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Tumors of the Salivary Glands

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Salivary gland anatomy: parotid, submandibular, sublingual, and minor salivary glands

The major salivary glands are shown here.

The major salivary glands are shown here. From the patient’s front are the left sublingual, submandibular, and parotid glands.

Last reviewed: October 4, 2026

Summary

Most salivary gland tumors are benign, and most arise in the parotid gland, in front of the ear. The smaller the gland, the more likely a tumor in it is to be cancerous: roughly 1 in 5 parotid tumors, about half of submandibular tumors, and most sublingual and minor salivary gland tumors are malignant [1]. Evaluation usually involves an examination, imaging, and a needle biopsy. Treatment is primarily surgical, with care taken to protect the facial nerve and other nearby nerves. The sections below describe the glands, how tumors are evaluated, the common tumor types, and what to expect from surgery, with references to the published studies at the end of the page.

The salivary glands produce saliva and have potential to develop a variety of benign or malignant tumors. There are three paired major salivary glands (parotid, submandibular, and sublingual) that deliver saliva to the oral cavity through ducts. The mouth also has hundreds of minor salivary glands dispersed throughout the lining of the oral cavity and throat.

How often a salivary gland tumor is cancerous

Salivary gland tumors are uncommon. For roughly every 100 parotid tumors there are about 10 submandibular tumors and 1 sublingual tumor, with minor salivary gland tumors about as frequent as submandibular tumors. Because the parotid is so much more often affected, about 80% of all salivary gland cancers arise there even though most parotid tumors are benign [1].

  • Parotid: about 20% malignant in commonly cited series [1]. A 30-year nationwide study from Iceland (687 tumors) found a lower figure, about 10% [2].

  • Submandibular: about 50% malignant in commonly cited series [1], and about 20% in the Icelandic study [2].

  • Sublingual: rare, but most are malignant; in a series of 559 patients from Taiwan, 80% of sublingual tumors were cancerous [3].

  • Minor salivary glands: reported rates range from about 25% to more than 80% malignant, depending on the series [1, 2].

evaluation of salivary gland tumors

A growth in a salivary gland is usually noticed by a patient or their physician, though occasionally a cancer in the salivary gland will have spread to a lymph node in the neck that may be identified first. A head and neck surgeon will obtain a history, perform a physical exam, and then, if indicated, may perform or arrange a biopsy, often a needle biopsy of the mass (with or without ultrasound imaging) and/or obtain cross sectional imaging (such as a CT scan or MRI).

A salivary gland cancer that has spread to the lymph nodes may present as a lump in the side of the neck; the evaluation of a neck lump is described on the neck tumors page.

Needle biopsy

Fine-needle aspiration (FNA) uses a thin needle to collect cells. (Why results can take several days is explained on the biopsy results page.) Results are now commonly reported using the Milan System, which places each result in a category with an estimated risk of cancer. In a meta-analysis of 35 studies including more than 10,000 salivary FNAs, the risk of cancer was 2.8% when the result was a benign tumor, about 38% when the result was a tumor of uncertain malignant potential, 84% when the result was suspicious for cancer, and 98% when the result was malignant. Overall, FNA correctly identified 88% of cancers and correctly identified 98.5% of benign tumors [4]. An FNA result therefore helps plan surgery, but a benign result does not entirely exclude cancer.

Core needle biopsy uses a slightly larger needle to remove a thin strip of tissue, usually under ultrasound guidance. In a meta-analysis of studies comparing the two methods, core biopsy gave fewer nondiagnostic results and was more accurate than FNA in detecting cancer; a small bruise or blood collection (hematoma) occurred in 0.3% of core biopsies [5]. The American Society of Clinical Oncology (ASCO) guideline suggests core biopsy when FNA is nondiagnostic or the tumor's location makes FNA difficult [6].

