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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.30 no.3 Barcelona may./jun. 2008

 

CASO CLÍNICO

 

Giant pleomorphic adenoma of minor salivary gland. Transoral resection

Adenoma pleomorfo gigante de glándula salivar menor. Extirpación a través de un abordaje transoral

 

 

C. de Paula Vernetta, F.J. García Callejo, J.B. Ramírez Sabio, M.H. Orts Alborch, A. Morant Ventura, J. Marco Algarra

Servicio de Otorrinolaringología. Hospital Clínico Universitario de Valencia. Facultad de Medicina. Valencia, España

Correspondence

 

 


ABSTRACT

Pleomorphic adenoma is a benign tumor of the salivary glands that consists of a combination of epithelial and mesenchymal elements. The tumor most commonly arises from the parotid (60- 70%) or submandibular glands. It develops less frequently on a minor salivary gland, presenting as an intraoral mass dependent on the palate or lip. A case is reported of giant pleomorphic adenoma resected using a transoral approach.

Key words: Pleomorphic adenoma; Minor salivary glands; Hard palate; Transoral surgery.


RESUMEN

El adenoma pleomorfo es un tumor benigno de las glándulas salivares formado por la combinación de elementos epiteliales y mesenquimales. Generalmente constituyen el 60-70% de los tumores de la glándula parótida y el 40-60% de los de glándula submaxilar. Menos frecuentemente es su desarrollo a partir de una glándula salivar menor, presentándose como una masa intraoral dependiente de paladar o labio. Se expone el caso de un adenoma pleomorfo gigante de paladar duro y su exéresis por la vía transoral.

Palabras clave: Adenoma pleomorfo; Glándulas salivares menores; Paladar duro; Abordaje transoral.


 

Clinical case

A 53-year-old Caucasian man without a medical history of interest came to the hospital emergency services for prolonged dysphagia and recent onset dyspnea that was more accentuated in supine position. On inspection, a mass apparently arising from the palate was observed. It was indurated, painless on palpation, nonfriable, and had superficial ulceration of the ventral surface (Fig. 1). The mass pressed the tongue against the floor of the mouth, which impaired its mobility. No enlarged lymph nodes of significant size were palpated. The lower cranial nerves (IX, X, XI, and XII) were not affected. Facial sensitivity was conserved. Nasofibroscopy revealed a globulous tumor that occupied most of the nasopharynx and oropharynx, particularly on the left side. In supine position, the tumor touched the posterior pharyngeal wall, impeding visualization of the glottal lumen. The rest of the ear, nose and throat examination was normal. Maxillofacial CT (Fig. 2) revealed a hypodense tumor measuring 10x8.5x5.6 cm that affected the oral cavity, oropharynx, and lowest part of the cavum. The tumor affected the buccinator and pterygoid muscles by contiguity, as well as the gingival region, soft palate, and tonsil area. Adjacent mandibular and maxillary erosion was present at the level of the posteroinferior aspect of the left maxillary sinus. Small bilateral lymph nodes were present in areas I, II, and III. MRI showed a lesion that was hypointense in T2 and hyperintense in T2 that moved with the palate, and compressed other structures, distorting pharyngeal morphology. The biopsy report was pleomorphic adenoma. The immunohistochemistry was positive for cytokeratin, S100 protein, and muscle-specific actin. The patient was intubated nasally to facilitate surgical maneuvers because orotracheal intubation could not be performed. After verifying mouth opening, the tumor was completely resected with tumor-free resection margins via a transoral approach using a Davis Boyle bite opener. The tumor was pediculated and dependent on the upper part of a minor salivary gland of the hard palate (Figs. 3 and 4). The postoperative period passed without incident and one year after surgery the patient was asymptomatic and free of clinical and radiologic evidence of recurrence.

 

Discussion

Tumors of the minor salivary glands are responsible for 2-4% of tumors of the head and neck, 10% of tumors of the oral cavity, and 15-23% of tumors of the salivary glands.1 The most frequent location of pleomorphic adenoma of a minor salivary gland is the hard palate, followed by the lips, oral mucosa, floor of the mouth, tonsil, pharynx, retromolar area, and nasal cavity. 2Pleomorphic adenomas do not usually present a sexual predisposition and they can appear at any age with the same clinical behavior.1 They are generally round, slow-growing tumors that are painless and firm in consistency. Microscopically, pleomorphic adenomas of the minor salivary glands consist of epithelial cells and mesenchymal elements that tend to be more cellular, with less myxoid or chondroid component, and located within the submucosa, in contrast with tumors of the major salivary glands. Tumors of the minor salivary glands do not have a fibrotic capsule (they have a very thin capsule) and they may have a false infiltrative appearance. One consequence of this is that CT and MRI imaging diagnosis will be necessary to evaluate as exactly as possible the extension and anatomic relations of the tumor in order to plan a suitable surgical approach. After studying the case, we decided to excise the tumor transorally.3 Despite the drawbacks of this approach (limited access, poor maneuverability, and need for nasal intubation), sufficient access can be obtained using a Davis Boyle bite opener after previously verifying the functionality of both temporomandibular joints (orthopantomography) and adequate cervical mobility. Like other authors,4, 5 we think that, in light of the initial benignity of the process, the most conservative possible surgical technique is preferable whenever resection is possible. The prognosis will be excellent if resection is adequate. Irradiation is reserved for recurrences and inoperable cases.6 Malignant transformation has been reported (2-9%), generally to adenocarcinoma or undifferentiated carcinoma. The risk of malignization increases with the duration of the tumor and mean age of the patient.7 Regular follow-up is required to detect local recurrence and malignization. We currently consider the transoral approach to be adequate and sufficient for correctly resecting benign tumors of the palate once it has been determined that there are no anatomic limitations that contraindicate the technique.

 

 

Correspondence:
Dr. Carlos de Paula Vernetta.
Calle Luis Santángel nº 19, piso 3º, puerta 5.
46005 Valencia, España
Email: carlospaula@telefónica.net

Recibido: 22.05.2006
Aceptado:16.06.2008

 

References

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4. Moraitis D, y cols. Pleomorphic adenoma causing acute airway obstruction. The J Laryngol Otol 2000;114:634-6.        [ Links ]

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6. Perez CA, y cols. Treatment of pleomorphic adenoma. Principles of practise of radiation oncology JB Lippincott company. Philadelphia 1987;521.        [ Links ]

7. Feinmersser R, y cols. Pleomorphic adenoma of the hard palate an invasive tumor? J Laryngol Otol 1983;97:1169-71.        [ Links ]

8. Nardone M, y cols. Pleomorphic adenoma in inusual anatomic sites: case reports and review of literature. Acta Otorhinolaryngol Ital 2002;22:158-63.        [ Links ]

9. Tucci E, y cols. Enucleation of a pleomorphic adenoma of the palate. A conservative choice. Minerva Stomatol 2004;53:111-5.        [ Links ]

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