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35 Diseases oftheSalivary Glands
Frequency (%) Malignant (%)
391
Parotid glands
Submandibular gl.
Sublingual gl.
Minor Salivary gl.
Fig. 35.3 Incidence of salivary gland tumors and per-
centage of malignancy according to localization
65 25
10
< 1
25
40
90
50
Rest equally distributed between submandibular gland (50% benign, 50% malignant) and minor
salivary glands (most are malignant) (Fig.35.3).
Tumors of the salivary gland
Benign Malignant
Epithelial
• Adenolymphoma
(Warthin tumor)
• Pleomorphic
adenoma
• Oncocytoma • Acinic cell carcinoma
• Other adenomas • Adenocarcinoma
Mesenchymal
• Hemangioma • Lymphoma
• Lymphangioma • Sarcoma
• Lipoma
• Neurobroma
• Mucoepidermoid carcinoma
(low grade, high grade)
• Cylindroma
• Malignant mixed tumor
• Squamous cell carcinoma
• Undifferentiated
carcinoma
35.4.1 Benign Masses
35.4.1.1 Common Salivary Gland
Tumors inChildren
– Hemangioma.
– Pleomorphic adenoma (most common).
– Lymphangioma.
– Neurogenic.
35.4.1.2 Pleomorphic Adenoma
– Most common salivary gland tumor.
– Most common in parotid gland, 90% in super-
cial lobe.
– Slow growing tumor, usually unilateral, pain-
less, rm mass, may progress rarely to cause
Fig. 35.4 T1 weighed MRI axial view of a case of right
pleomorphic adenoma in an adult male
dysphagia, dyspnea, hoarseness, facial nerve
involvement.
– Deep lobe involvement presents as intraoral
swelling.
– Solitary vs. synchronous/metachronous
neoplasms.
– Histopathology includes epithelial (varied growth
patterns), mesenchymal (spindle-shaped nuclei)
components and stromal component (myxoid,
chondroid, broid, or osteoid components).
– Ten percent risk of malignancy after 15years.
– Diagnosed by clinical presentation, MRI,
FNA (Fig.35.4 and 35.5).
– Treatment: complete surgical excision, avoid
enucleation and tumor spill.
35.4.1.3 Warthin’s Tumor (Papillary
Cystadenoma
Lymphomatosum)
Seen ONLY in the parotid gland.
Parotid is the last gland embryologically to be
encapsulated.
The development of ectopic ductal epithelium
within intraparotid lymph nodes, or hypersensitivity disease results in metaplasia of the duct.
Second most common tumor in the salivary
gland.
– Risk factors: male sex, smoking.
– Ten percent bilateral, 10% multicentric.
392
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H. Haidar et al.
Signs suggesting maligancy
Fig. 35.5 T2 weighed MRI axial view of a case of right
pleomorphic adenoma in an adult male
– Clinically presents as slow growing, painless,
cystic, compressible mass.
– Biphasic composition (abundant lymphoid
sheets and lining epithelium with bilayer of
oncocytic papillary cells).
– No risk of malignancy.
– Diagnosed by biopsy, FNA, radiosialography.
– Treatment: surgical resection (supercial or
deep parotidectomy).
35.4.1.4 Oncocytoma
– Most commonly in the parotid gland.
– Also known as oxyphilic adenoma.
– Slow growing, well circumscribed, but not
encapsulated.
– High density of mitochondria with sheets of
oncocytic cells (Technetium-99m
scintigraphy).
– Treatment—surgical resection.
35.4.1.5 Monomorphic Adenoma
– Most commonly in minor salivary glands.
– No mesenchymal stromal component (unlike
pleomorphic adenomas).
– Basal cell is the most common type.
– Other types: Clear cell, membranous, canalicu-
lar, myoepithelioma adenoma, glycogen-rich.
Facial nerve involvement
Large size (>5 cm)
Fig. 35.6 Features suggesting malignancy
Fixation to underlying or
overlying strutures
Cervical adenopathyOverlying ulceration
35.4.1.6 Hemangioma
– Benign.
– Usually discovered a few weeks after birth,
enlarges for 6–12months.
