CoreIeatures

Embryology of the salivary glands and their as-

sociatedstructures
Detailedanatomyoftheparotid,submandibular,
sublingual,andminorsalivaryglands,including
nervousinnervation,arterialsupply,andvenous
andlymphaticdrainage
Histologyandorganizationoftheaciniandduct
systemswithinthesalivaryglands
Physiology and function of the glands with re-
specttotheproductionofsaliva
Considerationswhentakingapatientshistory
Te intra- and extraoral aspects of inspection
andpalpationduringaphysicalexamination

Chapter
Anatomy,Iunction,andvaIuation
oftheSaIivaryGIands
F. Christopher Holsinger and Dana T. Bui
1
1
Contents
Introduction 2
DevelopmentalAnatomy 2
ParotidGland 2
Anatomy 2
Fascia 3
StensensDuct 3
NeuralAnatomy 4
AutonomicNerveInnervation 4
ArterialSupply 5
VenousDrainage 6
LymphaticDrainage 6
ParapharyngealSpace 6
SubmandibularGland 6
Anatomy 6
Fascia 6
WhartonsDuct 7
NeuralAnatomy 7
ArterialSupply 8
VenousDrainage 8
LymphaticDrainage 8
SublingualGland 8
MinorSalivaryGlands 9
Histology 9
PhysiologyofSalivaryGlands 11
EvaluationoftheSalivaryGlands 13
History 13
PhysicalExamination 13
RadiologicandEndoscopicExamination
oftheSalivaryGlands 14
Introduction
Tehumansalivaryglandsystemcanbedividedintotwo
distinct exocrine groups Te major salivary glands in-
cludethepairedparotid,submandibular,andsublingual
glandsAdditionally,themucosaoftheupperaerodiges-
tive tract is lined by hundreds of small, minor salivary
glands Te major function of the salivary glands is to
secrete saliva, which plays a signifcant role in lubrica-
tion,digestion,immunity,andtheoverallmaintenanceof
homeostasiswithinthehumanbody
DeveIopmentaIAnatomy
In the last 15years, signifcant improvement has been
made in our understanding of the molecular basis of
salivary gland development, supplanting and expanding
classical teaching in the embryology and developmental
anatomy
Early work suggests that development of the salivary
glandsbeginsduringthesixthtoeighthembryonicweek
whenoralectodermaloutpouchingsextendintothead-
jacentmesodermandserveasthesiteoforiginformajor
salivaryglandgrowthTedevelopmentofmajorsalivary
glands is thought to consist of three main stages [1, 8]
Tefrststageismarkedbythepresenceofaprimordial
anlage(fromtheGermanverbanlagen,meaningtolaya
foundationortoprepare)andtheformationofbranched
ductbudsduetorepeatedepithelialclefandbuddevel-
opment Ciliated epithelial cells form the lining of the
lumina, while external surfaces are lined by ectodermal
myoepithelial cells [2] Te early appearance of lobules
and duct canalization occur during the second stage
Primitive acini and distal duct regions, both containing
myoepithelial cells, form within the seventh month of
embryoniclifeTethirdstageismarkedbymaturation
oftheaciniandintercalatedducts,aswellasthedimin-
ishingprominenceofinterstitialconnectivetissue
Tefrstoftheglandstoappear,duringthesixthges-
tationalweek,istheprimordialparotid glandItdevelops
fromtheposteriorstomodeum,whichlaterallyelongates
into solid cords across the developing masseter muscle
Tecordsthencanalizetoformducts,andaciniareformed
at the distal ends A capsule formed from the ambient
mesenchymesurroundstheglandandassociatedlymph
nodes[14]Smallbudsappearinthefoorofthemouth
lateraltothetongueduringthesixthweekofembryonic
lifeandextendposteriorlyaroundthemylohyoidmuscle
into the submandibular triangle Tese buds eventually
develop into the submandibular glands A capsule from
the surrounding mesenchyme is fully developed around
theglandbythethirdgestationalmonth[8]Duringthe
ninth embryonic month, the sublingual gland anlage is
formedfrommultipleendodermalepithelialbudsinthe
paralingualsulcusofthefoorofthemouthAbsenceof
acapsuleisduetoinfltrationoftheglandsbysublingual
