benign and malignant disorders of salivary glands By Dr. Rakhi Arjariya

1. Benign and
malignant
disorders of
salivary
glands
D R . R A K H I A R J A R I YA
P G R E S I D E N T
I N D E X M E D I C A L C O L L E G E ,
H O S P I TA L A N D R E S E A R C H
H O S P I TA L

2. Salivary glands
Definition: exocrine glands secreting salivary contents into the mouth.
Classification according to size:
Major(paired)-
 Parotid
 Submandibular
 Sublingual gland
Minor(unpaired)-
800 in number
• Buccal, palatine, lingual, floor of mouth, retromolar area, oropharynx.

3. Developmen
t
• Parotid gland: 6th to 8th
week of IU life;
Ectodermal origin
• Submandibular
gland: 6th week;
endodermal origin
• Sublingual and minor
glands: 8th-12th weeks;
endodermal origin

4. Parotid Gland
 Largest salivary gland; wt-25gm
 Located in the retromandibular
fossa (parotid bed), between
ramus of mandible and SCM.
 Enveloped by the investing layer of
deep cervical fascia.
 Divided into superficial and deep
lobe by the facial nerve.
 The accessory parotid gland is a
separate part, lying on the
masseter between parotid duct
above and zygomatic arch below.

5. Relations:
• Anterior: masseter, medial
pterygoid
• Posterior: posterior belly
digastric
muscle, sternocleidomastoid,
mastoid process
• Superior: EAM, TMJ
• Inferior: SCM, Post belly of
digastric
• Lateral: investing layer of deep
cervical fascia, platysma and
skin
• Medial: Investing layer of deep
fascia, styloid process, IJV, ICA,
pharyngeal wall.

6. STENSON’S DUCT
• Arises from the anterior part of
the gland; 1.5 cm inferior to
zygomatic arch.
• 5cm in length; 6mm diameter
• Passes over the masseter
• Pierces buccinator, opening
opposite to the upper second
molar.
• Intraoral course provides valve
like mechanism.
•

7. Arterial supply Branches of external carotid artery
Venous drainage Retromandibular vein into EJV
Facial vein into IJV
Lymphatic drainage Intra parotid LN
Deep cervical nodes
Level IIa IIb
Nerve innervation •Parasympathetic-Secretomotor
•Sympathetic-Superior cervical ganglion
•Sensory- Greater auricular nerve
Histology • Serous cells
• Serous acini
embryology • Ectodermal myoepithelial origin

8. Important
structures
• 3 chief structures either in part or
in whole traverse the gland and
branch inside it. From superficial
to deep these are:
• Facial nerve.
• Retromandibular vein.
• External carotid artery,
dividing into the superficial
temporal and maxillary
branches.
Click to add text

9. Relationship to Facial nerve
• Facial nerve exits skull base from the stylomastoid foramen and enters posterior surface of the
gland.
• Within the substance divides into
 Upper zygomatico-temporal division
 Lower cervico-facial division
• Facio-venous plane of patey
• 5 peripheral branches: pes anserinus
 Temporal
 Zygomatic
 Buccal
 Mandibular
 cervical

10. Submandibular gland
• The gland wraps around the
posterior border of mylohyoid
muscle.
• It is composed of 2 parts: (a)
a large superficial part and (b)
a small deep part.
• Superficial lobe is located in
the submandibular triangle.
• Deep part is located within the
floor of the mouth.
•

11. Superficial lobe: 3 Surfaces
Superficial(inferior) surface relations:
covered by fibrous layer-capsule
Medial surface:
• Anteriorly to Mylohyoid, nerve to
mylohyoid, submental vessels
• Posteriorly to Hyoglossus,
submandibular ganglion, lingual
nerve, hypoglossal nerve, styloid
process and posterior belly of
digastric.
Lateral surface is related to: body of
mandible

12. Anatomic relations: Deep part
• Medially: Hyoglossus
and styloglossus
• Anteriorly: post. end of
sublingual gland
• Posteriorly wraps around
the free edge of
mylohyoid

13. Wharton's duct
• 5 cm long
• Arises from the deep part.
• It runs between mylohyoid and
hyoglossus and onto
genioglossus opens into the oral
cavity lateral to the frenulum of
the tongue.
• Lingual nerve double crosses the
duct, starting medially and ends
laterally.
• Hypoglossal nerve runs parallel
and inferior to it.

