SALIVARY GLANDSSURGICAL ANATOMY & APPROACH

CONTENTS:-

• INTRODUCTION• GROWTH & DEVELOPMENT

• SALIVARY GLANDS-TYPES

• PAROTID REGION• SUBMANDIBULAR REGION

• SUBLINGUAL GLAND• APPROACHES

INTRODUCTION….

GROWTH AND DEVELOPMENT……

SALIVARY GLANDS:TYPES……

PAROTID REGION

Consists of parotid glands and str in immediate relation to it

PAROTID GLAND

CAPSULE

PAROTID DUCT

STRUCTURES WITHIN PAROTID GLAND

FACIAL NERVE:-

1) TEMPORAL

2) ZYGOMATIC

3) BUCCAL

4) MARGINAL MANDIBULAR

5) CERVICAL

RETROMANDIBULAR VEIN:-UNION OF SUP. TEMPORAL AND MAX. VEINS

EXT.CAROTID ARTERY:-LEAVES CAROTID TRIANGLE BY PASSING DEEP TO POST. BELLY OF DIGASTRIC,ASCENDS AND ENTERS PAROTID GLAND

AURICULOTEMPORAL NERVE:-ARISES FROM POST. DIV OF MANDIBULAR DIV OF TRIGEMINAL NERVE AND ENTERS ANTEROMEDIAL SURFACE OF PAROTID GLAND,PASSES UPWARD AND OUTWARD TO EMERGE AT SUP. BORDER OF THE GLAND

RELATIONS OF PAROTID GLAND:-

- SUPERFICIAL RELATION:-PAROTID LYMPH NODES,GREATER AURICULAR NERVE,SKIN,SUP.FASCIA

- SUPERIOR RELATION:-EXT.AUTIDORY MEATUS,POSTERIOR SURFACE OF TMJ,GLENOID LOBE

- POSTEROMEDIAL RELATION:-MASTOID PROCESS,STERNOCLEIDOMASTOID,POST.BELLY OF DIGASTRIC,STYLOID PROCESS,CAROTID SHEATH,ICA,IJV & (VAGUS,ACESSORY,GLOSSOPHARYNGEAL,HYPOGLOSSAL,FACIAL)NERVES

- ANTEROMEDIAL RELATION:-POSTERIOR BORDER OF RAMUS,TMJ,MEDIAL PTERYGOID,TEMPORAL BRANCH OF FACIAL NERVE AND STYLOMANDIBULAR LIGAMENT

BLOOD SUPPLY:-

- ARTERIES

- VEINS

LYMPHATICS: NERVE SUPPLY:- SECTRETOMOTOR FIBRES FROM INF.SALIVARY

NUCLEUS OF 9TH (GLOSSOPHARYNGEAL N.) CRANIAL NERVE

- NERVE FIBRES THEN PASS TO OTIC GANGLION THROUGH LESSOR PETROSAL & GLOSSOPHARYNGEAL NERVE

- POSTERIOR GANGLIONIC PARASYMPATHETIC NERVE FIBRES REACH PAROTID GLAND VIA AURICULOTEMPORAL NERVE

- POSTERIOR GANGIONIC SYMPATHETIC NERVE FIBRES REACH THE GLAND AS NERVE PLEXUS AROUND ECA

THE SUBMANDIBULAR REGION

MUSCLESALIVARY GLANDS: SUBMANDIBULAR & SUBLINGUAL GLANDSNERVESBLOOD VESSELS LYMPH NODES

SUBMANDIBULAR GLAND

TYPE AND PARTS OF GLANDS:-

RELATIONS OF SUBMANDIBULAR GLAND

SUPERFICIAL PART RELATIONS:-

ANTERIORLY:ANTERIOR BELLY OF DIGASTRIC

POSTERIORLY:POSTERIOR BELLY OF DIGASTRIC,STYLOHYOID,STYLOMANDIBULAR LIGAMENT,PAROTID GLAND

MEDIALLY:MYLOHYOID,HYOGLOSSUS,MYLOHYOID NERVES AND VESSELS,LINGUAL AND HYPOGLOSSAL NERVE

LATERALLY:SUBMANDIBULAR FOSSA,DEEP CERVICAL FASCIA,PLATYSMA,SKIN,SUBMANDIBULAR LYMPH NODES,CROSSED BY CERVICAL BRANCH OF FACIAL NERVE

