Salivary Gland Tumors, Major, Benign Treatment & Management

Inflammatory infectious masses (eg, reactive, fungal) and lymphoma should be medically treated.

Salivary gland excision is also sometimes indicated when symptomatic, recurrent chronic gland infection (eg, parotitis) proves refractory to conservative treatments.

Management of benign SGTs includes complete removal with an adequate margin of tissue to avoid recurrences. This usually involves a complete removal of the gland in which the tumor developed. Excision is performed under general anesthesia and without paralysis. The endotracheal tube is usually positioned in the corner of the mouth opposite to the surgical field.

The key to this procedure is to localize the facial nerve at the main trunk proximal to the gland safely. Include the possibility of total parotidectomy in the preoperative plan. Also discuss the potential need to sacrifice the facial nerve, with immediate grafting, cervical lymphadenectomy, and mandibulectomy.

Superficial parotidectomy remains the initial procedure of choice for benign parotid gland tumors. The incision usually starts just anterior to the ear helix, extends inferiorly below the ear lobe, and then moves anteriorly to parallel the angle of the jaw within a 2 cm distance. Dissection is usually performed sharply down to the superficial parotid fascia. Then, the skin flap is sutured and retracted from the surgical field. Dissection is continued to expose the remainder of the gland anteriorly and the anterior border of the sternocleidomastoid muscle. At this location, the greater auricular nerve is identified and preserved because it carries sensation to the ear lobule and provides the best option for nerve grafting, if needed. Note that, occasionally, deeper-lobe parotid tumors may displace the facial nerve to a more superficial location, where it can be easily injured.

In a parotid gland that is being operated on for the first time, a facial nerve stimulator is generally not necessary to identify the facial nerve. Rather, the surgeon should locate the main trunk of the facial nerve based upon recognized anatomical landmarks. At the end of the operation, the nerve stimulator may be valuable in confirming integrity of the individual nerve branches should a transient dysfunction become an issue in the postoperative period. Proper use of the stimulator involves testing it on an adjacent muscle, such as the sternocleidomastoid muscle, at a setting of 0.5 mA.

Submandibular gland surgery is performed with the patient under general anesthesia with endotracheal intubation. Head rotation is to the opposite side of the tumor.

An incision is made at the mastoid process and curved along the inferior aspect of the mandible, approaching the midline. The length of the incision is approximately 4-6 cm. Take the incision down through the platysma muscle, leaving the muscle attached to the skin as a musculocutaneous flap. At this point, the marginal branch of the facial nerve is identified and preserved unless it is directly involved with the tumor. The nerve is located just below the muscle and superficial to the facial vessels. The safest technique is to divide the inferior aspect of the posterior facial vein and to raise the flap to the depth of the vessels and nerve.

Start the dissection of the gland at the level of the hyoid bone and the lower aspect of the gland. Identifying the digastric muscle is important because the hypoglossal nerve with the vessels runs in between the gland and the digastric muscle. Dissection continues on the posterior aspect of the gland, superiorly to where the facial artery is located. At this level, the blood supply to the gland is ligated. The lingual nerve is visualized by anterior retraction of the mylohyoid muscle, and the pedicle of the gland is then carefully ligated, with attention to the main trunk of the lingual nerve. Next, the Warthin duct is identified and ligated to conclude the resection.

To complete the procedure, ensure hemostasis, place a suction drain (with or without an outside pressure dressing), and perform a cosmetic layered closure.

A history of rapid growth and physical signs and symptoms (eg, facial nerve involvement) should be elicited, discussed with the patient, and documented in the preoperative evaluation chart for future reference.

Intraoperatively, the involvement of the main trunk of the facial nerve or one or more of the main branches of the facial nerve may be encountered with the tumor. This finding may alter the plan, based on the pathology of the tumor. This is precisely the reason why it is imperative to preoperatively discuss with the patient the variable case presentations and to agree on the treatment plan. A clearly written consent, with clear preoperative documentation, is essential.

Evaluate postoperative facial, hypoglossal, and lingual nerve function. Occasionally, transient facial nerve paresis occurs; however, it usually resolves within 3-12 weeks after surgery.

Remove any nondissolvable sutures and drains. Detect recurrence, which could present years after surgery.

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat.

Recurrence is usually caused by inadequate excision (spillage) or inoculation. The recurrence rate, as reported after a mean follow-up period of 11.8 years, is as high as 25%.

Use proper hemostasis techniques with suction drains and compression dressing to minimize the risk of bleeding and seroma.

Iatrogenic injury is usually recognized during surgery, and, in this scenario, it should be immediately repaired.

If the facial nerve is sacrificed because of direct tumor involvement, immediate grafting (using the greater auricular nerve or sural nerve) is required.

Transient facial nerve paralysis (paresis) takes a few weeks to resolve spontaneously but can last as long as 6 months. Direct trauma to the nerve, devascularization, or postoperative nerve inflammation is believed to cause paresis.

Frey syndrome is a known complication after parotidectomy, and manifestations range from erythema related to eating to copious gustatory sweating. The cause is believed to be an aberrant connection of the parasympathetic fibers to the sweat gland of the overlying flap of skin. To minimize the chance of the patient developing postoperative Frey syndrome, raise a thick parotid flap just above the parotid fascia.

Salivary fistulae with wound healing are very uncommon.

When a submandibular gland is removed, follow surgical recommendations to avoid unintentional injury to the lingual, hypoglossal, or mandibular branch of the facial nerve.

With the appropriate treatment of benign SGTs (ie, complete excision, superficial parotidectomy), the outcome is excellent and the recurrence rate is very low.