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2. SALIVARY GLAND NEOPLASMS BYMD.NUMANUDDIN 3. Anatomy 3 major salivary glands: The parotid glands The submandibular glands The sublingual glands Many minor salivary glands in mucosa ofcheeks, lips, palate. 4. Parotid gland Largest salivary gland Lies b/w sternomastoid and mandiblebelow the EAM Coverings : True capsule False capsule a layer from the deep cervicalfascia 5. Lobes of parotid gland Parotid divided into superficial and deeplobes by the facial nerve Fasciovenous plane of Patey 6. Structures within the parotid gland1. External carotid artery :2. Retromandibular vein3.Facial nerve. 7. Structures within the parotid gland3. 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. 8. Facial nerve over the deep lobe ofparotid 9. Parotid duct Stensens duct 5cm in length Comes out through anterior surface ofglands. Peirces buccinator and opens in buccalmucosa opposite crown of second uppermolar tooth. 10. Submandibular gland Composed of superficial part and deeppart Divided by mylohyoid muscle Superficial part lies in the submandibulartriangle b/w 2 bellies of digastric muscle Deep part lies abv & deep to mylohyoid inthe floor of mouth 11. Submandibular duct (Whartonsduct) About 5 cm long Runs fwd from the deep part of the glandto enter floor of the mouth Opens on a papilla beside the frenulum ofthe tongue 12. Structures in relation tosubmandibular gland The Lingual nerve The Facial artery 13. Neoplasms of the salivary gland Salivary gland neoplasms forms 1% of allhead 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 insubmandibular glands. Of these 50% are benign and 50% and malignant. In carcinomas mucoepidermoid ca> adenoidcystic ca > adenocarcinoma 14. 10% of salivary tumors occur in sublingualand minor salivary glands 60-70% of these are malignant 15. ClassificationA. Epithilial tumorsB. Connective tissue tumorsC. Metastatic tumors 16. A. Epithilial tumors Benign Pleomorphic adenoma (Mixed tumor) Oxyphil adenoma Adenolymphoma (Warthins tumor) Basal cell adenoma 17. Epithilial tumors Malignant Mucoepidermoid carcinoma Adenoid cystic carcinoma Acinic cell carcinoma Papillary adenocarcinoma Squamous cell carcinoma Undifferentiated carcinoma Carcinoma arising in pleomorphic adenoma 18. Connective tissue tumors Benign Hemangioma Lipoma Neurilemmoma Fibroma Malignant Malignant lymphoma Above mentioned benign tumors may turnmalignant. 19. Pleomorphic adenoma It is a Mixed tumor Commonest tumor of salivary glands. Histologically it is charcterized by complexintermingling of epithelial component andmesenchymal areas. Sites : 90% Parotids7% Submandibular gland3% restOrigin:According to the multicellar theory,thesetumours orginate from intercalated duct cells andmyoepithelial cells of the salivary glands. 20. Pathology Macro : rubbery, on cut section, mucoidappearance with zones of cartilage. Micro : pleomorphic stroma withpseudocartilage, lymphoid, myxoid andfibrous elements besides epithelial cells. 21. 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 22. 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. 23. Treatment The tumor is radioresistant. Excision is the treatment of choice. For diagnosis FNAC can be done butincisional biopsy is contraindicated. Superficial parotidectomy is the treatmentof choice. Submandibular gland : submandibulargland excision. 24. ADENOLYMPHOMA (Warthinstumor): Adenolymphoma was first reported byAlbrecht 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 parotidgland. 25. Pathology Gross : soft and frequently cystic Micro : cores of papillary processes withabundant lymphoid tissue. 26. Clinical features Age : middle and old age Sex : much more common in males Painless slow growing tumor over angle ofjaw May be bilateral Surface is smooth 27. Management Treatment : superficial parotidectomy withcare taken to preserive the facial nerve. 28. ONCOCYTOMA(OXYPHILICADENOMA):>Primarily occur in parotid and are composed ofclusters of large eosinophilic granularcells(oncocytes).