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    Salivary Gland Tumors

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    Mugdha Francis
    The document discusses the history, anatomy, investigation, classification, staging, and management of salivary gland tumors. It details the various surgical procedures performed for tumors in major salivary glands including the parotid, submandibular, and sublingual glands. Complications of the surgeries are also outlined.

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    Salivary Gland Tumors

    Uploaded by

    Mugdha Francis
    20 views68 pages
    The document discusses the history, anatomy, investigation, classification, staging, and management of salivary gland tumors. It details the various surgical procedures performed for tumors in major salivary glands including the parotid, submandibular, and sublingual glands. Complications of the surgeries are also outlined.

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    Salivary gland tumors

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    The document discusses the history, anatomy, investigation, classification, staging, and management of salivary gland tumors. It details the various surgical procedures performed for tumors in major salivary glands including the parotid, submandibular, and sublingual glands. Complications of the surgeries are also outlined.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    20 views68 pages

    Salivary Gland Tumors

    Uploaded by

    Mugdha Francis
    The document discusses the history, anatomy, investigation, classification, staging, and management of salivary gland tumors. It details the various surgical procedures performed for tumors in major salivary glands including the parotid, submandibular, and sublingual glands. Complications of the surgeries are also outlined.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 68

    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

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