Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Benign Tumors of Major Salivary Glands Treatment & Management

  • Author: Fadi Chahin, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Oct 26, 2015
 

Approach Considerations

Indications for surgical treament of salivary gland tumors (SGTs) include a mass of the face, neck, and floor of the mouth and the presence of clinical signs of malignancy (eg, a rapid growth on a slow-growing tumor, bleeding, airway compromise due to larger tumors, and nerve dysfunction such as paresthesia). Experienced clinicians generally agree that surgical excision is indicated for all patients in whom a parotid or salivary gland enlargement develops, unless associated medical problems preclude general anesthesia. Surgical excision aids in establishing the diagnosis and in determining the treatment plan.

Eneroth et al and others have advocated the use of fine-needle aspiration biopsy (FNAB) and reported accuracy rates of 74-90%.[13] FNAB is mainly useful for nonneoplastic masses, metastatic tumors to the parotid gland, and nonsurgical lymphomas. Only positive diagnostic results from FNAB are significant; hence the recommendation that almost all neoplasms be removed surgically.

Next

Medical Therapy

Inflammatory infectious masses (eg, reactive, fungal) and lymphoma should be treated medically. When symptomatic, recurrent chronic gland infection (eg, parotitis) proves refractory to conservative treatments, salivary gland excision is sometimes indicated.

Previous
Next

Surgical Therapy

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 with general anesthesia and without paralysis. The endotracheal tube is usually positioned in the corner of the mouth opposite to the surgical field.

Surgical options

Parotidectomy

The key to parotidectomy is safe localization of the facial nerve at the main trunk proximal to the gland. The possibility of total parotidectomy should be includede in the preoperative plan. There should also be discussion of 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 distance of 2 cm. 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. 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, deep-lobe parotid tumors may displace the facial nerve to a more superficial location, where it can easily be 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 by using recognized anatomic 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, at a setting of 0.5 mA.

Submandibular gland surgery

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

A 4- to 6-cm incision is made at the mastoid process and curved along the inferior aspect of the mandible, approaching the midline. The incision is taken down through the platysma, with the muscle left 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.

Dissection of the gland starts 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 between the gland and the digastric muscle. Dissection continues on the posterior aspect of the gland, superior 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, 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, hemostasis is ensured, a suction drain is placed (with or without an outside pressure dressing), and a cosmetic layered closure is performed.

Procedural details

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, 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, depending on the pathology of the tumor. This is precisely the reason why it is imperative to discuss the variable case presentations with the patient preoperatively and to agree on the treatment plan beforehand. A clearly written consent, with clear preoperative documentation, is essential.

Postoperatively, it is important to evaluate facial, hypoglossal, and lingual nerve function. Occasionally, transient facial nerve paresis occurs; however, it usually resolves within 3-12 weeks after surgery. Any nondissolvable sutures and drains should be removed. Alertness should be maintained for recurrence, which could present years after surgery.

Complications

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; 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 risk of 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.

Previous
 
Contributor Information and Disclosures
Author

Fadi Chahin, MD Aesthetic and Reconstructive Surgery, Private Practice

Fadi Chahin, MD is a member of the following medical societies: American College of Surgeons, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Chadi Chahin, MD Consulting Staff in Vascular and Interventional Radiology, Glendale Adventist Medical Center

Chadi Chahin, MD is a member of the following medical societies: American College of Radiology, Society of Interventional Radiology

Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers

Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Matthew R Kaufman, MD, FACS Partner, The Institute for Advanced Reconstruction at the Plastic Surgery Center

Matthew R Kaufman, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Society of Plastic Surgeons, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

Sanjiv S Agarwala, MD Chief of Oncology and Hematology, St Luke's Cancer Center, St Luke's Hospital and Health Network; Professor, Temple University Shool of Medicine

Sanjiv S Agarwala, MD is a member of the following medical societies: American Association for Cancer Research, American Head and Neck Society, European Society for Medical Oncology, American Society of Clinical Oncology, Eastern Cooperative Oncology Group

Disclosure: Received honoraria from BMS for speaking and teaching; Received consulting fee from Novartis for consulting; Received consulting fee from Merck for consulting.