– But typically regress by second year of life.
– Fifty percent parotid hemangiomas are associ-
ated with cutaneous hemangiomas.
– two types—capillary and cavernous, capillary is
more common, cavernous enlarges quickly and
less chance of regression compared to capillary.
35.4.2 Salivary Gland Malignancies
(Fig.35.6)
35.4.2.1 Mucoepidermoid Carcinoma
• Most common salivary gland malignancy.
• Parotid most commonly, then minor salivary
gland (palate), and submandibular gland.
• Low grade vs. high grade depends on
mucinous- to-epidermoid cell ratio.
• Low grade: Higher amount of mucinous cells.
– Similar to benign lesion but capable of
local invasion and metastasis.
– Seventy percent 5-year survival rate.
– Treatment—surgical excision.
• High grade.
– Low ratio of mucinous-to-epidermoid cells
with high content of solid nests of cells.
– Behaves similar to squamous cell carci-
noma. Fifty percent 5-year survival rate.
– Treatment—surgical excision with elective
neck dissection (possible adjuvant radiation) (Fig.35.7).
AL GRAWANY
35 Diseases oftheSalivary Glands
Fig. 35.7 Indications
for neck dissection and
for adjuvant
radiotherapy in
mucoepidermoid
carcinoma
Indications for neck dissection Indications for adjuvant radiotherapy
Cervical
metastases
393
High-grade
malignancies
Tumors >4cm
High-grade
malignancies
35.4.2.2 Adenoid Cystic Carcinoma
– Most common malignancy of submandibular
gland and minor salivary glands.
– Also known as cylindroma.
– High-grade tumor with perineural spread.
– Three types:
Solid: worst prognosis.
Tubular: best prognosis.
Cribriform: most common subtype and interme-
diate prognosis (swiss cheese appearance).
– Treatment: surgical resection. ± postoperative
XRT.
– Prognosis: good 5-year survival, poor
10–15- year survival due to late metastasis
to lungs.
35.4.2.3 Acinic Cell Carcinoma
– Second most common parotid and pediatric
malignancy, low grade, better prognosis com-
pared to adenoid cystic.
– Bilateral parotid disease in 3%.
– Derived from serous cells.
– Low-grade tumor.
– Treatment—surgical resection ± postoperative
XRT.
35.4.2.4 Adenocarcinoma
– Most commonly in minor salivary glands.
– High grade and aggressive.
Tu mors >4cm
Facial nerve
involvement
Extension to
extraglandular tissue
– Treatment—surgical resection with elective
neck dissection (possible adjuvant radiation).
35.4.2.5 Polymorphous Low-Grade
Adenocarcinoma
– Low grade.
– Second most common malignancy of the
minor salivary gland (palate and buccal
mucosa).
– Treatment—surgical resection.
35.4.2.6 Malignant Mixed Tumors
– High grade, aggressive, poor prognosis.
– Treatment is usually Resection + Post Op
Radiotherapy ± Selective Neck Dissection.
– Types:
– Metastasizing Mixed Tumor: distinct from
carcinoma ex-pleomorphic, remains histologi-
cally benign.
– Carcinosarcoma: contains components of both
carcinomas and sarcomas.
– Noninvasive Carcinoma: carcinoma in situ
within a pleomorphic adenoma.
35.4.2.7 Other Salivary Gland
Malignancy Types
Squamous cell carcinoma, lymphomas, malignant oncocytoma, epithelial-myoepithelial carcinoma, salivary duct carcinoma.
394
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35.5 Miscellaneous
35.5.1 Frey’s Syndrome
– Gustatory sweating from aberrant reinnerva-
tion of post-ganglionic parasympathetic
nerves to the sweat glands after injury to the
auriculotemporal nerve.
– May occur upto 5years post op.
– Presents as sweating and redness of the preau-
ricular area during meals.
– Diagnosis with starch iodine test.
– Treatment includes:
Medical: scopolamine, glycopyrrolate,
diphemanil methylsulfate (anticholinergics),
Botox injections
Surgical: tympanic neuronectomy (controver-
sial with high recurrence rates)
Radiation therapy: for severe symptoms
35.5.2 Mucous Retention Cysts,
Mucoceles, andRanulas
– Pathophysiology: obstruction of minor saliva-
tory glands (may be from trauma).