Imaging

Ultrasound is often the first test for a lump in the parotid or submandibular gland. When cancer is suspected, the ASCO guideline recommends imaging with neck ultrasound, contrast-enhanced CT, and/or MRI to define the extent of the tumor and look for spread to lymph nodes [6]. MRI is particularly useful for showing tumors in the deep part of the parotid gland and spread along nerves.

common types of salivary gland tumors

Salivary glands have many different types of cells, each specialized to perform a certain task. Each of the cell types is thought to have potential to develop into a specific type of tumor, and thus, there are several different types of tumors that can arise in a salivary gland. Identification of the tumor type is done with a biopsy, and the advantage of knowing the tumor type is that it allows reasonable prediction of the behavior of the tumor and the best strategy for treatment.

The most common benign salivary gland tumors include:

  • Pleomorphic adenoma: Overall the most common type of salivary gland tumor, this benign neoplasm typically grows indefinitely. Left in place, a pleomorphic adenoma has the potential to transform into a cancer (called “carcinoma ex-pleomorphic adenoma), which, becomes more aggressive in growth and can spread to other parts of the body. How often this happens is debated. Older series suggested that up to 10% of long-standing pleomorphic adenomas become malignant, but a 2023 study of 260 patients with untreated pleomorphic adenomas found cancer in 3.2% at the time of removal, and the risk was linked to larger tumor size and older age rather than how long the tumor had been present [7]. After removal, a pleomorphic adenoma can recur; in a series of 705 cases, 3.4% of primary tumors recurred, and recurrence was more likely when the tumor was not removed intact [8]. This is one reason the tumor is removed with a cuff of normal tissue rather than shelled out.

  • Warthin's tumor (papillary cystadenoma lymphomatosum): Warthin’s tumor, also known as cystadenoma lymphomatosum, is a benign salivary gland tumor usually found in the parotid gland, and it is not unusual for people to have this type of tumor on each side. Tobacco smoking is a significant risk factor for the development of a Warthin’s tumor. In a nationwide case-control study, people who had ever smoked had about 15 times the odds of developing a Warthin’s tumor, while smoking had no clear link to pleomorphic adenoma [9].

  • Myoepithelioma: Benign myoepithelioma are treated with simple excision. They are less prone to recurrence than pleomorphic adenoma. It is rare for a myoepithelioma to be malignant.

  • Basal cell adenoma: Treatment is by surgical excision with a margin of healthy tissue. Although the recurrence rate is high, the prognosis is generally good.

  • Oncocytoma: The salivary gland oncocytoma, also known as an oxyphilic adenoma is a well-circumscribed, benign neoplastic growth. It comprises about 1% of all salivary gland tumors. Salivary gland oncocytomas are most common in ages 70–80, females, the parotid gland (85–90%), and are firm, slowly growing, painless masses of less than 4 cm diameter.

The most common malignant (cancerous) salivary gland tumors include:

  • Mucoepidermoid carcinoma is the most common type of minor salivary gland malignancy in adults, but is also found in the major salivary glands as well as in other organs, such as bronchi (lower windpipes), lacrimal sac (tear duct), and thyroid gland. Generally, there is a good prognosis for low-grade tumors, and a poor prognosis for high-grade tumors, however recent research have found reoccurring low grade tumors also have a poor prognosis. In a United States population study of 2,400 patients with parotid mucoepidermoid carcinoma, 5-year disease-specific survival was 99% for low-grade, 97% for intermediate-grade, and 67% for high-grade tumors, and high-grade tumors were far more likely to have spread to lymph nodes (34% compared with 3% for low-grade) [10]. Surgery is the recommended treatment for localized resectable disease. When the tumor is incompletely resected (positive margins) post-operative radiotherapy gives local control comparable to a complete resection (clear margins). Sometimes when surgery is not possible due to extent of disease or if a patient is too frail for surgery, or declines surgery, palliative radiotherapy may be helpful.