14. • Blood Supply : branches of facial &
lingual arteries.
• Venous drainage: facial & lingual
veins
• Lymph drainage : level Ib
 submandibular
deep cervical lymph nodes

15. Submandibular Gland
Supply
• Parasympathetic: secretomotor fibers
from superior salivary nucleus of facial
nerve via chorda tympani nerve to join
lingual nerve and pass into
submandibular ganglion.
• Postganglionic parasympathetic
secretory fibers from ganglion via
lingual nerve into gland.
• Sympathetic fibers: from plexus of
nerves around Facial + Lingual
arteries.
• Sensory: lingual nerve

16. Sublingual glands
• It is located beneath the
mucosa in the floor of the
mouth.
• Between mandible and
genioglossus
• Bound inferiorly
by mylohyoid muscle.
• It’s largely mucus in nature
and weighs about 3-4 g.

17. • Blood supply-The sublingual and submental arteries.
• Nerve supply- Through chorda tympani nerve;
• Preganglionic fibres arise from superior salivatory nucleus; Postganglionic
fibres arise from submandibular ganglion
• Lymphatic drainage-Level Ia and Ib
• The gland possesses about 20 ducts.
• Ducts of Rivinus: open individually on the sublingual fold
• Duct of Bartholin: which opens into the submandibular duct.

18. Classification of salivary gland disorders
Salivary gland
disorders
Developmental Inflammatory Obstructive
Other benign
disorders
Tumours
Benign Malignant Rare

19. 1.Development Disorders
1. Atresia
2. Aplasia
3. Aberrancy: Staphne’s bone cyst, below the inferior dental
neurovascular bundle.
4. Congenital fistula
5. Hyperplasia of gland
6. Diverticula of salivary gland

20. • Salivary diverticulum is a small pouch or out-pocketing of the duct system of a major salivary gland.
Such diverticuli typically cause pooling of saliva and recurrent sialadenitis, especially parotitis or sialoliths.

21. 2.Inflammatory Conditions
1.Acute Bacterial Sialadenitis(suppurative parotitis)
• MC affects parotid gland, caused by S.Aureus, S. Pyogenes
• Sudden onset painful diffuse swelling of the involved gland; regional
lymphadedopathy and fever.
• Often seen in debilitating patients with poor oral hygiene.
2.Chronic bacterial Sialadenitis
• Most commonly due to salivary calculi causing partial or complete obstruction of
the salivary duct.
• Most commonly seen in submandibular gland.
• Chronic, intermittent, pain with unilateral swelling of the gland.

22. 3.Viral Sialadenitis(Mumps parotitis):
• Paramyxo virus induced infection of parotid(mostly) or submandibular occasionally;
• bilateral gland swelling, swollen cheek appearance
• Low grade fever, mild headache, loss of appetite and abdominal pain
• Complications include meningitis / encephalitis, deafness, pancreatitis, and orchitis.
4.Irradiation induced sialadenitis
• Complication of radiotherapy
• Directly related to dose of radiation and severity of damage
• Irreplaceable damage followed by fibrous replacement of the acini causing Xerostomia.

23. 3.Obstructive disorders: Sialothiasis
• Clinical features:
 Acute painful swelling, precipitated by eating
 Resolves 1-2 hrs after eating(complete obstruction);
 Recurrent attacks.
• Male preponderance seen
• Middle age
Organic
nidus
Calcium
salt
deposition
Calculi
formation
obstruction

24. Sialolithiasis
Clinically, enlarged gland, tender on
bimanual palpation.
Majority of sialoliths occur in salivary
gland.
Investigation: X ray/ sialography ​(90
percent submandibular stones are
radioopaque and 90% parotid stones
are radiolucent)

25. Treatment
• Sialoendoscopy(dormia
basket)
• >4 mm stones: intra/extra
corporeal lithotripsy-
>removal
• Surgical methods:
• Incision over the duct, f/b stone
retrieval.
• If fails, submandibular gland
excision f/b duct ligation

26. Cysts of salivary glands
1. Mucus retention cysts:
occur in minor salivary glands;
secondary to obstruction
2. Mucus extravasation cyst:
Trauma to the region
causes pooling of mucus in
the area followed by
inflammatory reaction.