>It was first reported by DUPLAY in 1875 andaccording to the multicellular theory of salivarygland neoplasms,oncocytomas orginate from thestriated duct cells. 29. Clinical features:age:they usually occur among olderindividuals,in their 8th decade of life.SEX:Female predilectionSITE:Superficial lobe of the parotid is the mostfavoured location.Clinically the tumor often produces slowenlarging,painless,uninodular or sometimesmultinodular, movable swealling anterior to theear or over the ramus of the mandible. 30. HISTOPATHOLOGY:The tumors are cellular,containing round eosinophiliccells with a granular cytoplasm.The nuclei are small and have indentations.The granular appearance of these cells is the result ofthe number of mitochondria present in the cytoplasm. 31. TREATMENT: Surgical excision by lobectomy. 32. MONOMORPHIC ADENOMA: It is characterized by proliferation of asingle epithelial cell type that has adistinctive architectural patter. It does not exhibit the wide cellulardiversities,which are normallyencountered in pleomorphic adenomas. Basal cell adenoma is the most commontype. 33. CLINICAL FEATURES: Basal cell adenomas: Age; commonly in 6th decade of life Sex:female Site:commonly involves parotid(70%) and20% lession are seen in oral cavity andintraoral lession commonly arises fromthe upper lip and buccal mucosa. It is slowenlarging,firm,encapsulated,movabilelesions and usually measure less than 3cm. 34. Canalicular adenoma: Age:in 7th decade of life Sex:female Site:Minor salivary glands of the upper lipare the most common site. Major gland rare. Clinically appear as small,painless,movableencapsulated lesions being covered by asmooth intact epithelium. 35. HISTOPATHOLOGY:Tumors contain epithelial parenchyma,which issharply denacreted from the scant stroma by athick prominet basement appearance.The epithelial cells have a palisading appearnce atthe periphery of the tumour parenchyma. 36. TREATMENT:Surgical excision with a margin of normal tissue forthese benign and nonaggressive tumors. 37. MALIGANT SALIVARYGLAND NEOPLASMS 38. MUCOEPIDERMOID TUMOR:It is an unusual type of malignant salivary gland neoplasm withvarying degree of aggressiveness.According to the multicellulartheory ,the mucoepidermiod tumors arises from the excretoryduct cells of the salivary gland.Tumor are graded into low,intermediate and high grade tumordepending upon their cells type.It is made of two types of cells they are-Mucous cells-Epidermoid cellsLow grade tumor have a higher proportion of mucous cellsthen epidermoid cells.High grade tumor have high epidermoid cells.Low grade tumors are smal,encapsulated,non-aggressive.High grade tumors are infiltrative,non-capsulated.largermases,solid,greyish white in appearance. 39. HISTOLOGICAL: >Low grade tumors contain sheets ofmucoid cells separated by bands ofepidermoid cells.Mucouc cells are clearand plump with small nuclei.Epidermoidcomponents resemble squamous cellcarcinoma. >High grade mucoepidermoid carcinomaare composed nearly entirely of nests ofmalignant epidermoid cells.Few mucouscells or none at all present. 40. CLINICAL FEATURES: Age:30 to 40 year Sex:Female predilection Site:The tumor frequently involve theparotid and minor salivary glands of thepalate,lips,buccal mucosa,tongue, andretromolar areas etc. 41. TREATMENT: Surgical excision and radiotherapy 42. 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 43. HISTHOPATHOLOGY:Tumor consists of either serous or mucous acinar cells ofthe salivary gland.Malignant cells are larger round or polyhedral in shapeand have granular basophilic cytoplasm and darkeccentrically placed nuclei.Cells are often arranged in acinus-like cluster and theyoften resemble the serious acinar cells of the salivarygland.Cell cytoplasm may be vacuolated or sometimes entirelyclearTumor cells may abe arranged in sheets or solid or cysticor even papillary cystic patters wuthin a lymphoid stroma. 44. TREATMENT: By wide local excision or superficialparotidectomy. 45. Adenoid Cystic Carcinoma Consists of myoepithelial and ductepithelial cells Slow growing but more invasive than theabove described malignant tumors Tumor is always more extensive than thephysical or radiological appearance Minor glands > submandibular > parotid 46. HISTOPATHOLOGY:Tumor consist of basaloid epithelial elements thatform cylindric structures. 