1. GOODMORNING
WELCOME

2. SALIVARY GLAND
NEOPLASMS
BY
MD.NUMANUDDIN

3. Anatomy
 3 major salivary glands:
◦ The parotid glands
◦ The submandibular glands
◦ The sublingual glands
 Many minor salivary glands in mucosa of
cheeks, lips, palate.

4. Parotid gland
 Largest salivary gland
 Lies b/w sternomastoid and mandible
below the EAM
 Coverings :
◦ True capsule
◦ False capsule – a layer from the deep cervical
fascia

5. Lobes of parotid gland
 Parotid divided into superficial and deep
lobes by the facial nerve
 Fasciovenous plane of Patey

8. Structures within the parotid gland
1. External carotid artery :
2. Retromandibular vein
3.Facial nerve.

9. Structures within the parotid gland
3. The facial nerve
◦ Enters upper part of posteromedial border
◦ Passes forward and downward and divides
into
Temporal br.
Temporofacial Zygomatic br.
Main trunk
Buccal branches
Cervicofacial Marginal mandibular br.
Cervial br.

10. Facial nerve over the deep lobe of
parotid

11. Parotid duct
 Stensen’s duct
 5cm in length
 Comes out through anterior surface of
glands.
 Peirces buccinator and opens in buccal
mucosa opposite crown of second upper
molar tooth.

12. Submandibular gland
 Composed of superficial part and deep
part
 Divided by mylohyoid muscle
 Superficial part lies in the submandibular
triangle b/w 2 bellies of digastric muscle
 Deep part lies abv & deep to mylohyoid in
the floor of mouth

13. Submandibular duct (Wharton’s
duct)
 About 5 cm long
 Runs fwd from the deep part of the gland
to enter floor of the mouth
 Opens on a papilla beside the frenulum of
the tongue

15. Structures in relation to
submandibular gland
 The Lingual nerve
 The Facial artery

16. Neoplasms of the salivary gland
 Salivary gland neoplasms forms 1% of all
head and neck tumours.
 75% occur in the parotid glands.
◦ In parotid glands, 80% of tumors are benign.
◦ Of these 80% are Pleomorphic adenomas.
 15% of salivary tumors occur in
submandibular glands.
◦ Of these 50% are benign and 50% and malignant.
 In carcinomas mucoepidermoid ca> adenoid
cystic ca > adenocarcinoma

17.  10% of salivary tumors occur in sublingual
and minor salivary glands
◦ 60-70% of these are malignant

18. Classification
A. Epithilial tumors
B. Connective tissue tumors
C. Metastatic tumors

19. A. Epithilial tumors
 Benign
◦ Pleomorphic adenoma (Mixed tumor)
◦ Oxyphil adenoma
◦ Adenolymphoma (Warthin’s tumor)
◦ Basal cell adenoma

20. Epithilial tumors
 Malignant
◦ Mucoepidermoid carcinoma
◦ Adenoid cystic carcinoma
◦ Acinic cell carcinoma
◦ Papillary adenocarcinoma
◦ Squamous cell carcinoma
◦ Undifferentiated carcinoma
◦ Carcinoma arising in pleomorphic adenoma

21. Connective tissue tumors
 Benign
◦ Hemangioma
◦ Lipoma
◦ Neurilemmoma
◦ Fibroma
 Malignant
◦ Malignant lymphoma
◦ Above mentioned benign tumors may turn
malignant.

22. Pleomorphic adenoma
 It is a ‘Mixed tumor’
 Commonest tumor of salivary glands.
 Histologically it is charcterized by complex
intermingling of epithelial component and
mesenchymal areas.
 Sites : 90%  Parotids
7% Submandibular gland
3% rest
Origin:According to the multicellar theory,these
tumours orginate from intercalated duct cells and
myoepithelial cells of the salivary glands.

23. Pathology
 Macro : rubbery, on cut section, mucoid
appearance with zones of cartilage.
 Micro : pleomorphic stroma with
pseudocartilage, lymphoid, myxoid and
fibrous elements besides epithelial cells.

24. Clinical features
 Age : any age but common around 40 yrs
 Sex : slightly more incidence in females.
 Painless swelling since years.
 Slow growth.
 Site : usually below the lobule of ear.
 Variable consistency : firm and rubbery

26. Malignant transformation
 Malignant transformation may occur in 3%
to 5%
 Signs of malignant transformation :
◦ Long duration (10-20yrs)
◦ Becomes painful
◦ Starts growing rapidly
◦ Becomes stony hard
◦ Facial nerve involvement
◦ L. node involvement.
◦ Jaw movement restriction.

27. Treatment
 The tumor is radioresistant.
 Excision is the treatment of choice.
 For diagnosis FNAC can be done but
incisional biopsy is contraindicated.
 Superficial parotidectomy is the treatment
of choice.
 Submandibular gland : submandibular
gland excision.

28. ADENOLYMPHOMA (Warthin’s
tumor):
 Adenolymphoma was first reported by
Albrecht and Arzt in the year 1910.
 It is primarily occuring in the parotid
 Represents 5-15% of parotid tumors.
 Occurs only in parotid.
 Almost always in lower portion of parotid
gland.