connective tissue Intraglandular lymph nodes and ma-
jorductsalsodonotgenerallydevelopwithinsublingual
glands Upper respiratory ectoderm gives rise to simple
tubuloacinarunitsTeydevelopintotheminor salivary
glandsduringthe12thintrauterineweek[17]
Recent work using murine models has shown the
complexity of the underlying molecular events orches-
trating classical embryological fndings Development
of the salivary glands is an example of branching mor-
phogenesis, a process fundamental to many developing
organs, including lung, mammary gland, pancreas, and
kidney [12] Branching organs develop a complex arbo-
rization and morphology through a program of repeti-
tive,self-similarbranchingforkstocreatenewepithelial
outgrowthsTedevelopmentalgrowthofamulticellular
organsuchasasalivaryglandisbasedonasetofinterde-
pendentmechanismsandsignalingpathwaysTeresult-
ing expression of these pathways is dynamic, organized,
and changes correspondingly with each developmental
stage Te sonic hedgehog (Shh) signaling plays an es-
sentialroleduringcraniofacialdevelopment[13]Other
pathways,includingthefbroblastgrowthfactorfamilyof
receptorsandassociatedligands,havealsobeenshownto
playacrucialrole[28]
ParotidGIand
Anatomy
Tepairedparotidglandsarethelargestofthemajorsali-
vary glands and weigh, on average, 1530g Located in
thepreauricularregionandalongtheposteriorsurfaceof
themandible,eachparotidglandisdividedbythefacial
nerve into a superfcial lobe and a deep lobe (Fig11)
Te superfcial lobe, overlying the lateral surface of the
masseter,isdefnedasthepartoftheglandlateraltothe
facial nerve Te deep lobe is medial to the facial nerve
andlocatedbetweenthemastoidprocessofthetemporal
2
1
I.ChristopherHoIsingerandDana7.8ui
bone and the ramus of the mandible Most benign neo-
plasms are found within the superfcial lobe and can be
removed by a superfcial parotidectomy Tumors arising
inthedeeplobeoftheparotidglandcangrowandextend
laterally, displacing the overlying superfcial lobe with-
out direct involvement Tese parapharyngeal tumors
can grow into dumbbell-shaped tumors, because their
growth is directed through the stylomandibular tunnel
[5]
Teparotidglandisboundedsuperiorlybythezygo-
maticarchInferiorly,thetailoftheparotidglandextends
down and abuts the anteromedial margin of the sterno-
cleidomastoid muscle Tis tail of the parotid gland ex-
tendsposteriorlyoverthesuperiorborderofthesterno-
cleidomastoid muscle toward the mastoid tip Te deep
lobe of the parotid lies within the parapharyngeal space
[10]
An accessory parotid gland may also be present lying
anteriorlyoverthemassetermusclebetweentheparotid
ductandzygomaItsductsemptydirectlyintotheparotid
ductthroughonetributaryAccessoryglandulartissueis
histologically distinct from parotid tissue in that it may
contain mucinous acinar cells in addition to the serous
acinarcells[6]
Iascia
Tedeepcervicalfasciacontinuessuperiorlytoformthe
parotid fascia, which is split into superfcial and deep
layers to enclose the parotid gland Te thicker superf-
cial fascia is extended superiorly from the masseter and
sternocleidomastoid muscles to the zygomatic arch Te
deep layer extends to the stylomandibular ligament (or
membrane), which separates the superfcial and deep
lobesoftheparotidglandTestylomandibularligament
isanimportantsurgicallandmarkwhenconsideringthe
resection of deep lobe tumors In fact, stylomandibular
tenotomy [22] can be a crucial maneuver in providing
exposure for en bloc resections of deep-lobe parotid or
other parapharyngeal space tumors Te parotid fascia
formsadenseinelasticcapsuleand,becauseitalsocovers
themassetermuscledeeply,cansometimesbereferredto
astheparotid masseteric fascia.