27. 3. Ranula: mucus extravasation cyst arising from sublingual glands
• Female preponderance; 2nd decade of life
• Possible association with HIV infection
• Treatment: marsupialisation, laser ablation or cryosurgery
4. Plunging ranula: Ranula are classified as simple when they lie above mylohyoid and
deep/plunging when they lie invade below this muscle.
• Painless,persistent, recurrent neck swelling; rarely spreads to upper chest wall
• Dumbell shaped, soft fluctuant swelling, in the submental/ submandibular region of the
neck
• Diagnosed on USG/ MRI.
• Treatment: removal of sublingual gland and aspiration of saliva out of the sac.

28. • Plunging ranula(left) and Ranula(right).
• Ranula: is a special type of mucocele which grows in the floor of the mouth, usually unilateral and is called due to its similar
appearance to enlarged abdomen region of a frog.
• Plunging ranula

29. Autoimmune
disorders : Sjogrens
syndrome
• It is an autoimmune disorder causing
progressive destruction of salivary
and lacrimal glands.
• F>M ; 10:1 ratio
• Most commonly affects parotid
gland.
• Outline of parotid gland is demaracted
in the picture.

30. Sjogren's
syndrome
xerostomia
Bacterial
sialadenitis
Enlargement
of salivary
glands

31. Management:
o Biopsy of the gland can aid with
the diagnosis.
o Treatment : symptomatic
o Hydration; NSAIDs
o Artificial tears, artificial salivary
substitute,etc
o ( picture above)B/L parotid swelling
o Extensive cervical caries is a complication
of dry mouth as patients tend to use sweet
to stimulate salivary flow.

32. Snowstorm
appearance
• Sialogram showing snowstorm
appearance of blobs of contrast
leaked from the duct system.
• Empyting and clearance of medium
are also delayed because of
reduced salivary flow.

33. 2.Mikulicz’s disease:
• Presentation: asymptomatic,
bilateral swelling of the parotid,
and submandibular salivary
glands+lacrimal glands.
• resembles Sjogren’s syndrome.
• Treatment- corticosteroid therapy
in the acute phase, prednisone 40
mg per day for 2–4 weeks followed
by a gradual tapering of the dose.

34. Other benign disorders:
1) Frey's syndrome
2) Sialorrhea
3) Xerostomia
4) Recurrent parotitis of childhood and obstructive parotitis
5) Sialodenosis
6) Granulomatous sialadenitis
7) Chronic sclerosing sialadenitis

35. 1. Frey's syndrome
• aka Auriculo temporal syndrome
• Sweating + erythema in the pre auricular and temporal areas
after gustatory stimulation.
• Caused due to faulty regeneration of sympathetic and
parasympathetic nerve fibres injured during parotid tumor
surgery/ramus resection.
• Starch Iodine test: Paint the area with iodine followed by dry
starch application, that turns blue on exposure to iodine in the
presence of sweat.

36. Management
• 1) Prevention: Using techniques
like
Sternomastoid muscle flap
Temporalis fascial flap
Insertion of artificial membranes
between skin and parotid bed.
• 2) Treatment:
Antiperspirants
Tympanic neurectomy
Botulinium toxin injection

37. 2.Sialorrhea
• Uncontrolled drooling in the presence of normal salivary production.
• Certain drugs or oral infections cause transient increase in salivary flow rates.
• It is seen in children with mental and physical handicap(Cerebral palsy).
• Medical management: Antisialogogues(anti cholinergic agents)
Surgical management include:
 Bilateral submandibular duct repositioning with sublingual gland excision
 Bilateral submandibular gland excision
 Transposition of parotid ducts with submandibular gland excision.

