Download - Benign and malignat tumors of salivary gland
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Neoplasms of salivary glands
Dr. Ramesh Parajuli, MSChitwan Medical College Teaching Hospital,
Chitwan, Nepal
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• Major salivary glands: paired1.Parotid2.Submandibular3.Sublingual
• Minor salivary glands: multiple, submucosal, upper aerodigestive tract eg. from nasal cavity and lips down to the esophagus and trachea
Salivary gland anatomy
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Salivary gland microanatomy
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Neoplams of salivary glands• Tumors of salivary glands –
uncommon
• 3% to 6% of all tumors of head & neck region
• Proportion of malignant and benign varies with gland of origin
• Larger the size of salivary gland, more the chance of tumor being benign
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• Distribution
– Parotid: 80% overall; 80% benign (80% pleomorphic adeoma) i.e. “Rule of 80”
– Submandibular: 15% overall; 50% benign
– Sublingual/Minor salivary gland: 5% overall; 40% benign
• Incidence of malignancy is higher in neoplasm of minor salivary glands. i.e.
Parotid- 25% Submandibular- 50% Minor salivary gland- 75%
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Risk factors for salivary neoplasms
• Low dose radiation exposure
• Wood dust
• Chemicals (leather tanning industry)
• Rubber industry
• Nickel compound/alloy
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Benign tumors• Pleomorphic adenoma
• Warthin’s tumor
• Oncocytoma
• Lymphangioma
• Haemangioma
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Pleomorphic adenoma(mixed tumor)
• Mixed tumor: contains both epithelial and mesenchymal elements
• Most common benign tumor of salivary glands
• Can arise from parotid, submandibular
• Parotid: usually arises from its tail, deep lobe
• Encapsulated• Slow growing tumor
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• Signs: Swelling in front, below & behind ear Raises ear lobule Retromandibular groove is obliterated
• Any swelling which raises ear lobule is due to parotid gland neoplasm unless proved otherwise
• It sends ‘pseudopods’ into surrounding gland surgical excision of the tumor should include normal tissue around it
• Superficial parotidectomy
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Oncocytoma (oxyphil adenoma)
• Rare: 2.3% of benign salivary tumors
• 6th decade
• Usually benign; malignant oncocytoma- less common• • Major salivary glands: Parotid,Submandibular gland
• Minor salivary glands: palate, buccal mucosa, tongue
• Superficial parotidectomy
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Warthin’s tumor(adenolymphoma)• Encapsulated • Exclusively in parotid gland• Parotid tail• Commonly seen btw 5th – 7th
decade• Male: female (7:1)• About 7% of salivary gland
tumor• Usually Fluctuant, slow growing• 10% bilateral• Histologically: epithelial &
lymphoid elements• Never malignant• Wide local excision
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Hemangioma & lymphangioma
• Haemangioma: Most common benign tumors of the parotid in children
• May involute spontaneously• Soft, painless and increase in size with crying
or straining • Surgical excision if do not regress • Lymphangioma:• Less common• Soft, cystic on palpation• Do not regress spontaneously surgical
excision
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Malignant neoplasms• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Carinoma ex- pleomorphic adenoma
• Adenocarcinoma
• Squamous cell carcinoma
• Non-hodgkin’s lymphoma
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Mucoepidermoid carcinoma• Most common salivary gland malignancy • Not encapsulated• Commonly in parotid glandClinical features:Slow growingFacial nerve palsyPresentation Low-grade: Slow growing, painless mass High-grade: Rapidly enlarging, +/- pain
Treatment: Total conservative parotidectomy
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Adenoid cystic carcinoma(Cylindroma)• 2nd most common salivary gland
malignancy• Slow growing• Infiltrates widely into the tissue
planes & muscles• Perineural spread• Commonly in submandibular
gland, sublingual or minor salivary glands
• Less commonly in parotid gland• Occasionally lymph node
metastasis• Local recurrence after surgical
excision(perineural and lymphatic spread)
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Treatment• Radical parotidectomy
• Post-operative radiotherapy
• Wide local excision of palate: for tumors of palate
Adenoid Cystic Carcinoma of right hard palate
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Carcinoma ex-pleomorphic adenoma• Usually from pre-
existing pleomorphic adenoma (only 1% arise ab-initio)
• Malignancy takes about 10 years to develop in an adenoma
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• Malignancy should be suspected when:- -Rapid growth -Facial nerve palsy -Painful -Skin infiltration -Get fixed to massester muscletrismus -Feels stony hard -Presence of lymph nodes in neck
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Adenocarcinoma & Squamous cell carcinoma
• Rare• Highly aggressive • Rapidly growing tumors• Local and distant metastases• Prognosis- very poor
• Squamous cell ca (SCC): Rule out metastasis in the parotid gland from neighbouring skin cancer or other head and neck tumor
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Parotid gland surgery
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Landmarks for facial nerve during parotid surgery
1.Tympano-mastoid suture: 6-8 mm deep to this suture
2.Groove between mastoid & bony EAC: bisected by facial nerve
3.Tragal pointer: 1 cm anteroinfero-medial is facial nerve
3.Styloid process: lateral lies facial nerve
4.Posterior belly of digastric: superior & parallel lies facial nerve
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Complications of parotid surgery (5 F’s)1. Flap necrosis: avoid acute bending(angle) of the
incision & use gentle retraction
2. Facial nerve palsy: nerve identification
3. Fluid collection: blood or seromadrain should be kept
4. Fistula (salivary): duct should be ligated
5. Frey’s syndrome (gustatory sweating): in 10% cases
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Frey’s syndrome• Several months after parotid surgery• Sweating and flushing of the preauricular skin during
mastication• Auriculotemporal nerve provides both -Parasympathetic innervation to Parotid gland-Sympathetic innervation to Sweat glands & Subcutaneous
blood vesselsNeurotransmitter to both fibers: Acetylcholine
Frey’s syndrome is due to regrowth of parasympathetic secretomotor fibers into distal cut ends of the sympathetic fibers of skin
Whenever patients eats reflex salivation occurs, the skin blood vessels dilate and sweat gland secretes
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Management: Reassurance
Aluminium chloride-antiperspirant, useful astringent
Anticholenergics-topical eg glycopyrolate
Botulinum toxin A- injection into affected skin
Surgical: Tympanic neurectomy: dennervation
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Submandibular gland excision
Nerves likely to be injured during SMG excision:-
1. Marginal mandibular nerve
2. Lingual nerve
3. Hypoglossal nerve
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Thank you