– Mucous Retention Cyst: it is a true cyst of the
minor salivary glands (lined with epithelial
layer).
– Ranula: mucous retention cyst of the oor of
mouth, usually from the sublingual gland.
– Plunging Ranula: ranula that extends into the
cervical tissues.
– Mucocele: not a true cyst, extravasation of
mucus into soft tissue.
– Clinically presents as a cystic mass on oor of
mouth, lip, buccal mucosa, or minor salivary
gland.
– Diagnosed through clinical history and exam,
excisional biopsy.
– Treatment is excision or marsupialization.
– Benign Lymphoepithelial Cysts: Presents as
asymptomatic, multiple parotid cysts, can be
bilateral, mostly in HIV patients.
– Diagnosed by clinical exam, FNA.
– Treatment can be aspiration or excision, anti-
viral therapy in HIV may cause regression,
doxycycline can also be used (limited).
H. Haidar et al.
Take Home Messages
• Most salivary glands lesions are of an
inammatory origin.
• Mumps virus is the most common cause
of acute parotid enlargement.
• Ninety percent of submandibular calculi
are radiopaque while 90% of parotid
calculi are radiolucent.
• Most neoplasms are in parotid 75%,
most of them are benign.
• Pleomorphic adenoma is the most common salivary gland tumor.
• Mucoepidermoid carcinoma is the most
common salivary gland malignancy.
• Adenoid cystic carcinoma is the most
common malignancy of submandibular
gland and minor salivary glands.
• Epithelial tumors are the most frequently encountered (>80%) salivary
glands tumor, mesenchymal tumors
which are a very mixed group (<20%),
and hematolymphoid tumors (lymphoma and plasmacytoma) making up
the rest.
Further Reading
1. Flint PW, Cummings CW. Cummings otolaryngology head & neck surgery. Maryland Heights: Mosby/
Elsevier; 2010.
2. Parkin DM, Ferlay J, Curado MP, et al. Fifty
years of cancer incidence: CI5 I-IX. Int J Cancer.
2010;127(12):2918–27.
3. Carvalho AL, Nishimoto IN, Califano JA, Kowalski
LP. Trends in incidence and prognosis for head and
neck cancer in the United States: a site- specic
analysis of the SEER database. Int J Cancer.
2005;114(5):806–16.
4. Barnes EL, Eveson JW, Reichart P, Sidransky
D.Pathology and genetics of head and neck tumours.
In: Kleihues P, Sobin LH, editors. World Health
Organization classication of tumours. Lyon: IARC
Press; 2005.
5. Barnes L, Eveson JW, Reichart P, Sidransky
D.Pathology and genetics of head and neck Tumours.
Lyon: IARC Press; 2005.
6. Saunders JR Jr, Hirata RM, Jaques DA. Salivary
glands. Surg Clin North Am. 1986;66(1):59–81.
AL GRAWANY
35 Diseases oftheSalivary Glands
395
7. Zou ZJ, Wang SL, Zhu JR, Wu QG, Yu SF.Chronic
obstructive parotitis. Report of ninety-two cases. Oral
Surg Oral Med Oral Pathol. 1992;73(4):434–40.
8. O’Brien CJ, Murrant NJ. Surgical management of
chronic parotitis. Head Neck. 1993;15(5):445–9.
9. Levy DM, Remine WH, Devine KD.Salivary gland
calculi. Pain, swelling associated with eating. JAMA.
1962;181:1115–9.
10. Epker BN.Obstructive and inammatory diseases of
the major salivary glands. Oral Surg Oral Med Oral
Pathol. 1972;33(1):2–27.
11. Stenner M, Klussmann JP. Current update on established and novel biomarkers in salivary gland carcinoma pathology and the molecular pathways involved.
Eur Arch Otorhinolaryngol. 2009;266(3):333–41.
