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939
© The Association of Oral and Maxillofacial Surgeons of India 2021
K. Bonanthaya et al. (eds.), Oral and Maxillofacial Surgery for the Clinician, https://doi.org/10.1007/978-981-15-1346-6_46
Salivary Gland Pathologies
NisheetAnantAgni
46.1 Introduction
The salivary glands secrete saliva which has lubricating,
immunologic, digestive, and cleansing functions. They are
affected by systemic and local inammatory conditions,
obstructive pathologies, as well as neoplasms. Most of the
tumors are parenchymal in origin, whereas few could be
interstitial. Majority of tumors affecting major glands are
benign, but those affecting minor salivary glands are more
often than not, malignant. The disorders that involve these
glands can either be acute or chronic inammatory lesions,
congenital abnormalities, systemic disorders, or benign and
malignant tumors. However the most, common disorders
affecting salivary glands are tumors and infections.
46.2 Surgical Anatomy
46.2.1 Parotid Gland
The gland lies in the retromandibular fossa bound medially
by the styloid process and superiorly by external acoustic
meatus and mastoid process, and it touches the medial ptery-
goid muscle and mandibular ramus (Fig.46.1). A part of the
gland may also cover the TMJ in front of the ear but never
extends beyond the zygomatic arch. The parotid capsule is a
dense, adherent brous condensation of deep cervical fascia
which is tough and unyielding. Hence parotid space infec-
tions show minimal swelling but are severely painful.
Incision and drainage is needed early on, without a frank
uctuant abscess to relieve the pressure within the capsule to
prevent pressure necrosis of the parenchyma. Due to weak-
ness in the capsule covering the deep surface of the gland,
parotid abscess may spread into the lateral pharyngeal space,
if not drained promptly [1]. Benign tumors grow slowly and
hence take a longer time to manifest as external bulges.
Parotid gland has a supercial lobe (80%) and a deep lobe
(20%) connected by an isthmus with the facial nerve passing
between the two lobes.
The facial nerve is related to the parotid gland in a number
of ways [2].
1. (a) Supercial and deep lobes are united above, so that the
gland is essentially folded over the nerve.
(b) An isthmus uniting the two lobes.
(c) Combination of (a) and (b)
2. The gland and nerve can also lie intertwined within super-
cial and deep lobes; relation will vary according to plane
of section.
The intratemporal and intraparotid facial nerve has varied
pattern of branching which is of immense surgical impor-
tance and might show bifurcation and trifurcation of the main
trunk within the mastoid segment (Fig.46.2). This intratem-
poral division of the facial nerve is associated with congenital
abnormalities of the pinna or inner ear (Table46.1).
Parotid duct or the Stensen’s duct crosses the masseter
about a nger breadth below the zygomatic arch. It then
takes a sharp turn medially at the anterior border of the mas-
seter further traversing through the buccal fat pad and buc-
cinator muscle. It then runs obliquely between the buccinator
and oral mucosa to open on the parotid papilla, opposite the
second maxillary molar. The obliquity of the duct in between
the buccinator and mucosa acts like a valve to prevent ina-
tion of the duct while blowing air. The duct lies between the
upper and lower buccal branches of the facial nerve. Its cali-
ber is about 3mm, but at the point where it penetrates the
buccinator muscle, an isthmus narrows down the duct to
1.2mm, and at the orice (ostium), it is 0.5mm.
46
N. A. Agni (*)
Department of Oral and Maxillofacial Surgery, SMBT Institute of
Dental Sciences and Research, Nashik, India
Electronic Supplementary Material The online version of this chap-
ter (https://doi.org/10.1007/978-981-15-1346-6_46) contains supple-
mentary material, which is available to authorized users.
940
Structures traversing the parotid gland from lateral to
medial (supercial to deep) include the facial nerve, retro-
mandibular vein, and external carotid artery. Few parotid
lymph nodes are also present within the gland.
Parasympathetic secretomotor bers from the inferior
salivary nucleus of the ninth cranial nerve supply the gland.
Nerve bers pass to the otic ganglion via the tympanic
branch of the glossopharyngeal nerve and the lesser petrosal
nerve. Postganglionic parasympathetic bers reach the
parotid gland via the auriculotemporal nerve, which lies in
contact with the deep surface of the gland. Postganglionic
sympathetic bers reach the gland as a plexus of nerves
around the external carotid artery [4].
46.2.1.1 Identication oftheFacial Nerve [5, 6]
The facial nerve identication can be done either proximally
or distally. Proximally the main trunk of the nerve is identi-
ed before it enters the gland. Distally it is identied as
branches after the nerve leaves the gland (Table46.2).
There are four facial nerve pointers at the stylomastoid
foramen. However more techniques have been added later on
by various authors. They are as follows:
1. The cartilaginous pointer of Conley (1978) is created at
its anterior inferior border and is the least reliable one.
The backward pull on the cartilage causes the meatus to
assume the shape of a horn, the curved extremity of which
allegedly points to the position of the facial nerve. The
nerve is located medial and inferior to the pointer
(Fig.46.3).
2. A short segment of the facial nerve lies in between the
stylomastoid foramen and parotid gland and is an ideal
location to identify it. It can be located in the tympano-
mastoid sulcus which is formed by the edge of the bony
external meatus and anterior face of the mastoid process.
The nerve emerges from the stylomastoid foramen some
3–4mm deep to the outer edge of the bony external canal.
The tympanomastoid sulcus is lled with brofatty lob-
ules that mimic the facial nerve trunk which may lie as
deep as 1cm to this landmark.
3. The anterior superior aspect of the posterior belly of the
digastric muscle is inserted just behind the stylomastoid
foramen. The posterior belly of the digastric muscle lies
just inferior to the nerve and is the most reliable landmark
to identify the nerve (Fig.46.4).
4. The styloid process is a conrmatory landmark. The
facial nerve lies lateral to the styloid process near the sty-
loid base. The posterior auricular artery bleeds frequently
while looking for the facial nerve since it lies below and
just lateral to the nerve, and hence it cannot be relied upon
for identication of the nerve.
5. Borle’s triangle has been recently introduced to locate
the facial nerve trunk. Lines are drawn from the tip of
the mastoid process, running along the superior border
of the posterior belly of digastric muscle and posterior
border of the ramus of the mandible. These two lines
intersect with each other anteriorly, forming the apex of
the triangle (angle a). The base of the triangle is marked
by drawing the third line starting from the tip of the
mastoid process (angle b), running anteriorly till it joins
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.1 Transverse section
of parotid gland
N. A. Agni
941
bca
ef
d
hi
g
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.2 (a)–(i) Katz-
Catalano classication based
on operative ndings
Table 46.1 Katz-Catalano classication
Type 1 25% Branches are separate
Type 2 14% Buccal branch fuses with zygomatic branch
Type 3 44% Major communicating, buccal, and other branches
Type 4 14% Complex branching between all branches
Type 5 3% More than one major trunk
Katz and Catalano [3], 1987
Table 46.2 Facial nerve identication
1
Anterograde approach—Direct identication of main trunk at
stylomastoid foramen
2 Retrograde approach—Early identication of mandibular branch
over posterior facial vein or other branches along the parotid duct
3 Supravital staining of parotid—gland is stained blue, tumor is
unstained, and facial nerve is gleaming white
46 Salivary Gland Pathologies
942
the second drawn line along the posterior border of the
ramus (angle c). The facial nerve trunk is often found
within this triangle just above the angle b formed by the
rst and the third line if gentle and blunt dissection is
carried out at this point. The mean distance of nerve
trunk from the angle b is 12.18±2mm within a range of
9–15 mm [7] [Fig. 46.5—https://www.ncbi.nlm.nih.
gov/pmc/articles/PMC6126203/. doi: https://doi.
org/10.1016/j.jobcr.2018.08.004. (open access)].
When identication of facial nerve trunk is difcult using
the above said pointers due to distorted anatomy due to the
tumor, a retrograde approach can be used by identifying a
peripheral branch of the nerve and tracing it proximally. The
easiest branch to locate is the marginal mandibular nerve.
Baker etal. have reported that the marginal mandibular nerve
is located 1–2cm below the inferior border of the mandible.
The marginal mandibular branch can be used to trace the
facial nerve in a retrograde direction by identifying it at the
point of emergence of the retromandibular vein and then car-
rying out a proximal dissection. By working backward along
the nerve, the two divisions, the other branches, and the main
trunk can be found [8].
Figure 46.6 represents the average distance of facial nerve
pointers from the surrounding landmarks (Table 46.3).
Intraoperative facial nerve monitoring using electromyo-
graphic techniques can also be used for identication of the
main branch or the peripheral branches in centripetal or retro-
grade approach. In pediatric population the facial nerve trunk
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.3 Showing relation of cartilaginous pointer and facial nerve
main trunk
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.4 Showing relation of the posterior belly of the digastric mus-
cle and main trunk of the facial nerve (muscle pointed by mosquito
forceps)
Fig. 46.5 Borle’s triangle. Line 1: Started from mastoid process tip
and running along the superior border of posterior belly of the digas-
tric muscle. Line 2: At the posterior border of ramus of the mandible.
Line 3: Starts from the tip of the mastoid process running anteriorly till
it joins the second line. Angle a: Lines 1 and 2 intersect with each other
forming the apex of triangle. Angle b: Is the base of the triangle. Angle
c: Is the angle where third line meets second line
N. A. Agni
943
exits the stylomastoid foramen and is found approximately
1cm anterior to mastoid process and 1.5 cm posterior to the
ramus of the mandible. The parotid does not extend posterior
to the ramus of the mandible in the newborn infant and conse-
quently covers only the lower distal branches of the nerve [9].
46.2.1.2 Facial Nerve Monitoring
There are two types of facial nerve monitoring:
• Electromyography
• Pressure or strain gauge sensor
Facial nerve monitoring is performed with a nerve stimu-
lator which can either be monopolar or bipolar. The monopo-
lar stimulator is more useful for identifying the nerve, while
the bipolar is more useful if the nerve course is evident.
However, a bipolar stimulator is more precise.
46.2.2 Submandibular Glands
It is a U-shaped gland with a smaller deep lobe and larger
supercial lobe enveloping the mylohyoid muscle. Hence
during surgical removal, the mylohyoid has to be retracted
anteriorly to expose the deep lobe and the Wharton’s duct.
The capsule is loosely attached to the gland substance, and
hence the gland can be shelled out easily.
Since the submandibular group of lymph nodes are in
contact with the gland or embedded in it, it is essential to
clear the nodes along with the gland during a neck
dissection.
The facial artery loops around the submandibular
gland. The facial artery is visualized by retracting the pos-
terior belly of the digastric muscle inferiorly. Hence, dur-
ing excision of the submandibular gland, the facial artery
and vein were customarily ligated. However, during neck
dissection, the current standard is to try and save it so that
it can be used for anastomosis during a free ap
reconstruction.
The facial artery is ligated away from the external carotid
artery, so that in case the vessel retracts into the tissue, it can
be located and religated and bleeding can be controlled. In
case the ligature slips and the facial artery retracts, the poste-
rior belly of the digastric muscle is divided for easy location
of the bleeding vessel.
The lingual nerve passes below the duct and forms a loop
around its outer aspect before inserting into the tongue
mucosa. It is at risk when the deep part of the gland is being
mobilized. The submandibular duct or Warton’s duct is lon-
ger and has a tortous, uphill course. Thus the secretions have
to be emptied against gravity, and there are increased chances
of retention. Also, the mineral content of the secretion is
high, especially calcium content which along with increased
retention of secretions results into higher incidence of calcu-
lus formation and inammatory pathologies in the subman-
dibular gland and duct.