38. 3.Xerostomia(dry
mouth)
Common causes:
• dehydration
• Post menopause
• Chronic anxiety or depression
• Anticholinergics( antidepressants)
• Sjogren's syndrome
• Radiotherapy
Treatment:
• hydration
• Withdraw the offending drugs

39. 4.Parotitis:
1. Recurrent parotitis of childhood:
 rapid swelling of one/both parotid glands
 Lasts 3-7days, f/b quiescent period of weeks-months
 varied number of attacks 1-5/year.
 Sialogram: punctate non obstructive sialectasis.
 Responsive to antibiotics and endoscopic washouts.
2. Obstructive Parotitis: Multiple causes including stones, strictures and papillary obstruction
 Strictures cause 20% of obstruction
 Obstruction is caused due to stagnation of mucus plugs.
 Present with meal time syndrome
 Trauma to papilla of parotid causes inflammation.

40. 5. Granulomatous sialadenitis
• Painless swelling of parotid or submandibular
glands; chronic condition
• Mycobacterial infection: TB and Non TB
sialadenitis + tumour like swelling of the gland;
without systemic upset.
• Sarcoidosis: sarcoid pseudotumour maybe
associated with xerostomia.
• Cat's scratch, toxoplasmosis, wegener's, syphylis,
deep mycosis, radiotherapy.

41. 6.
Sialadenosis
• Sialadenosis: aka sialosis
• enlargement of salivary glands
• non-inflammatory
• non-neoplastic
• Parotid is commonly affected.
• Associated with:
 Endocrine disorders: (1) Diabetes mellitus/insipidus;
(2) Acromegaly (3) Hypothyroidism (4) Pregnancy.
 Nutritional status: (1) Anorexia nervosa; (2) Bulimia; (3)
Chronic alcoholism; and (4) General malnutrition.

42. • Also known as Kuttner’s tumour .
• chronic inflammatory reaction
secondary to ductal obstruction
and subsequent salivary stasis.
• Presentation: painful, hard swelling of
submandibular salivary gland.
• M>F
• CT scan: Chronic sclerosing sialadenitis
of submandibular gland.
7. Chronic sclerosing
sialadenitis

43. Classification of Salivary Gland tumours
Type Subgroup Examples
Epithelial tumours
Adenoma
Pleomorphic
Monomorphic
Pleomorphic Adenoma
Adenolymphoma(Warthin's tumour)
Carcinoma Low Grade
High Grade
Acinic Cell Carcinoma
Adenoid Cyctic Carcinoma
Low grade Mucoepidermoid Carcinoma
Adenocarcinoma
Squamous Cell Carcinoma
High grade Mucoepidermoid Carcinoma
Non-epithelial tumours Hemangioma; Lymphagioma
Lymphomas Primary Lymphomas
Secondary Lymphomas
Non Hodgkin's lymphoma
Sjogren's Syndrome
Secondary tumours Local
Distant
Tumours of Head/neck
Skin and bronchus
Tumour like Lesions Solid
Cystic
Benign lymphoepithelial lesion
Adenomatoid Hyperplasia
Salivary Gland cysts

45. 1.Pleomorphic adenoma
• Also known as Mixed tumor, Endothelioma, etc.
• 75% of all benign salivary tumours(MC)
• Parotid gland (85% of cases) > submandibular gland (5% of cases)> minor salivary
glands (10% of cases).
• F>M ; 4th-5th decade
• Epithelial+myoepithelial components
• Clinical features: Slowly growing painless, tumour+ facial nerve
associated symptoms
• 5% Risk of malignant transformation into carcinoma ex pleomorphic adenoma.
• Age, smoking habits, alcohol abuse, a diet rich in cholesterol and previous
radiation therapy treatments in the face and neck regions, are the risk factors.

46. 1) solitary, ovoid, firm to soft with well defined borders; cut surface tan
to white
2)Mixture of epithelial, myoepithelial and stroma component.

