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SECTION III — Diseases of Oral Cavity and Salivary Glands
Figure 44.12. Exophytic growth on the right lateral border of tongue
in a 60-year-old male. It was squamous cell carcinoma.
TABLE 44.2 TNM CLASSIFICATION (AJCC, 2002) OF
CANCERS OF LIP AND ORAL CAVITY
Primary tumour (T)
T
1
T
2
T
3
T4 (lip) Tumour invades adjacent structures (e.g. cortical
T4a (oral
cavity)
Regional lymph nodes (N)
N
1
N
2
N
3
Distant metastasis (M)
M
0
M
1
Source: AJCC, Cancer Staging Manual, Chicago, 2002.
Tumour 2 cm or less in greatest dimension
Tumour > 2 cm but not more than 4 cm in greatest
dimension
Tumour > 4 cm in greatest dimension
bone, inferior alveolar nerve, floor of mouth, skin
of face).
Tumour invades adjacent structures (e.g. cortical
bone, deep (extrinsic) muscles of tongue,
maxillary sinus, skin. Superficial erosion alone
of bone/tooth socket by gingival primary is not
sufficient to classify as T4.
Metastasis in a single ipsilateral lymph node 3 cm or
less in greatest diameter.
Metastasis in a single ipsilateral lymph node > 3 cm
but not more than 6 cm in greatest dimension
(N2a); or multiple ipsilateral lymph nodes none
more than 6 cm in greatest dimension (N2b) or
bilateral or contralateral lymph nodes none more
than 6 cm in greatest dimension (N2c).
Metastasis in lymph node more than 6 cm in
greatest dimension.
No distant metastasis
Distant metastasis
Figure 44.13. Cancer under surface of tongue.
Symptomatology
(a) Early lesions are painless and remain asymptomatic
for a long time.
(b) Pain in the tongue locally at the site of ulcer.
(c) Pain in the ipsilateral ear; it is due to common nerve
supply of the tongue (lingual nerve) and ear (auric-
ulo temporal) from the mandibular division of the
trigeminal nerve.
(d) A lump in the mouth.
(e) Enlarged lymph node mass in the neck.
(f) Dysphagia, difficulty to protrude the tongue, slurred
speech and bleeding from the mouth are late features.
For staging, see TNM classification (Tables 44.2 and 44.3).
Treatment. Aim of treatment is to treat primary tumour
in the tongue, control neck disease (nodal metastasis) and
preserve function of the tongue as much as possible.
Small tumours (T1N0) give equal results if treated with
radiotherapy or surgery.
T2N0 tumours can also be treated by radiotherapy including the neck nodes to eliminate micrometastases.
They can also be treated by surgical excision with prophylactic neck dissection.
Stage III or IV tumours require combined treatment
with surgery and postoperative radiotherapy. It gives better results than either modality alone. Block dissection
neck is always done.
TABLE 44.3 STAGING OF CARCINOMA LIP AND
ORAL CAVITY
Stage I T
Stage II T
Stage III T
Stage IV A T
1
2
3
T
1
T
2
T
3
4
T
4
Any T N
Stage IV B Any T N
Stage IV C Any T Any N M
N
0
N
0
N
0
N
1
N
0
N
1
2
3
M
0
M
0
M
0
0
M
0
M
0
M
0
M
0
1
Depending on the size and extent of the primary
lesion of the tongue, surgery may consist of hemiglossectomy including a portion of the floor of mouth, segmental or hemimandibulectomy and block dissection of neck
nodes—the so-called “commando operation.”
4. carcinoma hard palate. It is either squamous
cell or glandular variety; the latter being more common.
Glandular variety arises from minor salivary glands of the
palate and may be adenoid cystic, mucoepidermoid or adenocarcinoma. It is common in India especially in people
who have the habit of reverse smoking, i.e. keeping the
burning end of bidi or cigar in the mouth. Both men and
women are affected.
Cancer starts as a superficial ulcer with rolled out edges
and gives no symptoms except painless irregularity on the
palate felt by the tongue. It may spread to the gingiva, lip,
Chapter 44 — Tumours of Oral Cavity
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soft palate or invade the bone of hard palate, floor of the
nasal cavity or the antrum. Lymphatic metastases may
spread to the submandibular and upper jugular nodes.
Cancer palate should be differentiated from cancer of
maxillary antrum or nose which has spread to the palate.