Figure 46.7a, b shows the relations of the submandibular
gland.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.6 Distance from
facial nerve pointers
Table 46.3 Distance of the facial nerve pointers from the surrounding
landmarks [10]
Sr.
no. Pointer
Distance in
mm
Mean in
mm
1 Tragal pointer 24.3–49.2 34
2 Posterior belly of the digastric
muscle
9.7–24.3 14.6
3 External auditory canal 7.3–21.9 13.4
4 Tympanomastoid suture 4.9–18.6 10.0
5 Styloid process 4.3–18.6 9.7
6 Transverse process of axis 9.7–36.8 16.9
7 Angle of the mandible 25.3–48.69 38.1
46 Salivary Gland Pathologies
944
b
a
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.7 (a, b) Relations of
submandibular gland
46.2.3 Sublingual Glands
They are located beneath the mucosa of the oor of the
mouth and appear as an elevation in the oor of the mouth.
The excretory ducts of the sublingual glands are very super-
cially located and open in the oor of mouth at a superior
level than the gland. Hence, they easily get damaged, and
any trauma or infection of the ducts leads to salivary reten-
tion and formation of a mucous retention cyst which is called
“ranula” due to its bluish color resembling the belly of a
frog. The international statistical classication of diseases
and related health problems shown in Table46.4.
N. A. Agni
945
46.3 Diagnosis andDiagnostic Aids
A thorough history followed by meticulous examination
holds the key to proper diagnosis of salivary gland patholo-
gies. Salivary gland neoplasms are usually slow growing
and non-tender. A slow-growing swelling of the salivary
gland is suggestive of a neoplasm, whereas a sudden, pain-
ful swelling is suggestive of an infective pathology although
it can sometimes indicate a malignant tumor with second-
ary infection. Nerve weakness and skin inltration are
always associated with malignant tumors which have
already inltrated the nerve or skin although the vice versa
is not always true.
Major salivary glands are palpated, and secretions milked
out to check ow, quantity, and quality of secretion. A turbid
salivary discharge may indicate an infection, whereas
reduced salivary ow could indicate either less secretion or
obstruction to ow. Function of facial nerve should be
checked and documented during parotid examination. On
inspection submandibular gland swelling can be easily iden-
tied and compared with the contralateral side; however the
submandibular glands are bimanually palpated (Figs. 46.8
and 46.9).
Various diagnostic aids for investigating salivary gland
diseases are as follows:
1. Diagnostic imaging
(a) Routine radiographs: It is useful only for diagnosing
sialoliths and parenchymal calcications. Radiopaque
salivary calculi in the gland or duct can be picked up
on plain lms such as occlusal X-ray for submandib-
ular gland and duct and a posteroanterior (PA) skull
with blown-out cheeks for parotid calculi.
Table 46.4 International statistical classication of diseases and
related health problems
K 11 Diseases of salivary glands
K 11.0 Atrophy of the salivary gland
K 11.1 Hypertrophy of the salivary gland
K 11.2 Sialadenitis
Excludes epidemic parotitis and uveoparotid fever
K 11.3 Abscess of the salivary gland
K 11.4 Fistula of the salivary gland
Excludes congenital stula of the salivary gland
K 11.5 Sialolithiasis
Calculus/stone of salivary gland or duct
K 11.6 Mucocele
Mucous extravasation cyst/retention cyst
Ranula
K 11.7 Disturbances of salivary secretion
Hypoptyalism
Ptyalism
Xerostomia
Excludes dry mouth NOS
K 11.8 Other diseases of the salivary glands
Benign lymphoepithelial lesion of the salivary gland
Mikulicz’ disease
Necrotizing sialometaplasia
Sialectasia
Stenosis/strictures of salivary ducts
Excludes Sicca syndrome (Sjögren’s syndrome)
K 11.9 Diseases of the salivary glands unspecied
Sialoadenopathy NOS
10th Revision (Version for 2003) [11]
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.8 Clinical photo showing submandibular gland enlargement,
right side
©
Association of Oral and Maxillofacial Surgeons of India
Fig. 46.9 Bimanual palpation
46 Salivary Gland Pathologies
946
(b) Ultrasonography: Ultrasonography (USG) is a nonin-
vasive modality that utilizes non-ionizing radiation,
gives good soft tissue discrimination, has excellent
sensitivity for mass lesions, and can be repeated as
frequently as required. Normal gland is relatively
homogenously hyperechoic than adjacent muscle,
and so is cyst and tumor from parenchyma [12, 13]. It
helps to distinguish a cystic lesion from a solid mass
in space- occupying lesion (Fig. 46.10). USG with
color Doppler is useful to rule out vascular lesions
and also aids in assessing vascularity of lesions.
(c) Sialography: It assesses obstructive pathology by
instillation of radiopaque contrast medium to locate
obstruction in the ductal system. The technique is
more or less obsolete now with the advent of MRI
imaging. It is a technique which involves injection of
a radiopaque dye into the ductal system of the major
salivary glands and taking plain X-rays to see the pat-
tern of the dye into the ductal systems. Most com-
monly the contrast dyes used are iodine based. They
can either be lyophilic (oil based) or aqueous (water
based or water soluble). Lyophilic (oil-based) con-
trast dyes include Lipiodol (iodized poppy seed oil)
and Pantopaque (organic iodine compound). Aqueous
contrast dyes include iothalamate (Conray) and
metrizoate (Triosil). Aqueous-based dyes are most
commonly preferred. Sialography is indicated to
diagnose obstructive pathologies and duct anomalies,
degenerative changes in the gland, chronic inamma-
tory conditions, and intra- and extraglandular tumors.
It is contraindicated in acute infections of the gland
and in case of allergies to the dye.
Procedure: The duct orice is enlarged using a
lacrimal probe and cannulated with a 22 gauge can-
nula after inltrating local anesthetic (Fig.46.11a, b).
The selected dye is injected into the ductal system
using a Luer lock syringe with gentle continuous
pressure with simultaneous massage of the gland.
Once the patient feels some discomfort, dye injection
is stopped. X-rays are taken during the lling phase
and emptying phase as well.
The X-rays show different patterns:
(i) The normal parotid gland shows “tree in winter”
or “leaess tree” pattern, and submandibular
gland shows “bush in winter” appearance. This
is because the normal acini do not allow dye to
enter and it is seen only in the ducts and ductules
(Fig. 46.12—normal sialography: leaess tree).
(ii) In chronic inammation the dye enters the duct-
ules, and the empty acini give a “blossom tree”
or “leafy tree” appearance.
(iii) Sjögren’s syndrome and Mikulicz’ disease show
a “snow storm” or “branchless fruit-laden”
appearance.
(iv) Stricture in a duct is seen as a lling defect,
whereas multiple strictures show a sausage
string appearance.
(v) “Cannon ball” appearance is seen in intraglan-
dular tumors, whereas extraglandular tumors
show a “ball in hand” appearance.
(vi) Duct perforation and sialocele show dye spillage
in the soft tissues.
(d) Radionucleotide scanning: It is used to distinguish
between obstructive and nonobstructive sialadenitis.
It involves both dynamic and static scanning.
Radionuclide scanning is useful when a sialogram is
contraindicated to distinguish between acute obstruc-
tive and nonobstructive sialadenitis [14].
(e) CT scan: It is used to evaluate masses in parotid
glands and surrounding structures as it gives excel-
lent soft tissue details (Fig. 46.13) especially when
used with a contrast dye. Bony changes in the course
of facial nerve like erosions, sclerotic margins, and
widening of stylomastoid foramen or fallopian canal
suggest involvement of nerve. Plain computed
tomography (CT) scans have a major role to play for
diagnosis of obstructive pathologies like a calculus.
(f) MRI scan: It allows assessment of salivary masses
and early diagnosis of perineural spread due to
excellent soft tissue contrast. In the case of neo-
plasms, it helps in demonstrating involvement of
the facial nerve (Fig.46.14).
(g) Arteriography: It assesses the vascularity and source
of vascular supply of the tumors.
©
Association of Oral and Maxillofacial Surgeons of India
Fig. 46.10 USG of submandibular gland
N. A. Agni
947
(h) Positron emission tomography (PET): Uptake of
radiotracer uorodeoxyglucose used with PET scans
by salivary glands makes this diagnostic technique
useful for salivary gland tumors. Although this is an
expensive technique, measurement of metabolic
activity makes it more reliable than CT and MRI
scans. It can be used to diagnose recurrences, tumor
hypoxia, and proliferation rates [15].
2. Histopathology: The gold standard of diagnosis for
neoplasms will always be histopathology (HPE).
However, as the major salivary glands are deeper struc-
tures, an FNAC (ne-needle aspiration cytology) is
considered as a standard of care for diagnosis to avoid
tumor seeding, which might follow an open biopsy. An
open biopsy can be considered for minor salivary gland
tumors or malignant tumors affecting major salivary
glands with skin inltration, needing skin excision to
achieve surgical clearance. HPE for salivary gland
ba
©
Association of Oral and Maxillofacial Surgeons of India
Fig. 46.11 (a, b) Sialography technique
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.12 Normal parotid gland in sialography
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.13 CT scan showing parotid tumor
46 Salivary Gland Pathologies
948
pathologies is very challenging, and hence diagnosing
lesions on FNAC is more difcult. It is important to dis-
tinguish benign and malignant pathologies on FNAC
even if the exact malignant variant is missed, because
except adenoid cystic carcinoma which has perineurial
spread, the surgery doesn’t change for any other malig-
nant tumor variant.
(a) Fine-needle aspiration cytopathology (FNAC): It
shows high diagnostic accuracy both for benign and
malignant tumors. Complete histological features
and status of invasion can’t be revealed by this
technique.
(b) Incisional biopsy: It is not a reliable technique as
there is high possibility of seeding of tumor cells as
well as fungation through skin.
3. Frozen sections: These help in diagnosing the nature of
tumor, but accurate histopathologic features can’t be
diagnosed.
46.4 Non-neoplastic Diseases (Table 46.5)
46.4.1 Acute Bacterial Sialadenitis
Parotitis (Fig.46.15) occurs secondary to decreased salivary
secretions, and various reasons are attributed.
The common etiologic factors for parotitis are reduced
salivary ow due to severe dehydration, in patients with
debilitating diseases, old age, post-operative patients,
post radiotherapy for head and neck cancers, poor oral
hygiene leading to recurrent infection, mechanical
obstruction to ow, compromised host resistance due to
systemic illnesses like Diabetes Mellitus, renal failure,
HIV, post transplant immunosuppresants. The drugs
which induce systemic dehydration such as antihyperten-
sives, diuretics, tricyclic antidepressants , phenothiazines,
barbiturates, anticholinergics and betablockers also lead
to reduced salivary ow rate [17].
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.14 MRI showing parotid tumor, right side
Table 46.5 Important terminologies in relation to salivary gland
diseases
Sialadenitis: Sialadenitis is inammation of the gland parenchyma.
It could either be suppurative (with pus) or nonsuppurative (without
pus). It can also be classied as acute, subacute, or chronic.
Sialodochitis: This refers to inammation of the salivary gland duct.
It may be associated with duct strictures and/or sialoliths.
Sialectasis: This refers to cystic dilatation of the ducts due to either a
sialolith or ductal strictures. It is most commonly seen in parotid
gland infections. It can occur due to any condition causing chronic
inammation of the gland.
Sialorrhea: This refers to excessive secretion of saliva or drooling of
saliva. It is most commonly seen in patients with cerebral palsy and
neuro-degenerative disorders.
Sialosis: It is dened as an asymptomatic, non-neoplastic, non-
inammatory parenchymal salivary gland disease which manifests as
persistent painless bilateral salivary gland swelling, most commonly
involving the parotid gland [16].
Sialodochoplasty: It is repair of the salivary gland duct usually by
translocating the ductal opening.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.15 Parotitis left side
N. A. Agni
949
It may be retrograde contamination of salivary ducts and
parenchymal tissues by oral microora providing a bacterial
source of infection. Stasis of salivary ow through the ducts
and parenchyma may also promote acute suppurative infec-
tion. There is a higher risk of sialolith in the submandibular
duct causing secondary suppurative sialadenitis (Fig.46.16
showing submandibular sialadenitis).
46.4.1.1 Clinical Features
• Sudden onset of pain and swelling, exacerbates with food
sighting or smelling
• Generalized malaise, fever, body ache, and sometimes
signs of dehydration.