29. Pathology
 Gross : soft and frequently cystic
 Micro : cores of papillary processes with
abundant lymphoid tissue.

30. Clinical features
 Age : middle and old age
 Sex : much more common in males
 Painless slow growing tumor over angle of
jaw
 May be bilateral
 Surface is smooth

31. Management
 Treatment : superficial parotidectomy with
care taken to preserive the facial nerve.

32. ONCOCYTOMA(OXYPHILIC
ADENOMA):
>Primarily occur in parotid and are composed of
clusters of large eosinophilic granular
cells(oncocytes).
>It was first reported by DUPLAY in 1875 and
according to the multicellular theory of salivary
gland neoplasms,oncocytomas orginate from the
striated duct cells.

33. Clinical features:
age:they usually occur among older
individuals,in their 8th decade of life.
SEX:Female predilection
SITE:Superficial lobe of the parotid is the most
favoured location.
Clinically the tumor often produces slow
enlarging,painless,uninodular or sometimes
multinodular, movable swealling anterior to the
ear or over the ramus of the mandible.

34. HISTOPATHOLOGY:
The tumors are cellular,containing round eosinophilic
cells with a granular cytoplasm.
The nuclei are small and have indentations.
The granular appearance of these cells is the result of
the number of mitochondria present in the cytoplasm.

35. TREATMENT:
 Surgical excision by lobectomy.

36. MONOMORPHIC ADENOMA:
 It is characterized by proliferation of a
single epithelial cell type that has a
distinctive architectural patter.
 It does not exhibit the wide cellular
diversities,which are normally
encountered in pleomorphic adenomas.
 Basal cell adenoma is the most common
type.

37. CLINICAL FEATURES:
Basal cell adenomas:
 Age; commonly in 6th decade of life
 Sex:female
 Site:commonly involves parotid(70%) and
20% lession are seen in oral cavity and
intraoral lession commonly arises from
the upper lip and buccal mucosa.
 It is slow
enlarging,firm,encapsulated,movabile
lesions and usually measure less than 3cm
.

38. Canalicular adenoma:
 Age:in 7th decade of life
 Sex:female
 Site:Minor salivary glands of the upper lip
are the most common site.
 Major gland rare.
 Clinically appear as small,painless,movable
encapsulated lesions being covered by a
smooth intact epithelium.

39. HISTOPATHOLOGY:
Tumors contain epithelial parenchyma,which is
sharply denacreted from the scant stroma by a
thick prominet basement appearance.
The epithelial cells have a palisading appearnce at
the periphery of the tumour parenchyma.

40. TREATMENT:
Surgical excision with a margin of normal tissue for
these benign and nonaggressive tumors.

41. MALIGANT SALIVARY
GLAND NEOPLASMS

42. MUCOEPIDERMOID TUMOR:
It is an unusual type of malignant salivary gland neoplasm with
varying degree of aggressiveness.According to the multicellular
theory ,the mucoepidermiod tumors arises from the excretory
duct cells of the salivary gland.
Tumor are graded into low,intermediate and high grade tumor
depending upon their cells type.
It is made of two types of cells they are
-Mucous cells
-Epidermoid cells
Low grade tumor have a higher proportion of mucous cells
then epidermoid cells.
High grade tumor have high epidermoid cells.
Low grade tumors are smal,encapsulated,non-aggressive.
High grade tumors are infiltrative,non-capsulated.larger
mases,solid,greyish white in appearance.

43. HISTOLOGICAL:
 >Low grade tumors contain sheets of
mucoid cells separated by bands of
epidermoid cells.Mucouc cells are clear
and plump with small nuclei.Epidermoid
components resemble squamous cell
carcinoma.
 >High grade mucoepidermoid carcinoma
are composed nearly entirely of nests of
malignant epidermoid cells.Few mucous
cells or none at all present.

44. CLINICAL FEATURES:
 Age:30 to 40 year
 Sex:Female predilection
 Site:The tumor frequently involve the
parotid and minor salivary glands of the
palate,lips,buccal mucosa,tongue, and
retromolar areas etc….

45. TREATMENT:
 Surgical excision and radiotherapy

46. Acinic cell tumor
 Almost all occur in parotid gland
 Composed of cells resembling acini
 Women > Men
 Rare and slow growing
 Tend to be soft and occasionally cystic

47. HISTHOPATHOLOGY:
Tumor consists of either serous or mucous acinar cells of
the salivary gland.
Malignant cells are larger round or polyhedral in shape
and have granular basophilic cytoplasm and dark
eccentrically placed nuclei.
Cells are often arranged in acinus-like cluster and they
often resemble the serious acinar cells of the salivary
gland.
Cell cytoplasm may be vacuolated or sometimes entirely
clear
Tumor cells may abe arranged in sheets or solid or cystic
or even papillary cystic patters wuthin a lymphoid stroma.