Treatment. Small tumours are resected along with the
underlying bone, larger ones require partial maxillectomy. If nodes are enlarged, block dissection is also combined. Surgical defect in the palate, left after excision of
the growth, is closed by a suitable prosthesis.
5. carcinoma oF alVeolar ridges. It is also called
gingival carcinoma; it is mostly seen in men. Usual site of
involvement is lower jaw behind the first molar. Tumour
may spread to the cheek, floor of mouth, retromolar trigone or the hard palate. Gingival cancer may invade the
underlying bone and then spread rapidly along the neurovascular bundle. Nodal metastases go to submandibular
and upper jugular nodes.
Treatment. Radiotherapy is avoided because of the risk
of radio-osteonecrosis. Surgery is the treatment of choice.
Early mucosal lesion on the lower alveolus is treated by
local excision with marginal resection of the mandible.
Extensive lesions require wide excision which may necessitate segmental or hemimandibulectomy. Block dissection may be combined if nodes are also palpable. Upper
alveolar lesions may require partial maxillectomy.
6. cancer Floor oF mouth. Squamous cell carcinoma
is the most common. It affects males more than females
in ratio of 4:1. Typically, lesions start anteriorly near
the opening of submandibular duct which may get obstructed, leading to enlargement of submandibular gland
(Figure 44.14).
Usually, the lesion is ulcerative or infiltrative type and
spreads locally into the adjoining areas such as ventral
aspect of the tongue, lingual gingiva, mandibular periosteum or deeply into the floor of mouth and submental space. Lymphatic metastases go to submandibular
nodes. Lesions of the floor of mouth remain asymptomatic for a long time or cause soreness or irregularity in
the floor of the mouth. A swelling in the submandibular
region may be either due to obstructive enlargement of
submandibular salivary gland or lymph node metastases
and this may require differentiation.
Treatment. Small lesions without involvement of
tongue, lingual gingiva or nodes can be treated by surgical excision or radiotherapy with equal results. Larger lesions with extension to the tongue, gingiva or mandible
require wide excision including marginal or segmental
mandibular resection. Block dissection is indicated when
cervical nodes show clinical evidence of metastases. Prophylactic neck dissection or irradiation is advised for N0
neck in stage II cancer because of high incidence of micrometastases (40%), stage III and IV cancers require surgery and radiotherapy.
7. carcinoma retromolar trigone. Involvement of
retromolar trigone may be primary or secondary to extension of growths from the gingiva, floor of mouth, buccal
mucosa or the palatine arch.
Treatment depends on the extent of lesion. Wide surgical excision often combined with block dissection is
required.
Multiple Primary Cancers
About 15% of patients with carcinoma of the oral cavity
have multiple primary cancers affecting the upper aerodigestive tract. This is because of the common risk factors
such as smoking and alcohol simultaneously operating at
various sites.
NONSQUAMOUS MALIGNANT LESIONS
In addition to carcinoma, other malignant lesions that
involve the oral cavity are:
1. minor saliVary gland tumours. In one series, 80–
90% of all minor salivary gland tumours were malignant.
Palate is the most common site but can involve tongue,
cheek, lip, gums and floor of mouth (Figure 44.15).
Adenoid cystic variety is the most common (40%).
Next in frequency are the adenocarcinoma (30%) and
Figure 44.14. Ulcerative squamous cell carcinoma in the floor of the
oral cavity (arrows) in a 55-year-old male.
Figure 44.15. A mixed salivary tumour palate.
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SECTION III — Diseases of Oral Cavity and Salivary Glands
mucoepidermoid carcinoma (20%). Treatment is wide
surgical excision along with block dissection, if the neck
nodes are positive.
2. melanoma. Mucosal melanomas of oral cavity and
oropharynx are rare. Peak age incidence is the sixth
decade; males are affected more (2:1). Palate and gingiva are the most common sites. They appear as areas of
higher pigmentation and later may ulcerate and bleed.
Amelanotic variety is also seen. Both cervical nodal and
distant metastases are seen. Treatment of choice is wide
surgical excision including underlying bone. Local recurrence is common. Prognosis is poor with 5-year cure rate
of only 15%.
3. lymphoma. Lymphomas can involve oral cavity or
oropharynx, majority of them occurring in the palatine
tonsils. Males are affected more. Usual presentation is
that of a smooth, submucosal bulky mass which is occasionally ulcerated. They are mostly of non-Hodgkin variety. Cervical nodes may be involved in 40–70% of the
patients. Treatment is radiation, alone or in combination
with chemotherapy.