• Diffuse inammatory swelling, induration, erythema,
edema, and extreme tenderness over the affected gland.
• Tense, glossy, and erythematous skin.
• Raised ear lobule is pathognomonic sign of parotid
swelling.
• The duct orices are inamed, and milking of gland may
exhibit lesser salivation or purulence.
• Systemic sepsis occurs more commonly in parotid sialad-
enitis as compared to submandibular sialadenitis.
• Parotid swellings are not uctuant due to xity of overly-
ing investing parotideomasseteric fascia and are extremely
painful due to the mounting pressure as the fascia is
nonyielding. This mounting pressure leads to ischemic
necrosis of the gland, and the abscess may spontaneously
burst in the external auditory canal.
Routine blood count to rule out impending sepsis in addi-
tion to a plain radiograph or USG to rule out a sialolith in the
duct is indicated. Sialography is contraindicated in cases of
acute infections and also sialoliths. Aspiration might not
yield frank pus.
46.4.1.2 Management
Treatment is managing underlying cause and adequate
hydration and systemic antibiotics. If swelling doesn’t sub-
side with medical management in 2 days or shows an increas-
ing trend, an incision and drainage is indicated. The cellulitic
phase may not yield any frank pus, but toxic uid is drained
and it releases the pressure over the gland and prevents pres-
sure necrosis of the gland parenchyma. Parotid space abscess
has the tendency to spread into the pharyngeal spaces and
cause respiratory distress and descending mediastinitis or
burst into the auditory canal or TMJ and cause septic arthritis
of the TMJ.
46.4.2 Chronic Bacterial Sialadenitis [18]
It is a recurrent sialadenitis with episodic relapsing swellings
of the salivary glands, most commonly seen in the parotid
gland. Salivary retention and stasis are the main predisposing
factor. It might be preceded by an acute sialadenitis. Strictures
may also form in the ducts leading to salivary stasis and
eventually chronic sialadenitis. Generalized constitutional
symptoms may be low grade, and salivary gland milking
may yield scanty saliva. MRI is more specic than CT scan.
46.4.2.1 Management
Management consists of short-term corticosteroids to elimi-
nate glandular inammation followed by use of sialogogues
to increase salivation and ush the debris. Sialoendoscopy
can play a role in increasing the salivary ow.
The sialoendoscope is advanced slowly into the duct
with continuous saline irrigation to help visualize the sys-
tem and also dilating the strictures with help of the sialob-
alloon. This is followed up by placing a stent into the duct
for 4 weeks.
Supercial parotidectomy with facial nerve preservation
can also be considered in case of chronic pain, provided
imaging studies determine the involvement of supercial
lobe.
Chronic recurrent parotitis if left untreated may lead to
benign lymphoepithelial lesion which can progress to lym-
phoproliferative disorders like non-Hodgkin’s lymphoma,
carcinoma, or pseudolymphoma.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.16 Submandibular sialadenitis left side
46 Salivary Gland Pathologies
950
46.4.3 Obstructive Disorders (Video 46.1)
Sialolithiasis or salivary calculi are most commonly seen in the
submandibular gland and duct (Fig.46.17a, b). Symptomatic
calculi are much lesser in occurrence. Only those cases with
superadded infection and inammation of the gland and duct
result into pain.
46.4.3.1 Etiology
Salivary stasis is a major etiologic factor for formation of
sialolith. The right-angle bend of the Stenson’s duct where it
pierces the buccinator and the 90° bend of the Wharton’s
duct at the border of the mylohyoid is the common location
for sialoliths. They can also result from chronic sialadenitis.
Systemic abnormalities of calcium metabolism are not asso-
ciated with any increased risk of salivary stone formations.
Gout is the only systemic illness known to predispose to sali-
vary stone formation [19].
Salivary stasis changes the mucoid element of saliva to a
gel framework for deposition of salts and organic substances
creating a stone. Unknown metabolic phenomenon increases
salivary bicarbonate content altering the calcium phosphate
solubility and leading to precipitation of calcium and phos-
phate ions [20]. Wharton’s duct is longer than the Stenson’s
duct, and the submandibular gland is situated at a lower level
than the opening of the duct. Hence the duct has to follow an
uphill, tortuous course and drain against gravity. So stagna-
tion of secretions is more common than parotid gland.
In the submandibular gland, the calculus results in sialad-
enitis, whereas in the parotid gland, sialadenitis causes cal-
culus formation. In the parotid gland, stones are most
commonly located at the hilum or parenchyma, whereas sub-
mandibular sialoliths develop in the duct [21]. Sometimes
typically the sialolith is expelled out of the gland through the
duct and is seen at the duct orice.
46.4.3.2 Diagnosis andManagement
Sialography can be used for diagnosis of sialoliths but is con-
traindicated if the calculus is already diagnosed on plain
radiographs. Smaller stones can be expelled out through the
ba
c
©
Association of Oral and Maxillofacial Surgeons of India
Fig. 46.17 (a, b) Left—Submandibular duct calculus (a). Right—Calculus after surgical removal (b). (c) Submandibular gland specimen show-
ing calculus at the gene
N. A. Agni
951
duct opening using local massage, sialogogues, and adequate
hydration. Larger stones are managed surgically according
to its location in the duct and gland.
If the stone is palpable in the oral course of the duct, the
duct is dilated with a lacrimal probe and cut open to retrieve
the stone. The duct margins are sutured to the adjacent
mucosa to avoid stricture formation. A stay suture can be
placed around the duct proximal to the stone to avoid acci-
dental pushing of the stone into deeper inaccessible part of
the duct. In submandibular stones which are at the genu of
the duct or deeper into the gland, a sialadenectomy is needed
(Fig.46.17c).
If the sialolith is posterior in the duct, a suture is placed
behind the stone to prevent slippage of stone into the duct.
The incision is placed over the duct to extract the stone, and
the duct is left without suturing (Fig.46.18a, b).
Sialodochoplasty is a procedure wherein the incised duct
margins are sutured with adjacent mucosa leading to a trans-
location of duct orice [22, 23].
In the case of parotid sialoliths, only those in the duct
distal to the masseter muscle can be accessed transorally and
removed. All deeper stones warrant a parotidectomy.
Extracorporeal shock wave lithotripsy and use of sialoen-
doscopy are newer modalities to manage sialoliths.
Lithotripsy reduces calculi to small fragments that are then
ushed out of the duct with spontaneous salivation or use of
sialogogue [24]. The primary requirement for salivary stone
lithotripsy is a functional gland which produces saliva which
will clear the fragmented stone. A “gum test” which involves
chewing of a sour gum can be done to test the functionality
of the salivary gland. If the salivary secretions are normal, a
visible swelling in the region of the gland will be noticed. If
the test is negative, the patient cannot be taken up for
lithotripsy.
46.5 Viral Infections ofSalivary Glands
46.5.1 Mumps
Mumps is an acute nonsuppurative viral parotitis caused by
paramyxovirus also known as epidemic parotitis. The term
“mumps” is derived from the Danish word “Mompen” which
means mumbling (like an old man) and describes the dif-
culty with speech because of inammation and trismus [17].
46.5.1.1 Pathogenesis
It is an endemic disease and spreads by airborne droplet dis-
semination. It has an incubation of 2–3 weeks followed by
3–5-day viremia. The virus localizes to the salivary glands,
ba
©
Association of Oral and Maxillofacial Surgeons of India
Fig. 46.18 (a, b) Technique of sialolith removal from submandibular duct
46 Salivary Gland Pathologies
952
germinal tissues, and CNS [25]. The infection has a strong
predilection for the parotid gland. It is highly contagious and
occurs in children below 15 years of age with peak incidence
being in the 4- to 6-year-old group of children [26]. Adults
are rarely infected due to the immunity because of childhood
exposure or due to the MMR vaccine [17].
46.5.1.2 Clinical Features
Prodromal symptoms include headache, myalgias, arthral-
gias, anorexia, and malaise prior to development of parotitis.
It starts with an earache, pain around the gland, trismus, and
dysphagia. Pain is exacerbated by salivary stimulation dur-
ing meals. The parotid papilla may be inamed and puffy.
Palpation of the gland reveals a swelling of the gland which
may be tense, rubbery, and rm with non-pitting-type edema.
The overlying skin is tensed and shiny without erythema or
increased local temperature. Swelling lasts for 1–5 days and
can displace the pinna. Seventy-ve percent cases result in
bilateral involvement of parotid gland. However, it begins as
a unilateral swelling and involves the contralateral gland
after a period of 1–5 days [25].
Diagnosis is primarily clinical, but a blood count shows
leukocytopenia with relative lymphocytosis. Serum amylase
levels are also raised. It peaks during the rst week and starts
declining in the second or third week and comes back to nor-
mal later [25].
“S” or soluble antibodies directed against the nucleopro-
tein core of the virus appear within the rst week of infection
and peak within 2 weeks and disappear within 8–9 months.
“V” or viral antibodies directed against the outer surface
hemagglutinin appear several weeks after the “S” antibodies
and persist at low levels for approximately 5 years following
exposure. A fourfold rise in antibody titer is diagnostic of
active infection. Mumps skin test is not useful in the diagno-
sis of acute infection because dermal hypersensitivity does
not develop until 3 or 4 weeks following viral exposure.
46.5.1.3 Treatment
The disease is self-limiting, and treatment is primarily sup-
portive such as rest, adequate hydration, antipyretics, and
anti-inammatory medicines.
Live attenuated Jerry Lynn vaccine is given combined
with measles and rubella as MMR vaccine after 12 months of
age. Immunized population is less likely to get the disease
but may be infected with a nonparamyxovirus.
46.5.1.4 Complications
Orchitis and oophoritis can occur as systemic manifestations
and rarely lead to complete sterility. Mastitis has been asso-
ciated with decreased lactation. Aseptic meningitis occurs in
10% of cases, and asymptomatic meningeal inammation is
more common. Five percent patients are affected by acute
pancreatitis, wherein serum lipase levels are also increased.
Sensorineural hearing loss complicates 0.05–4% of patients
and may be permanent and profound [26]. Tinnitus, aural
fullness, and vertigo are associated symptoms, but they
resolve over a period of few weeks. Additional complica-
tions include myocarditis, polyarthritis, hemolytic anemia,
plasmacytosis, lymphocytic leukemoid reactions, and throm-
bocytopenia [12]. These conditions are self-limiting or
resolve with or without steroid therapy.
46.5.2 HIV Parotitis
HIV-associated salivary gland disease is the term used to
describe the diffuse enlargement of the salivary glands that
affects HIV patients throughout all stages of the disease. In
fact, HIV-SGD may be the rst presenting sign of HIV.Like
most of the salivary diseases, the parotid gland is the most
frequently affected. Clinically, HIV-infected individuals
show reduced salivary ow rates. Parotid gland enlargement
is reported to occur in 1–10% of the HIV-infected popula-
tion. It is usually secondary to development of benign lym-
phoepithelial cysts within the parotid gland [25].
46.5.2.1 Management
Antiretroviral therapy with zidovudine, maintenance of oral
hygiene, and use of sialogogues form the mainstay of
management.
46.6 Noninfectious Inammatory Diseases
Mikulicz’ disease and Sjögren’s syndrome are closely related
to each other and are autoimmune in origin, wherein the sali-
vary tissue itself becomes antigenic [27].
46.6.1 Mikulicz’ Disease
46.6.1.1 Clinical Features [28]
Middle-aged females are affected commonly. It behaves
like an inammatory as well as a neoplastic disease.
Presenting symptoms may be diffuse, poorly outlined, uni-
lateral or bilateral enlargement of the parotid or subman-
dibular glands with an occasional increase or decrease in
size of the swelling. There is mild local discomfort, occa-
sional pain, and xerostomia. Fever, upper respiratory tract
infection, tooth extraction, or some other local inamma-
N. A. Agni
953
tory disorder may precede the disease. Sometimes the lac-
rimal glands may be enlarged. FNAC can help diagnose the
condition.