DEEP PART RELATIONS:-

ANTERIORLY: SUBLINGUAL GLAND

POSTERIORLY: STYLOHYOID,POSTERIOR BELLY OF DIGASTRIC,STYLOMANDIBULAR LIGAMENT,PAROTID GLAND

MEDIALLY: HYOGLOSSUS AND STYLOGLOSSUS

LATERALLY: MYLOHYOID MUSCLE AND SUPERFICIAL PART OF GLAND

SUPERIORLY: LINGUAL NERVE AND SUBMANDIBULAR GANGLION

INFERIORLY: HYPOGLOSSAL NERVE

CAPSULE

DUCT:-

BLOOD SUPPLY

- ARTERIES

- VEINS

LYMPH DRAINAGE

NERVE SUPPLY:-

- PARASYMPATHETIC SECRETOMOTOR SUPPLY FROM SUP.SALIVARY NUCLEUS OF 7TH CRANIAL NERVE

- THE NERVE FIBERS PASS TO SUBMANDIBULAR GANGLION VIA CHORDA TYMPANI NERVE AND LINGUAL NERVE

- POSTGANGLIONIC PARASYMPATHETIC FIBERS REACH GLAND DIRECTLY OR ALONG THE DUCT

SUBLINGUAL GLANDS

TYPE & LOCATION:-

RELATIONS OF LINGUAL GLAND:-

ANTERIORLY: GLAND OF OPPOSITE SIDE

POSTERIORLY: DEEP PART OF SUBMANDIBULAR GLAND

MEDIALLY: GENIOGLOSSUS MUSCLE,LINGUAL NERVE,SUBMANDIBULAR DUCT

LATERALLY: SUBLINGUAL FOSSA OF MEDIAL SURFACE OF MANDIBLE

SUPERIORLY: SUBLINGUAL FOLD(MUCOUS MEM OF FLOOR OF MOUTH ELEVATED BY GLAND)

INFERIORLY: MYLOHYOID MUSCLE

DUCTS:-

BLOOD SUPPLY

- ARTERIES- VEINS

LYMPH DRAINAGE

NERVE SUPPLY:-

- PARASYMPATHETIC SECRETOMOTOR SUPPLY FROM SUPERIOR SALIVARY NUCLEUS OF 7TH CRANIAL NERVE

- THE NERVE FIBERS PASS TO SUBMANDIBULAR GANGLION VIA CHODA TYMPANI NERVE AND LINGUAL NERVE

- POSTGANGLIONIC SYMPATHETIC FIBERS REACH GLAND AS A PLEXUS OF NERVES AROUND FACIAL AND LINGUAL ARTERIES

SURGICAL APPROACHES…

APPROACH TO PAROTID GLAND:-

TOTAL PAROTIDECTOMY

SUPERFICIAL PAROTIDECTOMY

PARTIAL SUPERFICIAL PAROTIDECTOMY

SUPERFICIAL PAROTIDECTOMY:-

- INCISION GIVEN IN SKIN CREASE BELOW MANDIBLE UPWARD TO MASTOID AND FORWARD TO PREAURICULAR CREASE

- LOBULE RETRACTED WID SUTURES

- NECK INCISION SHOULD BE THROUGH PLATYSMA UPTO DEEP CERVICAL FASCIA.

- ANTERIOR FLAP IS THINNED(ONLY WITH SKIN N SUBCUTANEOUS TISSUE) AND DISSECTED NOT TOO MUCH ANTERIORLY TO PREVENT FACIAL NERVE

- HAEMOSTASIS ACHIEVED THROUGH DITHERMY WHEN NEEDED

- GREATER AURICULAR NERVE IS IDENTIFIED AND DIV WHERE IT CROSSES PAROTID

- ANT.BORDER OF STERNOMASTOID IS SEPARATED FROM POSTERIOR BORDER OF THE GLAND.

- SULCUS B/W THEM IS DEEPENED TO EXPOSE POST.BELLY OF DIGASTRIC.

- GLAND SEPARATED FROM EXT.MEATUS WITH HELP OF BIPOLAR CAUTERY

- MAIN TRUNK OF FACIAL NERVE IS FOUND OUT

- GLANDULAR TISSUE IS INCISED TO EXPOSE POSTER BORDER OF GLAND

- SAME PROCEDURE REPEATED FOR SUPERIOR BORDER OF FACIAL NERVE

- DUCT MAY BE TIED IF IDENTIFIED- SUPERFICIAL LOBE OF PAROTID IS REMOVED- AFTER COMPLETE REMOVAL OF GLAND

INCISION IS CLOSED IN 2 LAYERS & EXCESS SKIN IS EXCISED

PARTIAL SUPERFICIAL PAROTIDECTOMYA superficial (or lateral) parotidectomy involves removing all of the gland superficial to the facial nerve, whereas a partial superficial parotidectomy involves removing only the portion of the gland surrounding a tumor or mass. In a partial superficial parotidectomy, only some branches of the facial nerve are usually dissected, whereas in a formal superficial parotidectomy, the entire cervicofacial and temporofacial divisions are dissected.

TOTAL PAROTIDECTOMY:-

- PERFORMED UNDER GA AND EVEN UNDER LA(JCPSP 2007, Vol. 17 (2): 116-117).

- STANDARD S-SHAPED CERVICOMASTOID FACIAL INCISION IS GIVEN

- The superficial gland is dissected free of all of the facial nerve branches to the extent feasible, and the branches are then completely mobilized and the deep portion of the gland removed.

- During the surgery the muscles of face were observed for contraction on command. Cervical lymph node was excised by extending the cervical incision anteriorly and then retracting the sternocleidomastoid muscle. No other lymph nodes were identified during surgery.