4. kaposi sarcoma. It is a vascular tumour, multifocal
in origin, primarily affecting skin but may occur in the
oral cavity. Its incidence is high in AIDS (acquired immune deficiency syndrome) patients. The lesion appears
as a reddish purple nodule or a plaque mostly on the
palate. Microscopically, it consists of spindle cells with
haemorrhagic cleft-like spaces. Treatment is not satisfactory. Kaposi sarcoma in non-AIDS patients may respond
to chemotherapy but its response in patients suffering
from AIDS is poor (see also p. 423).
CHEMOPREVENTION
It is the use of certain pharmacological agents to halt, delay
or reverse the process of carcinogenesis. It has been used to
prevent oral premalignant lesions to develop into cancer
or to prevent the development of second primary cancers
after the main primary cancer has been treated. Agents
used have been vitamin A, beta carotene, alpha tocopherol (vitamin E), selenium and natural or synthetic retinoids
such as 13-cis retinoic acid. Beta carotene and vitamin A
induced remission of oral leukoplakia is seen in 25–50% of
patients. Similarly, in a controlled trial, 13-cis retinoic acid
reduced the incidence of second primary lesions in the
aerodigestive tract. The beneficial effect of these agents
may be limited to the duration of treatment only.
In addition to their use in head and neck, retinoids
have shown significant chemopreventive activity in cancers of lung, skin, cervix, bladder and ovary. Trials are also
being conducted in Cox-2 inhibitors (e.g. celecoxib) in
the prevention of oral premalignant lesions.
Chapter 45
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Non-neoplastic Disorders
of Salivary Glands
MUMPS (VIRAL PAROTITIS)
It is a viral infection caused by paramyxovirus. Disease is
contracted by droplet infection and fomites. Children are
most often affected but adults can also contract the disease. Incubation period is 2–3 weeks (7–23 days). Patient
is infective even before the appearance of clinical manifestations and remains so 7–10 days after parotid swelling subsides. Virus is excreted through salivary, nasal and
urinary excretions.
CLINICAL FEATURES
The initial period of viraemia causes fever (up to 103°F
or 39.4°C), malaise, anorexia and muscular pains. Parotid swelling may appear only on one side. Other parotid
gland may be enlarged simultaneously or after some time.
Submandibular and sublingual salivary glands may also
be enlarged but isolated involvement of submandibular
gland is rare. Swelling subsides in about a week.
COMPLICATIONS
• Orchitis with painful and tender testis, on one but un-
commonly both sides, may occur. Sterility following
mumps is rare.
• Ophritis causes lower abdominal pain. Female sterility
is almost never seen.
• Pancreatitis causes pain in abdomen.
• Aseptic meningitis or meningoencephalitis may occur
with or without the salivary gland involvement. Headaches, neck stiffness and drowsiness may occur.
• Unilateral sensorineural hearing loss can occur due to in-
volvement of the labyrinth. Sudden deafness has been
noticed.
• Other complications include thyroiditis, myocarditis,
nephritis and arthritis.
DIAGNOSIS
Usually clinical; difficulties arise when parotids are not
enlarged.
1. Serum and urinary amylase are raised during the first
week of parotitis.
2. Serology. Serum IgG and IgM are measured as early as
possible and after 10–14 days of illness. Presence of
IgG indicates past exposure and possible immunity.
However rise in IgG titre more than four times from
acute to convalescent serum indicates recent infection.
Similarly presence of IgM also indicates recent infection. IgM is present in 100% patients by day 5.
TREATMENT
Parotitis is treated by proper hydration, rest, analgesics
and cold or hot compresses over the parotid to relieve
pain. Food which encourages salivary flow should be
avoided as they cause pain. Parotid swelling persists for
about 1 week.
Orchitis is treated by cold compresses and support to
the scrotum, and administration of analgesics. Steroids
have not been found useful.
PREVENTION
An infant has maternal immunity for 1 year. After that
immunization can be given by MMR (Mumps, Measles,
Rubella) vaccine at the age of 15 months. Older children,
adolescents and adults who were not protected by MMR
and have not had mumps, and are in contact with children should receive monoclonal mumps or MMR vaccine.
Mumps immunoglobulin is of no value as a prophylaxis or in established disease.