46.6.1.2 Management
Mild cases once diagnosed do not warrant any treatment. In
some cases, the swelling might regress spontaneously.
Persistent cases can be managed by sialadenectomy [28].
46.6.2 Sjögren’s Syndrome
Sjögren’s syndrome or Sicca syndrome is a chronic autoim-
mune disorder of the exocrine glands involving multiple
extraglandular sites and can even evolve into a lymphoid
malignancy. Sjögren’s syndrome shows a triad of symp-
toms—keratoconjunctivitis sicca, xerostomia, and a sys-
temic disease, usually but not always rheumatoid arthritis.
Primary Sjögren’s syndrome also known as Sicca complex
presents with only dry eyes and dry mouth. Secondary
Sjögren’s syndrome has in addition to the above features sys-
temic manifestations such as systemic lupus erythematosus,
polyarteritis nodosa, polymyositis or scleroderma, and rheu-
matoid arthritis [28].
Arthritis is the most frequent rst complaint, followed by
ocular complaints and then xerostomia which leads to dif-
culty in chewing and swallowing, sore mouth, recurrent den-
tal caries, and fungal infections in the oral cavity. The tongue
appears bald with loss of liform papillae and ssuring of
tongue. The saliva is usually cloudy due to pus and abnor-
mally viscous due to gel-like consistency. Parotid gland
enlargement is seen in 25–66% cases of primary Sjögren’s
syndrome but is uncommon in secondary cases. Xeropthalmia
leads to chronic irritation and destruction of the corneal and
bulbar conjunctival epithelium, referred to as kerato-
conjunctivitis sicca. The patient complains of redness, itchi-
ness, or burning sensation in the eye, rope-like secretions,
dryness, and a foreign body sensation in the eye and may not
be able to tolerate smoke, air draft, or light [27].
Schirmer’s test is used to conrm lacrimal secretions.
Patients complain of easy fatigue, general malaise, low-
grade fever, myalgias, and arthralgias. Respiratory tract
symptoms range from dry cough due to xerotrachea to dys-
pnea due to interstitial disease or even airway obstruction.
High-resolution CT scan shows bronchial and peribronchial
thickening, whereas transbronchial biopsies show bronchio-
lar lymphoid inltrates and follicular bronchiolitis [29].
Sensorineural hearing loss is associated with Sjögren’s syn-
drome in 21–46% of cases [30]. Dysphagia results from dry-
ing of the pharynx and esophagus. Other complications
include renal disease, Raynaud’s disease, inammatory vas-
cular disease, peripheral sensory or sensorimotor polyneu-
ropathy or mononeuritis multiplex, skin dryness, vasculitis,
and frequent allergic reactions. Labial salivary gland biopsy
is used as a means of assessment of salivary pathology in
Sjögren’s syndrome.
46.6.2.1 Management
Xerostomia and keratoconjunctivitis sicca are managed by
use of 0.5% methylcellulose articial saliva and tears.
Preventive dental care and uoride application and mainte-
nance of general hygiene are necessary. Eye patching and
boric acid ointment can be used for corneal ulcers.
Pilocarpine hydrochloride can be used as a secretagouge
for management of xeropthalmia and xerostomia. Systemic
corticosteroids can be used for systemic complications
such as vasculitis, glomerulonephritis, and interstitial lung
disease.
46.6.3 Mucoceles (Video 46.2)
Mucous retention cyst arises from ductal obstruction in a
minor or accessory salivary gland due to traumatic severance
of the duct due to biting of the lips, cheeks, and tongue or
due to injury due to lip pinching during extraction. Majority
of cases are an extravasation type of cysts which result from
collection of salivary secretions in the soft tissues due to
traumatic injury to the gland or duct. Lower lip was affected
in 44–79% of cases. It occurs in any age with no gender pre-
dilection [31].
46.6.3.1 Clinical Features
Supercial lesions appear like a circumscribed, raised ves-
icle with a bluish translucent hue due to the thin overlying
mucosa. However, deeper lesions being covered by normal
mucosa have a normal color and texture. Mucoceles may
get traumatized and rupture spontaneously and may recur
later.
46.6.3.2 Management
Surgical excision of the mucocele along with a few normal minor
salivary glands is the procedure of choice. Care should be taken
to avoid creation of any other partially transected minor salivary
glands which might give rise to the recurrent mucocele.
Mucocele can be excised by giving an elliptical incision
around the lesion and closure (Fig.46.19a–d), [32] or as the
case requires, an incision may be given over the mucocele;
lesion can be excised carefully without rupture and closure
attained (Fig.46.19e–h).
46 Salivary Gland Pathologies
954
Huang I etal. [33] recommended use of carbon dioxide
laser vaporization to treat the lower lip mucocele with good
results and less complications.
46.6.4 Ranula
Ranula is a mucocele arising from the sublingual salivary
gland in the floor of the mouth (Fig.46.20). It presents as
a large blue, tense vesicle in the floor of the mouth. The
appearance is of that of a frog’s belly, hence the term
ranula (frog belongs to genus Rana). It is firm on palpa-
tion. The cyst is usually present above the mylohyoid
curtain, but when it presents in the upper part of the neck,
it is called as a “plunging ranula.” Plunging ranulas
maygrow to a sufficient size so as to compromise respi-
ration and swallowing and may also extend into medias-
tinum [32].
46.6.4.1 Management
Excision of the ranula and entire sublingual gland through a
transoral approach is management of choice taking care to
avoid damage to the lingual nerve. The incision is made
through the mucosa in the lingual fold from the second molar
to canine tooth. Blunt dissection is done up to the mylohyoid
muscle. The gland is dissected free from the surrounding soft
tissues and the Wharton’s duct. The gland can be retracted
using holding sutures, and blunt dissection is carried out till
the lingual nerve is identied as it crosses the Wharton’s
duct. The gland is delivered once it is dissected free from the
entire surrounding soft tissues taking care to prevent damag-
ing the submandibular duct and lingual nerve [34].
Marsupialization can be used as an alternative modality
wherein the ranula is deroofed and the mucosa sutured to the
cystic lining followed by open packing of the cyst and
sequentially reducing the size of the pack till it heals
completely.
Fig. 46.19 (a)–(d) Figure showing surgical removal of mucocele by elliptical incision. (e)–(h) Figure showing excising mucocele by incision
directly over the lesion
ba
dc
N. A. Agni
955
Higher recurrence rate (61–85%) has been reported with
simple marsupialization and ranula excision. To lower the
rate of recurrence, total sublingual excision is the treatment
of choice [35].
Kono etal. [36] recommended an injection of sclerosing
agent, OK-432 (Picibanil), as a safe and effective method of
treating intraoral ranulas. The number of injections used was
1–4 (mean 1.70) in their study.
46.7 Salivary Gland Tumors
46.7.1 Etiology
Although no specic etiology has been attributed to occur-
rence of salivary gland tumors, its association with radia-
tions, viruses, hormones, lifestyle, or occupation and like
factors can’t be denied.
• Radiation: Evidence exists regarding susceptibility of
lymphoid component rather than parenchymal compo-
nent of gland to low radiation and UV ray damage
(140rad) [37–39].
• Viruses: It is believed that genetic component, environ-
ment, and immunity of host play a key role in malignant
transformation of salivary gland tumors. Viruses like
human papillomavirus, Epstein-Barr virus, cytomegalovi-
rus, and polyomavirus have been speculated to be respon-
sible for occurrence of salivary gland tumors.
• Hormones: Endogenous hormones play an important role
in carcinogenesis of these tumors. Patients of breast can-
cer are more prone to salivary gland neoplasms.
fe
hg
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.19 (continued)
46 Salivary Gland Pathologies
956
• Lifestyle: Tumors like Warthin’s tumor or epidermoid
carcinoma have been associated with cigarette smok-
ing. Salivary gland enlargements are observed in nutri-
tional deciencies, but there are no reports of
malignancies [40].
• Occupation: Those who engage in occupations which
involve manufacturing and use of rubber products, asbes-
tos mining, and plumbing are at increased risk of develop-
ing salivary gland tumors [37].
46.7.2 Incidence
Salivary gland tumors occur rarely both among Indian pop-
ulation and around the world. Incidence of benign and
malignant salivary gland tumors in major portion of the
world ranges from 1 to 2 cases per 100,000 people per year
[41]. There is no specic predilection of occurrence of
these tumors in any particular gender, although Warthin’s
tumor is more common in males and acinic cell tumor in
females. Site wise incidence varies for both benign and
malignant tumors. Seventy-ve to eighty percent of benign
tumors occur in the parotid glands, 5–10% in submandibu-
lar glands, and only 1–2% in sublingual glands. Malignant
tumors are more common in sublingual glands (80%) and
least in parotid glands (17–20%). Benign tumors affect a
mean age group of 40 years, and malignant tumors affect an
age group of 55 years. Both benign and malignant tumors
by large resemble each other clinically. Hence, histopatho-
logic examination is pivotal to establish a correct
diagnosis.
46.7.3 TNM Staging ofSalivary Gland Tumors
According toAmerican Joint
Commission onCancer (AJCC) 2002 [42]
Tumor (T): T with a letter/number describes the location or
size of the tumor
TX: Indicates the primary tumor cannot be evaluated.
T0 (T plus zero): No evidence of a tumor was found.
T1: Describes a small, noninvasive (has not spread) tumor
that is 2centimeters (cm) at its greatest dimension.
T2: Describes a larger, noninvasive tumor between 2cm and
4cm.
T3: Describes a tumor that is larger than 4cm but not larger
than 6cm and has spread beyond the salivary glands but
does not affect the seventh nerve, the facial nerve that
controls expression, such as smiles or frowns.
T4a: The tumor has invaded the skin, jawbone, ear canal,
and/or facial nerve.
T4b: The tumor has invaded the skull base and/or the nearby
bones and/or encases the arteries.
Nodes (N): N is for lymph nodes. Lymph nodes of the head
and neck region are regional lymph nodes, and those
away from this region are distant nodes.
NX: The regional lymph nodes cannot be evaluated.
N0: There is no evidence of cancer in the regional nodes.
N1: Cancer has spread to a single node on the same side as
the primary tumor, and the cancer found in the node is
3cm or smaller.
N2: Describes any of these conditions:
• N2a: The cancer has spread to a single lymph node on
the same side as the primary tumor and is larger than
3cm but smaller than 6cm.
• N2b: The cancer has spread to more than one lymph
node on the same side as the primary tumor, and none
measures larger than 6cm.
• N2c: The cancer has spread to more than one lymph
node on either side of the body, and none measures
larger than 6cm.
N3: The cancer found in the lymph nodes is larger than
6cm.
Metastasis (M): Describes the cancer that spreads to differ-
ent body parts.
MX: Indicates distant metastasis cannot be evaluated.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.20 Ranula in the oor of the mouth
N. A. Agni
957
M0: Indicates the cancer has not spread to other parts of the
body.
M1: Describes cancer that has spread to other parts of the
body.
46.7.4 Classication ofSalivary Gland Tumors
Salivary gland tumors were rst classied by WHO in 1972.
It was later modied in 1991 wherein the term “tumor” was
replaced by “carcinoma” to denote acinic cell carcinoma and
mucoepidermoid carcinoma [43]. It was further revised in
1997, and a greater number of entities of adenomas (myoepi-
thelial adenoma, basal cell adenoma, canalicular adenoma)
and carcinomas (acinic cell carcinoma, mucoepidermoid
carcinoma, polymorphous low-grade adenocarcinoma, sali-
vary duct carcinoma, myoepithelial carcinoma) were rede-
ned with emphasis on the prognosis and therapy [44]. A
revised classication was put forth by WHO in 2005 also.
The latest classication of WHO which was given in 2017
consisted of the following changes:
• Secretory carcinoma, borderline tumor—sialoblastoma—
and sclerosing polycystic adenosis were added as new
entities under malignant tumors.
• Simplication of terminologies of polymorphous adeno-
carcinoma, clear cell carcinoma, and intraductal carci-
noma was done.