  • Acinic cell carcinoma is a malignant tumor representing 2% of all salivary tumors. 90% of the time found in the parotid gland, 10% intraorally on buccal mucosa (cheek lining) or palate. The disease presents as a slow growing mass, associated with pain or tenderness in 50% of the cases. Prognosis is good for acinic cell carcinoma of the parotid gland, with five-year survival rates approaching 90%, and 20-year survival exceeding 50%. Patients with acinic cell carcinomas with high grade transformation have significantly worse survival. Acinic cell carcinoma is known for its potential to spread to the lungs and grow there so slowly that detection may occur decades after the salivary gland primary tumor has been treated.

  • Polymorphous low-grade adenocarcinoma (PLGA), now called polymorphous adenocarcinoma in the World Health Organization classification [11], is an uncommon, asymptomatic, slow-growing malignant salivary gland tumor. It is most commonly found in the minor salivary glands of the palate. PLGAs are treated with wide local surgical excision and long-term follow-up. There is a recurrence rate of 14%.

  • Adenoid cystic carcinoma is a rare type of cancer that can exist in many different body sites. This tumor most often occurs in the salivary glands, but it can also be found in many other anatomic sites, including the trachea, and the paranasal sinuses. It is the third-most common malignant salivary gland tumor overall. It represents 28% of malignant submandibular gland tumors, making it the single most common malignant salivary gland tumor in this region. Patients may survive for years with metastases because this tumor is generally well-differentiated and slow growing. In a 1999 study of a cohort of 160 ACC patients, disease-specific survival was 89% at 5 years, but only 40% at 15 years, reflecting deaths from late-occurring metastatic disease [12]. In that study, spread along major nerves, positive surgical margins, and a solid growth pattern under the microscope were associated with worse outcomes [12].

  • Epithelial-myoepithelial carcinoma (EMCa) is a rare malignant tumour that typically arises in a salivary gland and consists of both an epithelial and myoepithelial component. They are predominantly found in the parotid gland and represent approximately 1% of salivary gland tumors.

  • Carcinoma ex pleomorphic adenoma  is a type of cancer typically found in the parotid gland. It arises from the benign tumour pleomorphic adenoma. Its prognosis depends on the stage. Early tumours have essentially a benign behavior. The signs and symptoms are similar to other malignant salivary gland tumors; however, it may have been preceded by an appreciable mass that was long-standing (typically for greater than a decade) and did not appear to be growing. Findings that suggest transformation of pleomorphic adenoma into a malignant salivary gland tumor include rapid growth, facial weakness (due to facial nerve compression or invasion), pain, skin ulceration, fixation of the mastoid tip and paresthesias (e.g., numbness or tingling on the nearby skin).

Treatment of salivary gland cancer

The ASCO guideline (2021) summarizes the current approach [6]:

  • Surgery to remove the tumor with clear margins is the main treatment for cancer that can be removed, with preservation of the facial nerve whenever it is not directly involved by tumor.

  • Neck dissection (removal of lymph nodes) is recommended when lymph nodes are involved. When no nodes are evident, treatment of the neck by surgery or radiation is recommended for large (T3 or T4) or high-grade cancers, because hidden spread is more common in these tumors.

  • Radiation therapy after surgery is recommended for features that raise the risk of the cancer returning, such as high grade, close or positive margins, spread along nerves, lymph node involvement, or a large tumor.

  • Drug therapy is used mainly for cancer that has come back or spread. Testing the tumor for specific markers, such as HER2, the androgen (male hormone) receptor, and NTRK gene fusions, can identify targeted treatments; for example, NTRK inhibitors produced responses in most patients with tumors carrying an NTRK fusion. The guideline does not recommend these drugs routinely after surgery outside a clinical trial.

removal of the parotid gland (parotidectomy)