ACUTE SUPPURATIVE PAROTITIS
It is most commonly seen in the elderly, debilitated and
dehydrated patients. Dry mouth due to any cause is a predisposing factor. Staphylococcus aureus is the usual causative organism though other Gram-positive and anaerobic
organisms have also been observed. Usual route of infection is from the mouth through the Stensen’s duct.
CLINICAL FEATURES
The onset is sudden with severe pain and enlargement
of gland (Figure 45.1). Movements of jaw aggravate the
pain. Opening of the Stensen’s duct is swollen and red
and may be discharging pus or the latter can also be expressed by gentle pressure over the gland. Patient is usually febrile and toxaemic.
INVESTIGATIONS
White cell count shows leukocytosis with increase in polymorphs. Causative organisms should be identified and
their sensitivity established by culture of blood and the
pus collected from the opening of the parotid duct.
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Figure 45.1. Acute suppurative parotitis on left side in a 58-year-old
female.
SECTION III — Diseases of Oral Cavity and Salivary Glands
TREATMENT
It consists of appropriate antibiotics, preferably administered through i.v. route, adequate hydration, measures
to promote salivary flow and attention to oral hygiene. If
fever does not subside and there is progressive induration
of the gland, in spite of adequate medical management,
surgical drainage should be done.
CHRONIC RECURRENT SIALADENITIS
This usually involves parotid gland which shows recurrent
bacterial infection. During acute exacerbation, parotid
is enlarged and tender, and pus can be expressed from
its duct. Between the acute episodes, gland is firm and
slightly enlarged. Culture of pus from the duct reveals
staphylococci or streptococci. Sialography shows normal
duct system. Treatment of acute episode is similar to that
of acute bacterial sialadenitis. Between the attacks, patient
is instructed to keep good oral hygiene, avoid drugs which
dry oral mucosa and use sialogogues to promote salivation.
SIALECTASIS
As the name implies, there is dilatation of the ductal system, leading to stasis of secretions, which predisposes
to infection. Clinically, sialectasis resembles chronic recurrent sialadenitis, but can be differentiated from it by
sialography. Different degrees of dilatation of the ductal
system—punctuate, globular or cavitary types—may
be seen. Sialectasis may be congenital, associated with
granulomatous disease or autoimmune disease such as
Sjogren’s syndrome.
GRANULOMATOUS INFECTIONS OF THE
SALIVARY GLANDS
Tuberculosis, sarcoidosis, actinomycosis and toxoplasmosis may involve the salivary glands.
TUBERCULOSIS
It can involve the parotid or submandibular salivary
glands; both in children and adults.
Parotid gland infection can occur via the parotid duct
from a source in the oral cavity, or a haematogenous
spread from the primary site in the lung.
It may present as acute parotid sialadenitis or as a longstanding parotid mass mimicking a tumour. Overlying
skin changes or fistulae may be seen.
Diagnosis is made by PPD (purified protein derivative)
skin test, FNAC or biopsy with demonstration of epithelioid granuloma or acid-fast bacilli which can be cultured.
X-ray of the chest may be negative.
Antitubercular chemotherapy is used as treatment.
Nonresponders may require excisional biopsy.
Atypical mycobacteria can also affect the gland or
lymph nodes. X-ray of the chest and the PPD test may
yield negative results. FNAC or biopsy shows acid-fast
organisms which should be cultured and their sensitivity established. Atypical infections are present as nonresponders to antitubercular treatment.
Uveoparotid fever is due to sarcoidosis of the parotid.
It is characterized by fever, enlargement of the parotid
and lacrimal glands, chorioretinitis and cranial nerve
palsies.
ACTINOMYCOSIS
It is an uncommon infection and follows dental infections or manipulations. It presents as a parotid swelling
or fistulae of the skin which discharge sulphur granules.
Diagnosis can be made with Gram stain showing non-acid-fast Gram-positive organisms. Penicillin, erythromycin
and tetracycline are effective, but the treatment has to be
prolonged for months.
TOXOPLASMOSIS
It is caused by Toxoplasma gondii. Humans are affected by
eating infected undercooked meat of lamb, beef or chicken or foods contaminated by cat’s faeces. Once in the
body, trophozoites spread through the blood stream and
settle in the lymphoid tissue. Isolated lymphadenopathy
can also occur. Diagnosis is made by serological tests of
both acute and convalescent sera and lymph node biopsy.
It is a self-limiting disease, but treatment is required for
immunocompromised individuals or pregnant women.