12. Rogers J, McCaffrey TV. Inammatory disorders
of the salivary glands. In: Flint PW, Haughey BH,
Lund VJ, et al., editors. Cummings otolaryngology
head and neck surgery. 5th ed. Philadelphia: Mosby
Elsevier; 2010. p.1151–61.
An Approach toNeck Masses
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SuzanSaeedMohamed, AbhishekMenon,
andWaheedRahman
Key Points
• Ultrasonography is used in all cases of
thyroid enlargement and in differentiating solid from cystic masses.
• Branchial cleft cysts most commonly
occur in the second or third decades.
• Thyroglossal duct cysts elevate on protrusion of the tongue.
• Biopsy is contraindicated in carotid
body tumors. MRI angiography is the
investigation of choice.
• Supercial parotidectomy is considered
as a diagnostic and therapeutic for most
benign tumors of the parotid gland.
36.1 Introduction
36
neurological, and musculoskeletal structures
between the head, trunk, and limbs and also the
aerodigestive tract. The neck can be subdivided
into various triangles and its subdivisions; it can
be divided into zones/levels, all based on multiple landmarks, some of which will be discussed
in this chapter.
36.2 An Approach totheNeck
Mass
Our approach involves an understanding of two
basic factors:
1. Anatomy—major structures of the neck and
lymph nodes of the neck.
2. Pathology that may arise in the above struc-
tures, i.e., the differential diagnosis.
The neck is the transitional area, the clavicles
inferiorly and the base of the skull superiorly. It
serves as a major conduit for the various vascular,
S. S. Mohamed · A. Menon · W. Rahman (*)
Hamad Medical Corporation, Doha, Qatar
e-mail: mohamed50@hamad.qa;
AMenon1@hamad.qa; wrahman@hamad.qa
© Springer Nature Switzerland AG 2021
A. Al-Qahtani et al. (eds.), Textbook of Clinical Otolaryngology,
https://doi.org/10.1007/978-3-030-54088-3_36
36.2.1 Prominent Landmarks
1. Hyoid bone
2. Thyroid cartilage
3. Cricoid cartilage
4. Trachea
5. Sternocleidomastoid muscle
6. Clavicle
AL GRAWANY
397
398
Anterior triangle
posterior triangl
1
level
S. S. Mohamed et al.
Mandible
Hyoid bone
Thyroid cartilage
Thyroid
Sternocleidomastoid muscle
trachea
clavicle
36.2.2 Triangles oftheNeck
Anterior
1. Anterior border of the SCM, midline, lower
border of the mandible
2. Subdivisions: submandibular, submental,
carotid, muscular
e
36.2.3 Lymph Node Levels oftheNeck
Posterior
1. Posterior border of SCM, clavicle, anterior
border of trapezius
2. Subdivisions: subclavian, occipital
infraauricular
Level 2
level 3
level 4
5
preauricular
Submental level
level 6
36 An Approach toNeck Masses
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399
36.3 Dierential Diagnosis
• Up to 80% of neck masses that occur outside
the thyroid are neoplastic in adults over the
• Congenital (developmental), inammatory or
age of 40 years.
neoplastic.
• 2–9% of head and neck cancers present as cervical masses without a known primary.
Differential diagnosis of neck masses
Development Infectious Benign neoplasm Malignancies Other
– Thyroglossal
cyst
– Branchial
cleft cyst
– Inclusion cyst
– Congenital
vascular
malformation
– Cystic
hygroma
– Laryngocele
– Bronchogenic
cyst
– Teratoma
– Viral (EBV,
CMV, HIV)
– Bacterial (strep.
pyogenes, staph.
aureus)
– Fungal
(histoplasmosis)
– Protozoal
(toxoplasmosis)
36.4 The Patient Presented
withNeck Lump, Swelling, or
Mass, What Is Your Workup?
– Thyroid nodule
– Lipoma
– Fibroma
– Parathyroid
adenoma
– Sebaceous cyst
– Neurobroma
– Benign salivary
tumor
(pleomorphic
adenoma,
Warthin’s tumors)
– Thyroid cancer
– Lymphoma
– Carotid body tumor
– Parathyroid
carcinoma
– Malignant salivary
gland
(mucoepidermoid)
Neck masses in children and young adults
are more commonly inammatory than congenital, and rarely neoplastic. In adults always
– Sjogren
– Sarcoidosis
– Sialolithiasis
there is suspicion to be neoplastic.
