show a tumor mass composed of round to ovoid to polygonal
glands and nests and small groups.
• Individual cell show bland nuclear chromatin, unnoticeable nucleoli
and scanty neoplasm
• Surrounding stroma show sheets of proliferating myoepithelial cells in
a loose myxoid matrix
• No malignant change suggestive of pleomorphic adenoma
 FINAL DIAGNOSIS
• Pleomorphic adenoma of minor salivary gland
 Treatment options
• If mucosa is not fixed to the tumour or tumour is encapsulated ,
crevicular incision is taken on palate extending to contralateral side
under anaesthesia.
• Palatal Envelop Flap is reflected and the whole tumour mass must be
separated out with careful dissection and excised.
• Then the palatal fap is sutured with resorbable sutures.
• If mucosa is fixed to the tumor mass, local wide excision of the mass
was done under anesthesia .
• Mucosa around the tumour should be marked maintaining 1cm margin
around the tumour and incised using the surgical blade.
• Then after performing wide dissection, the whole encapsulated tumour
mass must be excised along with the mucoperiosteum and the eroded bone
of the palate with the boundary line localized in the surrounding healthy
tissue
• Reconstruction of the palatal defect using temporal fascia graft
• Various approaches for temporal fascia graft
Gillies temporal approach
Preauricular incision
• Temporalis fascia may be harvested from the postauricular
incision(incision A).
• Transcanal incision over the fascia may be used to obtain the graft
(incision B).
• Harvest fascia from a more superior position (incision C).
• After incision layer by layer
dissection is carried out through skin
subcutaneous tissue ,temporoparietal
fascia,loose aerolar tissue to reach
temporalis fascia from where it is
harvested.

• The TPF lies just beneath the hair

follicles and subcutaneous fat of the
temporal region.

• This fascia is attached superiorly to

the superior temporal line and
inferiorly to the lateral and medial
surfaces of the zygomatic arch.
• The TPF must be distinguished from the denser and anatomically deeper
temporalis fascia, which invests the temporalis muscle.
• The TPF is a 2-mm to 4-mm-thick layer of connective tissue which lies in the
same plane with superficial muscular apo-neurotic system (SMAS) and
extends to the parietal region.
• Temporal and superficial temporal fascia's are fused in the superior temporal
line and both are attached at the level of zygoma. Loose areolar tissue exists
between these two fascias.
• The superficial temporal artery which is the terminal branch of the
external carotid artery runs within the TPF and supplies this fascia.
• Approximately 2-4 cm superior to the zygomatic arch artery divides
frontal and parietal branches.
Advantages –
• location of donor site
• Easy to harvest
• Requires less nutrtion and high survival
• No size limitation
• Used more than one piece overlapping one another

Disadvantages
• Can eventually become thin and atrophic
• It lacks elasticity and resistance to pressure changes
• Removable acrylic surgical splint on surgical site

Enucleation should not done to avoid spillage and chance of recurrence.

 Classification (WHO 1991)
Benign
• Pleomorphic adenoma
• Warthin’s tumor
• Oncocytoma
• Sebacceous adenoma
• Sialoblastoma
• Canalicular adenoma,
• Basal cell adenoma
• Myoepithelioma
Malignant
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Carcinoma ex- pleomorphic
adenoma
• Acinic cell adenocarcinoma
• Salivary ductal carcinoma
• Squamous cell carcinoma
• Oncocytic carcinoma
 Pleomorphic adenoma (PA)
• Suggested by Willis
• Also known as benign mixed
tumor, is the most common
salivary tumor, constituting up to
two-thirds of all salivary gland
neoplasms.
• Mostly, PA is located in the
parotid glands (85%), minor
salivary glands (10%), and the
submandibular glands (5%) .

Califano J, Eisele DW. Benign salivary gland neoplasms. Otolaryngol Clin North Am, 1999; 32:861-73.
• In the majority of cases, tumours originate in the superficial lobe.
Ocasionally may involve the deep lobe of the parotid gland and the
parapharyngeal space.
• Minor salivary gland tumours are frequently encountered on the palate,
followed by the lip, cheek, tongue and floor of the mouth.
• It usually manifest as a slow progressing asymptomatic, parotid gland
swelling without facial nerve involvement .
• They are best treated by a wide local excision with good safety margins
and follow-up for at least 3-4 years.