Pyrimethamine is effective in toxoplasmosis.
SIALOLITHIASIS (SALIVARY CALCULI)
Calculi may form in the ducts of submandibular or parotid glands. They are formed by the deposition of calcium
phosphate on the organic matrix of mucin or cellular debris. About 90% of the stones are seen in the submandibular but only 10% in the parotid. Stones may form in
the duct or parenchyma of the gland.
The presenting feature is intermittent swelling of the
involved gland, and pain due to obstruction to outflow of
saliva. Sometimes, a stone is visible at the duct opening
or can be palpated intraorally. About 80% of the stones
are radio-opaque and can be seen on appropriate X-rays
Chapter 45 — Non-neoplastic Disorders of Salivary Glands
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Figure 45.3. A radio-opaque stone seen in the right submandibular
duct (arrow) in occlusal view.
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Figure 45.2. (A) An adult having submandibular sialadenitis. (B) X-ray
lateral view shows a radio-opaque stone in the submandibular gland
(arrow).
(Figures 45.2 and 45.3). Sialography may be required for
radiolucent stones.
Stones in peripheral part of submandibular or parotid
ducts can be removed intraorally, while those at the hilum or in the parenchyma require excision of the gland.
Diagnosis of radiolucent stones is a challenge. If
palpation does not reveal a stone, contrast sialography,
ultrasound, magnetic resonance sialography or digital
subtraction sialography can be attempted. Recently sialoendoscopy has been used both to diagnose and treat
such stones.
SJOGREN’S SYNDROME (SICCA
SYNDROME)
Lymphoepithelial sialadenitis is an autoimmune disorder
involving exocrine glands of the body. It may be primary
or secondary.
1. Primary Sjogren’s syndrome consists of xerostomia and
xerophthalmia and is due to involvement of salivary
and lacrimal glands. Parotid is the most often involved
gland. It has also been called as benign lymphoepithe-
lial lesion of parotid or Mikulicz’s disease. Both sexes are
equally involved.
2. Secondary Sjogren’s syndrome consists of three major
components: (i) keratoconjunctivitis sicca (due to involvement of lacrimal gland); (ii) xerostomia (due to
involvement of salivary glands and minor mucous
glands of the oral cavity); (iii) autoimmune connective tissue disorder, usually the rheumatoid arthritis,
sometimes the systemic lupus erythematosus (SLE). In
scleroderma or polymyositis, there is often a bilateral
swelling of the salivary glands. Moreover, 90% of the
cases occur in females. Sjogren’s syndrome histopathologically shows destruction of acini and lymphocytic
infiltration and has therefore earned the name of lymphoepithelial lesion.
Diagnosis depends on the history and physical exami-
nation of keratoconjunctivitis and xerostomia. Schirmer’s
test may be done to prove decreased tear formation. Biopsy of the lower lip is performed to determine the involvement of minor salivary glands. SS-A and SS-B antibodies
are necessary for diagnosis. Raised erythrocyte sedimentation rate, positive rheumatoid factor and positive antinuclear
antibodies tests help to exclude associated rheumatoid arthritis or SLE.
SIALOMETAPLASIA
It is an important condition that simulates carcinoma.
Most often it involves minor salivary glands in the palate
but may occur in major salivary glands, nose or nasopharynx. It may present as a swelling or an ulcerated lesion,
usually involving males in their forties. Histologically
there is destruction of acini with squamous metaplasia
(pseudoepitheliomatous hyperplasia).
Diagnosis is made by biopsy and differentiating
it from squamons cell or mucoepidermoid carcinoma. Lesions of sialometaplasia heal spontaneously in
5–6 weeks.
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SIALADENOSIS
Clinically it presents with bilateral and in some cases
unilateral enlargement of the parotid glands. Histologically acinar cells become hypertrophied two to three
times their normal size. It is a non-inflammatory, nonneoplastic condition.
The aetiology is unknown, but it is often seen in diabetes, alcoholism, malnutrition, obesity and prolonged
intake of anticholinergic drugs.
Clinically sialadenosis needs to be differentiated from
other conditions which cause bilateral parotid swelling
such as sarcoidosis, tuberculosis, lymphoepithelial lesions, lymphomas and sialadenitis. Fine needle aspiration
or gland biopsy may be helpful.