47. Treatment:
• Superficial (Patey's operation)/total parotidectomy.
• The tumors of the submandibular glands: simple
excision procedure+ preservation of adjacent
nerves
• Minor salivary glands: 5 mm margin should be
obtained; wide local excision with cuff of normal
tissue.
• Parapharyngeal extention- external cervical
approach
• These tumors do not invade into periosteum. Thus,
the bone need not be resected.

48. Warthin Tumour
• Papillary cystadenoma lymphomatosum
• 2nd MC benign salivary tumour.
• M>F
• MC site: tail of parotid gland(exclusively seen in
parotid)
• Clinical features: A painless, slow-growing bump in front
of the ear, on the bottom of the mouth, or under the
chin.
• Etiologic factors: Epstein Barr virus infection,
tobacco,smoking, autoimmune disease, ionizing
radiation, and chronic inflammation.
• Malignant transformation of Warthin tumor is extremely
rare and accounts for 0.3% of the cases.

49. Warthin
Tumor
• Grossly, Warthin tumor is a well-circumscribed
spherical to oval mass. On cut section, there are solid
areas and multiple cysts with papillary projections. The
cystic spaces often contain mucoid creamy brown or
white fluid.

50. Management: complete surgical
excision

51. Oncocytic papillary
cystadenoma
• Benign minor salivary gland tumour.
• Mc site: false vocal cords and ventricles of
larynx
• Presents with hoarseness of voice and
painless mass.
• Gross-smooth, rounded, cystic, pedunculated
mass.
• Treatment- complete surgical excision.

52. Myoepithelioma
• Origin from contractile myo-epithelial cells
lining the acini and ducts of salivary glands.
• <1% of all salivary neoplasms
• Benign but locally aggressive
• 3rd-6th decade
• Minor glands>parotid>submandibular gland
• Presents asymptomatic, slow growing mass
• Micro: spindle shaped plasmacytoid cells.
• Treatment: wide local excision

53. Monomorphic adenomas
• No mesenchymal stromal component;
predominantly epithelial.
• Benign salivary tumor composed of nests
and cords of small basaloid cells with
inner ductal epithelial cell
• Basal cell, canalicular, sebaceous, clear
cell are the types.
• Basal cell adenoma is the commonest.
• 6th decade
• More common in parotid, minor glands of
upper lip.

54. Canalicular adenoma
• Site: Minor salivary glands, mainly upper
lip.(1st picture)
• <1% of salivary glands tumours
• Asymtomatic slow growing mass
• Histologically: cells arranged in parallel
rows forming 'duct like' structures.(2nd
picture)
• Treatment: surgical excision

55. Oncocytoma
• Rare, <1% of benign salivary tumours
• 6th decade
• Parotid>submandibular> minor glands over
palate, buccal mucosa, tongue
• Enlarging painless mass
• Locally aggressive
• Gross: encapsulated, circumscribed
• Micro: large eosinophilic cells; mitochondial
hyperplasia
• Treatment: surgical excision

56. Malignant Salivary gland tumors
• The main malignant tumour types (from most to least common) are:
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Acinic cell carcinoma
• Squamous cell carcinoma
• Adenocarcinoma
•

57. Muco epidermoid Carcinoma
• Most common(29-43%) malignant tumor of the
salivary gland in both adults and children,
• Parotid>minor SG>submandibular
• Arises from the epithelium of the interlobular
and intralobular salivary ducts.
• F: M ratio 3:2
• Mean age of onset is 5th decade.
• Smoking, viral infections, working in rubber
manufacturing and prior exposure to radiation.

58. Muco epidermoid carcinoma
• Symptoms: tenderness, otorrhea,
dysphagia, and trismus.
• Gross features: Unencapsulated, firm, cysts with
mucoid content.
• Histology: 3 types of cells; epidermoid, mucous,
intermediate cells.
• Low grade: slow growing, painless mass, higher %
mucinous cells; better prognosis
• Intermediate grade: intermediate symtoms; mix of
epithelial and mucinous cells
• High grade: rapidly enlarging, +/-pain;
higher % epithelial cells; worse prognosis