• Rare entities like adenocarcinoma, NOS, canalicular ade-
noma, and poorly differentiated carcinoma were
regrouped (Table46.6).
46.7.5 Pleomorphic Adenoma
“Pleomorphic adenoma” suggested by Willis closely resem-
bles the unusual histologic pattern of the lesion [28]. The
tumor derives its name from the Greek words Pleos = many
and morphus = form because of the heterogeneous nature of
its histologic appearance [46].
46.7.5.1 Clinical Features
Most frequently found in the supercial lobe of the parotid
gland, it presents as a rm, slow-growing asymptomatic
mass which is smooth, rounded, lobular, and mobile with a
rubbery consistency causing ear lobule to be raised
(Fig.46.21a). If the tumor involves both the supercial and
deep lobes of parotid, it is classically referred to as dumbbell
tumor. Incidence of the tumor except those found in the phar-
ynx is more in females than males, and they are often seen in
the fourth and fth decade. A bilateral tumor occurrence rate
is estimated at 1in 40,000 [47].
They are encapsulated and do not show xity to the deeper
tissues or the overlying skin in major salivary gland tumors,
which can be conrmed on an MRI (Fig.46.21b), but in the case
of the minor salivary glands of the palate, it may appear to be
xed to the underlying palatal bone but does not invade or erode
the bone. Pain is uncommon but 50% patients experience a pres-
sure sensation. Accumulation of mucus can occur so that elastic
swellings or frankly uctuant cysts may form in the tumors.
In the case of the submandibular gland, palpation of the
mass both extraorally and bimanually helps inlocalizing it
and differentiating it from a lymph node, but FNAC is always
needed to differentiate it from sialadenitis.
46.7.5.2 Histopathology [48]
On light microscopy morphologically complex and diverse
cellular elements are seen. Both epithelial and myoepithelial
elements are present. Based on cellular types, Foote and Frazel
[49] have classied pleomorphic adenomas as follows:
• Principally myxoid (36%)
• Equally myxoid and cellular (30%)
• Predominantly cellular (22%)
• Extremely cellular (12%)
Table 46.6 Revised classication of salivary gland tumors (2017) [45]
Malignant Tumors Benign Tumors
Mucoepidermoid carcinoma Pleomorphic adenoma
Adenoid cystic carcinoma Myoepithelioma
Polymorphous adenocarcinoma Basal Cell Adenoma
Epithelial-myoepithelial
carcinoma
Warthin’s tumor
Clear cell carcinoma Oncocytoma
Basal cell adenocarcinoma Lymphadenoma
Sebaceous adenocarcinoma Cystadenoma
Intraductal carcinoma Sialadenoma papilliferum
Cystadenocarcinoma Ductal papillomas
Adenocarcinoma, NOS Sebaceous adenoma
Myoepithelial carcinoma Canalicular adenoma and other
ductal adenomas
Carcinoma ex pleomorphic
adenoma
Other Epithelial Lesions
Carcinosarcoma Sclerosing polycystic adenosis
Poorly differentiated carcinoma
1) Neuroendocrine and
non-neuroendocrine
2) Undifferentiated carcinoma
3) Large cell neuroendocrine
carcinoma
4) Small cell neuroendocrine
carcinoma
Nodular oncocytic hyperplasia
Lymphoepithelial lesions
Intercalated duct hyperplasia
Soft Tissue Lesions
Hemangioma
Lymphoepithelial carcinoma Lipoma/sialolipoma
Squamous cell carcinoma Nodular fasciitis
Oncocytic carcinoma Hematolymphoid Tumor
Borderline Tumors Extranodal marginal zone
lymphoma of MALT
Sialoblastoma
46 Salivary Gland Pathologies
958
46.7.5.3 Management
Surgical excision is the treatment of choice. Historically,
enucleation was practiced which resulted in inadequate sur-
gery and recurrences [50]. Supercial parotidectomy is the
most widely accepted technique in the treatment of pleomor-
phic adenomas in the supercial lobe of the parotid gland,
and total gland excision with facial nerve preservation is car-
ried out. Tumors of the submandibular gland are usually con-
tained within the gland, and their resection is usually conned
to the gland and surrounding fat or lymph nodes until the
neoplasm is a malignant and invasive tumor. As with the
parotid gland, most neoplasms are asymptomatic. Small pal-
atal pleomorphic adenomas usually cause pressure resorp-
tion of the palate but do not invade the bone. A disk of palatal
mucosa is outlined well clear of the visible swelling because
the tumor is attened owing to the toughness of the palatal
tissues. The tumor along with the periosteum of the palate is
excised in continuity with each other. In case the pleomor-
phic adenoma invades the palate or proliferates into the oor
of the maxillary sinus, a partial maxillectomy or total maxil-
lectomy depending on the extension of the tumor has to be
performed.
Although pleomorphic adenoma is a benign tumor, it may
cause problems in clinical management due to its tendency
to recur and risk of malignant transformation.
46.7.6 Monomorphic Adenoma
The WHO classication subdivides the monomorphic ade-
nomas into three groups [45]:
• Adenolymphoma (Warthin’s tumor)
• Oxyphilic adenoma (oncocytoma)
• Others
A number of other classications of monomorphic adeno-
mas have been put forth, but there is no unanimity. Two main
histologic patterns have evolved:
• Basal cell adenoma
• Canalicular adenoma
46.7.7 Warthin’s Tumor
Warthin’s tumor, also known as papillary cystadenoma lym-
phomatosum and adenolymphoma, is the second most com-
mon benign tumor of the salivary glands, around 5% of
neoplasms [51].
It was rst described by Hildebrand in 1895 as a form of
congenital cyst of the neck. It is known as Warthin’s tumor in
ba
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.21 (a) Parotid tumor showing elevation of ear lobule (pathognomonic sign). (b) MRI axial view showing the tumor
N. A. Agni
959
recognition of the pathologist who rst described it in the
USA in 1929. He described two cases and also coined the
term papillary cystadenoma lymphomatosum [52].
46.7.7.1 Clinical Features
The majority of the tumors arise in the parotid gland,
more often bilaterally, in the elderly and occurs in the fth
and sixth decades of life. A predilection for male sex is
seen, more in Caucasians. Both tumors do not occur
simultaneously but are metachronous in their manifesta-
tion. A concept of multicentric and multifocal disease has
been put forth to explain this. It is a solitary, nodular,
slowly enlarging swelling, most commonly located in the
inferior pole of the parotid next to the angle of the man-
dible. It varies from moderately rm to uctuant on palpa-
tion and is asymptomatic. It is not as discrete as the mixed
tumor. Very few patients present with complain of pain,
pressure, or rapid increase in the tumor size. Scintigraphy
may be helpful due to its increased uptake of technetium-
99m pertechnetate. It appears as a smooth-margined,
radiopositive “hot” nodule in contrast to the mixed tumors,
nonfunctioning malignant tumors, and metastatic tumors
which appear as a “cold” nodule in scintigraphy. Positive
scintigraphy with 123I is indicative of Warthin’s tumor but
may also signify presence of ectopic thyroid or metastatic
thyroid tumor.
46.7.7.2 Management
Surgical removal is the established treatment for Warthin’s
tumor. As the tumor is supercial in the parotid gland, it is
easily removed with minimal loss of glandular function and
with preservation of the facial nerve.
Treatment philosophies given are:
• Tumor enucleation with resection of minimal amount of
surrounding normal tissue
• Supercial parotidectomy, which is more aggressive than
enucleation
• Local excision of parotid gland
Local excision of the tumor is preferred to enucleation of
the tumor because lymph nodes at the posteroinferior part of
the gland cannot be cleared by enucleation. Preoperative
diagnosis of Warthin’s tumor must be conrmed by coordi-
nating the clinical ndings with imaging and ne-needle
aspiration biopsy reports before local excision is carried out.
If there is associated chronic obstructive parotitis, supercial
parotidectomy is essential. Similarly, if the tumor is located
in front of the ear, a supercial parotidectomy is the treat-
ment of choice.
46.7.8 Oncocytoma
An oncocytoma is a tumor characterized by large epithelial
cells, i.e., oncocytes that contain a brightly eosinophilic, gran-
ular cytoplasm. The oncocyte is derived from the Greek word
“onkousthai” meaning swollen or enlarged and was described
in 1897 by Schaffer who observed this tumor in ductal and
acinar elements of salivary glands in the tongue, pharynx, and
esophagus. Jaffe was the rst to introduce the term oncocy-
toma [53]. However, he had termed Warthin’s tumor as onco-
cytoma. The other terminologies used to describe this tumor
are oxyphilic adenoma and acidophilic adenoma.
46.7.8.1 Clinical Features
There is no race predilection for occurrence of this tumor.
Oncocytoma is predominantly a tumor of the major salivary
glands, parotid being the most common. Bilateral occurrence
is also known. Among minor salivary glands, which are
rarely affected, palatal mucosa followed by buccal mucosa
and tongue is affected.
The oncocytoma is a small benign lesion which generally
does not attain a great size. It most frequently presents as an
indolent, single, often multi-lobulated, rm, solid, and mobile
mass in the supercial lobe of the parotid gland. It can also be
located in the deep lobe of the parotid gland and may be insin-
uated between the branches of the facial nerve. However, it
does not cause any symptoms of pain or paresthesia unless the
branches of the facial nerve are compromised. Tumor size var-
ies with the duration of the lesion but generally does not
increase beyond 4.0cm. Intraoral tumors do not exhibit any
special characteristic diagnostic features. However, their over-
lying mucosa may become ulcerated due to trauma [53].
46.7.8.2 Management
Partial parotidectomy with facial nerve preservation when-
ever possible is the treatment of choice. It ensures complete
removal of the tumor and reduces the rate of recurrence.
Curettage or simple enucleation of the tumor is to be avoided
to avoid recurrence. Complete sialadenectomy is the treat-
ment of choice in cases of submandibular gland oncocyto-
mas. In the case of minor gland tumors, local excision of the
tumor with a margin of normal tumor-free tissue is carried
out. Radiation therapy after surgery has been tried but it has
shown to be ineffective.
46.7.9 Basal Cell Adenoma
It was rst reported as a separate entity by Kleinsasser and
Klein in 1967 [28].
46 Salivary Gland Pathologies
960
46.7.9.1 Clinical Features
Basal cell adenomas occur between the third and ninth
decade, but the peak incidence is in the sixth decade with a
slight male predilection of 5:1 [28]. They are clinically indis-
tinguishable from mixed tumors and occur in the supercial
portion of the parotid gland. They are slow-growing, painless,
round or ovoid, well-circumscribed, and freely mobile masses
with a smooth-surfaced capsule and a soft to moderately rm
consistency. They may be mistaken for a hyperplastic lymph
node because of their encapsulation, size, and color.
Clinically basal cell carcinoma of skin, ameloblastoma,
pleomorphic adenoma, and adenoid cystic carcinoma can be
considered in the differential diagnosis.
On the basis of histopathologic appearance, they may be
divided into four subtypes:
• Solid
• Trabecular
• Tubular
• Membranous
46.7.9.2 Management
Surgical excision with a sufcient clear margin of normal
tissue is the treatment of choice.
46.7.10 Canalicular Adenoma
46.7.10.1 Clinical Features
It is seen between the fourth and ninth decade, highest inci-
dence being in the seventh decade with a female/male ratio
of 1.7 to 1.0 and a higher incidence in Caucasians. It is seen
more commonly in the minor salivary glands of the lip and
cheek and rarely affects the major salivary gland [54].
It presents as a non-ulcerated, painless, mobile nodule
that exhibits slow growth unless it is traumatized, wherein
there is presence of ulceration. Clinical appearance is similar
to that of a mucocele [54]. The overlying mucosa may be
normal colored or bluish.
In the case of upper lip lesion, a sialolith, mucocele,
mucous retention cyst, and pleomorphic adenoma can be
considered in the differential diagnosis.