Surgery to remove the parotid gland (parotidectomy) may be undertaken to diagnose or treat a tumor. The incision tends to heal nicely (as it is basically the same incision used for a facelift). Since the facial nerve runs through the parotid gland, every effort is made to identify and protect the main nerve and all of its branches as they make their way to muscles of the face. A separate nerve that provides sensation to the skin of around the outer ear is often unable to be spared, leading to numbness of that patch of skin which gradually becomes less noticeable over time. On occasion, a phenomenon known as “gustatory sweating” or Frey’s syndrome can set in after parotidectomy. This is when situations in which one would normally salivate (before or during a meal) can cause sweating of the skin over the operated parotid gland, and is due to the microscopic nerves that relay the need for salivation from the brain to the parotid gland lose their target with parotidectomy and with time and nerve healing, they grow right into the sweat glands of the skin. If this occurs, it usually begins some months after surgery. Many people with it have only mild symptoms or do not notice it [16], but it can persist. Avoiding a sweaty cheek during a meal is most effectively and economically treated by applying a clear antiperspirant deodorant to the skin. Botox injections are also effective and last about three months at a time. A similar phenomenon can occur with the tear gland on that side of the face, called “Crocodile tear syndrome,” in which the healing nerves find their way to the lacrimal gland and the eye waters before or during a meal. Less commonly, pain syndromes can occur after parotidectomy. The “first bite syndrome” is when the first bite of food, especially if it is tart, can cause a spasm of pain in the cheek. This too is often temporary, resolving over months or years, and is best treated by starting a meal with something bland or a sip of water before eating anything tart. Much less commonly, a deeper pain can arise in the surgical site on occasion, but this problem is uncommon unless the tumor surgery involved extensive dissection into an area called the parapharyngeal space.

What the studies show

  • Facial nerve weakness. In a multicenter database of 2,650 parotid operations, 20% of patients had some facial weakness after surgery: 17.2% temporary and 4.5% permanent. The branch to the lower lip (marginal mandibular branch) was most often affected. Weakness was more likely with cancer, large tumors, tumors extending deep to the parotid (parapharyngeal space), and weakness already present before surgery [13].

  • Extent of surgery for benign tumors. For a benign tumor, the surgeon may remove the portion of the gland containing the tumor (partial or superficial parotidectomy) or, for some small, mobile tumors near the surface, the tumor with a thin rim of tissue (extracapsular dissection). The evidence comparing these approaches is mixed. A systematic review of 2,095 patients found recurrence of pleomorphic adenoma in 3.3% after extracapsular dissection, 0.7% after partial superficial parotidectomy, and 2.4% after superficial parotidectomy [14]. In a Vienna series of 894 patients, extracapsular dissection had more recurrences (7.2% compared with 2.2%) and more permanent facial weakness (2.2% compared with 0.6%) than superficial parotidectomy [15]. The choice depends on the size, type and location of the tumor.

  • Numbness and Frey’s syndrome. In a study that examined 76 patients after parotidectomy for benign tumors, decreased skin sensation was the most common after-effect (71%), and 28% had a positive sweat test for Frey’s syndrome, although not all of them noticed symptoms [16]. A meta-analysis found that techniques that place a layer of tissue between the skin and the parotid bed reduce the rate of Frey’s syndrome and the hollow appearance after surgery [17].

  • First bite syndrome. In a series of 499 patients who had surgery of the deep lobe of the parotid or the parapharyngeal space, 9.6% developed first bite syndrome. It was most common after parapharyngeal space dissection and removal of the deep lobe alone, and rare (0.8%) after total parotidectomy. Most patients had partial improvement over time [18].

