SALIVARY GLANDS

There are multiple salivary glands of varying sizes in the face, neck, and lining mucous membranes of the mouth & throat. The largest is the parotid gland (outlined in Green) which sits in front and below the ear; interestingly it produces only 10% of your saliva. The next largest gland is the submandibular gland (outlined in blue) that produces the most amount of saliva at 25%.

The sublingual glands (outlined in orange) produce a smaller portion of saliva, and the minor salivary glands are very small glands that line the lips, cheeks, palate & throat. They continually produce saliva to keep the mouth moist & begin the process of digestion.

There are 3 main categories of diseases that happen in the salivary glands: Tumors (benign or cancers), inflammatory (infection or autoimmune), and obstructive (stones).

We have a variety of excellent tools that can help the doctors at the CENTER diagnose the source of your parotid disease. Scans can
show the anatomy of the parotid gland and if there is a tumor or stone in the glands, or if the gland is simply enlarged. Blood tests can
tell us if there is inflammation, infection or an autoimmune reaction. Needle biopsy can tell us the exact type of tumor that is present in
the gland.

IMAGING SCANS

There are 4 main modalities used for parotid cancer imaging. They are ultrasound, CT scan, MRI & PET scan. Each has its own particular indication and utility

ULTRASOUND

Ultrasound, specially when done in the office by the parotid surgeon can be very helpful because it can immediately give you very important detail about the tumor. It can show the exact size and shape of the tumor; also wether the borders of the tumor are clearly visible, and is it invading any of the surrounding structures. Lymph nodes inside the parotid gland and in the other areas of the neck can be clearly seen to see if they are enlarged or appear abnormal.

Ultrasound can also be used safely to do a needle biopsy of the parotid tumors, submandibular gland tumors or lymph nodes

CT SCAN

Tumors

CT scans are quick and can give a fair amount of information. Some tumors are very visible as seen in the images to the right; the parotid glands on each side are outlined in blue, the jawbone in yellow, the throat in orange and the tumor in green. A great majority of tumors may not be quite so visible and distinct. It is not the primary scan that we chose at the CENTER to evaluate parotid tumors. CT scans show bone structures really well, such the jaw bone and the bone behind the ear (mastoid bone) that has the facial nerve going through it. It is primarily used when the tumor is close to this area of the skull where the facial nerve comes out skull (stylomastoid foramen). In these rare situations the CT scan tell us if there is room between the tumor and the exit point of the facial nerve to allow for safe identification of the main branch of the nerve during surgery

Stones

CT scans can show stones in the salivary glands & their ducts very well. Salivary stones or sialoliths are made up to a large part from calcium which on a CT scan shows as a light (white) colored object (arrow pointing to it). The jawbone in yellow is also white since all bones are made up mostly of calcium. Additionally the submandibular gland is visible and outlined in blue, the throat in orange and the tongue in red.

The advantage of the CT scan for stones is that it can tell you not only the size and shape of the stone but also wether the stone is in the salivary gland (parotid or submandibular glands) or if it is in the duct of the gland. This is very important because the treatment will be significantly different in each location.

MRI SCAN

MRI is a very sophisticated scan that shows the parotid gland itself in detail, along with the dimensions and shape of a tumor. It also shows other soft tissue structures such as muscles, fat, blood vessels, lymph nodes, and the spinal cord in great detail. It uses magnets to create the image, meaning there is no radiation exposure. It is very useful in showing the characteristics of the tumor that may indicate it has features that are suspicious for cancer and how to best approach tumors that are deeper in the parotid gland for a needle biopsy.

PAROTID TUMOR – In the images on the right, you can clearly see the anatomy with both parotids outlined in blue, the top portion of the jawbone just in front of it in yellow, and the throat outlined in orange. In the top set of images, the tumor is bright white (outlined in green) with smooth borders, extending from the superficial to the deep aspect of the parotid behind the jawbone. It is impossible from these images to tell if this is a cancerous or benign tumor, but it is clear that the tumor is distinct and not invading the surrounding tissues (bone or muscle).

The bottom images show a tumor whose borders are not distinct at all; It is hard to tell where it begins or ends; a rough outline is drawn in red, but there is a possibility that the tumor is invading the muscles behind it. This lack of distinct borders is very suspicious for a cancerous process. The areas of the lymph nodes in the neck can also be examined to see if there are any enlarged, suspicious lymph nodes. This allows the surgeon to plan the optimal surgical strategy and determine what type of reconstruction should be done.

PAROTID ENLARGEMENT – In the images on the right, you can see the parotid glands well outlined in blue. The normal-sized parotid glands are flat and occupy very little space on the side of the face. The enlarged parotid glands occupy significantly more space. In the case shown here, the parotids are both very enlarged, bulging outward, as well as growing inwards and forward towards the duct.

The jawbone, outlined in yellow, shows how much of the parotid gland is growing deeper inwards and towards the throat, while the majority of it is growing outward and bulging against the skin.

PET SCAN

PET Scans are based on looking at areas of the body that take in high concentrations of low-dose radiolabeled sugar. Sugar is easy fuel for a growing cancer and concentrates in cancer cells. The scan can detect any area of the body that has a high concentration of the labeled sugar (blue circle). Based on that, your doctor can determine if your tumor is limited to its area of origin (parotid gland, for example) or if it has spread to the lymph nodes in the neck, lungs, bones, liver, etc.

This is very helpful because it tells us if the cancer is limited to the site of origin (parotid gland), which may be treated with surgery. On the other hand, if the tumor has spread to other parts of the body, then the plan of action may change to treating with combination therapy rather than surgery.