46.7.10.2 Management
Surgical excision, enucleation, or limited extracapsular exci-
sions have been used as treatment modalities in these tumors
with success.
46.7.11 Sialadenoma Papilleferum
First described by Abrams and Finck in 1969, it was termed
sialadenoma papilleferum because of its histologic similarity
to syringocystadenoma papilleferum of skin adnexal origin
[55].
46.7.11.1 Clinical Features
Sialadenoma papilleferum presents as a subcentimetric,
asymptomatic, exophytic, papillary surface lesion which can
be confused with squamous papilloma. The most common
site of occurrence is the minor salivary glands at the junction
of soft and hard palate with the tumor located on one side of
the midline. This tumor occurs at an average age of 56 years,
cases being reported from 2 years to 87 years. Male predilec-
tion is seen in the ratio of 1.5 to 1. However, there is no racial
predominance [55].
Clinically it resembles a squamous papilloma, and a dif-
ferential diagnosis of verrucous carcinoma or a warty dys-
keratoma needs to be considered.
46.7.11.2 Management
Being small, these tumors are easily excised usually with a
clinical diagnosis of a squamous papilloma. However, recur-
rence is rare.
46.7.12 Inverted Ductal Papilloma
Inverted ductal papilloma is a rare tumor and was rst
described by White etal. in 1982 when they reported four
cases [56].
46.7.12.1 Clinical Features [56]
It occurs as a rm, asymptomatic, discrete nodule of
1–1.5cm beneath the normal mucosa which in some cases
may be contiguous with a small surface pore. The mean age
of occurrence is 50 years without any sex predilection. The
sites usually involved are the lower lip and buccal vestibular
mucosa in descending order with occasional cases reported
in the upper lip, oor of mouth, and soft palate.
46.7.12.2 Treatment andPrognosis
It is treated by simple surgical excision as it is not known to
recur.
46.7.13 Intraductal Papilloma
It is a rare tumor. These tumors present as asymptomatic,
submucosal swellings that vary in size from less than 1 to
1.5 cm in the minor salivary glands. The ages of patients
range from 29 to 77 years, with a mean age of 54 years. Men
and women are equally affected.
46.7.13.1 Treatment andPrognosis
Excision is curative, and these tumors are not known to recur.
In case the tumors are small, all types of papillomas of the
N. A. Agni
961
minor salivary glands, including intraductal, inverted, and
sialadenoma papilliferum, can be excised in the dental ofce
or the clinic under local anesthesia [55].
46.7.14 Mucoepidermoid Carcinoma
Mucoepidermoid carcinoma is the most common malignant
salivary gland neoplasm. They are classied as grade I (low
grade) which are well differentiated, grade II (intermediate
grade) which are moderately differentiated, and grade III
(high grade) which are poorly differentiated tumors.
46.7.14.1 Clinical Features
Mucoepidermoid carcinomas occur more commonly in the
minor salivary glands with a female predilection [57]. It
occurs as a painless, circumscribed, mobile solitary enlarge-
ment of the body or tail of the parotid or the submandibular
region with over a year duration generally. Pain, facial paral-
ysis, and xation to the overlying skin are usually suggestive
of high-grade lesions [57]. Minor salivary gland lesions pres-
ent as a bluish or red-purple, uctuant, smooth-surfaced
mass that is often clinically mistaken for a mucocele or hem-
angioma [57]. Large lesions at the base of the tongue or in
the oropharynx may cause dysphagia. Aggressive tumors
show ulceration. Numbness of the teeth may occur when the
bone is involved. Histopathologically, mucoepidermoid car-
cinomas are graded as low-grade, intermediate-grade, and
high-grade carcinomas. They are generally partially encap-
sulated and don’t show adequate circumscription.
46.7.14.2 Management
Complete, adequate, and radical surgical excision is the
treatment of choice for all grades of mucoepidermoid
carcinomas [58]. In the case of stage I and stage II muco-
epidermoid carcinomas of the parotid gland, conservative
excision with preservation of the facial nerve, if possible,
is recommended. The affected submandibular gland
should be removed entirely. Radical neck dissection is
performed in patients with clinical evidence of cervical
node metastasis and is considered in any patient with a
T3 lesion. In the case of facial nerve involvement, total
parotidectomy with facial nerve sacrifice up to histologi-
cally tumor-negative nerve trunk is done. The 5-year dis-
ease-free rate in patients receiving this aggressive
treatment was about 60% [58].
Treatment of minor salivary gland mucoepidermoid
carcinomas entails a wide surgical excision with the bone
if involved, to achieve a negative margin, and the wound is
left to heal secondarily [59]. For small low-grade tumors
in the absence of bone involvement, wide excision down to
periosteum with 1 or 2 cm tumor-free lateral margins is
adequate therapy [59]. High-grade and advanced stage
tumors must be treated aggressively at any site. The over-
all recurrence rate of mucoepidermoid carcinomas is
approximately 25%. Better survival is seen among younger
patients and among females. Tumors in the submandibular
gland and in the base of the tongue generally have a poorer
outlook than those at other major and minor salivary gland
sites. Also invasion into bone signies a poorer prognosis.
Survival is closely related to the clinical stage and the his-
tologic grade.
46.7.15 Adenoid Cystic Carcinoma
Adenoid cystic carcinoma (ACC) is a highly aggressive,
destructive, and clinically unpredictable tumor of the head
and neck region [60]. The other terms used for ACC used
in the past are cylindroma and adenomyoepithelioma.
Foote and Frazell [49] proposed the currently accepted
term adenoid cystic carcinoma in their classic paper in
1953 and in their fascicle on major salivary gland tumors
in 1954.
46.7.15.1 Clinical Features
Adenoid cystic carcinoma occurs in adults between 50
and 70 years of age with equal prevalence in males and
females [61]. The most frequent locations of this tumor
are the parotid, submandibular, and palatal salivary glands
[62]. They are only rarely observed in the sublingual
gland [61].
Clinically adenoid cystic carcinoma manifests in the
major and intraoral accessory salivary glands as a slow-
growing swelling or mass. Pain and fixation to skin as
well as surrounding deeper structures generally occur
during the course of tumor growth. An ominous feature
of adenoid cystic carcinoma of the parotid gland is paral-
ysis of the facial nerve. Radiographic examination is
valuable in assessing the extent of osseous destruction.
Symptoms may have been present for months or years
and are generally of longer duration than those associated
with squamous carcinoma, which is the most frequent
malignancy of this location. Adenoid cystic carcinomas
of the maxillary antrum, nasal cavity, and ear canal pro-
duce symptoms of pain, obstruction, and deafness,
respectively.
Histopathologically, ACC are classied into cribriform
pattern, tubular pattern, and solid pattern. A major micro-
scopic feature in most adenoid cystic carcinomas is the pro-
pensity for the tumor to involve peripheral nerves, reported
to occur in 20–80% of the patients. Although perineural inva-
sion is characteristic of adenoid cystic carcinoma, it is not
unique to the tumor.
46 Salivary Gland Pathologies
962
46.7.15.2 Management ofAdenoid Cystic
Carcinoma
Complete excision like all other tumors is the treatment of
choice. Elective regional lymph node dissection is not
indicated, because distant metastasis is more common
than cervical (regional) node involvement. According to
Maciejewski etal., radical surgical excision with histo-
logically proven negative margins with postoperative
radiotherapy for all cases should be the treatment of
choice. Lymph node dissection is recommended only in
cases of histologically proven positive lymph nodes [60].
A frozen section diagnosis to achieve tumor-free safe
margins is necessary to specically look for safe perineu-
ral margins because ACC is known to spread quickly
along the nerve.
The slow biologic growth of adenoid cystic carcinoma
along with a late metastasis of the disease results in relatively
favorable 5-year survival rates. Factors that indicate a poor
prognosis include failure to achieve clear margins at rst sur-
gery, a solid pattern histologically, recurrent disease, and dis-
tant metastasis [63].
In a study by Witten etal., local recurrences have been
seen in almost 32% of the cases [63]. The risk of distant
metastasis is also high, approximately 40%, and can occur in
less than 8 years after treatment.
46.7.16 Clear Cell Carcinoma
Clear cell neoplasms of salivary glands have been classied
as both adenomas and carcinomas [64].
46.7.16.1 Clinical Features
It occurs predominantly in the palatal minor salivary glands
followed by parotid and submandibular glands without any
sexual or racial predilection. It occurs between the ages of
18 and 86 years, mean 56 years. Clinical manifestation is of
a swelling similar to other tumors. It may be confused with
mucoepidermoid and acinic cell carcinoma as well as meta-
static renal cell carcinoma. A positive reaction to mucicar-
mine would preclude the possibility of renal cell
carcinoma.
46.7.16.2 Management
Due to their inltrative growth and the incidence of recur-
rence and regional lymph node metastases, it is appropriate
to consider them low-grade adenocarcinomas. Hence surgi-
cal treatment is the mainstay of management.
46.7.17 Epithelial-Myoepithelial Carcinoma
The epithelial-myoepithelial carcinoma of intercalated duct
origin is a rare biphasic type of low-grade salivary gland car-
cinoma that constitutes less than 1% of salivary gland
neoplasms.
46.7.17.1 Clinical Features
It occurs more commonly in females around 60–70 years of
age. Parotid gland is the most frequently affected [65].
Patients present with an asymptomatic or painful salivary
gland swelling with a history of steady increase in size over
an extended period of time and may also present with facial
paralysis [66]. In patients with maxillary involvement, nasal
obstruction and facial deformity may be the presenting
complaints. Differential diagnosis includes pleomorphic
adenoma, acinic cell adenocarcinoma, adenoid cystic carci-
noma, mucoepidermoid carcinoma, sebaceous carcinoma,
and oncocytoma.
46.7.17.2 Management
Surgery is considered the primary mode of treatment. Total
parotidectomy with facial nerve preservation is advocated
for tumors in the parotid gland unless the nerve is involved
by the tumor. Recurrences and distant metastasis are a known
complication.
46.7.18 Carcinosarcoma
Carcinosarcoma, also known as true malignant mixed tumor,
shows malignant cells in both the stromal and epithelial
components [67]. When these tumors metastasize, both com-
ponents metastasize together.
46.7.18.1 Clinical Features
Carcinosarcomas are rare tumors with an average incidence
of 0.4% in major salivary glands and 1% in minor salivary
glands. It occurs between 25 and 85 years of age (average
58.5 years) with the frequency of occurrence being more in
parotid than submandibular gland and then minor glands in
palate and tongue [67].
It presents as an enlarging mass with a rapid increase in
size and may be associated with pain and facial nerve paraly-
sis. Rarely, patients present with metastases or experience
difculty in swallowing or breathing. A patient with a central
nervous system metastasis has been reported to present with
headaches [67].
46.7.18.2 Management
The data available is insufcient to recommend one type of
therapy as denitive. However radical surgical excision,
together with radiation therapy and lymph node dissection
for palpable disease, seems to be the most prudent form of
therapy. Radiotherapy as the only means of therapy has not
proved effective. Tumor metastasis is most frequent to the
lungs followed by hilar and cervical lymph nodes. Distant
metastasis is also rarely found [67].
N. A. Agni
963
46.7.19 Undierentiated Carcinomas
This group includes three distinct entities:
1. Lymphoepithelial carcinomas (malignant lymphoepithe-
lial lesion): It is more prevalent in females and occurs
between fourth and fth decade of life. The parotid gland
is most commonly involved followed by submandibular
gland. Painful indurated mass and occasional facial paral-
ysis are the presenting symptoms. It might be preceded by
benign lymphoepithelial lesion for many years. It is man-
aged by wide surgical excision with or without neck dis-
section and may be supplemented with radiotherapy.
2. Undifferentiated large cell carcinomas: It occurs predom-
inantly in older population with a male predilection. It
most commonly affects the parotid followed by subman-
dibular and minor salivary glands. Histologically it shows
predominantly poorly differentiated large cell compo-
nents. It carries a poor prognosis and has a higher risk of
locoregional as well as distant metastasis and recurrences.
