1. Salivary glands
Dr. Tanuj Paul Bhatia

2. Anatomy
3 major salivary glands:
The parotid glands
The submandibular glands
The sublingual glands
Many minor salivary glands in mucosa of cheeks, lips, palate.
3. Parotid gland
Largest salivary gland
Lies b/w sternomastoid and mandible below the EAM
Coverings :
True capsule
False capsule a layer from the deep cervical fascia
4. Lobes of parotid gland
Parotid divided into superficial and deep lobes by the facial nerve
Fasciovenous plane of Patey
5. 6. 7. Structures within the parotid gland
1. External carotid artery :
Gives terminal branches in the gland
Maxillary artery and superficial temporal artery.
2. Retromandibular vein
Formed by union of sup. Temporal and maxillary vein
Joins post. Auricular vein to form the external jugular vein.
8. Structures within the parotid gland
3. The facial nerve
Enters upper part of posteromedial border
Passes forward and downward and divides into
Temporal br.
Temporofacial
Zygomatic br.
Main trunk
Buccal branches
Cervicofacial
Marginal mandibular br.
Cervial br.
9. Facial nerve over the deep lobe of parotid
10. Parotid duct
Stensens duct
5cm in length
Comes out through anterior surface of glands.
Peircesbuccinator and opens in buccal mucosa opposite crown of second upper molar tooth.
11. Inflamatory diseases of parotid
Acute suppurativeparotitis
Acute parotitis (mumps parotitis)
Recurrent subacuteparotitis / chronic parotitis
12. Acute suppurativeparotitis
Causative organisms : Staph. aureus, streptococcus viridans, pneumococci commonly.
Route : usually from stensens duct, rarely blood born
Predisposing factors :
Dehydrated patients
Obstructed duct
13. Clinical features
Pain and swelling on the side of face
BRAWNY edematous swelling over parotid region with all signs of inflamation
Fever
If pressed pus may be seen coming from the opening of stensens duct.
14. Treatment
Improve general condition.
Improve oral hygeine.
Soft diet as chewing is painful.
Antibiotics.
If no response incision and drainage :
Vertical incision on skin but transverse incision on the parotid fascia to safeguard facial nerve and branches
15. Acute parotitis
Usually due to viral parotitis.
Rarely in association with tuberculosis, actinomycosis and cat scratch disease.
MUMPS commonest cause
Non suppurative
Initially unilateral but proceeds to bilateral affection.
16. Recurrent subacute and chronic parotitis
If on both sides, suspect Sjogrens syndrome.
Other causes : calculus, autoimmune
Recurrent attacks of pain and swelling.
Gland progressively replaced by fibrous tissue.
17. Management
Investigation : sialography
Treatment
Control infection by antibiotics.
Remove stone
Dilate the duct if it is constricted
Total conservative parotidectomy if all above measures fail
18. Neoplasms of the salivary gland
75% occur in the parotid glands.
In parotid glands, 80% of tumors are benign.
Of these 80% are Pleomorphic adenomas.
15% of salivary tumors occur in submandibular glands.
Of these 50% are benign and 50% and malignant.
In carcinomas mucoepidermoid ca> adenoid cystic ca > adenocarcinoma
19. 10% of salivary tumors occur in sublingual and minor salivary glands
60-70% of these are malignant
20. Classification
Epithilial tumors
Connective tissue tumors
Metastatic tumors
21. A. Epithilial tumors
Benign
Pleomorphic adenoma (Mixed tumor)
Oxyphil adenoma
Papillary cystadenomalymphomatosum (Warthins tumor)
Basal cell adenoma
22. Epithilial tumors
Malignant
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Acinic cell ca
Papillary adenocarcinoma
SCC
Undifferentiated ca
Ca arising in pleomorphic adenoma
23. Connective tissue tumors
Benign
Hemangioma
Lipoma
Neurilemmoma
Fibroma
Malignant
Malignant lymphoma
Above mentioned benign tumors may turn malignant.
24. Pleomorphic adenoma
Mixed tumor
Commonest tumor of salivary glands.
There is cartilage besides epithelial cells on histology.
Sites : 90% Parotids
7% Submandibular gland
3% rest
25. Pathology
Macro : rubbery, bosselated, on cut section, mucoid appearance with zones of cartilage.