Removal of the submandibular gland (submandibular gland excision)

A submandibular gland is located under the jaw on the left and another on the right. Excision of this gland may be undertaken to diagnose and treat a tumor, but is also performed for other conditions such as chronic infection or the presence of stones. About half of submandibular gland tumors are cancerous; in a German series of 258 submandibular gland removals, 42% of the tumors were malignant [19]. Lymph node removal may be included with removal of the submandibular gland if cancer has spread or is likely to have spread to these lymph nodes. When the gland alone is removed, the incision is placed below and parallel to the lower jaw, extending about 5 cm (2 inches). The marginal mandibular branch of the facial nerve, which controls movement of the lower lip on that side, the lingual nerve, responsible for sensation and taste in that side of the tongue, and the hypoglossal nerve, which controls the tongue muscles on that side are at some risk of weakness or complete dysfunction from surgery, which may be temporary or permanent. In that series, temporary weakness of the lower lip occurred in 9% and temporary lingual nerve symptoms in 2%, with permanent lower-lip weakness in fewer than 1% [19]. A Danish study with long-term follow-up of 139 patients found early lower-lip weakness in 18.7%, falling to 2.7% at long-term follow-up, permanent lingual nerve symptoms in 4.4%, and no hypoglossal nerve injuries [20]. When a submandibular gland, but no other major salivary gland, is removed, generally a person does not notice any decrease in saliva production. Usually, a small indentation or lack of volume in this aspect of the neck is apparent to a close observer, but the cosmetic defect is typically minimal. Radiation therapy may be recommended after surgery, depending on the available information, including the surgical pathology report.

Sublingual gland excision

One left and one right sublingual gland exists under the tongue, toward the front of the mouth. Excision of a sublingual gland may be undertaken for a ranula, which is a collection of saliva and mucus within the gland, or for a tumor. Tumors of the sublingual gland are rare, but most are malignant [3]. In removing a tumor of the sublingual gland, additional tissue around the gland, including some of the tongue may need to be excised. Additionally, lymph nodes to which cancer cells have or are likely to have spread may need removal at the time of surgery. The lingual nerve, responsible for sensation and taste in that side of the tongue, and the hypoglossal nerve, which controls the tongue muscles on that side are at some risk of weakness or complete dysfunction from surgery, which may be temporary or permanent. Reconstruction of the floor of mouth defect with tissue taken from elsewhere may be necessary. Radiation therapy may be recommended after surgery, depending on the available information, including the surgical pathology report.

Summary

  • Most salivary gland tumors are benign and arise in the parotid gland; tumors of the smaller glands are more often cancerous [1].

  • A needle biopsy and imaging usually establish the likely diagnosis before surgery; core biopsy is more accurate than FNA when FNA is unclear [4, 5].

  • Pleomorphic adenoma, the most common tumor, is removed to prevent growth, recurrence, and the small risk of cancer developing within it [7].

  • Cancer treatment is primarily surgical, with lymph node treatment, radiation, or targeted drugs added based on the tumor's grade, stage, and markers [6].

  • Temporary facial weakness is fairly common after parotid surgery; permanent weakness is uncommon and more likely with large or malignant tumors [13].

References

  1. Mantravadi AV, Moore MG, Rassekh CH. AHNS series: Do you know your guidelines? Diagnosis and management of salivary gland tumors. Head Neck. 2019;41(2):269-280. doi:10.1002/hed.25499

  2. Aegisdottir AL, Tryggvason G, Jonsdottir AM, Jonasson JG. Salivary gland tumours in Iceland 1986-2015: a nationwide epidemiological analysis over a 30-year time period. APMIS. 2021;129(2):55-60. doi:10.1111/apm.13090

  3. Liao WC, Chih-Chao C, Ma H, Hsu CY. Salivary gland tumors: a clinicopathologic analysis from Taipei Veterans General Hospital. Ann Plast Surg. 2020;84(1S Suppl 1):S26-S33. doi:10.1097/SAP.0000000000002178

  4. Wang Z, Zhao H, Guo H, An C. Application of the Milan System for Reporting Salivary Gland Cytopathology: a systematic review and meta-analysis. Cancer Cytopathol. 2022;130(11):849-859. doi:10.1002/cncy.22604

  5. Cho J, Kim J, Lee JS, et al. Comparison of core needle biopsy and fine-needle aspiration in diagnosis of malignant salivary gland neoplasm: systematic review and meta-analysis. Head Neck. 2020;42(10):3041-3050. doi:10.1002/hed.26377