The worst prognostic factor is the size of the lesion. Less
than 4cm, mean survival time was 46 months, and more
than 4cm it was reduced to 7.7 months [51].
3. Undifferentiated small cell carcinomas: It rarely affects the
salivary glands and is primarily a pulmonary tumor. When
it occurs, it shows a male preponderance and occurs
between fth and seventh decade, in the parotid mainly fol-
lowed by submandibular gland. It presents as a rapidly
growing mass which may or may not be painful.
Management is primarily wide surgical excision with neck
dissection for clinically positive neck node involvement.
Chemoradiotherapy may be used as an adjunctive modality
for treatment. It tends to metastasize via the hematogenous
route, and hence a distant metastasis needs to be ruled out.
46.7.20 Squamous Cell Carcinoma
The diagnosis of primary squamous cell carcinoma is limited
to the major glands because distinction between possible
minor salivary gland primary tumors and those originating
from mucosal surface epithelium is generally not possible.
46.7.20.1 Clinical Features
It occurs between 7 and 95 years of age, the mean age being
60.5 years with a male predilection of 2:1. Parotid gland is the
most commonly involved followed by submandibular and sub-
lingual glands [68]. It presents as an asymptomatic mass with
occasional pain and facial nerve palsy. This tumor often replaces
the entire gland with xation to underlying structures and skin.
Ductal squamous metaplasia, high-grade mucoepider-
moid carcinoma, and lymphoepithelial carcinoma should be
considered in the differential diagnosis of squamous cell car-
cinoma of the salivary gland.
46.7.20.2 Management
Surgical management is the mainstay of treatment.
Parotidectomy with or without facial nerve preservation
depending on the case is needed for parotid tumors.
Submandibular sialadenectomy is needed for submandibular
gland tumors. A neck dissection is done in clinically positive
necks at the slightest suspicion. Locoregional failure is the
most signicant problem, and hence a composite resection in
larger submandibular malignancies might be needed.
Postoperative radiotherapy when combined with surgery
may improve the locoregional control [68].
46.8 Surgical Management ofParotid
Tumors (Video 46.3)
46.8.1 Skin Incisions forParotidectomy [69]
The ideal incision should combine good exposure with the
best ultimate cosmetic result. This part of the procedure is
common to all the resection procedures unless skin is being
excised because it is involved by the tumor.
Gutierrez (1903)—The incision had a temporal extension,
a preauricular component, and a limb extending onto the
neck in one of the skin creases (Fig.46.22). The chief draw-
back of this incisions was esthetics in case of development of
a keloid.
Redon and Vaillant and Laudenbach—The incision line is
similar to that proposed by Adson (Fig.46.23).
Adson and Ott have described a “Y”-shaped incision with
a preauricular part, a postauricular part, and a cervical inci-
sion line that splits off from the site of union of the rst two
branches (Fig. 46.24). The advantage of this incision is
improved esthetics because it lacks a temporal incision line,
but the drawback is that it impairs dissection. Also, one sec-
tion of the incision is located in the carotid region.
Samengo (1961)—The incision has a preauricular, a post-
auricular, and a neck extension in the incision line
(Fig.46.25).
The following procedures are performed:
• Local excision of the parotid gland
• Supercial parotidectomy
• Functional supercial parotidectomy
• Complete parotidectomy with facial nerve
preservation
• Radical parotidectomy with or without neck
dissection
• Parotidomandibulectomy
• Temporoparotidectomy
46 Salivary Gland Pathologies
964
Appiani (1967)—The incision within the lower portion
of the scalp is hidden by the hair instead of the vertical inci-
sion line. The benet of this incision is better esthetics.
However, the temporal extension of this incision is short,
and this impairs access to the anterior portion of the gland
(Fig.46.26).
Ferreria JL et al. [69] modied Appiani’s incision by
extending the temporal incision line but not beyond the hair-
line. It provides a better access to the anterior portion of the
parotid gland without compromising esthetics. Also, the
angles are rounded off where the incision line changes direc-
tion reducing dehiscence and salivary stula formation.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.23 Redon and Valliant and Laudenbach incision
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.24 Adson and Ott incision
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.25 Samengo incision
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.22 Gutierrez incision
N. A. Agni
965
Farrior et al. recommended a single curved incision
1.5–2.0 cm below the mandible and extending over the
mastoid region 1.5cm behind the postauricular crease in
children. The preauricular crease used in adults is avoided
because of the supercial location of the facial nerve and
possibility of facial nerve damage during ap elevation
[68] (Fig.46.27).
The Blair incision is an S-shaped incision that starts from
the preauricular region and extends in the neck. The major
disadvantage of the Blair incision is a visible scar in the neck
that may cause facial or cervical disgurement causing
patients dissatisfaction [70].
The standard incision is a modied Blair incision
(Fig.46.28) wherein the skin incision is placed in a preau-
ricular crease and doesn’t extend beyond the level of the root
of the helix. It extends inferiorly around the ear lobule over
the mastoid tip. It gently curves down along the sternocleido-
mastoid muscle and then slightly forward in a natural crease
in the upper neck [71].
A facelift incision can be used to avoid the hollowing
after parotidectomy, and the defect can be lled with SMAS
advancement ap (Bananno and Casson [72], 1992).
However, the SMAS-lifting technique is not a routine proce-
dure for many surgeons [73].
Rai A etal. [74] advocated use of posterior belly of the
diagastric muscle ap (PBDMF) for reconstruction of the
surgical defect after supercial parotidectomy. PBDM inserts
very close to stylomastoid foramen, and it is considered as an
important landmark in the identication of facial nerve main
trunk. The harvesting and dissection of PBDMF becomes
easier as it lies in the surgical site, and no extra incision is
required to harvest it. It can be used in thin and young
patients with good esthetic results.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.26 Appiani’s incision
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.27 Modied Blair incision in pediatric patient
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.28 Modied Blair incision in adults
46 Salivary Gland Pathologies
966
46.8.2 Identication oftheFacial Nerve
This has been previously described in the section on applied
anatomy of the parotid gland.
46.8.3 Surgical Management
The selection of type of procedure for surgical management
of parotid tumors depends on the site, size and clinicohisto-
pathologic features. The various procedures are described
briey as under:
46.8.3.1 Local Excision ofParotid Gland
This technique is used for management of a small tumor in
the tail of the parotid gland less than 3.5cm. Due to small
tumor size, most of the functional gland along with the duct
can be preserved.
46.8.3.2 Parotidectomy withPreservation
oftheFacial Nerve [75]
After marking the incision, inltration is usually done with
Saline Plus 1in 200,000 parts adrenaline instead of ligno-
caine with adrenaline to avoid blocking the facial nerve
bers. In case lignocaine is used, care should be taken to
avoid deep injections. Care should be taken to avoid extend-
ing the incision too far posterior beneath the ear lobe to avoid
persistent edema [75].
The incision in the neck crease is deepened to raise a ap
in the subplatysmal plane (Fig.46.29). The greater auricular
nerve is identied and preserved. It branches over the surface
of the gland where two or more branches should be followed
and then divided.
Once the deep fascia has been identied, rest of the wound
is deepened to this level and skin reected forward from it.
At the zygomatic bone, some subcutaneous fat should be left
on the fascia to avoid damaging the branches of facial nerve
which lie more supercially as they emerge from the upper
part of the parotid. The main trunk of the nerve is found by
rst separating the lower pole of the gland from the anterior
border of the sternomastoid and then from the mastoid pro-
cess and the cartilaginous part of the external auditory
meatus (Fig.46.30). The wound is deepened anterior to the
margin of the sternomastoid, and the lower pole is dissected
free as far forward as the external jugular, uncovering the
posterior belly of the digastric muscle. The vein should not
be divided and tied at this stage because this will increase the
venous engorgement of the parotid and the ooze from its
divided tissues.
Neither should the lower pole be raised further forward
because the branches of the facial nerve often pass super-
cial to the vein and emerge from the gland anterior to it. The
parotid is retracted forward as the dissection proceeds and
the pointed, lower extremity of the tragal cartilage (pointer)
will be uncovered. Where possible, the edge of the fascia
should be raised and the underlying tissue separated by blunt
dissection until the nerve is seen as white cords some 2–3mm
thick.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.29 Flap raised in the sub platysmal plane exposing the super-
cial surface of tumor
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.30 Representing facial nerve main trunk
N. A. Agni
967
The stylomastoid branch of the posterior auricular artery
passes supercial to the nerve to enter the stylomastoid fora-
men. Damage to this vessel should be avoided as bleeding
may hamper vision, and also it supplies a nutrient branch to
the nerve. The curved mosquito forceps are used for dissec-
tion by opening the blades a little at a time to stretch the tis-
sues and raise it, so as to lift the gland substance off the
surface of the nerve, and then expose it by cutting through
the gland with scissors. At all times when a cut is made, the
adjacent nerve must be seen clearly.
Almost immediately the nerve trunk starts to travel later-
ally within the parotid, and just below the neck of the con-
dyle, it splits into an upper temporofacial and a lower
cervicofacial division. Follow the lower division rst, and
trace the cervical or the marginal mandibular branch anteri-
orly to a point in front of the parotid to mobilize the lower
pole completely. Then by progressing upward, branch by
branch further mobilization can be achieved (Fig. 46.31).
Some tissue should always be left on the tumor to ensure
complete removal.
In general, the nerves pass supercial to the retromandibular
vein, but some may pass deep to it. Careful mobilization of
both nerve and vein with division and ligation of the latter is
necessary. Tiny vessels should be sealed with bipolar dia-
thermy avoiding damage to adjacent nerves.
46.8.3.3 Functional Supercial Parotidectomy
[76]
This is supercial parotidectomy where gland function is
preserved by preservation of the Stenson’s duct. If the duct is
supercial to the buccal branch, its preservation is contrain-
dicated as it will obstruct the surgical procedure. After rais-
ing the skin ap and exposing the parotid gland, the duct is
identied passing on the masseter muscle. Stenson’s duct is
located; dissection and ligation of the duct are avoided unless
it is located supercial to the buccal branches of the facial
nerve. Rest of the procedure is similar to supercial
parotidectomy.
Advantages
• It is a simpler surgery than conservative supercial
parotidectomy.
• It preserves partial function of the parotid gland.
• It avoids the inuence of subsequent gland atrophy on
facial contour.
It decreases postoperative complications.
46.8.3.4 Partial Supercial Parotidectomy
This is similar to local excision of parotid gland. Maximum
healthy tissue is left behind without compromising on the
clearance. The advantage of this procedure over supercial
parotidectomy is relatively low incidence of Frey’s syn-
drome. The reported incidence of this complication is 4.8%
[77]. In addition, better gland function is preserved due to
more parenchyma that is left back [78].
46.8.3.5 Intraoral Deep Lobe Tumor Excision [79]
It is a transoral approach used in removal of few benign
tumors of the deep lobe, which are easily visible displacing
the superior portion of the tonsil and soft palate medially. An
incision is made with cautery or knife over the most promi-
nent aspect of the swelling in the tonsil and palate area,
extending above and below the apparent location of the
tumor. The constrictor muscle is identied, and dissection is
continued through thinned constrictor muscle by dividing it
above and below the tumor. Pressure on the neck often assists
in removal of the tumor. Fascial connections from the tumor
into the adjacent bed are removed with blunt dissection, and
the tumor is delivered into the mouth. Any vascular connec-
tions to the tumor should be cauterized, and meticulous
hemostasis should be achieved. The superior and inferior
portions of the wound are closed with interrupted sutures.
The middle portion of the wound is left open to heal
secondarily.
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.31 Parotidectomy with preservation of the facial nerve
46 Salivary Gland Pathologies
968
Complications
• Tumor rupture
• Incomplete removal
• Uncontrolled hemorrhage
46.8.3.6 Total Parotidectomy withor Without
Facial Nerve Preservation
It is usually indicated in tumors affecting the deep lobe. A
neoplasm of the deep part of the parotid enters the soft palate
through the interval between the styloid process and the back
of the mandible and is often of dumbbell shape with the isth-
mus lying in this gap. After raising a skin ap, the facial
nerve is identied and dissected out leaving a layer of glan-
dular tissue on it. An access osteotomy either in the form of
vertical subsigmoid or mandibular body distal to the mental
foramen is used to open up the interval between the mandible
and the styloid process through which the tumor has passed.
