Submandibular Gland Tumors

Most submandibular gland tumors present with a slow-growing, painless mass inferior to the man-

Submandibular Gland Mass
Figure 9.1. A 64-year-old man with a painless submandibular mass.

dible (Figure 9.1). In a series of 87 submandibular gland carcinomas, 94% presented with a palpable mass and 39% with pain (Kaszuba, Zafero, and Rosenthal et al. 2007). As tumors of the gland are rare and inflammatory swelling secondary to sialo-lithiasis is seen more often, they may not be initially diagnosed and can present with late disease. In one series 50% of all referred patients with submandibular gland tumors had already had their submandibular gland removed on the presumption that the involved process was benign (Camilleri et al. 1998). The average tumor size in 370 cases of cancer of the submandibular gland was 2.9 cm (Bhattacharyya 2004). Inflammatory disease, however, is often painful and usually characterized by exacerbations and resolutions of the swelling in relation to eating. In a series of 258 submandibular gland excisions, 119 (46%) had sialolithiasis, 88 (34%) sialadenitis, and 51 (20%) tumors (Preuss, Klussmann, and Wittekindt et al. 2007).

Examination usually reveals a smooth, firm to hard mass in the submandibular triangle that is most commonly discrete and mobile. Fixation of the mass to the skin or underlying mylohyoid muscle is a sign of malignancy with advanced extracapsular infiltration (Figure 9.2). Neural involvement of the mandibular branch of the facial nerve with ipsilateral lower lip palsy, the lingual nerve with ipsilateral anesthesia/paresthesia of the tongue, or the hypoglossal nerve with ipsilateral palsy of the tongue muscles are also signs of cancer. Associated hard cervical nodes due to regional metastasis may also be present in malignant tumors.

The differential diagnosis of a solitary mass in the submandibular triangle with no overt signs of malignancy will include lymphadenopa-thy, plunging ranula, vascular malformation, and branchial cysts. It may be difficult to differentiate a lymph node from the enlarged gland on clinical examination alone. If the mass is bimanu-ally palpable from within the floor of the mouth it is more likely to be a submandibular gland mass, and if it can be "rolled" over the lower border of the mandible on palpation it is a lymph node. The plunging ranula is usually soft-cystic in consistency but can become firm if chronically encysted. Vascular lesions are also soft and may "pit" on firm pressure or have thrills and murmurs. Branchial cysts lie more posterior and are partially

Cysts Adenoma Submandibular Gland

Figure 9.2b. Lateral facial view shows skin fixation and tethering.

Figure 9.2a. Elderly lady with hard submandibular mass (adenoid cystic carcinoma on fine needle aspiration biopsy) who presented with a palsy of the marginal mandibular branch of the facial nerve.

Figure 9.2b. Lateral facial view shows skin fixation and tethering.

beneath the anterior border of the sternocleidomastoid muscle.

Imaging techniques to delineate submandibu-lar gland lesions include ultrasound, CT, and MR. As the submandibular gland is superficial in the neck high-resolution ultrasound can distinguish intraglandular from extraglandular masses and can differentiate benign tumors from those that are malignant (Alyas, Lewis, and Williams et al. 2005). CT scanning may be useful in detecting early cortical erosion of the mandible and identifying cervical nodes in malignant cases (Figure 9.3). In a study to identify whether a submandibular mass was intra- or extraglandular, the accuracy of contrast enhanced CT was 87%, CT sialography 85%, and MR 91% (Chikui, Shimizu, and Goto et al. 2004).

Cysts Adenoma Submandibular Gland

Figure 9.2c. Histopathology of adenoid cystic carcinoma of submandibular gland.

Radiolucencies Submandibular Gland
Figures 9.3a and 9.3b. CT scans showing submandibular mass with differing regions of radiolucency and opacity. Histopathology showed pleomorphic adenoma.

These authors did not find displacement of the facial vein and its relationship to the mass a helpful guide.

Open biopsy of the submandibular gland mass is contraindicated for similar reasons that were discussed in relation to the parotid (see chapter 8). Fine needle aspiration biopsy (FNAB) is the method of choice for these tumors, one literature review finding an overall accuracy of greater than 80% in skilled hands, which is comparable with the accuracy of frozen section (Pogrel 1995).

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