Salivary Gland Masses

The salivary glands are divided into major and minor glands.

The major glands are the parotid, which sits in front of the ear, the submandibular, which sits under the jaw, and the sublingual, which sits under the tongue. The minor glands are hundreds of small glands in the upper digestive tract. Together they produce about 1000 to 1500 cc of saliva a day.

The main diseases of the salivary glands are infection, stones and tumours. Infections are followed with medical treatment. Stones and tumours need surgery. The glands operated on most are the parotid and the submandibular.

Salivary gland stones

Stones form most often in the submandibular gland, because of the direction and the consistency of its secretion.

What the patient feels depends on where the stone sits, how much it blocks the flow of saliva, and whether it has infected the gland. Patients usually describe a sudden swelling while they eat, which goes down again after a while. Sometimes the swelling does not go down and infection joins it, with pain, heat and redness. In that case the infection of the gland is treated first with medicines.

Salivary gland tumours

80 per cent of salivary gland tumours start in the parotid, about 10 per cent in the submandibular gland, and the rest in the sublingual and the minor glands. 80 per cent of parotid tumours are benign.

The commonest benign tumour in adults is the pleomorphic adenoma. In surgery for it, only the superficial layer of the parotid gland is removed.

The commonest malignant tumour is mucoepidermoid carcinoma. Here the whole parotid gland is removed together with the lymph nodes in the neck, and depending on the diagnosis and the grade the pathologist gives, some patients have radiotherapy after the operation.

What the patient notices

Patients usually come with a slowly growing swelling in front of the ear.

The doctor asks how long the mass has been there, how fast it has grown and whether it is painful. During the examination the doctor checks the size of the mass, whether it is painful, whether the patient has developed facial paralysis, and the state of the gland on the other side.

A mass that has grown suddenly, or that is stuck and fixed to the tissue underneath, is a warning sign.

Tests

Ultrasound is used most, along with MRI and CT. A fine needle aspiration biopsy is taken for pathological examination. It gives an idea about the tumour, though the definite diagnosis comes only after the whole mass is removed and examined.

Treatment

Treatment is based on surgery. Even a benign tumour must be planned for surgery, because, with a very low probability, it can turn into a malignant one.

The operation is planned from the examination findings, the ultrasound findings and the result of the fine needle aspiration. When the tumour is very probably benign, only the superficial layer of the gland and the tumour are removed. That operation is called superficial parotidectomy.

If you can feel a swelling in a salivary gland, see an ear, nose and throat doctor. It can be a simple infection of the gland, and it can also be a malignant tumour you have not noticed. Early diagnosis and treatment make the treatment easier here, as in every disease.

Parotidectomy (surgery on the gland in front of the ear)

The most important anatomical and surgical feature of the parotid gland is that the facial nerve runs through it. The nerve divides the gland into a deep and a superficial lobe. The facial nerve, which drives the expressions of the face, branches inside the parotid gland and reaches the muscles of facial expression. If these nerves are damaged, movement is lost in the area they supply.

Under general anaesthesia the surgeon makes a cut that starts just in front of the ear and runs down towards under the jaw. The surgeon passes through the skin and the tissue under it and reaches the gland, then lifts the sheath over the gland, called the SMAS. After the mass is removed, that sheath is stretched and stitched back, so that the face does not sink in where the mass was and the skin stays firm. Specific anatomical landmarks are then used to find the main trunk of the facial nerve.

Complications

Infection, bleeding, temporary or permanent paralysis of the facial nerve, numbness around the earlobe, and Frey’s syndrome, which is sweating and redness of the face while eating. Frey’s syndrome is rare and can be treated with botulinum toxin or with other surgical methods.

Avoiding this surgery because of the risk of facial paralysis lets the mass in the parotid grow, lets it stick to the nerve, and can allow a malignant tumour to develop.

Submandibular gland surgery

Under general anaesthesia the surgeon makes a cut about two fingers below the jaw, passes through the skin and the tissue under it, and reaches the gland.

The submandibular gland sits next to many important vessels and nerves. These must be recognised during surgery and left unharmed. The vessels are tied, the nerves are protected, the gland is separated from the surrounding tissue, and its duct is tied as close as possible to the mouth. A drain is left in the area.

Complications

Bleeding and infection. Injury to the hypoglossal and the lingual nerve, which move the tongue and carry its sensation. Temporary or permanent paralysis of the marginal nerve, which is the branch of the facial nerve that runs to the corner of the mouth.