StensensDuct
Te parotid duct, also known as Stensens duct, secretes
aseroussalivaintothevestibuleoftheoralcavityFrom
Fig. 1.1:Teparotidglandandthefacial
nervebranching
3 Anatomy,Iunction,andvaIuation Chapter1
theanteriorborderofthegland,ittravelsparalleltothe
zygoma, approximately 1cm below it, in an anterior di-
rectionacrossthemassetermuscleItthenturnssharply
topiercethebuccinatormuscleandenterstheoralcavity
oppositetheseconduppermolartooth
NeuraIAnatomy
Tefacialnerve(CNVII)exitstheskullbaseviathesty-
lomastoidforamen,whichisslightlyposterolateraltothe
styloidprocessandanteromedialtothemastoidprocess
Beforeenteringtheposteriorportionoftheparotidgland,
threemotorbranchesaregivenoftoinnervatethepos-
teriorbellyofthedigastricmuscle,thestylohyoidmuscle,
andthepostauricularmuscles
Temaintrunkofthefacialnervethenpassesthrough
theparotidglandand,atthepes anserinus(Latin:gooses
foot), divides into the temporofacial and lower cervico-
facialdivisionsapproximately13cmfromthestylomas-
toidforamenTeuppertemporofacial divisionformsthe
frontal, temporal, zygomatic, and buccal branches Te
lowercervicofacial divisionformsthemarginalmandibu-
lar and cervical branches Branches from the major up-
per and lower branches ofen anastomose to create the
diversenetworkofmidfacialbuccalbranches
Te temporal branch traverses parallel to the super-
fcial temporal vessels across the zygoma to supply the
frontal belly of the occipitofrontalis muscle, the orbicu-
larisoculi,thecorrugatorsupercilii,andtheanteriorand
superiorauricularmusclesTezygomatic branchtravels
directlyovertheperiosteumofthezygomaticarchtoin-
nervate the zygomatic, orbital, and infraorbital muscles
Te buccal branch travels with Stensens duct anteriorly
overthemassetermuscletosupplythebuccinator,upper
lip,andnostrilmusclesBuccalbranchescaneitherarise
from the upper temporofacial or the lower cervicofacial
divisionTemarginal mandibular branchcoursesalong
theinferiorborderoftheparotidglandtoinnervatethe
lowerlipandchinmusclesItliessuperfcialtothepos-
teriorfacialveinandretromandibularveinsintheplane
ofthedeepcervicalfasciadirectlybeneaththeplatysma
muscleTecervical branchsuppliestheplatysmamuscle
Likethemarginalmandibularbranch,itislocatedwithin
theplaneofthedeepcervicalfasciadirectunderneaththe
platysma
Smallconnectionscanexistamongthetemporal,zy-
gomatic,andbuccalbranches,andanatomicvariationsin
facial nerve branching patterns occur commonly Each
terminalbranchcanbelocateddistallyandtracedretro-
grade across the parotid gland to the main trunk of the
facialnerveTefacialnervecanalsobeidentifedatthe
stylomastoidforamenbyperformingamastoidectomyif
identifcation by the usual landmarks is not possible [5,
10,23]
Te great auricular nerve is a sensory branch of the
cervical plexus, particularly C2 and C3, and innervates
the posterior portion of the pinna and the lobule Te
nerveparallelstheexternaljugularveinalongthelateral
surface of the sternocleidomastoid muscle to the tail of
theparotidgland,whereitsplitsintoanteriorandposte-
rior branches Te great auricular nerve is ofen injured
duringparotidectomy,whichcanresultinlong-termsen-
sory loss in the lobule Harvesting of this nerve can be
usedforfacialnervegrafingincertaincases
Te auriculotemporal nerve is a branch of the man-
dibular nerve, the third inferior subdivision of the tri-
geminalnerve(V3)Aferexitingtheforamenovale,the
nervetraversessuperiorlytoinnervatetheskinandscalp
immediatelyanteriortotheearItscourserunsparallelto
thesuperfcialtemporalvesselsandanteriortotheexter-
nalauditorycanal
AutonomicNerveInnervation
Te glossopharyngeal nerve (CNIX) provides visceral
secretory innervation to the parotid gland Te nerve
carries preganglionic parasympathetic fbers from the
inferior salivatory nucleus in the medulla through the
jugular foramen (Fig12) Distal to the inferior gan-
glion, a small branch of CNIX (Jacobsens nerve) reen-
ters the skull through the inferior tympanic canaliculus
and into the middle ear to form the tympanic plexus
Te preganglionic fbers then course along as the lesser
petrosal nerve into the middle cranial fossa and out the
foramen ovale to synapse in the otic ganglion Postgan-
glionic parasympathetic fbers exit the otic ganglion be-
neaththemandibularnervetojointheauriculotemporal
nerve in the infratemporal fossa Tese fbers innervate