Micro : pleomorphicstroma with pseudocartilage, lymphoid, myxoid and fibrous elements besides epithelial cells.
26. Clinical features
Age :any age but common around 40 yrs
Sex : slightly more incidence in females.
Painless swelling since years.
Slow growth.
Site : usually below the lobule of ear.
Variable consistency : firm and rubbery
27. 28. Malignant transformation
Malignant transformation may occur in 3% to 5%
Signs of malignant transformation :
Long duration (10-20yrs)
Becomes painful
Starts growing rapidly
Becomes stony hard
Facial nerve involvement
L. node involvement.
Jaw movement restriction.
29. Treatment
The tumor is radioresistant.
Excision is the treatment of choice.
For diagnosis FNAC can be done but incisional biopsy is contraindicated.
Superficial parotidectomy is the treatment of choice.
Submandibular gland : submandibular gland excision.
30. Warthins tumor
Represents 5-15% of parotid tumors.
Occurs only in parotid.
Almost always in lower portion of parotid gland.
31. Pathology
Gross :soft and frequently cystic
Micro : cores of papillary processes with abundant lymphoid tissue.
32. Clinical features
Age : middle and old age
Sex :much more common inmales
Painless slow growing tumor over angle of jaw
May be bilateral
Surface is smooth
33. Management
FNAC
Hot spot in 99mTC pertechnate scan
Treatment : superficial parotidectomy
34. Mucoepidermoid carcinoma
Slow growing
Invade local tissues to a limited degree
Occasionally metastasise to lymph nodes, lungs or skin.
Clinically they are hard, become fixed when very large.
35. Acinic cell tumor
Almost all occur in parotid gland
Composed of cells resembling acini
Women > Men
Rare and slow growing
Tend to be soft and occasionally cystic
36. Adenoid Cystic Carcinoma
Consists of myoepithelial and duct epithelial cells
Slow growing but more invasive than the above described malignant tumors
Tumor is always more extensive than the physical or radiological appearance
Minor glands > submandibular > parotid
37. Adenocarcinomas, Epidermoid ca &Undifferentiated Ca
Resemble various glandular elements seen in salivary glands
Divided according to predominant cell type
Demonstrate fixation to adjacent bone, pain, anesthesia of skin and paralysis of muscles
38. In case of parotid gland, facial nerve irritability occurs first, later gives rise to facial paralysis
Limitation of jaw movements
39. Submandibular gland
Composed of superficial part and deep part
Divided by mylohyoid muscle
Superficial part lies in the submandibular triangle b/w 2 bellies of digastric muscle
Deep part lies abv & deep to mylohyoid in the floor of mouth
40. 41. Submandibular duct (Whartons duct)
About 5 cmlong
Runs fwd from the deep part of the gland to enter floor of the mouth
Opens on a papilla beside the frenulum of the tongue
42. 43. Structures in relation to submandibular gland
The Lingual nerve
The Facial artery
44. Sialography
Radio opaque liquid like
Hypaque (Sodium diatrizoate)
Lipiodol
Injected into duct system of the gland and radiograph taken
Volume of 0.5-2ml used
45. Shows
Obstruction, Dilatation & narrowing of duct
Position and size of salivary neoplasm
Extraglandular mass
Fistula and abscess cavities
46. 47. Acute suppurativesialadenitis of submandibular gland
Usually secondary to obstruction of Whartons duct
Organism S. aureus common
Responds well to antibiotics and improved oral hygiene
Rarely, I & D is required
48. Recurrent subacute and chronic sialoadenitis
These inflamations are always secondary to obstruction or autoimmune disease.
Recurrent attacks of pain and swelling
Sialography confirms the diagnosis and gives a clue about the cause
Treatment is of the primary condition
49. 50. Tumors of submandibular glands
Tumors in this gland are uncommon
Enlargement is more due to calculus
Of all tumors, mixed tumor is most common
Swelling is hard but not stony hard and should be differentiated from submandibular lymph node
51. 52. Obstruction of a major salivary gland duct
Characteristic symptom : Recurrent painful swelling of the affected gland at mealtimes.