References
  1. Dumitriu D, Dudea S, Botar-Jid C, Baciut M, Baciut G. Real-time sonoelastography of major salivary gland tumors. AJR Am J Roentgenol. 2011 Nov. 197(5):W924-30. [Medline].

  2. Cho HW, Kim J, Choi J, Choi HS, Kim ES, Kim SH, et al. Sonographically guided fine-needle aspiration biopsy of major salivary gland masses: a review of 245 cases. AJR Am J Roentgenol. 2011 May. 196(5):1160-3. [Medline].

  3. Heaton CM, Chazen JL, van Zante A, Glastonbury CM, Kezirian EJ, Eisele DW. Pleomorphic adenoma of the major salivary glands: Diagnostic utility of FNAB and MRI. Laryngoscope. 2013 Jun 18. [Medline].

  4. Beahrs OH, Adson MA. The surgical anatomy and technic of parotidectomy. Am J Surg. 1958 Jun. 95(6):885-96. [Medline].

  5. Mohammadi Ghahhari N, Mohammadi Ghahhari H, Kadivar M. GSK3ß and CREB3 gene expression profiling in benign and malignant salivary gland tumors. Iran Biomed J. 2012. 16(3):140-4. [Medline]. [Full Text].

  6. Przewozny T, Stodulski D, Stankiewicz C. Major salivary gland disorders in children and adolescents. Otolaryngol Pol. 2011 Sep. 65(5):350-356. [Medline].

  7. Buxton RW, Maxwell JH, French AJ. Surgical treatment of epithelial tumors of the parotid gland. Surg Gynecol Obstet. 1953 Oct. 97(4):401-16. [Medline].

  8. Conley J, Arena S. Parotid gland as a focus of metastasis. Arch Surg. 1963. 87:69.

  9. Strympl P, Kodaj M, Bakaj T, Kominek P, Starek I, Sisola I, et al. Color Doppler Ultrasound in the pre-histological determination of the biological character of major salivary gland tumors. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2012 Sep 5. [Medline].

  10. Aghaghazvini L, Salahshour F, Yazdani N, Sharifian H, Kooraki S, Pakravan M, et al. Dynamic contrast-enhanced MRI for differentiation of major salivary glands neoplasms, a 3-T MRI study. Dentomaxillofac Radiol. 2015. 44 (2):20140166. [Medline].

  11. Witt BL, Schmidt RL. Ultrasound-guided core needle biopsy of salivary gland lesions: a systematic review and meta-analysis. Laryngoscope. 2014 Mar. 124 (3):695-700. [Medline].

  12. Song IH, Song JS, Sung CO, Roh JL, Choi SH, Nam SY, et al. Accuracy of Core Needle Biopsy Versus Fine Needle Aspiration Cytology for Diagnosing Salivary Gland Tumors. J Pathol Transl Med. 2015 Mar. 49 (2):136-43. [Medline].

  13. Eneroth CM, Franzen S, Zajicek J. Aspiration biopsy of salivary gland tumors. A critical review of 910 biopsies. Acta Cytol. 1967 Nov-Dec. 11(6):470-2. [Medline].

  14. Chalian A, Weber RS. Salivary gland tumors. Winchester DP, Daly JM, Jones RS, Murhpy GP, eds. Cancer Surgery for the General Surgeon. Philadelphia, Pa: Lippincott-Raven; 1999. 89-98.

  15. Cross DL, Gansler TS, Morris RC. Fine needle aspiration and frozen section of salivary gland lesions. South Med J. 1990 Mar. 83(3):283-6. [Medline].

  16. Granick MS, Solomon MP, Hanna DC. Management of benign and malignant salivary gland tumors. Georgiade GS, Riefkohl R, Levin LS, eds. Georgaide Plastic, Maxillofacial, and Reconstructive Surgery. 3rd ed. Baltimore, Md: Williams & Wilkins; 1997. 155-65.

