In this episode of PodMD, Head and Neck Surgeon, Surgical Oncologist and General Surgeon Dr Jingyi Cao will be discussing the topic of salivary gland tumours and stones. We discuss what salivary gland tumours and stones are, how they typically present, initial work up in general practice, their management, and more.
- Transcript
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*As always, all in this PodMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Jingyi Cao.
Dr Jing is a head and neck surgeon, surgical oncologist, and general surgeon specialised in treating thyroid, parathyroid, and salivary gland diseases, as well as soft tissue tumours and advanced skin cancers.
Graduating from the University of Melbourne School of Medicine in 2010, Jing went on to obtain her fellowship in general surgery with the Royal Australasian College of Surgeons in 2019. She further specialised in head and neck surgery and surgical oncology at Westmead Hospital and the Crown Princess Mary Cancer Centre, Westmead.
Jing was also awarded a Master of Philosophy in Medicine from the University of Sydney in recognition of her clinical research and thesis on the surgical management of secondary and tertiary hyperparathyroidism.
Today we’ll be discussing the topic of salivary glands, stones, and tumours, a common yet sometimes overlooked cause of head and neck presentations in general practice.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD. If you do have a patient on whom you require specific advice then please seek advice from a colleague with appropriate expertise in that area.
Jing, thanks for talking with us on PodMD today.
Jing: Thank you for having me.
So the topic of today’s discussion is salivary gland stones and tumours. Jing, can you describe for our listeners what salivary glands, stones, and tumours are?
Jing: Certainly. Salivary gland stones are stones that form in the ducts of salivary glands, such as the parotid gland or submandibular gland, which can cause obstructive symptoms. Salivary gland tumours are benign or malignant growth within the parenchyma of salivary glands, which may or may not require surgical excision depending on its nature and symptoms.
Question 1
Alright, let’s start with salivary gland stones. How common are they in general practice?Jing: They’re not rare. Sialolithiasis is the most common salivary gland disorder actually, with an incidence of around 1 in 10,000 to 30,000 people annually. They actually account for up to 50% of major salivary gland disease.
Question 2
And which glands are usually affected?Jing: About 80% to 90% occur in the submandibular gland because of the gland’s long uphill duct and thicker mucous secretions. Parotid stones make up most of the remainder, while sublingual and minor salivary gland stones are very rare.
Question 3
What should GPs look out for in history and examination?Jing: Classically, patients describe pain and swelling of the gland when eating, known as mealtime syndrome. On exam, you may see or palpate a firm nodule along the duct, where the underlying stone is, or diffuse gland swelling. Chronic cases may present with recurring infections or abscesses.
Question 4
What’s the initial workup in general practice?Jing: A thorough history and oral examination would be a really good start. If palpable, gently try to milk the duct to check for pus or discharge suggestive of active infection. Ultrasound is the first-line imaging. It’s quick, cheap, and accurate for stones. CT can be considered if ultrasound is inconclusive or complications are suspected.
Question 5
How should GPs manage uncomplicated cases?Jing: Conservative measures to help reduce inflammation, treat infection, and help passing of small stones are the first steps. So we encourage hydration. We also encourage salivary secretion by chewing on lemon or sour lollies. Massage and warm compresses can help, and NSAIDs for pain relief is often useful, which also helps reducing inflammation. If there is infection though, prescribe antibiotics, usually covering staph and oral flora. If symptoms persist or recur, then refer to a head and neck surgeon, as the patient may sometimes require surgical intervention.
Question 6
When should GPs send the patient to an emergency department or urgently discuss with a head and neck surgeon?Jing: Certainly severe infections with any signs of spreading cellulitis or abscess formation, if the patient develops high fever or systemic sepsis symptoms, or in rare cases, if there is concern of airway compromise. Otherwise, non-urgent referral for persistent stones or recurrent symptoms is quite appropriate.
Question 7
Okay, let’s move on to tumours. How do salivary gland tumours typically present?Jing: They usually present as a painless, slow growing mass in the parotid or submandibular gland. Sometimes they are picked up as incidental findings on imaging. Red flag symptoms should raise suspicion for malignancy, which we will discuss about later.
Question 8
Which glands are most commonly involved?Jing: About 80% arise in the parotid gland, 10 to 15% in the submandibular gland, and the rest in minor salivary glands. Importantly, though, malignancy risk is higher in the smaller glands. So notably, about 20% of primary parotid tumours are malignant, about 50% of submandibular gland tumours are malignant, and up to 80% of sublingual or minor salivary gland tumours are malignant.
Question 9
What are the most common tumour types?Jing: So we can break this down into benign and malignant tumours. So in terms of benign tumours, the most common type is pleomorphic adenoma. Even though they’re benign, they usually require surgical excision because of the risk of malignant transformation, which is around 1.5% at five years. The second most common benign salivary gland tumour is Warthin’s tumour. Importantly, there is a strong association with smoking, with peak incidence at about 50 years of age, and more prevalent in male than females. It can be bilateral and/or multifocal as well. There is no risk of malignant transformation with Warthin’s tumour.
However, occasionally surgical excision is indicated if they’re large with significant mass effect, if we’re dubious about the clinical diagnosis, or in rare cases for cosmetic reasons. In terms of malignant salivary gland tumours, the most common primary malignancy of salivary gland is mucoepidermoid carcinoma. The other types include adenoid cystic carcinoma, acidic cell carcinoma, and malignant pleomorphic adenocarcinoma, which arise from pre-existing pleomorphic adenoma. Secondary malignancy in salivary glands can be metastases from head and neck skin cancers or oral mucosal cancers.
Question 10
Okay then, what are the red flags that GPs should never miss?Jing: A number of things. Important red flag symptoms such as facial nerve palsy, rapid growth or painful swelling, hard, fixed or irregular mass, cervical lymphadenopathy on the examination or imaging, skin ulceration or tethering of the lump.
Question 11
And what’s the GP’s role in initial workup?Jing: A careful history and head and neck examination would be a really good start. Ultrasound is usually the first-line imaging. Early referral to a head and neck surgeon for further investigations, including further imaging with CT and/or MRI, plus minus FNA biopsy is ideal.
Question 12
How are these tumours managed?Jing: The approach really depends on the gland, histology, and stage. For example, parotidectomy for benign pleomorphic adenoma or malignant parotid tumours with nerve preservation where possible, and selective neck dissection where indicated, plus/minus adjuvant radiotherapy if indicated. whereas for Warthin’s tumours, generally not operative, unless if complicated or dubious in diagnosis.
Question 13
What about their prognosis?Jing: Benign tumours of the salivary glands have excellent outcomes after surgery, though pleomorphic adenoma has a recurrence risk if not fully excised. Malignant prognosis varies, low-grade mucoepidermoid carcinoma has good outcomes, while adenoid cystic carcinoma tends to recur and metastasise even years later.
Question 14
Thanks for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on salivary gland tumours and stones?Jing: Absolutely. For salivary stones, think painful swelling at mealtimes. Manage conservatively, but refer if recurrent or complicated. Secondly, for tumours, any persistent, firm gland lump should be referred to a head and neck surgeon, especially with red flag symptoms. Thirdly, ultrasound is first-line imaging. Further imaging and FNA should ideally be organised by the specialist surgeon, with early referral potentially making a big difference to the patient’s outcome.
Thanks again for your time and the insights you’ve provided, Jing.
Jing: My pleasure. Thank you for having me.