First indication may be acute/ subacute infection
53. Causes of obstruction
Salivary calculi
Strictures of the duct wall
Edema or fibrosis of the papilla
Pressure on the duct
Invasion of the duct by malignant neoplasm
54. Salivary calculi
Submandibular calculi are most common
Easily demonstrated on plain X ray
Calculi within the duct removed via floor of mouth
Calculi within the gland or chronic infection excision of the gland
55. 56. 57. Sublingual and minor salivary gland diseases
Mucous cyst (retention cyst) : pink, soft swellings on inner surface of lips and cheeks
Cyst and associated minor gland should be excised together
Tumors : usually malignant
palate > upper lip > rest
Treatment : wide excision and grafting
58. 59. Ranula
Extravasation cysts arising from a damaged sublingual duct
Ranula = frog (latin)
Transluscent bluish swelling in the floor of mouth with vessels running over it
May flow over post margin of mylohyoid and present as a plunging ranula
Rx : excision, marsupilization
60. 61. 62. Mikuliczs disease
Characterized by
Enlargement of all salivary glands
Enlargement of both lacrimal glands
Dry mouth
This occurs due to replacement of glandular tissue by lymphocytes
Occurs b/w 20 and 40 yrs of age
Thought to be autoimmune process
63. Sjogrens syndrome
All features of Mikuliczs disease plus
Dry eyes (Keratoconjuntivitissicca)
Generalized arthritis
64. Surgery of salivary glands
65. Freys syndrome
Also called as auriculo-temporal syndrome
Occurs due to damage to the autonomic innervation of the salivary gland
Inappropriate regeneration of parasympathetic fibers
Stimulation of sweat glands of overlying skin with stimulus of salivation
66. Causes :
Surgery of the parotid gland
Injury to parotid gland
Clinical features : sweating and erythema at the site of parotid surgery by smell or taste of food.
67. Investigation :
Starch iodine test :
After painting the area with iodine Starch applied over the area becomes blue on gustatory stimulus.
68. Prevention
Sternomastoid muscle flap
Temporalisfascial flap
Artificial membranes
Form a barrier between skin and parotid bed to minimise inappropriate regeneration of autonomic nerve fibres.
69. Treatment
Initially conservative management
Most recover in 6 months
Anti-perspirants
Denervation by tympanic neurectomy
Injection of botulinum toxin into the afected skin.
70. Parotidectomy
Types :
Superficial parotidectomy : superficial to facial nerve
Total conservative parotidectomy : for benign diseases involving deep lobe. Facial nerve is preserved.
Radical parotidectomy :
For carcinomas
Facial nerve, fat, facia, muscles and lymph nodes are removed.
Later reconstruction using hypoglossal or greater auricular nerve.
71. Incision
Lazy S incision
Pre-auricularmastoid-cervical incision
72. 73. Identificaton of facial nerve
Conleys pointer : inferior portion of cartilagnous canal. Facial nerve is 1cm deep and inferior to its tip.
Upper border of posterior belly of the digastric muscle. Fascial nerve immediately superior to this.
By nerve stimulator
74. How To Save The Facial Nerve During Parotid Salivary Gland Tumor Surgery.flv
75. Complications of parotid surgery
Haematoma formation
Infection
Temporary facial nerve weakness
Permanent facial nerve weakness
Sialocele
Facial numbness
Freys syndrome
76. Facial nerve injury(Lower motor neuron lesion)
Causes
Trauma
Parotid surgery
Compression of facial nerve(Bells nerve)
77. Clinical features
Inability to close the eye lid
Difficulty in blowing and clenching
Drooping of the angle of mouth
Obliteration of naso-labial fold
78. Treatment
Usually temporary, recovers in 6 months
Nerve grafting
Suspension of angle of mouth to zygomatic bone
Lateral tarsorrhaphy
79. Submandibular gland excision
Indications :
Chronic sialoadenitis
Stone in submandbular gland
Submandibular gland tumors
80. Incision
Placed 2-4 cm below thmandie, parallel to it
Preserve :
Marginal mandibular nerve
Lingual nerve
Hypoglossal nerve
81. 82. Complications
Hemorrhage
Infection
Injury to mandibularnerve, lingual nerve , hypoglossal nerve
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