60. Management
Treatment is influenced by site, stage, grade
Stage I, II
• Wide local excision- minor salivary gland tumours
• High-grade tumors are generally treated with surgical excision with wide margins followed by
postoperative radiotherapy
• Parotidectomy(superficial/total conservative) for parotid
• Submandibular gland excision in submandibular gland tumours.
Stage III & IV
• Radical excision +/- Neck dissection
• +/- post operative radiotherapy

61. Adenoid Cystic Carcinoma
• 2nd most common malignancy.
• 10-15% of all malignant
salivary neoplasms
• Most common in parotid, sublingual, and
minor salivary glands.
• M=F, 5th and 6th decade.
• ACC is typically an aggressive form of
cancer that has a poor long-term outlook.
• Known for neurotropism, slow
growth, local recurrence, and distant
mets.

62. Clinical picture
• Adenoid cystic carcinoma (ACC) of salivary
glands
 a slow-growing, often asymptomatic mass
 Pain, paresthesia, facial weakness
• Neural invasion in 50%; 25% develop distant
mets(lung); skip mets seen along the nerves.
• Tumors of the lacrimal gland may cause a
bulging eye or changes in vision.
• Those affecting the windpipe or voice box may
cause respiratory symptoms or changes
in speech, respectively.

63. Microscopic features:
ACC has three histopathologic
patterns
• Tubular: Intermediate nature
• Cribriform: glandular; Best
prognosis
• Solid pattern: Epithelial nature,
tumour necrosis; Best prognosis

64. Treatment:
• Total parotidectomy
• Perineural invasion: ?facial nerve sacrifice
• Post operative IMRT(intensity modulated radiotherapy)
Prognosis:
• Local recurrence: 42%
• Distant metastasis: lung
• 100% primary site recurrence at 30yrs
• 100% lung metastasis at 20 yrs

65. Acinic cell Carcinoma
• low-grade malignant salivary neoplasm; 6-8% of all salivary
malignancies.
• Most common site: parotid gland (80%)
• Presentation- solitary, slow growing, often painless mass
• Most common sites in the oral cavity are the buccal mucosa
and upper lip
• F>M
• 2nd most common salivary malignancy in children (after
mucoepidermoid carcinoma.)
• 3rd most common salivary malignancy in adults (after
mucoepidermoid carcinoma and adenoid cystic carcinoma)
• Previous radiation exposure and familial predisposition
are the risk factors for ACC.

66. Multilocular radiolucent lesion extending
from the ascending ramus to periapical area
of left mandibular canine. Mandibular canal
involvement was clear.
sheets of large acinar cells with
basophilic to amphophilic cytoplasm with
numerous dark-staining granules and
round small eccentrically located nuclei.
Acinic cell carcinoma

67. Squamous cell carcinoma
• Malignant epithelial tumor of major salivary
glands composed of epidermoid cells.
• 0.3-1.5% of salivary gland neoplasms
• M>F
• Painless mass; ulceration maybe present
• Facial palsy in 10%, neck metastasis in 50%
and distant metastasis in 10%.
• Treatment:
 Radical excision
 Neck dissection
 Post op XRT

68. Adenocarcinoma
Gross features:
• focally circumscribed
• Hemorrhagic and necrotic areas
Microscopic features: 4 patterns
• Solid
• Cords
• Ducts and tubules
• glands

69. Polymorphous low grade adenocarcinoma
• Aka ' terminal duct carcinoma'.
• Originates from intercalated ducts
• 2nd most common malignancy of salivary glands
• 6th-7th decade
• F>M
• Painless submucosal mass
• Cervical metstasis in 10%
• Perineural spread seen
• Treatment: complete yet conservative excision.

