ABSTRACT:Objective: To study demographic, clinical andhistopathological features of salivary gland disorders in a tertiary carehospital.Patientsand Methods: Thisprospective cross sectional study of 4 years was carried out in the Departmentof Surgery, Fatima Jinnah Medical University, Sir Ganga Ram Hospital Lahore. Thestudy was carried out on 58 patients suffering from salivary gland disorderspresenting to our surgical outpatient department, from January 2013 to October2017.All admitted cases were assessed by thorough history, physical examinationand relevant investigations. After performing relevant surgical procedures,specimens were examined by histopathology department.
Results:In this study age range of thepatients was from 15 to 80 years with mean ± SD age of 34±1.4 year. Males were23 and females were 35 with male: female ratio of 1:1.52.
Most of the patientspresented in 2nd and 3rd decades (60.3%). Swelling was thecommonest clinical feature with mean duration of 2±2.
2 years. Pleomorphicadenoma was the commonest benign tumor (86.2%), affecting parotid gland in95.
55% of cases. Mucoepidermoid carcinoma was the commonest malignant tumor(6.9 %) predominantly found in submandibular glands (18.18 %), followed by parotidglands (4.5%).
No sublingual tumor was found in this studyConclusion:Salivary gland disorders predominantlyaffecting middle age female population. Benign tumors are the commonlyoccurring salivary gland tumors. Pleomorphic adenoma is commonly occurringbenign tumor affecting predominantly parotid gland while mucoepidermoidcarcinoma is the commonest malignant tumor of submandibular glands. Inflammatorydisorder (Chronic sialadenitis) is also common in submandibular glands.KeyWords: Benign,Malignant, Histopathology, Pleomorphic adenoma, Mucoepidermoid carcinoma. INTRODUCTION:Salivarygland tumors are a heterogeneous group of neoplasm in the head and neck region.The major salivary glands are parotid, submandibular and sublingual, whileminor salivary glands are located throughout submucosa of upper aero-digestivetract with maximum amount on the palate.
Benign and malignant both can developin all salivary glands. Although salivary gland tumors are less than 1% of all thetumors, however prevalence of these reported in the literature differs.1 Salivary gland tumors constitutes 2% to 4% ofall the head and neck tumors. The prevalence of salivary gland tumors isreported to be from 0.4 to14 cases per anum per 100,000 population across theglobe. While the prevalence of malignant salivary gland range from 0.
4 to 2.6per 100,000 population per anum. Among all the salivary gland disorders thecommonest benign and malignant tumors are pleomorphic adenoma andmucoepidermoid carcinoma, respectively.2 About 80% involves parotidglands, while 10% to 20% occur in submandibular and sublingual glands incidencewise. Approximately 80% of benign tumor of parotid glands is pleomorphicadenoma.1 The cause of these tumors is still unknown;probably ionizing radiation, vitamin A deficiency, tobacco, prolonged exposureto sunlight, and chemotherapy may contribute in the development of thesedisorders.
A longstanding lump is the presenting features of benign salivarygland tumors, while malignant tumors can present with rapidly growing lump, pain,facial nerve palsy, trismus, fistula formation, skin involvement, cervical lymphadenopathyand weight loss2,3. Malignant parotid tumors mayinvade facial nerve in about one third of cases, while malignant tumors ofsubmandibular and sublingual glands may involve hypoglossal nerve, followed bytrigeminal and facial nerves. Embryologically salivary glands develop as aresult of initial thickening of the epithelium of the stomodeum, whereassubmandibular and sublingual glands develop from endodermal germ layers3, while parotid gland develops from oral ectoderm. Itis a diagnostic dilemma for histopathologist on one hand and challenging taskfor its classification on the other hand, due to complexity and rarity of thesedisorders. In 1972 World Health Organization (WHO) published firstclassification of salivary gland tumors, which has been amended so many timesin last 4 decades.
4 The diagnosis of salivarygland disorders can be achieved with clinical features complemented with fineneedle aspiration cytology, ultrasonography, magnetic resonance imaging, andcomputed tomography confirmed by histopathological study of the specimen. However sometimes fine needle aspiration cytology alone cannot distinguishbetween benign and malignant tumors2,4. Benignsalivary gland tumors of parotid glands are treated by superficialparotidectomy, while benign submandibular gland tumors are excised totally,followed by observation for any recurrence. Treatment of malignant salivarygland tumors is total excision of primary tumor along with removal of thesurrounding involved tissues, plus neck dissection followed bychemo-radiotherapy.
The incidence of complications especially facial nervedamage is common in malignant tumors due to close relationship of nerve withgland.5 As salivary gland tumors are common in ourPakistani society and sizeable cases are frequently presenting to our surgicaloutpatient departments, which are admitted and treated properly. So the purposeof this study was to look into demographic, clinical and histopathological featuresof salivary gland disorders.PATIENTSAND METHODS:This cross sectional study of 4years (January 2013 to October 2017) was carried out in the Department ofsurgical unit 2, Fatima Jinnah Medical University, Sir Ganga Ram HospitalLahore. After getting approval from hospital ethical board, all patients withsalivary gland disorders were included. Well informed written consent was takenfrom each patient explaining risks, benefits, associated complication of thesurgical procedure, prognosis of the disease and about publication ofphotographs if needed.