the parotid gland for the secretion of saliva Postgangli-
onic sympathetic fbers innervate salivary glands, sweat
glands,andcutaneousbloodvesselsthroughtheexternal
carotid plexus from the superior cervical ganglion Ace-
tylcholine serves as the neurotransmitter for both post-
ganglionicsympatheticandparasympatheticfbers[10]
Tisphysiologiccoincidenceallowsforthedevelopment
ofgustatorysweating(alsoknownasFreyssyndrome)
4
1
I.ChristopherHoIsingerandDana7.8ui
followingparotidectomy[19,26]Patientsdevelopsweat-
ingandfushingoftheskinoverlyingtheparotidregion
during eating due to aberrant autonomic reinnervation
ofthesweatglandsbytheregeneratingparasympathetic
fbers from any residual parotid gland Freys syndrome
mayoccurinasmanyas2560%ofpatientspostopera-
tivelyTeriskforFreyssyndromecanbeminimizedfrst
by complete and meticulous superfcial parotidectomy
Second, by developing skin faps of appropriate thick-
ness, exposed apocrine glands of the skin are protected
from ingrowth and stimulation by the severed branches
oftheauriculotemporalnerveandtheirparasympathetic
stimulationduringmealsTerearenumerousnonsurgi-
calandsurgicaltreatmentsforpersistentFreyssyndrome
following parotidectomy (see Chapter5, Treatment of
FreysSyndrome)
ArteriaISuppIy
Te blood supply to the parotid gland is from branches
of the external carotid artery, which courses superiorly
fromthecarotidbifurcationandparalleltothemandible
undertheposteriorbellyofthedigastricmuscleTear-
tery then travels medial to the parotid gland and splits
into two terminal branches Te superfcial temporal
artery runs superiorly from the superior portion of the
parotid gland to the scalp within the superior pretragal
region Te maxillary artery leaves the medial portion
of the parotid and supplies the infratemporal fossa and
thepterygopalatinefossaDuringradicalparotidectomy,
this vessel must be controlled especially when marginal
orsegmentalmandibulectomyisrequiredTetransverse
facial artery branches of the superfcial temporal artery
andrunsanteriorlybetweenthezygomaandparotidduct
to supply the parotid gland, parotid duct, and the mas-
setermuscle[10]
Fig. 1.2:Parasympatheticsupply
tothemajorsalivaryglands
5 Anatomy,Iunction,andvaIuation Chapter1
VenousDrainage
Te retromandibular vein, formed by the union of the
maxillary vein and the superfcial temporal vein, runs
through the parotid gland just deep to the facial nerve
to join the external jugular vein Tere is substantial
variationinthesurgicalanatomyoftheretromandibular
vein,whichmaybifurcateintoananteriorandposterior
branchTeanterior branchcanunitewiththeposterior
facial vein, forming the common facial vein Te pos-
terior facial vein lies immediately deep to the marginal
mandibular branch of the facial nerve and is therefore
ofen used as a landmark for identifcation of the nerve
branch,especiallyattheantegonialnotchofthemandible
wherethenervedipsinferiorly[3]Teposterior branch
of the retromandibular veinmaycombinewiththepost-
auricularveinabovethesternocleidomastoidmuscleand
drainintotheexternaljugularvein
LymphaticDrainage
Contrarytothelymphaticdrainageoftheothersalivary
glands,thereisahighdensityoflymphnodeswithinand
aroundtheparotidglandTeparotidistheonlysalivary
glandwithtwonodallayers,bothofwhichdrainintothe
superfcial and deep cervical lymph systems Approxi-
mately90%ofthenodesarelocatedinthesuperfciallayer
betweentheglandulartissueanditscapsuleTeparotid
gland, external auditory canal, pinna, scalp, eyelids, and
lacrimalglandsarealldrainedbythesesuperfcialnodes
Tedeeplayerofnodesdrainsthegland,externalaudi-
torycanal,middleear,nasopharynx,andsofpalate[7]
ParapharyngeaISpace
Tumors of the deep parotid lobe ofen extend medially
intotheparapharyngealspace(PPS)Tisspacejustpos-
teriortotheinfratemporalfossaisshapedlikeaninverted
pyramid Te greater cornu of the hyoid bone serves as
theapexandthepetrousboneoftheskullbaseactsasthe
pyramidalbaseTePPSisboundmediallybythelateral
pharyngeal wall,whichconsistsofthesuperiorconstric-
tor muscles, the buccopharyngeal fascia and the tensor
velipalatineTeramusofthemandibleandthemedial
pterygoid muscle make up the lateral border Te para-
pharyngealspaceisborderedanteriorlybythepterygoid
fascia and the pterygomandibular raphe Te posterior
borderislinedbythecarotidsheathandprevertebralfas-
cia