70. Staging of Salivary gland malignancies

71. Lymph node
staging

72. Parotidectomy
• Indications: Benign tumours; Malignant tumours; chronic inflammation of
the gland.
• Incision: Modified blair's incision; facelift incision.
• Critical steps
1) Flap elevation(subplatysmal or superficial muscular aponeurotic region)
2) Identification of Facial nerve(Digastric, tragal pointer, tympanomastoid
suture line)
3) handling the nerve( tunnel, lift, coagulate, cut)
4) Delivery and closure

73. Types
of incision
• Retro-auricular hairline incision
• Modified Blair's incision
• Modified facelift incision

74. Types of parotidectomy
• Extracapsular dissection: Tumour is
removed, leaving a parted but intact
parotid. Facial nerve is not dissected,
unless it lies in close vicinity.
• Partial/superficial parotidectomy: The
tumor is resected with a cuff of parotid
tissue, used for benign lesions and lymph
node metastasis into the superficial lobe.

75. • Total conservative parotidectomy: Entire
gland is removed; for aggressive
malignant tumors, deep lobe tumors,
sentinel lymph node excision when located
in the deep lobe, positive margin after
superficial parotidectomy.
• Radical parotidectomy: The entire gland
and the facial nerve is removed, mostly
used when preoperative facial paralysis is
well established, or circumferential
involvement of the nerve
by malignant tumor is encountered.
• Simultaneous nerve grafting or other facial
reanimation procedures can be employed

76. Landmarks used for facial nerve identification:
• Tragal pointer
• Posterior belly of digastric
• Mastoid process
• Tympanomastoid suture line
• Retrograde dissection
Management:
• If nerve is non functional preoperatively: excision done
• Excise if tumour is adherant to it
• In case of adenoid cystic carcinoma: if sectioned nerve
is involved excise till free stump is obtained on frozen
section
• Immediate cable grafting can be done with sural or GAN.

77. Submandibular gland excision
• Benign Tumours: Excision in supracapsular
plane
• Malignant Tumours: Wide excision + neck
dissection
• Clinically high-grade tumours: treat aggressively
with excision of the gland plus a 2 cm margin of
apparently healthy tissue.
• Resection of involved nerves with microscopic
negative margins is desirable.
• Large infiltrative tumours with bony
involvement: composite resection of tumour,
adjacent soft tissue cuff and bony resection.
• N0 neck: clearance of nodes+ selective neck
dissection (levels 1 and 2A).

78. Submandibular gland excision
Excision involves 6 phases
 Incision ( horizontal skin crease, 2 fingers
breadth below ramus of mandible)
 Superior(subplatysmal) flap is raised
 Identify and Preserve mandibular marginal
nerve
 Superficial lobe mobilised
 Dissection of deep lobe and identification of
lingual nerve
 Proximal part facial A is ligated; duct is
transected
 Wound closure

79. Sublingual
gland
excision:
• Plunging ranula

80. Non Surgical Management
• For a salivary gland tumor, radiation therapy is most often used in combination with
surgery, depending on the size, grade, extent, and location of the cancer and whether
there are some cancer cells in the margin around the tumor removed by surgery.
• If radiation therapy is recommended, it should be started within 8 weeks of the surgery.
Radiation therapy may also be given along with chemotherapy
• There are 2 main types of radiation therapy used for salivary gland cancer:
• External beam radiation
• Internal beam radiation
• Chemotherapy has limited role in terms of salivary gland tumours

82. Recommendations
• USG guided FNAC is recommended for all salivary tumours and cytology.
• Adjuvant radiotherapy (RT) following surgery is recommended for all malignant submandibular tumours
except in cases of small, low-grade tumours that have been completely excised.
• In the event of intra-operative tumour spillage, most cases need long-term follow-up for clinical
observation only. The merits of adjuvant RT ought to be discussed.
• As a general principle, if the facial nerve function is normal pre-operatively then every attempt to
preserve facial nerve function should be made during parotidectomy and if the facial nerve is divided
intra-operatively then immediate microsurgical repair (with an interposition nerve graft if required) should
be considered.
• Where malignant parotid tumours lie in close proximity to the facial nerve there should be a low
threshold for adjuvant RT.
• Adjuvant RT should be considered in high grade or large tumours or in cases where there is incomplete
or close resection margin.
• Adjuvant RT should be prescribed on the basis of clinical factors in addition to histology and grade, e.g.
stage, pre-operative facial weakness, positive margins, peri-neural invasion and extracapsular spread.

83. References:
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84. Thank
you!!!