48. TREATMENT:
 By wide local excision or superficial
parotidectomy.

49. Adenoid Cystic Carcinoma
 Consists of myoepithelial and duct
epithelial cells
 Slow growing but more invasive than the
above described malignant tumors
 Tumor is always more extensive than the
physical or radiological appearance
 Minor glands > submandibular > parotid

50. HISTOPATHOLOGY:
Tumor consist of basaloid epithelial elements that
form cylindric structures.

51. TREATMENT:
 Surgical excision of the tumor along with
the part of the neural tissue involved is
important.

52. Adenocarcinomas, Epidermoid ca &
Undifferentiated Ca
 Resemble various glandular elements seen
in salivary glands
 Divided according to predominant cell
type
 Demonstrate fixation to adjacent
bone, pain, anesthesia of skin and paralysis
of muscles

53.  In case of parotid gland, facial nerve
irritability occurs first, later gives rise to
facial paralysis
 Limitation of jaw movements

54. CARCINOMA EX-
PLEOMORPHIC ADENOMA:
This refers to an epithelial caercinoma arising from
pleomorphic adenoma.
This tumor consist of malignant epithelial component
only with no mesenchymal element.
It is rare.

55. CLINICAL FEATURE:
 Sudden rapid increase in size of a slow-
growing or stable mass.Facial nerve
involvement is another important feature.
 The gross tumor appears firm ,non-
encapsulated ,nodular with areas o0f
central necrosis and heamorrhage.

56. TREATMENT:
 SURGICAL EXCISION

57. SQUAMOUS CELL CARCINAMO:
 Primary squamous cell carcinoma is rae in
salivary glands.
 High grade mucoepidermoid carcinoma
should be ruled out which may appaear
similar to squamous cell carcinoma.
 Also SCC of skin or upper respiratiry
tract with metastasis to salivary glads
should be ruled out
 It has a tendency for local and reginol
spread.

58. TREATMENT:
 SURGICAL EXCISION

59. TREATMENT OF SALIVARY
GLAND TUMORS:
1.Medical treatment:
a)Chemotherapy
b)Neutron therapy
2.Surgical treatment:

60. SURGERY OF SALIVARY
GLANDS

61. Frey’s syndrome
 Also called as auriculo-temporal syndrome
 Occurs due to damage to the autonomic
innervation of the salivary gland
 Inappropriate regeneration of
parasympathetic fibers
 Stimulation of sweat glands of overlying skin
with stimulus of salivation

62.  Causes :
◦ Surgery of the parotid gland
◦ Injury to parotid gland
 Clinical features : sweating and erythema
at the site of parotid surgery by smell or
taste of food.

63.  Investigation :
◦ Starch iodine test :
◦ After painting the area with iodine Starch
applied over the area becomes blue on
gustatory stimulus.

64. Prevention
 Sternomastoid muscle flap
 Temporalis fascial flap
 Artificial membranes
 Form a barrier between skin and parotid
bed to minimise inappropriate
regeneration of autonomic nerve fibres.

65. Treatment
 Initially conservative management
 Most recover in 6 months
 Anti-perspirants
 Denervation by tympanic neurectomy
 Injection of botulinum toxin into the
afected skin.

66. Parotidectomy
Types :
1. Superficial parotidectomy : superficial to
facial nerve
2. Total conservative parotidectomy : for
benign diseases involving deep lobe. Facial
nerve is preserved.
3. Radical parotidectomy :
◦ For carcinomas
◦ Facial nerve, fat, facia, muscles and lymph nodes
are removed.
◦ Later reconstruction using hypoglossal or
greater auricular nerve.

67. Incision
 Lazy ‘S’ incision
 Pre-auricular—mastoid-cervical incision

69. Identificaton of facial nerve
 Conley’s pointer : inferior portion of
cartilagnous canal. Facial nerve is 1cm
deep and inferior to its tip.
 Upper border of posterior belly of the
digastric muscle. Fascial nerve
immediately superior to this.
 By nerve stimulator

70.  How To Save The Facial Nerve During
Parotid Salivary Gland Tumor Surgery.flv

71. Complications of parotid surgery
1. Haematoma formation
2. Infection
3. Temporary facial nerve weakness
4. Permanent facial nerve weakness
5. Sialocele
6. Facial numbness
7. Frey’s syndrome

72. Facial nerve injury(Lower motor
neuron lesion)
 Causes
◦ Trauma
◦ Parotid surgery
◦ Compression of facial nerve(Bell’s nerve)

73. Clinical features
 Inability to close the eye lid
 Difficulty in blowing and clenching
 Drooping of the angle of mouth
 Obliteration of naso-labial fold

74. Treatment
 Usually temporary, recovers in 6 months
 Nerve grafting
 Suspension of angle of mouth to
zygomatic bone
 Lateral tarsorrhaphy

75. Submandibular gland excision
 Indications :
◦ Chronic sialoadenitis
◦ Stone in submandbular gland
◦ Submandibular gland tumors

76. Incision
 Placed 2-4 cm below th mandie, parallel
to it
 Preserve :
◦ Marginal mandibular nerve
◦ Lingual nerve
◦ Hypoglossal nerve

78. Complications
 Hemorrhage
 Infection
 Injury to mandibular nerve, lingual nerve
, hypoglossal nerve

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