In long-standing cases, acini undergo degeneration
and replacement with fatty tissues, leading to xerostomia. Treatment is initiated if the cause is discovered. In
later stages, artificial saliva and sialogogues are required
to combat xerostomia.
Chapter 46
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Neoplasms of Salivary Glands
The tumours of major or minor salivary glands are either
from epithelial or mesenchymal tissues. Larger the size of
salivary gland, more are the chances of a tumour being
benign. Eighty per cent of parotid, 50–60% of submandibular and only about 25% of other minor salivary gland
tumours are benign. In other words, chances of malignant tumours in minor salivary glands are higher.
Rapid growth, restricted mobility, fixity of overlying skin,
pain and facial nerve involvement indicate the possibility of
tumour being malignant.
Table 46.1 shows benign and malignant tumours of
salivary glands.
BENIGN TUMOURS
PLEOMORPHIC ADENOMA
It is the most common benign tumour of salivary glands.
It can arise from the parotid, submandibular or other
minor salivary glands. In the parotid it usually arises
from its tail. It can also arise from the deep lobe of the
parotid and present as a parapharyngeal tumour in the
oropharynx.
Pleomorphic adenomas are slow-growing tumours and
may be quite large at initial presentation. They are usually seen in the third or fourth decade, with propensity
for females. They are called “mixed tumours” because both
epithelial and mesenchymal elements are seen in histology. The stroma of the tumour may be mucoid, fibroid,
vascular, myxochondroid or chondroid and its proportion to the epithelial element may vary.
Though tumour is encapsulated, it sends pseudopods
into the surrounding gland which are left behind if the
tumour is simply shelled out. It is therefore essential that
surgical excision of the tumour should include normal
gland tissue around it. In the parotid, it amounts to superficial parotidectomy.
ADENOLYMPHOMA (PAPILLARY
CYSTADENOMA LYMPHOMATOSUM,
WARTHIN TUMOUR)
They are commonly seen between fifth and seventh decade with preponderance in males (5:1). They mostly involve the tail of the parotid and are bilateral in 10% of
the patients. They may be multiple. Adenolymphoma
is a rounded, encapsulated tumour, at times cystic, with
mucoid or brownish fluid. Histologically, epithelial and
lymphoid elements are seen. Treatment is superficial parotidectomy though they can be enucleated without danger of recurrence.
ONCOCYTOMA (OXYPHIL ADENOMA)
They arise from acidophilic cells called oncocytes and comprise less than 1% of all salivary gland tumours. Mostly
seen in the elderly, they usually do not grow larger than
5 cm and involve the superficial lobe of parotid. Benign
oncocytomas are cystic rather than solid. Malignant oncocytomas are also seen. Oncocytomas show increased
uptake of technetium-99.
Treatment for parotid oncocytomas is also superficial
parotidectomy.
HAEMANGIOMAS
Haemangiomas are the most common benign tumours of
the parotid in children, predominantly affecting females.
Most of them are discovered at birth, grow rapidly in the
neonatal period and then involute spontaneously. Cutaneous haemangioma may coexist in 50% of the patients.
They are soft and painless and increase in size with crying
or straining. Overlying skin may show bluish discoloration. Surgical excision is indicated if they do not regress
spontaneously.
LYMPHANGIOMAS
They are less common and may involve parotid and
submandibular glands. On palpation, they feel soft and
cystic. They do not regress spontaneously and are surgically
excised.
Lipoma and neurofibroma are rare.
MALIGNANT TUMOURS
MUCOEPIDERMOID CARCINOMA
Some pathologists do not consider it to be malignant
and call it mucoepidermoid tumour and not cancer, but
it is known to metastasize and kill. Generally, it is slowgrowing but can invade the facial nerve. Histologically,
there are areas of mucin-producing cells and the squamous cells, and hence the name. Greater the epidermoid
element, more malignant is the behaviour of the tumour.
The tumours have been further classified as low grade and
high grade. Low-grade tumours have good prognosis (90%,
5 years survival rate), high-grade tumours are more aggressive and have poor prognosis (30%, 5 years survival
rate). Low-grade tumours are more common in children.
Behaviour of mucoepidermoid tumours of minor salivary glands is more aggressive and akin to adenoid cystic
carcinoma, but in the major salivary glands they behave
like pleomorphic adenoma.
