CHAPTER I

INTRODUCTION

A. Background

Salivary glands have many functions, including to produce saliva,

which contains enzymes to begin the process of digesting food as well as

antibodies and other substances that help prevent infections of the mouth and

throat. There are two main types of salivary glands: the major salivary glands

and minor salivary glands. The major salivary glands are consisted of three

sets, the parotid glands in front of the ears, the submandibular glands below

the jaw and the sublingual glands under the floor of the mouth and on the

sides of the tongue. The minor salivary glands are several hundreds and are

located beneath the lining of the lips, tongue, in the roof of the mouth, and

inside the cheeks, nose, sinuses, and Larynx (Dimas, 2015).

Salivary gland tumors most often present as painless enlarging masses.

Most are located in the parotid glands and most are benign. Tumors of the

salivary glands are uncommon and represent 2-4% of head and neck

neoplasms. They may be divided into three broad categories, as follows:

Benign neoplasms, Tumor-like conditions, Malignant neoplasms. The salivary

glands are divided into two broad categories, major and minor. The major

salivary glands include the following: Parotid, Submandibular, Sub lingual.

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The minor glands are dispersed throughout the upper aero-digestive sub

mucosa (ie, palate, lip, pharynx, nasopharynx, larynx, and parapharyngeal

space) (Chahin, 2015).

Salivary gland tumors in the parotid or submandibular glands usually

present as an enlarging mass. This may be associated with neurological

symptoms such as facial nerve paralysis or pain if the tumor is malignant.

Minor salivary gland tumors present as a submucosal intraoral mass which

subsequently ulcerates. Clinical features suspicious for malignancy include

ipsilateral facial nerve palsy, sudden tumor growth, pain, tumor fixation to the

overlying skin or underlying muscle, and cervical lymphadenopathy

(Victor,2012).

The global incidence of these tumors is 0.4–13.5 per 100,000 persons

annually. Salivary gland neoplasms are also relatively uncommon with an

estimated annual incidence in the United States of 2.2 to 2.5 cases per 100,000

people, they constitute only about 2% of all head and neck neoplasms.

(Elizabeth, 2002). Among salivary gland neoplasms, 80% arise in the parotid

glands, 10-15% arise in the submandibular glands, and the remainder arise in

the sublingual and minor salivary glands. Most series report that about 80% of

parotid neoplasms are benign, with the relative proportion of malignancy

increasing in the smaller glands. Incidence rate of malignant salivary gland

tumors in the Italian 1981 census population is of 1/100,000 per year in males

and 0.8/100,000 per year in females. A useful rule of thumb is the 25/50/75
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rule. That is, as the size of the gland decreases, the incidence of malignancy of

a tumor in the gland increases in approximately these proportions (Steve,

2015). The current largest and most detailed classifications of salivary gland

tumors are the WHO Seifert and Sobin classification and the Ellis and Auclair

Armed Forces Institute of Pathology (AFIP) classification. Pleomorphic

adenoma is considered as the most common benign salivary gland neoplasm,

comprising about 50%-74% of all parotid tumors. It is followed by Warthin’s

tumor, which accounts for about 4-14% of all parotid tumors. Approximately

90% of parotid tumors occur in the superficial lobe while the remaining 10%

occur in the deep lobe, lying under to the facial nerve. If there is clinical

evidence of bilateral parotid swelling, Warthin’s tumor should be suspected,

being the most frequent synchronous or metachronous bilateral histological

type (Ungari,2008).

The parotid, and indeed any of the other major salivary glands can

become swollen for a number of reasons, most common amongst them are

from viral or bacterial infections, stone formation and inflammation. The

above conditions are often transient and benign, and will resolve in most

instances with medical treatment, except for parotid stones which may require

surgical removal. The parotid gland may also develop tumors or neoplasms.

These typically present as a painless lump located over the angle of the jaw or

just under the earlobe. Tumors may also arise from the submandibular and

sublingual glands (located below the jaw-line and under the tongue
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respectively), but these are less common than those of the parotid gland.The

salivary glands are the site of origin of a wide variety of neoplasms

(Sivanandan, 2007).

Etiologic factors of this group of neoplasms have not been recognized

exactly however; Ionizing radiation, sunlight, chemotherapy, smoking and

vitamin A deficiency have been pointed out in the literature. These tumors

have inconsistent characteristics in different countries and it seems that

geographic location and ethnic factors may affect clinicopathologic profile of

these tumors (Jaafari,2013).

Clinical history and physical exam is reported as giving adequate

information to focus on a feasible diagnosis. If patient history and clinical

exam only are inadequate, further investigation by Ultrasound (US), US-

guided Fine-Needle Aspiration Cytology (FNAC), Magnetic Resonance

Imaging (MRI) or by Computed Tomography. (CT) might be required. only

surgery can give histological certainty of tumor nature and prevents long term

malignant degeneration or lump infection or size-dependent facial nerve

damage risk. Conservative parotidectomy is the most widely accepted surgical

treatment for parotid tumors removal (Ungari,2008). Based on the above, the

author would like to discuss about parotid tumor and its treatment.

B. Purpose

1. Determine the classification of parotid tumor

2. Knowing how to diagnose and treatment of parotid tumor

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C. Benefit

1. To understand how classification and treatment for patient with parotid

tumor

2. To understand the classification and metastases which may occur in

patient with parotid tumor.