The stylohyoid muscle may be divided close to the styloid
process and turned forward. The external carotid artery will
be encountered emerging above the muscles and should be
divided. The origin of the facial artery should be identied to
check the identity of the vessel.
As the parotid gland and the tumor are freed, it may be raised up
between the two nerve bundles or below both bundles. Next
entry is made intraorally over the tumor, and under direct vision
tissues are divided to deliver the mass. Care is taken to avoid
damaging the internal jugular vein and internal carotid artery
which lie deep to styloid process. Following removal of the
mass, the wound is irrigated, and the oral tissues closed with
care using resorbable suture. The drapes are replaced over the
mouth, gloves changed, and the mandibular fragments xed
together and the wound closed in the normal way.
46.8.3.7 Parotidectomy Using SMAS Plane
forDissection [73]
The advantages of this ap are that exposure of the gland is
sufcient and the dissection is easy to perform. There is no
donor-site morbidity, minimum additional operating time,
and no extra cost. It seems to decrease the incidence of Frey’s
syndrome. The speed of the recovery of the facial nerve has
been highlighted in the literature. It is more satisfactory from
the patient’s point of view.
46.8.3.8 Parotidomandibulectomy
andTemporoparotidectomy [80]
Parotidomandibulectomy is indicated where there is invasion
of the mandible by a malignant neoplasm.
In temporoparatidectomy, small-scale resection of the exter-
nal auditory canal may be included with the excision of the
pinna and overlying skin of the parotid where these struc-
tures are involved. The deciency may be made good with a
deltopectoral or other suitable ap.
46.8.4 Parotidectomy inContinuity
withNeck Dissection
In the case of lymph node metastasis as stated in surgical
pathology, neck dissection can be done in continuity with
parotidectomy by increasing the neck skin crease incision
and clearing the lymphatic structures.
46.8.5 Complications ofParotid Surgery
• Facial paresis or paralysis often results from poor tech-
nique and failure to preserve small nerve branches.
• Bleeding and hematoma formation, which can signi-
cantly compromise the airway.
• Rarely, persistent salivary leakage or sialocele formation
occurs.
• Frey’s syndrome.
• Skin ap necrosis.
46.9 Surgical Management
ofSubmandibular andSublingual
Gland Tumors
Small tumors conned to the gland are treated by sialadenec-
tomy, and tumors spreading beyond the connes of the gland
are treated with a wider en bloc excision, which may include
resection of the oor of mouth and mandible depending on
extent of tumor. The neurotropic tumors might involve the
lingual, hypoglossal, mylohyoid, and marginal mandibular
nerve leading to a perineurial spread which can be conrmed
on frozen section. Thickening and nodularity of the nerves
may indicate perineural involvement [81].
46.9.1 Incision
For submandibular sialadenectomy, a skin crease incision
below 3cm from the lower border of mandible is taken to
avoid damaging the marginal mandibular nerve which loops
below the lower border of the mandible (Fig.46.32).
For simple excision of the sublingual gland, an incision is
made in the oor of the mouth lateral to the submandibular
N. A. Agni
969
duct taking care to limit it up to premolar region, as at the
molar region, there is a chance to damage the lingual nerve.
When sublingual gland excision is necessary for a tumor, it
should be removed with a wide margin including a rim resec-
tion of the mandible.
46.9.2 Extracapsular Excision
oftheSubmandibular Salivary Gland [82]
After making an incision in the neck crease, skin ap is
raised in the subplatysmal plane (Fig.46.33). The capsule of
the gland should be left intact when the sialadenectomy is
being done for a tumor, which might compromise the
marginal mandibular nerve. The facial artery and nerve are
identied as close to the gland as possible. After transection,
they are elevated superiorly to identify and reect the mar-
ginal mandibular nerve. Nowadays the facial artery is spared
during surgery to allow free ap anastomosis during onco-
surgeries (Fig.46.34). The investing fascia is then divided at
the lower border of mandible, and the gland is delivered out
from between the anterior and posterior bellies of the digas-
tric muscle. Anteriorly the gland is separated from the mylo-
hyoid muscle, and lingual nerve, hypoglossal nerve, and
Wharton’s duct are identied. The lingual nerve shares the
same facial sheath as the gland at the upper pole. This attach-
ment of the lingual nerve to the gland represents its parasym-
pathetic supply. The Wharton’s duct is inferior to lingual
nerve and is often surrounded by sublingual glands. As fascia
and gland are mobilized upward from the surface of the hyo-
glossus, the hypoglossal nerve is identied more inferiorly. It
is accompanied by ranine vein. Posteriorly the angular tract
of fascia has to be cut with scissors to allow the gland in its
fascial envelope to be drawn down without grasping the
gland with instruments. Where necessary the upper pole may
be mobilized via the mouth. An assistant can then depress the
gland toward the submandibular wound to enable the opera-
tion to be concluded.
The duct and the branch of the lingual nerve supplying the
submandibular gland are ligated and transected. The duct is
divided close behind the papilla. During excision for inam-
matory disease, the nerve is always separated from the gland
with knife or scissors. However, if the nerve appears to be
involved in a tumor, it is sectioned in front of and behind the
gland and the cut ends sutured. The wound is closed in layers
with drainage in the usual way.
©
Association of Oral and Maxillofacial Surgeons of India
Fig. 46.32 Submandibular incision
©
Association of Oral and Maxillofacial Surgeons of India
Fig. 46.33 Submandibular gland exposure with subplatysmal
dissection
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.34 Facial artery preservation in submandibular
sialadenectomy
46 Salivary Gland Pathologies
970
46.10 Management ofMinor Salivary Gland
Tumors
Surgical resection of minor salivary gland tumors depends
on the site of origin and extent of disease. This may range
from a wide local excision of localized low-grade tumors to
more radical excision, including marginal or segmental man-
dibulectomy and/or partial or total resection of the hard or
soft palate, partial or total maxillectomy, infratemporal fossa
dissection, and/or anterior craniofacial resection for larger
and/or high-grade tumors. The V2 and V3 divisions of the
trigeminal nerve are at potential risk for perineural spread of
minor salivary gland malignancy and may facilitate an early
skull base metastasis. Resection of the cranial base may be
required in some cases to eradicate the tumor and obtain
negative surgical margins [81].
46.10.1 Excision ofPalatal Pleomorphic
Adenomas [83]
Small pleomorphic adenomas on the palate can cause
pressure resorption of the bone but do not cause true bony
invasion. They are managed by local excision along with
the periosteum. In the case of involvement of greater pala-
tine foramen area, the lesion is freed until it can be drawn
down, and the vessels clamped and cauterized under direct
vision. If not, the vessel retracts into the canal and causes
irritating bleeding. The wound is left to granulate
secondarily.
46.10.2 Excision ofPalatal Mucoepidermoid
Carcinoma [83]
Low-grade mucoepidermoid carcinomas may be treated by
the excision of a full-thickness disk of palate, including pala-
tal and alveolar bone. Nasal and oral mucous membranes are
sutured together around the defect in the soft palate. Primary
reconstruction is avoided and an obturator is used instead
(Fig.46.35a, b).
46.10.3 Excision ofPalatal Adenoid Cystic
Carcinoma [83]
Spread along the perineurial tissues makes an inadequate surgi-
cal margin very likely after surgical management of ACC.A
combination of surgery and radiotherapy is best. Surgical exci-
sion should be generous. Hemimaxillectomy including the
orbital oor is a minimum, unless there is very good evidence
that less will be sufcient. Where the soft palate and pterygoid
region are involved, extended maxillectomy approach is essen-
tial to ensure adequate excision under direct vision.
46.10.4 Excision ofNeoplasms oftheCheek
andLips
A primary excision with a margin of normal adjacent tissue
can be used, but if there is any doubt, it can be preceded by
a biopsy. Re-operation following incomplete extirpation
ba
©Association of Oral and Maxillofacial Surgeons of India
Fig. 46.35 (a) CT scan showing mucoepidermoid carcinoma of palate (red arrow). (b) Surgical excision of tumor using standard Weber-Ferguson
incision
N. A. Agni
971
could mean the unnecessary sacrice of tissue to ensure an
adequate margin on the second occasion. Clinically aggres-
sive neoplasms must be biopsied, since adequate treatment
may involve radiotherapy and full-thickness excision and
repair.
More aggressive tumors affecting the palatal salivary
glands are managed by partial maxillectomy or total maxil-
lectomy or extended maxillectomy based on the extent of
disease.
46.10.5 Complications
• A hematoma may develop in the dead space after gland
excision. It can be avoided by meticulous hemostasis and
placement of suction drain to clear out any collection. In
case a hematoma develops, it can be aspirated or sucked
under aseptic precautions. However, it may not be com-
pletely effective. The patient can be just put on good anti-
biotic coverage, and it will resolve without getting
infected.
• Trismus occurs due to masseter muscle spasm or inam-
mation in the TMJ.It generally resolves spontaneously
and hence should be just managed symptomatically.
• Salivary stula occurs uncommonly due to discontinuity
between the residual salivary gland parenchyma and the
salivary duct. In majority of cases, the problem is self-
limiting. Management includes repeated aspiration, pres-
sure dressings, wound care, an antisialogogue medication
(glycopyrrolate), and patience.
• Facial nerve dysfunction results from traction injury to
the facial nerve (neuropraxia) during dissection in parotid
surgery. Complete recovery within a few months can be
expected if nerve integrity has been maintained. In case
the nerve is transected, it should be followed by immedi-
ate nerve grafting repair.
• Auriculotemporal syndrome of Frey is also called gusta-
tory sweating. It manifests as ushing and sweating of the
skin of upper cheek, temporal region, and forehead coin-
cident with eating and smelling of food. Following dam-
age to the auriculotemporal nerve or to communicating
branches to the facial nerve, secretomotor parasympa-
thetic nerves from the otic ganglion and also sympathetic
bers to the sweat glands traveling in the same nerve are
divided. Following regeneration, bers from otic ganglion
come to supply the sweat glands. Minor’s starch-iodine
test is used for diagnosis [78]. It can be managed by sim-
ple treatment of antiperspirant application; 1% local
application of glycopyrrolate is effective. The only effec-
tive cure is to divide the parasympathetic bers from the
glossopharyngeal nerve.
Sensory abnormalities associated with greater auricular
nerve sacrice, reect as sensory decit in the lower third of
pinna including earlobe as well as adjacent preauricular and
postauricular skin.
46.11 Recent Advances [84]
Robotic sialadenectomy of the submandibular gland has
been done via a modied face lift approach. Virgilio etal.
performed robotic sialadenectomy of the submandibular
gland in ve patients (two patients each with sialolithiasis
and pleomorphic adenoma and one patient of ranula) with
success. They used three robotic arms, two operative arms,
and a facedown 30° endoscopic arm. The operative left arm
is equipped with Maryland forceps and right arm with har-
monic scalpel.
46.12 Conclusion
Salivary gland pathologies may be neoplastic, non- neoplastic,
inammatory, or non-inammatory. Early surgical interven-
tion after a good clinical, radiological, and histopathological
diagnosis is need of an hour to minimize the postoperative
complications. Early diagnosis and management with recent
advanced technologies is the key factor in achieving excel-
lent prognosis of the disease.
Acknowledgment Author wishes to thank Dr. Anshul Rai for
Figs.46.3, 46.4, 46.9, 46.13, 46.17a, b, and 46.20.
Author wishes to thank Dr. Kedar Saraf, Professor, Dept. of OMDR,
SMBT Institute of Dental Sciences, Sangamner, Maharashtra, for
Figs.46.11a, b, and 46.12.
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46 Salivary Gland Pathologies
