KOCHI: Ever felt saliva gushing into your mouth at the mere thought of a piping hot biriyani or pickled mango? Saliva has an important role to play in our bodily functions rather than just salivating after food! It cleanses and lubricates the mouth; it initiates digestion, supplies much-needed minerals and has an antibacterial action.
The glands
The salival ducts that open into the mouth originate from three pairs of major and several minor salivary glands. Major salivary glands — parotid gland, submandibular gland and sublingual gland — are situated on either side of the face, under the jaw and under the tongue, respectively. The minor salivary glands are peppered all around the mouth and throat. Much like every other gland in our body, swellings that arise in these glands are either because of inflammation or due to a tumour. While the inflammatory process can be controlled by medication, the ideal treatment for the tumour is surgery.
Salivary gland tumours
Salivary gland tumours are found usually among smokers and alcoholics, individuals exposed to radiation and certain blue-collar professions such as plumbers or workers who handle asbestos regularly.
The tumour may also present as facial weakness or pain to the side of the face. The patient may experience difficulty opening the jaw and/or bleeding inside the mouth.
The tumours are broadly categorised as benign or malignant, with a majority of them occurring in the parotid gland. Nearly 70% of such swellings are benign whereas malignant tumours have an increased potential to recur and can spread into the neck and body. However, there are also chances of recurrence even in benign tumours.
The glands are near to important nerves in the head and neck region. The parotid gland has a complex anatomy that requires an experienced eye and a trained hand for dissection. The facial nerve (innervates muscles of facial expression) lies within the parotid gland, separating it into superficial and deep parts. It is so intricate that it is often a challenge to identify and preserve all the branches of the nerve. The submandibular gland is also close to a branch of the facial nerve and nerves supplying muscles of the tongue.
Assessment
The evaluation for a tumour usually involves radiological investigation (USG, CECT, MRI) and a histopathology test (Needle cytology/biopsy). However, none of these tests are a replacement for a thorough clinical examination.
For example, a female patient presented with an ultrasound and biopsy report from another centre, which suggested a benign tumour that required only an adequate resection. However, after engaging in a comprehensive discussion about her symptoms and conducting a thorough examination, the clinician suspected the tumour to be not as innocent as it appeared. An MRI and an ultrasound-guided biopsy proved that the tumour was malignant with extension towards the throat, which required a more extensive surgery.
Treatment
Frozen section is a method of pathology examination that gives results within 30 minutes. By this method, we can determine whether the tumour is benign or malignant and thus tailor the surgical clearance. Another patient, with multiple swellings in the parotid region, reported that he had been operated on twice previously for a benign disease. The recurrence would probably have been a result of incomplete removal or a breach in the tumour leading to seeding. The third frozen section reported it as a malignancy requiring a more extensive procedure.
The tumour rarely infiltrates the nerve and requires resection. Often with salvageable nerve stumps, it is possible to reconstruct the nerve by certain techniques. If such a reconstruction is not possible, facial reanimation techniques can be applied.
For example, a girl who unfortunately needed nerve resection along with the tumour was rehabilitated in the same sitting thanks to cable grafting the cut ends with a stump obtained from a nearby nerve. After surgery, she started physiotherapy and could regain the nerve functions within a year.
While surgery is the main treatment for salivary gland tumours, the patient may sometimes require the intervention of a radiation oncologist or medical oncologist.
The writer is a consultant of head & neck surgical oncology at Aster MIMS, Kozhikode
Mind and Body
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