Alinefromthestyloidprocesstothemedialportion
ofthemedialpterygoidplatedividestheparapharyngeal
space into two compartments Te prestyloid compart-
mentcontainsthedeeplobeoftheparotidgland,minor
salivary glands, as well as neurovascular structures, in-
cludingtheinternalmaxillaryartery,ascendingpharyn-
gealartery,theinferioralveolarnerve,thelingualnerve,
andtheauriculotemporalnerveTepoststyloid compart-
mentcontainstheinternaljugularvein,carotidarteryand
vagus nerve within the carotid sheath, as well as cranial
nervesIX, X, XI, and XII and the cervical sympathetic
chain Neurogenic tumors or paragangliomas from the
cervicalsympatheticsorcranialnervescanthusarisein
thiscompartment[4]
SubmandibuIarGIand
Anatomy
Tesubmandibulargland(inoldertexts,thisglandwas
sometimesreferredtoasthesubmaxillarygland)isthe
second largest major salivary gland and weighs 716g
(Fig13)Teglandislocatedinthe submandibular tri-
angle,whichhasasuperiorboundaryformedbytheinfe-
rioredgeofthemandibleandinferiorboundariesformed
bytheanteriorandposteriorbelliesofthedigastricmus-
cleAlsolyingwithinthetrianglearethesubmandibular
lymph nodes, facial artery and vein, mylohyoid muscle,
andthelingual,hypoglossal,andmylohyoidnervesMost
ofthesubmandibularglandliesposterolateraltothemy-
lohyoidmuscleDuringneckdissectionorsubmandibu-
larglandexcision,thismylohyoidmusclemustbegently
retractedanteriorlytoexposethelingualnerveandsub-
mandibularganglionOfen,smaller,tongue-likeprojec-
tions of the gland follow the duct, as it ascends toward
theoralcavity,deeptothemylohyoidmuscle[29]How-
ever,theseprojectionsshouldbedistinguishedfromthe
sublingual gland which lies superior to the mylohyloid
muscle(Formoredetail,seeChapter21,Managementof
TumorsoftheSubmandibularandSublingualGlands)
Iascia
Temiddlelayerofthedeepcervicalfasciaenclosesthe
submandibularglandTisfasciaisclinicallyrelevantbe-
6
1
I.ChristopherHoIsingerandDana7.8ui
causethemarginalmandibularbranchofthefacialnerve
issuperfcialtoit,andcaremustbetakentopreservethe
nerveduringsurgeryinthesubmandibularregionTus,
division of the submandibular gland fascia, when onco-
logically appropriate, is a reliable method of preserving
andprotectingthemarginalmandibularbranchofthefa-
cialnerveduringneckdissectionand/orsubmandibular
glandresection
WhartonsDuct
Te submandibular gland has both mucous and serous
cellsthatemptyintoductules,whichinturnemptyinto
the submandibular duct Te duct exits anteriorly from
the sublingual aspect of the gland, coursing deep to the
lingualnerveandmedialtothesublingualglandIteven-
tuallyformsWhartonsductbetweenthehyoglossusand
mylohyoid muscles on the genioglossus muscle Whar-
tonsduct,themainexcretoryductofthesubmandibular
gland,isapproximately45cmlong,runningsuperiorto
thehypoglossalnervewhileinferiortothelingualnerve
Itemptieslateraltothelingualfrenulumthroughapapilla
inthefoorofthemouthbehindthelowerincisortooth
Teopeningsforthesublingualgland,orthesublingual
caruncles, are located near the midline of the sublingual
foldintheventraltongue
NeuraIAnatomy
Both the submandibular and the sublingual glands are
innervatedbythesecretomotorfbersofthefacialnerve
(CNVII)Parasympatheticinnervationfromthesuperior
salivatory nucleus in the pons passes through the ner-
vus intermedius and into the internal auditory canal to
jointhefacialnerveTefbersarenextconveyedbythe
chorda tympani nerveinthemastoidsegmentofCNVII,
whichtravelsthroughthemiddleearandpetrotympanic
fssure to the infratemporal fossa Te lingual nerve, a
branch of the marginal mandibular division of the ffh
cranialnerve(CNV),thencarriesthepresynapticfbers
to the submandibular ganglion Te postsynaptic nerve
leavesthegangliontoinnervateboththesubmandibular
andsublingualglandstosecretewaterysalivaAsinthe
parotidgland,sympatheticinnervationfromthesuperior
cervical ganglion accompanies the lingual artery to the
submandibulartissueandcausesglandularproductionof
mucoidsalivainstead[5]
Te lingual nerve branches of the mandibular divi-
sion of the trigeminal nerve (V3) in the infratemporal
fossa to supply general sensation and taste to the ante-
riortwothirdsofthetongueTenervecourseslaterally
betweenthemedialpterygoidmuscleandramusofthe
mandible and enters the oral cavity at the lower third
molar to then travel across the hyoglossus along the
Fig. 1.3:Tesubmandibulargland