All patients were evaluated in terms of detailedhistory, thorough local, oral cavity and systemic examination complemented byrelevant investigations especially fine needle aspiration cytology (FNAC) ofthe swelling, ultrasonography and in certain suspicious cases CT scans of headand neck with IV contrast were also done. Every swelling was assessed for itssize, duration, transillumination, fluctuation, consistency, bimanualpalpation, lymphadenopathy, skin and neurological involvement. After gettingdiagnosis of the lesion based on clinical examination, radiologicalinvestigation and FNAC, surgical procedure was performed accordingly.
Thespecimens were examined by histopathologist to confirm the disease. The datawere analyzed through SPSS version 20.RESULTS:Inthis study 58 patients were included with mean ± SD age of 34±1.4 years (agerange 15–80 years). Males were 23(39.
7%) and females were 35(60.3%) with male:female ratio of 1:1.52. Most of the patients presented in 2nd and 3th decades (60.3% ,35). And out of those 35patients in this age group pleomorphic adenoma was the commonesthistopathological finding (58.
0%, 29), followed by mucoepidermoid carcinoma(50%, 2). (Table 01). Regarding clinical features of salivary gland disorders,swelling was the commonest (100%) presentation with mean duration of 2±2.2years. Most of the swellings (87.9%, 51) were firm on palpation and slow growthof the swellings was noticed in most of the patients (72.41% ,42).
Otherfeatures found were pain, facial nerve palsy, fixity, skin involvement,transillumination, and cervical lymphadenopathy, in 17.2%, 1.7%, 3.4%, 3.4%,3.
4%, 3.4%, respectively (Table 02).Overall benign salivary gland disorderswere 54 (93.
1%), and malignant were 4(6.9%). Among all benign disorders 50cases (86.2%) were benign tumors, while 2 (3.7%) were inflammatory and twocases proved to be benign cysts. Overall benign tumors were noticed in parotidglands followed by submandibular glands. No tumor was found in sublingualglands.
Among the benign, pleomorphic adenoma was the commonest histopathologicalfinding (95.55%) in parotid glands followed by submandibular (63.33%). Theoverall incidence of malignancy was common in submandibular glands (18.
18%) 2, followedby parotid glands (4.5%) 2. Among the malignant tumors mucoepidermoid carcinomawas the commonest histopathological finding (6.9%) 4. (Table 3). Table01 Age wise distribution of Salivary Gland Disorders – N(%) (n-58) Age Histopathology Pleomorphic adenoma Mucoepidermoid carcinoma Chronic sialadenitis Lymphoepithelial cyst Epidermal inclusion cyst Total <20 8(16.0) 0 0 0 0 8(13.8) 21-40 29(58.
0) 2(50) 2(100) 1(100) 1(100) 35(60.3) 41-60 10(20.0) 2(50) 0 0 0 12(20.7) >60 3(6.0) 0 0 0 0 3(5.2) Total 50 4 2 1 1 58 Table 02 Clinical features of the studyParticipants Clinical Features (n=58) % Swelling 58 100% Pain 10 17.2% Slow Growth Pattern 42 72.41% Facial palsy 1 1.
7% Fixity 2 3.4% Skin involvement 2 3.4% Transillumination 2 3.4% Cervical lymphadenopathy 2 3.4% Consistency : Soft 3 5.2% Firm 51 87.9% Hard 4 6.9% Table 03 Distribution of Salivary gland tumors according tohistopathology- N(%) (n-58) Salivary gland disorders Total N(%) Parotid glands (n-45) Submandibular glands (n-11) Sublingual glands (n-2) Benign (n-54) · Pleomorphic adenoma 50 (86.
2) 43 (95.55) 7 (63.33) 0 · Chronic sialadenitis 2 (3.7) 0 2 (18.18) 0 · Lymphoepithelial cyst 1 (1.85) 0 0 1 (1.85) · Epidermal inclusion cyst 1 (1.
85) 0 0 1(1.85) Malignant (n-4) · Mucoepidermoid carcinoma 4 (6.9) 2 (4.5) 2 (18.18) 0 Fig:1. A 22 years young girl withrecurrent mucoepidermoid carcinomaFig: 2.
CT scan of a patient withpleomorphic adenoma in a suspicious (Bimanually palpable) case Fig: 3. Total excision of parotid gland with deep lobeinvolved (pleomorphic adenoma) DISCUSSION:Themajor salivary glands are parotid and submandibular. Tumors may arise frommajor as well as minor salivary glands. Both benign and malignant tumors can affectthese glands irrespective of the age. In this study mean±SD age of the patientswas 34±1.4 years (age range 15-80 years), coinciding with Ashkavandi’s6 study with age range from 5-83 years and meanage 41.
8±16.7, and Shrestha’s7 study withage range of 12-75 years and mean age of 44.76 years. We found femalepredominance in this study with female: male ratio of 1.52:1 contradictingreports of Memon, Shrestha and Lawal with male: female ratio of 1.5:1, 1.