• History Age:
syndrome
• congenital: cystic hygroma, thyroglossal cyst
• inflammatory: very common
Children
(0-15 years):
young adult
16-35 years)
Adult (35 +
years)
• salivary disease: inflammatory
• thyroid disease: inflammatory
• Neoplastic: Rare
• congenital: brancheal cyst
• inflammatory: less common
• salivary disease: Sialolithiasis
• thyroid disease: papillary carcinoma
• Neoplastic: Lymphoma, Metastases
• congenital: very uncommon
• inflammatory: Rare
• salivary disease: Neoplam
• thyroid disease: Endocrine disease
• Neoplastic: Lymphoma, Squamous cell carcinoma, Metastases
AL GRAWANY
400
S. S. Mohamed et al.
36.4.1 Duration
• Inammatory disorders are usually acute in
onset and resolve within 6 weeks.
• Cervical lymphadenitis is often associated
with recent upper tract infection.
• Congenital masses are often present from
birth as small masses, which enlarge rapidly after mild upper respiratory tract
infection.
• Metastatic carcinoma tends to have a short
history of progressive enlargement.
36.4.2 Others
• Family Hx: cancer, TB, etc.
• Social Hx: smoking, alcohol, and history of
travel and contact.
36.5 Examination
• Physical examination
– General examination: vital sign, the gen-
eral condition of the patient
– Full head and neck examination include:
The oral cavity, oropharynx, hypopharynx and nasopharynx
Palpation of the neck (all levels and thyroid gland)
Laryngeal examination: bro-optic.
Cranial nerves.
Assessment of the swelling, mass or
lumps: relation to muscles, trachea, and
hyoid bone.
The location, mobility, and consistency
of a neck mass.
36.6 Some oftheFeatures Raise
Suspicion ofMalignancy
1. Voice change
2. Odynophagia
3. Dysphagia
4. Hemoptysis
5. Previous radiation
6. Oral lesions, recent trauma, globus sensation
7. Constitutional symptoms (e.g., night sweats,
anorexia, weight loss)
8. Unilateral nasal discharge or epistaxis
9. Family history of cancer and previous tumors
36.7 Diagnostic Tools
1. Blood Investigations:
• Full blood count
• Throat swab: occasionally helpful but must
be sent immediately in the proper medium
• Viral serology: Epstein–Barr virus, HPV,
cytomegalovirus, and toxoplasmosis
• Thyroid function tests
2. Images:
• Ultrasonography is used in all cases of thyroid enlargement and in differentiating
solid from cystic masses.
• Chest X-ray in smokers with a persistent
neck lump.
• CT scan and MRI to determine the extent
of the masses.
• PET scan: Not rst line, used for metastatic
squamous cell carcinoma of unknown
primary and further workup for known
diagnosis.
3. Tissue diagnosis
• FNA (ne needle aspieration)
• Excisional / incisional biopsy
• Pan-endoscopy and biopsy
• Tonsillectomy (tonsils are found to be the primary source in 20–40% of these patients)
36 An Approach toNeck Masses
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401
Pediatric
New neck
mass
(0-15years)
Young adult
(16-40 years)
Older adult
(> 40 years)
Infectious
symptoms
Order Image
36.8 Treatment Diers According
tothe Diagnosis
36.8.1 Cystic Hygroma
(Lymphangiomas)
yes
No
Order Image
Antibiotic
Non cystic
NON-Vascular
Vascular
trial
cystic
Resolution
NO Resolution
Image support
congeital origin
Image DO NOT
support
congenital origin
FNA
• It is a congenital lesion usually present within
the rst year of life (posterior triangle).
• Usually, remain unchanged into adulthood.
• Is soft, cystic, multilocular, partially com-
pressible, and brilliantly transilluminate and
may present with pressure effects.
•
CT or MRI may help dene the extent of the
neoplasm.
• Treatment includes injection with picibanil or
excision of easily accessible lesions or those
affecting vital functions.
AL GRAWANY
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