6. Aggarwal A, Singh R, Sheikh S, Pallagatti S, Singla I. Pleomorphic adenoma of minor salivary gland: A case
report. RSBO Revista Sul-Brasileira de Odontologia, 2012; 9:97- 101.
 Etiology
• Unknown
• Incidence of this tumour has been increasing in the last 15-20 years in
relation to the exposure of radiation.
• Oncogenic simian virus (SV40) may play a role in the onset or
progression of pleomorphic adenoma.
• Prior head and neck irradiation is also a risk factor.
• It occurs in individuals of all ages most common - third to sixth decades.
• More female predilection
• Accounts for 70-80% of benign salivary gland tumours and are especially
common in the parotid gland.
• Distribution among the various salivary glands is as follows:

• Parotid gland: 84%

• Submandibular gland: 8%
• Minor salivary glands: 6.5%
 Microscopic features
• Microscopically pleomorphic adenoma
has a highly variable appearance, hence
the name pleomorphic.
• It is characterized by mixed proliferation
of polygonal epithelial and spindle-shaped
myoepithelial cells in a variable stroma
matrix of mucoid, myxoid, cartilaginous
or hyaline origin.
• Epithelial elements are usually of
polygonal, spindle or stellate-shaped cells
which may be arranged to form duct-like
structures, sheets, clumps, or interlacing
strands.
• The ducts and tubules are seen usually exhibiting an outer lining in
addition to an inner cuboidal epithelial cell layer.
• This is outer myoepithelial cell layer (or layers) which merges into the
surrounding stroma which also contains dispersed or clumped
myoepithelial element cells.
• Areas of squamous metaplasia and epithelial pearls can be found. The
tumour lacks the true capsule and is surrounded by a fibrous pseudo
capsule of variable thickness.
• The tumour extends through normal glandular parenchyma in the form
of finger-like pseudopodia. These microscopic extensions account for
the high risk of recurrence.
Clinical features
• It presents as a solitary mobile slow-growing, painless mass, which may
be present for many years.
• Symptoms and signs mainly depend on size, location, and potential to
undergo malignant transformation.
• In the parotid gland, signs of facial nerve weakness occur when the tumor
is large or if it undergoes malignant change.
• Pleomorphic adenoma in the deep lobe of the parotid gland may present as
an oral retro tonsillar or para-pharyngeal mass which is visible or usually
palpable.
• Dumbbells shaped appearance-grows in medial direction between ramus
and stylomandibular ligament.
• Rapid enlargement of a tumor nodule should raise a concern of malignant
change.
• Minor salivary gland tumors may present with a variety of symptoms,
including dysphagia, hoarseness, dyspnea, difficulty in chewing, and
epistaxis dependent on the site of the tumor.
 DIAGNOSIS

• Tissue sampling and radiographic studies.

• Tissue sampling procedures including fine needle aspiration (FNA) and
core needle biopsy.
• FNA can determine whether the tumor is malignant in nature with an
approximate sensitivity of 90%.
• Core needle biopsy is more invasive but provides more accurate histological
typing of the tumor with a diagnostic accuracy of around 97%.
Immunohistochemistry may prove to be supportive in delineating the
different cell components.
Sialography
• CT examination a pleomorphic
adenoma usually appears as smoothly
marginated or lobulated homogeneous
soft tissue density globular mass.
• Necrosis can be seen in larger masses.
Few foci of calcification are common.
• Smaller tumors show early
homogenous prominent enhancement
while in the case of larger tumors
enhancement is less marked and
delayed.
• MRI is similar to CT; smaller
masses appear well-circumscribed
and homogeneous whereas larger
tumors appear heterogeneous.

• Ultrasound guided biopsy or FNA

are minimally invasive and cost
effective procedures.

• Angiography (DSA)
 Treatment
• Enucleation procedure has been abandoned -because of high rates of
recurrence.
• Presently pleomorphic adenoma of the parotid gland is treated either with
superficial (Patey's operation) or total parotidectomy with the latter being
the more frequently performed procedure due to lower incidence of
recurrence.
• Meticulous technique is required to preserve the facial nerve. The tumours
of the submandibular glands are treated with simple excision procedure
with preservation of adjacent nerve including the mandibular branch of the
trigeminal nerve, the hypoglossal nerve, and the lingual nerve.
• When in the minor salivary glands, a five mm margin should be
obtained. These tumors do not invade into periosteum. Thus, the bone
need not be resected.

• Pleomorphic adenomas harbor a small risk of malignant transformation.

The malignant potential is proportional to the time the lesion is in situ
(1.5% in the first five years, 9.5% after 15 years).

• Therefore, excision is warranted in almost all cases. Other risk factors

for malignancy include advanced age, radiation therapy, large size, and
recurrent tumors
Recurrence after surgery
DUE TO : Spillage
• Inadequate margin
• Retained pseudopods
• Multicentricity
• Improper technique
• Recurrent tumor is multinodular without capsule
Carcinoma in ex pleomorphic adenoma
• Long standing Pleomorphic adenoma-malignant transformation
• Recent increase in size
• Pain , nodularity
• Involvement of skin, ulceration
• Involvement of masseter
• Involvement of facial nerve
• Neck lymph node
• Restriction of jaw movements
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