andimportantanatomiclandmarks
7 Anatomy,Iunction,andvaIuation Chapter1
foor of the mouth in a submucosal plane Beneath the
mandible, a small motor nerve branches of and trav-
els posteriorly from the lingual nerve to innervate the
mylohyoid muscle Tese fbers are usually sacrifced
during surgical removal of the submandibular gland
Parasympatheticfbersarecarriedviathelingualnerve
tothesubmandibularganglion,andpostsynapticfbers
exit along the course of the submandibular duct to in-
nervatethegland
Tehypoglossalnerve(CNXII)suppliesmotorinner-
vationtoallextrinsicandintrinsicmusclesofthetongue
exceptforthepalatoglossusmuscleFromthehypoglos-
sal canal at the base of the skull, the nerve is pulled in-
feriorly during embryonic development down into the
neck by the occipital branch of the external carotid ar-
teryFromhere,thehypoglossalnervetravelsjustdeepto
the posterior belly of the digastric muscle and common
tendonuntilitreachesthesubmandibulartriangleHere
CNXIIliesdeepinthetrianglecoveredbyathinlayerof
fasciaItslocationisanterior,deepandmedialrelativeto
thesubmandibularglandTypicallythenervehasaclose
relationshiptotheanteriorbellyofthedigastricmuscle
Itthenascendsanteriortothelingualnerveanditsgenu
deep to the mylohyoid muscle Extreme care should be
taken to preserve this important nerve during head and
necksurgery
ArteriaISuppIy
Both the submandibular and sublingual glands are sup-
plied by the submental and sublingual arteries, branches
ofthelingualandfacialarteriesTefacial artery,thetor-
tuous branch of the external carotid artery, is the main
arterialbloodsupplyofthesubmandibularglandItruns
medialtotheposteriorbellyofthedigastricmuscleand
then hooks over to course superiorly deep to the gland
Te artery exits at the superior border of the gland and
the inferior aspect of the mandible known as the facial
notchItthenrunssuperiorlyandadjacenttotheinferior
branches of the facial nerve into the face During sub-
mandibularglandresection,thearterymustbesacrifced
twice, frst at the inferior border of the mandible and
againjustsuperiortotheposteriorbellyofthedigastric
muscleTelingual arterybranchesinferiortoorwiththe
facial artery of the external carotid artery It runs deep
to the digastric muscle along the lateral surface of the
middleconstrictorandthencoursesanteriorandmedial
tothehyoglossusmuscle
VenousDrainage
Te submandibular gland is mainly drained by the an-
terior facial vein, which is in close approximation to the
facialarteryasitrunsinferiorlyandposteriorlyfromthe
facetotheinferioraspectofthemandibleBecauseitlies
justdeeptothemarginalmandibulardivisionofthefacial
nerve,ligationandsuperiorretractionoftheanteriorfa-
cialveincanhelppreservethisbranchofthefacialnerve
during submandibular gland surgery It forms extensive
anastomoseswiththeinfraorbitalandsuperiorophthal-
micveinsTecommon facial veinisformedbytheunion
oftheanteriorandposteriorfacialveinsoverthemiddle
aspectoftheglandTecommonfacialveinthencourses
lateraltotheglandandexitsthesubmandibulartriangle
tojointheinternaljugularvein
LymphaticDrainage
Teprevascularandpostvascularlymphnodesdraining
the submandibular gland are located between the gland
anditsfascia,butarenotembeddedintheglandulartis-
sue Tey lie in close approximation to the facial artery
and vein at the superior aspect of the gland and empty
intothedeepcervicalandjugularchainsTesenodesare
frequently associated with cancers in the oral cavity, es-
peciallyinthebuccalmucosaandthefoorofthemouth
Tus, when ligating the facial artery and its associated
plexusofveins,greatercaremustbetakennotonlytore-
sectallassociatedlymphoadiposetissue,butalsotopre-
servethemarginalmandibularbranchofthefacialnerve,
whichrunsincloseproximitytothesestructures
SubIinguaIGIand
Tesmallestofthemajorsalivaryglandsisthesublingual
gland,weighing24gConsistingmainlyofmucousaci-
narcells,itliesasafatstructureinasubmucosalplane
withintheanteriorfoorofthemouth,superiortothemy-
lohyoidmuscleanddeeptothesublingualfoldsopposite
thelingualfrenulum[11]Lateraltoitarethemandible
andgenioglossusmuscleTereisnotruefascialcapsule
surrounding the gland, which is instead covered by oral
mucosaonitssuperioraspectSeveralducts(of Rivinus)
fromthesuperiorportionofthesublingualglandeither
secrete directly into the foor of mouth, or empty into
Bartholins ductthatthencontinuesintoWhartonsduct