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APPROACH TO SUBMANDIBULAR GLAND:-

INTRAORAL APPROACH

EXTRAORAL APPROACH

TRANSORAL APPROACH

EXTRAORAL APPROACH:-

- UNDER LA- SUPINE POSITION WITH MODERATE NECK

EXTENTION AND CHIN ROTATED AWAY.- INCISION GIVEN-3CM BELOW LOWER BORDER

OF MANDIBLE TO AVOID DAMAGE TO FACIAL NERVE

- 7CM LONG INCISION APPROX.- INCISION MADE DIRECTLY DOWN THE PLATYSMA

UNTIL GLAND REACHED USING NO.15 BLADE- UNDERLYING INVESTING LAYER OF DEEP

CERVICAL FASCIA IS DIVIDED.

- SUPERIOR LOBE OF GLAND IS MOBILIZED AND RETRACTED TO REVEAL POST.BELLY OF DIGASTRIC.

- THEN POSTEROSUPERIOR PART OF GLAND IS DISSECTED

- FACIAL VESSELS TAKEN CARE OF.

- FACIAL VEIN LIGATED

- FACIAL ARTERY DOUBLE LIGATED IF NEEDED

- THEN DISSECTION OF SUPERIOR PART OF GLAND IS DONE.

- THEN DISSECTION OF DEEP PART OF GLAND IS DONE WITH DOWNWARD DETRACTION OF GLAND

- THEN V-SHAPED LINGUAL NERVE IS IDENTIFIED THAT IS CONNECTED TO SUBMANDIBULAR GLAND

- THIS CONNECTION IS CUT OFF.- THEN GLAND CONNECTED TO DUCT

ANTERIORLY,DUCT HAS TO BE CLAMPED,DIVIDED AND TIED AS FAR AS POSSIBLE

- INCISION CLOSED WID INTERRUPED OR SUBCUTICULAR SUTURES

INTRAORAL APPROACH:-

This procedure is anatomically safe and can be performed with minimal morbidity

Infiltration with Xylocaine plus epinephrine with an adequate waiting period for hemostasis; The intraoral approach (IOA) consisted of an incision on the floor of mouth from the caruncle of Wharton's duct to the retromolar trigone

careful identification of the submandibular duct/lingual nerve relationship;

Anterior retraction of the mylohyoid muscle to expose the superficial lobe;

superiorly directed, extraoral, manipulation of the submandibular gland;

close and blunt dissection to the gland laterally to avoid injury to the facial artery and vein.

(PMID: 10839409 [PubMed - indexed for MEDLINE]Division of Plastic and Reconstructive Surgery at the University of California, Los Angeles 90095-1665, USA.)

TRANSORAL APPROACH:-The neck is prepared and marked in the standard

fashion for transcervical submandibular gland excision.

A Dingman mouth gag is placed in an inverted fashion into the oral cavity.

The tongue is then retracted to the contralateral side of operation, and bimanual palpation of the floor of mouth identifies the position and size of the gland.

This maneuver allows for delivery of the superior portion of the gland.

After infiltration of lidocaine with epinephrine, the incision is created from the retromolar trigone to within 1 cm of the lingual surface of the alveolar ridge, at the caruncle of Wharton's duct.

Dissection along Wharton's duct from the caruncle of the duct to the gland identifies the lingual nerve, located on the superior-posterior-lateral surface of the gland, which is carefully dissected away.

Wharton's duct is circumferentially dissected, from the caruncle to the gland, so that it may be elevated and excised en bloc with the gland.

The gland is then dissected off of the muscles of the tongue and floor of mouth. Posteriorly and laterally, dissection identifies the facial artery and vein branches involved in the gland, which are clipped and divided.

After dissection of the anterior and lateral portions of the gland, the hypoglossal nerve should be identified inferior and lateral to the gland.

The submandibular ganglion is identified and divided from the lingual nerve.

The wound is then irrigated, inspected for hemostasis and closed with interrupted sutures.

APPROACH TO SUBLINGUAL GLAND:-

INTRAORAL APPROACH:-

- LINEAR INCISION IS MADE PARELLEL AND LATERAL TO SUBMANDIBULAR DUCT

- INCISION SHOULDN’T EXTEND MORE POSTERIORLY TO 1ST MOLAR TOOTH TO AVOID DAMAGE TO LINGUAL NERVE

- THE SUBMANDIBULAR DUCT IS CAREFULLY IDENTIFIED AND RETRACTED MEDIALLY

- STAY SUTURES-PASSEING THROUGH MARGINS OF MUCOSA TO AID IN RETENTION

- USING BLUNT DISSECTION(SCISSORS) LINGUAL NERVE IS IDENTIFIED- THE SUBLINGUAL GLAND LYING ADJACENT TO INNER CORTEX OF

MANDIBLE IS MOBILIZED AND ITS MULTIPLE DUCTS ARE DIVIDED CAREFULLY TO AVOID DAMAGE TO IT.

- THE ANTEROLATERAL PART OF SUBLINGUAL GLAND MAY BE ATTACHED TO PERIOSTEUM OF MANDIBLE BY FIBROUS TISSUE WHICH MUST BE DIVIDED CAREFULLY.

- FOLLOWED BY REMOVAL OF GLAND AS AND WHEN NECESSARY

………...CONCLUSION……….