Maxfacts

Surgical removal is the first line treatment for salivary gland malignancies, whenever possible. Many of the surgical interventions to treat these malignancies are not fundamentally different from surgical techniques for the treatment of non-malignant conditions of salivary glands.

Non-malignant salivary gland conditions are far more common than malignancies; this is the reason why we describe surgical interventions (in particular procedures to remove sublingual, submandibular or parotid glands) in the section covering the treatment of non-malignant salivary gland conditions.

There are some differences in the surgical (and additional) treatment schemes between malignant and non-malignant salivary gland conditions. Of relevance for the treatment of malignant salivary gland conditions are the following points.

• Resection (removal) of a gland (and surrounding tissue(s)) may have to be more radical than for a non-malignant condition, to ensure a margin of healthy tissue is maintained.
• The required degree of radical resection in some cases will necessitate surgical reconstruction of the defect created in the ablative surgery, for hard (bone) and/or soft tissues as required.
• If in the removal of a parotid gland the facial nerve (which is embedded in the parotid gland) has to be sacrificed, then some form of functional rehabilitation is necessary. There is no evidence to support resection of a functioning facial nerve in parotid or submandibular gland malignancy in order to achieve a 1 cm margin of clearance in terms of 5 year survival. The facial nerve is mainly a motor nerve (it also has some sensory functions) and its loss leads to facial paralysis. This is a significant morbidity and if the nerve is functioning prior to resection for salivary gland malignancy, the aim should be to excise the gland and tumour but maintain structural integrity of the nerve wherever possible.  The most appropriate approach for rehabilitation is, to some extent, also determined by the prognosis of the underlying condition. In circumstances where surgery is carried out with curative intent and with a good overall long-term prognosis, sophisticated (and invasive) reconstructive nerve grafting may be the best option to restore function. In other circumstances and where treatment is palliative in nature, it may be better to opt for less invasive, simpler rehabilitation options such as a lateral tarsorrhaphy (reducing the opening of the eyelids) to minimise ephiphora (excessive watering of the eye) and prevent scleral exposure (exposure of the eyeball), and a temporalis muscle and fascia flap to raise the corner of the mouth combined with a simple rhitidectomy (‘face lift’).

• Depending on the clinical findings at diagnosis stage, it may be necessary to include a neck dissection in the surgery (lymph nodes in the neck may have to be removed in a more or less radical manner).
• Depending on the clinical and pathological findings, after surgery additional radiotherapy may be required. Sometimes, for example for inoperable or fungating tumours (ulcerating tumours breaking through skin) or in palliative care, radiotherapy will be the treatment modality of choice. It will not be a curative treatment in such circumstances.
• Chemotherapy currently is of no benefit in the treatment of salivary gland malignancies.
• Malignancies affecting minor salivary glands, in the palate or the buccal mucosa (oral lining tissue of the cheek), are treated the same way as squamous cell carcinoma of the mouth; similarly, malignancy of the sublingual gland is treated the same way as a thick squamous cell carcinoma of the floor of mouth.
• Careful long-term monitoring and reviewing in an out-patient setting are highly desirable for all malignancies of the salivary glands.