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TABLE 46.1 TUMOURS OF SALIVARY GLANDS
Benign Malignant
Epithelial
• Pleomorphicadenoma
• Adenolymphoma(Warthin
tumour)
• Oncocytoma
• Otheradenomas
Mesenchymal
• Haemangioma
• Lymphangioma
• Lipoma
• Neurobroma
Epithelial
• Mucoepidermoidcarcinoma
• Low grade
• High grade
• Adenoidcysticcarcinoma
(cylindroma)
• Aciniccellcarcinoma
• Adenocarcinoma
• Malignantmixedtumour
• Squamouscellcarcinoma
• Undifferentiatedcarcinoma
Mesenchymal
• Lymphoma
• Sarcoma
Low-grade tumours of the parotid are treated by superficial or total parotidectomy, depending on the location
of the tumour. Facial nerve is preserved.
High-grade tumours being more aggressive are treated
by total parotidectomy. Facial nerve may be sacrificed
if invaded by the tumour. Some surgeons also combine
radical neck dissection because of high incidence of microscopic spread of the tumour.
ADENOID CYSTIC CARCINOMA
(CYLINDROMA)
It is a slow-growing tumour but infiltrates widely into the
tissue planes and muscles. It also invades perineural spaces and lymphatics and thus causes pain and VIIth nerve
paralysis. It can metastasize to lymph nodes. Local recurrences after surgical excision are common and can occur
as late as 10–20 years after surgery. Distant metastases go
to the lung, brain and bone.
Treatment is radical parotidectomy with largest cuff of
grossly normal tissue around the boundaries of the tumour. Radical neck is not done unless nodal metastases
are present. Postoperative radiation is given if margins of
the resected specimen are not free of tumour.
ACINIC CELL CARCINOMA
It is a low-grade tumour which appears similar to a benign mixed tumour. It presents as a small, firm, movable
and encapsulated tumour, sometimes bilateral. Metastases are rare. A conservative approach of superficial or total
parotidectomy is adopted.
ADENOCARCINOMA
More often it arises in minor salivary glands. It is highly
aggressive locally and sends distant metastasis.
MALIGNANT MIXED TUMOUR
There are two varieties of this tumour:
1. Carcinoma developing in pre-existing benign mixed
tumour and
2. A“de novo” tumour.
The latter has much shorter history. Rapid growth and
pain developing in a benign tumour should always arouse
a suspicion of malignant change. Treatment of malignant
tumour is radical parotidectomy. Facial nerve sacrificed
during operation is grafted immediately.
SQUAMOUS CELL CARCINOMA (FIGURE 46.1)
It is a rapidly growing tumour that infiltrates, causes pain
and ulcerates through the skin. It can metastasize to neck
nodes. Treatment is radical parotidectomy which may include cuff of muscle or even a portion of mandible, temporal bone and the involved skin. Radical neck is combined if
nodal metastases are present. Surgery is followed by postoperative radiation to primary site and the neck.
UNDIFFERENTIATED CARCINOMA
It is a rare, but aggressive tumour. It has a tendency to
spread rapidly, causes pain, becomes fixed to skin and
ulcerates. It causes facial paralysis and cervical nodal
metastasis. Treatment is wide excision, radical neck and
postoperative radiation.
Figure 46.1. Squamous cell carcinoma of the right parotid. Patient presented with a parotid swelling (A) and facial palsy (B).
Chapter 46 — Neoplasms of Salivary Glands
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LYMPHOMA
It is a rare tumour usually associated with systemic disease,
but may occasionally be a primary tumour. Treatment is
same as for other lymphomas.
SARCOMA
Rarely other sarcomas, e.g. rhabdomyosarcoma may arise
from the parotid.
FREY’S SYNDROME (GUSTATORY
SWEATING)
Frey’s syndrome arises as a complication of parotid
surgery usually manifesting several months after the
operation. It is characterized by sweating and flushing
of the preauricular skin during mastication causing nuisance to the person or social embarrassment. It is the
result of aberrant innervation of sweat glands by parasympathetic secretomotor fibres which were destined for
the parotid. Now instead of causing salivary secretion
from the parotid, they cause secretion from the sweat
glands. The condition can be treated by tympanic neurectomy which intercepts these parasympathetic fibres at
the level of middle ear. Some people like to place a sheet
of fascia lata between the skin and the underlying fat to
prevent secretomotor fibres reaching the sweat glands.
Subcutaneous infiltration of botulinum toxin has also
been used to alleviate the symptoms. Generally, no treatment other than reassurance is required in most of these
patients.
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