  6. Geiger JL, Ismaila N, Beadle B, et al. Management of salivary gland malignancy: ASCO guideline. J Clin Oncol. 2021;39(17):1909-1941. doi:10.1200/JCO.21.00449

  7. Levyn H, Subramanian T, Eagan A, et al. Risk of carcinoma in pleomorphic adenomas of the parotid. JAMA Otolaryngol Head Neck Surg. 2023;149(11):1034-1041. doi:10.1001/jamaoto.2023.3212

  8. Alzumaili B, Xu B, Saliba M, et al. Clinicopathologic characteristics and prognostic factors of primary and recurrent pleomorphic adenoma: a single institution retrospective study of 705 cases. Am J Surg Pathol. 2022;46(6):854-862. doi:10.1097/PAS.0000000000001837

  9. Sadetzki S, Oberman B, Mandelzweig L, et al. Smoking and risk of parotid gland tumors: a nationwide case-control study. Cancer. 2008;112(9):1974-1982. doi:10.1002/cncr.23393

  10. Chen MM, Roman SA, Sosa JA, Judson BL. Histologic grade as prognostic indicator for mucoepidermoid carcinoma: a population-level analysis of 2400 patients. Head Neck. 2014;36(2):158-163. doi:10.1002/hed.23256

  11. Seethala RR, Stenman G. Update from the 4th edition of the World Health Organization classification of head and neck tumours: tumors of the salivary gland. Head Neck Pathol. 2017;11(1):55-67. doi:10.1007/s12105-017-0795-0

  12. Fordice J, Kershaw C, El-Naggar A, Goepfert H. Adenoid cystic carcinoma of the head and neck: predictors of morbidity and mortality. Arch Otolaryngol Head Neck Surg. 1999;125(2):149-152. doi:10.1001/archotol.125.2.149

  13. Warda A, Radomska K, Pietruszewska W, et al. Facial nerve palsy in parotid gland surgery: a comprehensive analysis of incidence, severity, duration, and risk factors; insights from the Polish Salivary Network Database. J Craniomaxillofac Surg. 2026;54(6):104497. doi:10.1016/j.jcms.2026.104497

  14. Pagnani G, Palma A, Bozza F, et al. Systematic review and case report on the surgical management of pleomorphic adenomas: lessons on recurrence and error prevention. J Clin Med. 2025;14(13):4541. doi:10.3390/jcm14134541

  15. Kadletz L, Grasl S, Grasl MC, Perisanidis C, Erovic BM. Extracapsular dissection versus superficial parotidectomy in benign parotid gland tumors: the Vienna Medical School experience. Head Neck. 2017;39(2):356-360. doi:10.1002/hed.24598

  16. Fiacchini G, Cerchiai N, Tricò D, et al. Frey syndrome, first bite syndrome, great auricular nerve morbidity, and quality of life following parotidectomy. Eur Arch Otorhinolaryngol. 2018;275(7):1893-1902. doi:10.1007/s00405-018-5014-4

  17. Curry JM, King N, Reiter D, et al. Meta-analysis of surgical techniques for preventing parotidectomy sequelae. Arch Facial Plast Surg. 2009;11(5):327-331. doi:10.1001/archfacial.2009.62

  18. Linkov G, Morris LG, Shah JP, Kraus DH. First bite syndrome: incidence, risk factors, treatment, and outcomes. Laryngoscope. 2012;122(8):1773-1778. doi:10.1002/lary.23372

  19. Preuss SF, Klussmann JP, Wittekindt C, et al. Submandibular gland excision: 15 years of experience. J Oral Maxillofac Surg. 2007;65(5):953-957. doi:10.1016/j.joms.2006.02.036

  20. Springborg LK, Møller MN. Submandibular gland excision: long-term clinical outcome in 139 patients operated in a single institution. Eur Arch Otorhinolaryngol. 2013;270(4):1441-1446. doi:10.1007/s00405-012-2175-4

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