7:1,1.2:1 respectively.7-9 This female predominancecannot be explained based on results of this study. In this study most of thepatients presented in 2nd and 3rd decades (60.
3%,35) followed by 4th decade which is in accordance with Kumar’s10 study with majority of patients received in 2nd and 3rd decades(25.0%, 18.3%) and Souvagini’s11 study withmaximum number of patients presented in 3rd and 4th decades (31.1%, 39.8%), while it iscontradicting Lawal’s9 report who found majorityof patients in late age of 5th to 6th decade (53.
5%). In this study right sided salivary glands werecommonly involved (53.44%, 31) and parotid was the commonly affected gland (77.
58%, 45),which is supported by Shetty’s12 studywhere right side and parotid glands were commonly affected followed bysubmandibular. Simmilarly Oti13 reportedthat right salivary glands were the commonest (17.35%) affected glands, predominantly parotid glands (9.91%), and in Wahiduzzaman’s13 study where parotid gland was commonlyinvolved (84.0%) followed by submandibular gland (16.0%). Inthis study the clinical features noted were slowly growing lumps for 1-4 years(53.44%, 31) with mean duration of 2±2.
2 years, firm on palpation (87.9%), pain,facial nerve palsy, fixity, skin involvement, transillumination, and cervicallymphadenopathy, in 17.2%, 1.7%,3.4%, 3.4%, 3.
4%, 3.4% respectively, which isconsistent with study of Souvagini11 whoreported that mostly the tumors were slow growing (80%),and were firm (86.66%) with associatedfacial (4.44%), hypoglossal nerve palsies (2.22%), pain (33.33%), and musclespasm (13.
33%). Likewise Wahiduzzaman13 found thatclinical features were swelling (100%), pain (12.0%), facial nerve palsy (6.0%)and palpable lymph nodes (10.0%). On histopathological examination among thesedisorders 54 cases (93.1%) were benign while 4 cases (6.
9%) were malignant.Pleomorphic adenoma was the commonest benign tumor (86.2%, 50), predominantlyaffecting parotid glands (95.55%,43) followed by submandibular glands(63.33%,7). Our results are keeping with study of Etit D14 who reported that out of 235 cases, 146(62.13%) were benign and 89 (37.87%) were malignant.
Among the major salivaryglands, parotid gland was commonly affected 82.38%, followed by submandibulargland 17.62%. He also found that the two most common benign tumors werepleomorphic adenoma (n = 98; 67.12%) and Warthin’s tumor (n = 31; 21.23%).
Ourresults are also supported by Ashkavandi’s6 resultwhere benign tumors constituted 248 (67.8%) of all tumors, pleomorphic adenomawas the most common tumor comprising 54.3%, and these neoplasms tend to involveparotid and submandibular glands more frequently. Similarly Morais15 revealed that out of 303 epithelial salivarygland tumors, (71%) were benign and (29%) were malignant; pleomorphic adenomawas the most frequently found benign tumor primarily affecting the parotid. Likewise Souvagini11 disclosed that benign tumorswere frequently encountered in parotid (71%) followed by submandibular (4.5%),whereas pleomorphic adenoma was the commonest benign tumor. Howevere my resultsvaries from Lawal’s9 study who noted that outof 413 salivary gland tumors, 221 (53.
5%) were malignant and 192 (46.5%) werebenign. Inthis study the overall incidence of malignancy was 6.9% and mucoepidermoidcarcinoma was the most common malignant tumor.
Mucoepidermoid carcinoma waspredominantly found in submandibular glands (18.18%), followed by parotid (4.5%).Regarding malignancy our results are in conformity with Wahiduzzaman13 who found that malignant tumors were 23.8%and mucoepidermoid carcinoma was the commonest malignant tumor affectingparotid gland (16.67%), while adenoid cystic carcinoma commonly affectingsubmandibular glands (50.0%).
Simmilarly in Shrestha’s7 study mucoepidermoid carcinoma was most common(38.1%) among the malignant salivary gland tumors. Parotid was the most commonsite of occurrence 26 (23.6%) for mucoepidermoid carcinoma followed by minorsalivary glands 10 (9.0%) and submandibular gland 6 (5.4%). In addition,Souvagini11 observed that overall malignancy was 20%, ofwhich mucoepidermoid carcinoma was 44.
4% and adenocystic carcinoma was 33.3% onpalate and cheek. Our results are also consistent with Memon’s8 report where malignant tumors were 20%,parotid was commonly affected (87%) and mucoepidermoid carcinoma was 2.5%.Likely in shetty’s12 study mucoepidermoidcarcinoma was 12.5% and adenoid cystic carcinoma was 8.9%. CONCLUSION:Itis concluded that salivary gland disorders predominantly affecting middle agefemale population.
Benign tumors are the commonly occurring salivary glandsdisorders in long standing swelling arising from salivary glands. Pleomorphicadenoma is the commonly occurring benign tumor affecting parotid glandspredominantly, while mucoepidermoid carcinoma is the commonest malignant tumorof salivary glands.