8
1
I.ChristopherHoIsingerandDana7.8ui
Both the sympathetic and parasympathetic nervous
systems innervate the sublingual gland Te presynaptic
parasympathetic(secretomotor)fbersofthefacial nerve
arecarriedbythechordatympaninervetosynapseinthe
submandibular ganglion Postganglionic fbers then exit
thesubmandibular ganglionandjointhelingualnerveto
supply the sublingual gland Sympathetic nerves inner-
vatingtheglandtravelfromthecervical ganglionwiththe
facialartery[5]
Blood is supplied to the sublingual gland by the sub-
mental and sublingual arteries,branchesofthelingualand
facialarteries,respectivelyTevenousdrainageparallels
thecorrespondingarterialsupplyTesublingualglandis
mainlydrainedbythesubmandibularlymphnodes
Ranulasarecystsormucocelesofthesublingualgland,
and they can exist either simply within the sublingual
space or plunging posteriorly to the mylohyoid muscle
intotheneckAsimpleranulawillmostcommonlypres-
entasabluish,nontendermassinthefoorofthemouth
and may either be a retention cyst or an extravasation
pseudocyst A plunging ranula will present as a sof,
painless cervical mass and is always an extravasation
pseudocyst (see Chapter10, Management of Mucocele
andRanula)
MinorSaIivaryGIands
About 600 to 1,000 minor salivary glands, ranging in
size from 1 to 5mm, line the oral cavity and orophar-
ynxTegreatestnumberoftheseglandsareinthelips,
tongue, buccal mucosa, and palate, although they can
alsobefoundalongthetonsils,supraglottis,andparana-
sal sinuses Each gland has a single duct which secretes,
directlyintotheoralcavity,salivawhichcanbeeitherse-
rous,mucous,ormixed
Postganglionic parasympathetic innervation arises
mainlyfromthelingual nerveTepalatinenerves,how-
ever, exit the sphenopalatine ganglion to innervate the
superiorpalatalglandsTeoralcavityregionitselfdeter-
minesthebloodsupplyandvenousandlymphaticdrain-
ageoftheglandsAnyofthesesitescanalsobethesource
ofglandulartumors[11]
HistoIogy
Allglandsingeneralarederivedfromepithelialcellsand
consistofparenchyma(thesecretoryunitandassociated
ducts)andstroma(thesurroundingconnectivetissuethat
penetratesanddividestheglandintolobules)Secretory
productsaresynthesizedintracellularlyandsubsequently
releasedfromsecretorygranulesbyvariousmechanisms
GlandsareusuallyclassifedintotwomaingroupsEndo-
crine glandscontainnoducts,andthesecretoryproducts
are released directly into the bloodstream or lymphatic
systemIncontrast,exocrine glandssecretetheirproducts
throughaductsystemthatconnectsthemtotheadjacent
externalorinternalepithelialsurfacesSalivaryglandsare
classifed as exocrine glands that secrete saliva through
ducts from a fask-like, blind-ended secretory structure
calledthe salivary acinus.
Teacinusitselfcanbedividedintothreemaintypes
Serous aciniinsalivaryglandsareroughlysphericaland
release via exocytosis a watery protein secretion that is
minimally glycosylated or nonglycosylated from secre-
tory(orzymogen)granulesTeacinarcellscomprising
theacinusarepyramidal,withbasallylocatednucleisur-
roundedbydensecytoplasmandsecretorygranulesthat
aremostabundantintheapexMucinous acinistoreavis-
cous, slimy glycoprotein (mucin) within secretory gran-
ulesthatbecomehydratedwhenreleasedtoformmucus
Mucinous acinar cells are commonly simple columnar
cellswithfattened,basallysituatednucleiandwater-solu-
blegranulesthatmaketheintracellularcytoplasmappear
clearMixed,orseromucous,acinicontaincomponentsof
bothtypes,butonetypeofsecretoryunitmaydominate
Mixedsecretoryunitsarecommonlyobservedasserous
demilunes(orhalf-moons)cappingmucinousacini
Between the epithelial cells and basal lamina of the
acinus,fatmyoepithelial cells(orbasketcells)formalat-
ticeworkandpossesscytoplasmicflamentsontheirbasal
side to aid in contraction, and thus forced secretion, of
the acinus Myoepithelial cells are also observed around
intercalatedducts,butheretheyaremorespindleshaped
[16]
Electrolyte modifcation and transportation of saliva
are carried out by the diferent segments of the salivary
glands duct system (Fig14) Te acini frst secrete
through small canaliculi into the intercalated ducts,
whichinturnemptyintostriatedductswithintheglan-
dularlobuleTeintercalatedductiscomprisedofanir-
regular myoepithelial cell layer lined with squamous or
low cuboidal epithelium Bicarbonate is secreted into
