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258 Salivary Gland Diseases in Children and Adolescents

and acinic cell carcinomas follow in frequency, each occurring at
approximately 5–10%. The mainstay of treatment of salivary gland
tumours is surgery.
Pleomorphic Adenoma
Pleomorphic adenoma (mixed tumour) is the most common childhood
salivary gland tumour, occurring mostly in the parotid gland. Typical
features are as a hard or firm or fluctuant, painless, slow-growing,
freely mobile, bossellated mass. Facial nerve paralysis in association
with pleomorphic adenoma never occurs, even in large grotesque swell-
ings seen in Africans (Figure 39.5). The most common intraoral site is
the palate, followed by the buccal mucosa and the lip (Figure 39.6).
In the minor salivary glands, the features include bossellated Figure 39.5: Pleomorphic adenoma of the parotid gland
ulcerated swelling, causing ill-fitting dentures and difficulty in speech,
which may occasionally erode the palatine bone. Ulceration is usually
as result of trauma or following topical application of herbal medication.
No childhood age is exempt, with a median of 15 years from some
studies, occurring predominantly in females.
At ultrasound, the pleomorphic adenoma varies from hypoechoicity
to isoechoicity relative to the rest of the gland, with occasional
hyperechogenic foci due to some calcifications within the mass. CT
and MRI demonstrate varying findings depending on the tumour size.
Small lesions are homogenous with well-defined margins, whereas
larger lesions are more heterogeneous with less well defined margins.
FNA cytology confirms the benignity of this tumour.
Microscopically, the pleomorphic adenoma tumour is composed Figure 39.6: Pleomorphic adenoma of the buccal mucosa.
of varying proportions of glandular-like epithelium and connective
tissue stroma. Epithelial cells may show nests, solid sheets, or ductal
structures with varying stroma, which may be myxoid, chondroid,
fibroid, or osteoid with some areas of squamous metaplasia and foci
of keratin.
Treatment is parotidectomy (superficial or total) with facial nerve
sparing. In the submandibular gland; treatment is submandibulectomy.
In the minor salivary glands, wide local excision with a circumscribed
incision of 3–5 mm of apparent normal tissue is made around the tumour.
There is a high recurrence, usually due to enucleation of the tumour.
Parotidectomy procedure
1. The external auditory canal is blocked with a pledget of cotton wool
to prevent blood from entering into the ear canal.
2. A lazy S incision starts anterior to the ear helix, extends posteriorly
over the mastoid bone, and curves anteriorly parallel to the angle of
the mandible or running along the submandibular incision line up to
about 3 cm.
Figure 39.7: Skin incision exposed and sutured down. The posterior belly of
3. A skin incision is raised, exposing the superficial parotid fascia, and digastrics and facial nerve are identified with forceps.
is retracted and sutured down (Figure 39.7).
4. The mastoid, the anterior border of the sternocleidomastoid muscle,
and the posterior belly of the digastrics muscles are identified. Finger
pressure is applied medial to feel for the styloid process.
5. The posterior belly of the digastrics muscle is retracted, exposing
the facial nerve as it exits from the stylomastoid foramen (see Figure
39.7).
6. The nerve is followed into the parotid gland, where it divides into its
five terminal branches under the superficial lobe.
7. For superficial parotidectomy, the gland is dissected off the nerve.
For total parotidectomy, the superficial lobe is removed and the deep
lobe is excised after elevating the nerve.
8. The surgical site is irrigated and a suction drain is inserted.
9. The wound is closed in layers and a compression dressing is applied
(Figure 39.8).

Figure 39.8: Wound closure with an in situ drain.