NEEDLE BIOPSY

Needle Biopsy

Needle biopsy of parotid tumors is a very accurate way of identifying the type of tumor you are dealing with. At the CENTER we perform ultrasound guided needle biopsy of almost all parotid tumors, and for our patients that live in other cities we help you arrange for a biopsy. Needle biopsies of salivary tumors are accurate in about 96% of cases; this means in roughly 4% of cases, the needle biopsy results that indicated a benign tumor will be found to be not benign during or after surgery. It is rare for the opposite to happen where the biopsy shows a cancer and on final pathology it is found to be benign.

The biopsy needle has a hollow core, and when it goes into the tumor, tumor cells are sucked into the needle’s hollow core. The needle is then withdrawn with all the tumor cells all inside the needle. The cells are then spread over a glass slide and prepared for the pathologist to look at under the microscope.

Needle biopsy of deeper tumors can also be done under ultrasound guidance or at times under CT guidance. Some tumors will be accessible through the mouth. The pathology reports can guide your surgeon how aggressive the cancer is, and what is the appropriate course of action.

NEEDLE BIOPSY REPORT

Needle biopsy most often will give a clear answer and tell us what type of tumor is present. The reporting protocol is called the Milan System, which not only tells you the category of diagnosis but also the risk of the diagnosis not being accurate and a cancer instead.

Combining the needle biopsy report with the timeline of tumor development, symptoms, and the way the tumor looks on scans can help the doctors at the CENTER figure out what is the next best step. The pathology results can show four categories of tumors, which are treated differently.

Category 1 – Benign tumors that have a very low chance of transforming into cancer. These can be left to be observed if they are not large, not growing, and not causing symptoms.

Category 2 – Benign tumors that have a high probability of transforming into cancer. These should be removed even if they are small and not causing any symptoms. A small amount of additional parotid tissue should be removed (3 millimeters) to prevent recurrence. The facial nerve is carefully identified and preserved.

Category 3 – Low-grade cancers that need to be removed with surgery fairly quickly. The amount of additional parotid tissue that needs to be removed is more than in Category 2, and usually, the lymph nodes in the neck are not involved and may not need to be removed. The facial nerve is uninvolved in low-grade tumors, and it should be carefully identified and preserved.

Category 4 – High-grade cancers that need to be thoroughly investigated to make sure they have not spread to other parts of the body. If limited to the parotid (or submandibular) gland, or the adjacent lymph nodes, then surgery is the best treatment option and should be done immediately. If the facial nerve is fully functional, then in most cases, at the CENTER, we are able to preserve its function. A larger amount of additional parotid tissue will need to be removed, and oftentimes, it is followed by further treatments.

The information the needle biopsy provides will allow you to know the optimal treatment options for you and what to expect with surgery.

Blood Tests

The blood tests have a limited role in helping diagnose parotid disease. They can help tell you if you have autoimmune salivary gland disease or Sjögren’s syndrome. They can also help to see if the parotid gland is affected by an in flammatory condition called Sarcoidosis. Some infections can be tested by blood tests. Work is ongoing for diagnosis of cancers
through blood tests.

Sjögren’s Syndrome:
  • ESR
  • C Reactive Protein
  • ANA
  • SS-A
  • SS-B
  • Parotid specific protein Ab
  • Carbonic Anhydrase VI Ab
  • Salivary protein 1 Ab
Sjögren’s Syndrome:
  • ACE levels
Sjögren’s Syndrome:
  • Mumps antibody titers

FREQUENTLY ASKED QUESTIONS

Can an MRI be done without contrast?

Benign tumors can be seen very well on an MRI without contrast. But for cancers of the parotid the contrast material helps show the cancer and its extent much better

Can a needle biopsy spread the tumor?

Fortunately not. There are no reported cases of tumor spread in the salivary glands from needle biopsy. More importantly, cancers either have a genetic make up (mutation) that allows them to spread or they don’t. If a cancer does not have the genetic mutation that allow it to spread, then it will not spread with anything including a needle biopsy. On the other hand, if it does have the genetic potential to spread, then the cancer cells will find lymph vessels or blood vessels inside the tumor or immediately next to itself to spread; basically it wont require an external factor like a biopsy needle to spread it

Can a needle biopsy harm the facial nerve?

Although the possibility exists, it is fortunately so incredibly rare that we at CENTER have not ever seen that occur.

Is the needle biopsy painful?

In the hands of an experienced doctor it should not be painful, because local anesthetic is used. And for anxious patients, at the CENTER we numb up the skin with anesthetic cream before we start. The one exception is in the cases of the tumor of the nerves (Schwannoma), which can be painful. Fortunately Schwannomas are exceedingly rare.

How long does it take to get needle biopsy results?

It usually takes 3-4 days to get results.

Is MRI better then ultrasound?

It really depends on what information is needed. In cases of small tumors that are super ficial, the ultrasound is more then adequate to show us the tumor’s size, shape and relationship to other structures. In cases of larger tumors that may have a component that goes deep to the jawbone, the MRI is better able to show the whole extent of the tumor, since ultrasound can’t see through bone.

In the MRI to image the tumor (bright white) is going deep to the jawbone
(yellow) and going towards the throat (orange)

Meet The Team

Led by board-certified parotid surgeon, Dr. Babak Larian, our team of specialists has decades of experience successfully diagnosing and treating diseases of the parotid glands with minimally invasive procedures. Distinguished by our compassionate care and cutting-edge techniques, the CENTER has developed a reputation for delivering the best parotid tumor surgery available.

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