47. TREATMENT: Surgical excision of the tumor along withthe part of the neural tissue involved isimportant. 48. Adenocarcinomas, Epidermoid ca &Undifferentiated Ca Resemble various glandular elements seenin salivary glands Divided according to predominant celltype Demonstrate fixation to adjacent bone,pain, anesthesia of skin and paralysis ofmuscles 49. In case of parotid gland, facial nerveirritability occurs first, later gives rise tofacial paralysis Limitation of jaw movements 50. CARCINOMA EX-PLEOMORPHIC ADENOMA:This refers to an epithelial caercinoma arising frompleomorphic adenoma.This tumor consist of malignant epithelial componentonly with no mesenchymal element.It is rare. 51. CLINICAL FEATURE: Sudden rapid increase in size of a slow-growing or stable mass.Facial nerveinvolvement is another important feature. The gross tumor appears firm ,non-encapsulated ,nodular with areas o0fcentral necrosis and heamorrhage. 52. TREATMENT: SURGICAL EXCISION 53. SQUAMOUS CELL CARCINAMO: Primary squamous cell carcinoma is rae insalivary glands. High grade mucoepidermoid carcinomashould be ruled out which may appaearsimilar to squamous cell carcinoma. Also SCC of skin or upper respiratirytract with metastasis to salivary gladsshould be ruled out It has a tendency for local and reginolspread. 54. TREATMENT: SURGICAL EXCISION 55. TREATMENT OF SALIVARYGLAND TUMORS:1.Medical treatment: a)Chemotherapy b)Neutron therapy2.Surgical treatment: 56. SURGERY OF SALIVARYGLANDS 57. Freys syndrome Also called as auriculo-temporal syndrome Occurs due to damage to the autonomicinnervation of the salivary gland Inappropriate regeneration ofparasympathetic fibers Stimulation of sweat glands of overlying skinwith stimulus of salivation 58. Causes : Surgery of the parotid gland Injury to parotid gland Clinical features : sweating and erythemaat the site of parotid surgery by smell ortaste of food. 59. Investigation : Starch iodine test : After painting the area with iodine Starchapplied over the area becomes blue ongustatory stimulus. 60. Prevention Sternomastoid muscle flap Temporalis fascial flap Artificial membranes Form a barrier between skin and parotidbed to minimise inappropriateregeneration of autonomic nerve fibres. 61. Treatment Initially conservative management Most recover in 6 months Anti-perspirants Denervation by tympanic neurectomy Injection of botulinum toxin into theafected skin. 62. Parotidectomy Types :1. Superficial parotidectomy : superficial to facial nerve2. 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. 63. Incision Lazy S incision Pre-auricularmastoid-cervical incision 64. Identificaton of facial nerve Conleys pointer : inferior portion ofcartilagnous canal. Facial nerve is 1cmdeep and inferior to its tip. Upper border of posterior belly of thedigastric muscle. Fascial nerveimmediately superior to this. By nerve stimulator 65. How To Save The Facial Nerve DuringParotid Salivary Gland Tumor Surgery.flv 66. Complications of parotid surgery1. Haematoma formation2. Infection3. Temporary facial nerve weakness4. Permanent facial nerve weakness5. Sialocele6. Facial numbness7. Freys syndrome 67. Facial nerve injury(Lower motorneuron lesion) Causes Trauma Parotid surgery Compression of facial nerve(Bells nerve) 68. Clinical features Inability to close the eye lid Difficulty in blowing and clenching Drooping of the angle of mouth Obliteration of naso-labial fold 69. Treatment Usually temporary, recovers in 6 months Nerve grafting Suspension of angle of mouth tozygomatic bone Lateral tarsorrhaphy 70. Submandibular gland excision Indications : Chronic sialoadenitis Stone in submandbular gland Submandibular gland tumors 71. Incision Placed 2-4 cm below th mandie, parallelto it Preserve : Marginal mandibular nerve Lingual nerve Hypoglossal nerve 72. Complications Hemorrhage Infection Injury to mandibular nerve, lingual nerve ,hypoglossal nerve 73. THANK YOUTHANK YOU