  17. Hanna EY, Suen JY. Neoplasms of the salivary glands. Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology: Head and Neck Surgery. 3rd ed. St. Louis, Mo: Mosby; 1998. Vol 2: 1255-98.

  18. Nythus L, Lloyd M, Baker R, eds. Anatomy of the parotid gland, submandibular triangle, and the floor of the mouth. Mastery of Surgery. 3rd ed. Boston: Little Brown; 1997. 293-312.

  19. Seifert G, Sobin LH. The World Health Organization's Histological Classification of Salivary Gland Tumors. A commentary on the second edition. Cancer. 1992 Jul 15. 70(2):379-85. [Medline].

  20. Sismanis A, Merriam JM, Kline TS, et al. Diagnosis of salivary gland tumors by fine needle aspiration biopsy. Head Neck Surg. 1981 Jul-Aug. 3(6):482-9. [Medline].

  21. Spiro RH. Salivary neoplasms: overview of a 35-year experience with 2,807 patients. Head Neck Surg. 1986 Jan-Feb. 8(3):177-84. [Medline].

  22. Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Salivary gland tumors. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia, Pa: WB Saunders; 2001. 547-52.

 
Previous
Next
 
Histology of the salivary gland unit.
Coronal MRI demonstrating benign tumor of the parapharyngeal space.
Facial nerves. Note the network between the zygomatic branch and the buccal branch.
Facial nerve branches.
Exposed facial nerve branches after superficial parotidectomy.
Right submandibular benign salivary gland tumor in a 42-year-old woman.
Pictures before and after treatment for a benign mandibular gland tumor. Specimen picture of the gland.
Facial nerves. Note the variations in the nerve sizes and the change of take-off locations of the branches.
Facial nerves. Note the 2 main trunks, frontozygomatic and cervical-marginal-mandibular.
The right parotid gland is slightly larger than the left-side normal variation.
Prominent bilateral parotid glands with homogenous parenchyma normal variation.
Normal right submandibular sialogram.
Normal CT scan after right submandibular sialogram.
Normal CT scan after right submandibular sialogram.
In this patient with a history of parotitis, note the 7-mm lobulated calcification anteriorly within the superficial right parotid gland with focally dilated ducts. Dystrophic calcifications due to remote inflammatory disease are also present bilaterally in the tonsillar fossa.
Note the 12-mm right parotid, smoothly marginated, multilobulated, solid lesion, without focal calcification or necrosis. This was proven to be pleomorphic adenoma.
Note the 2 X 1.5-cm uniformly enhancing, smoothly marginated mass in the superficial right parotid gland without necrosis or calcification, which is consistent with an epithelial neoplasm such as pleomorphic adenoma.
Coronal image of a patient with a history of parotitis.
Heterogeneous, predominantly low-density mass in the tail of the right parotid gland with minimal thin peripheral enhancement consistent with a Warthin tumor.
In this patient with infectious sialoadenitis, note the inhomogeneous, enlarged left submandibular gland with mild thickening of the adjacent platysma.
After radiation treatment of right parotid sialoadenitis.
After radiation treatment of right sialoadenitis.
Nodular and cystic changes in both parotid glands. These changes are stable in this patient with a history of chronic sialoadenitis.
Dense, small, solid lesions in the parotid glands (more on the left side than on the right) in a patient with lymphoma. This is representative of lymphomatous involvement of the glands.
Ill-defined masses in the parotid glands bilaterally, proven to be large B-cell lymphoma in this patient with known Sjögren disease.
Large B-cell lymphoma in a patient with known Sjögren disease.
Large B-cell lymphoma in a patient with known Sjögren disease.
Bilateral, solid, inhomogeneous parotid gland masses that are larger on the left side than on the right, with minimal necrosis. These were caused by lymphoma.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.