whilechlorideisabsorbedfromtheacinarproductwithin
theintercalatedductsegmentStriatedductshavedistin-
guishing basal striations due to membrane invagination
and mitochondria and are lined by a simple columnar
9 Anatomy,Iunction,andvaIuation Chapter1
epithelium Tese ducts are involved with the reabsorp-
tionofsodiumfromtheprimarysecretionandthecon-
comitant secretion of potassium into the product Te
abundant presence of mitochondria is necessary for the
ducts transport of both water and electrolytes Te aci-
nus, intercalated duct, and striated duct are collectively
knownasasinglesecretoryunitcalledasalivon [15]
Tenextsegmentoftheductsystemismarkedbythe
appearanceoftheinterlobularexcretoryductswithinthe
connective tissue of the glandular septae Te epithelial
lining is comprised of sparse goblet cells interspersed
amongthepseudostratifedcolumnarcellsAsthediam-
eteroftheductincreases,thecompositionoftheepithe-
lial lining transitions to stratifed columnar, and then to
nonkeratinizedstratifedsquamouscells,withintheoral
cavity[16]
Tearterialbloodfowreceivedbythesalivaryglands
is high relative to their weight and is opposite the fow
of saliva within the duct system Te acini and ductules
aresuppliedbyseparateparallelcapillarybedsTehigh
permeability of these vessels permits rapid transfer of
molecules across their basement membranes Te high
volumeofsalivaproducedbythesalivaryglandsrelative
to their weight is partly due to the high blood fow rate
throughtheglandulartissue
Te serous acini that make up the parotid gland are
roughly spherical, and they are comprised of pyramidal
epithelialcellssurroundedbyadistinctbasementmem-
braneMerocrinesecretionbytheepithelialcellsreleases
a secretory mixture containing amylase, lysozyme, an
IgA secretory piece, and lactoferrin into the central lu-
menoftheacinusTemainexcretoryductisalsoknown
asStensens ductandemptiesintotheoralcavityopposite
theseconduppermolartooth
Tesubmandibular glandisclassifedasamixedgland
thatispredominantlyserouswithtubularaciniTema-
jorityofacinarcellsareserouswithverygranulareosino-
philiccytoplasmOnlyapproximately10%oftheaciniare
mucinous, with large, triangular acinar cells containing
centralnucleiandclearcytoplasmicmucinvacuolesrang-
inginsizeTemucinouscellsarecappedbydemilunes,
whicharecrescent-shapedformationsofserouscellsTe
intercalatedductsofthesubmandibularglandarelonger
than those of the parotid gland, while striated ducts are
shorterbycomparisonWhartons ductservesasthemain
excretoryductandemptiesintothefoorofthemouth
Like the submandibular gland, the sublingual gland
has mixed acini with observable serous demilunes
within the glandular tissue Unlike the submandibular
gland, however, the sublingual gland is predominantly
Fig. 1.4:Functionalhistology
ofthesalivon
10
1
I.ChristopherHoIsingerandDana7.8ui
mucinous Te main duct empties into the submandib-
ular duct and is also known as Bartholins duct Several
smaller ducts (of Rivinus) also directly secrete into the
foorofthemouth
Te minor salivary glands are found throughout the
oralcavity,withthegreatestdensityinthebuccalandla-
bialmucosa,theposteriorhardpalate,andtonguebase
Teyarenotasofenobserved,however,intheattached
gingiva and closely associated anterior hard palatal mu-
cosaTemajorityoftheseglandsareeithermucinousor
seromucinous,exceptfortheserousEbners glandsonthe
posterioraspectofthetongueTesedeepposteriorsali-
varyglandsofthetonguearealsomarkedbythepresence
of ciliated cells, especially within the distal segments of
theexcretoryductsTeminorsalivaryglandductsystem
is simpler than that of the major salivary glands, where
theintercalatedductsarelongerandthestriatedductsare
eitherlessdevelopedornotpresent[15]
PhysioIogyofSaIivaryGIands
Saliva production, the main function of the salivary
glands, is crucial in the processes of digestion, lubrica-
tion, and protection in the body Saliva is actively pro-
ducedinhighvolumesrelativetothemassofthesalivary
glands,anditisalmostcompletelycontrolledextrinsically
byboththeparasympatheticandsympatheticdivisionsof
theautonomicnervoussystem
Salivaplaysacrucialroleinthedigestionofcarbohy-
dratesandfatsthroughtwomainenzymesPtyalinisan
-amylaseinsalivathatcleavestheinternal-1,4-glyco-
sidicbondsofstarchestoyieldmaltose,maltotriose,and
-limitdextrinsTisenzymefunctionsatanoptimalpH
of 7, but rapidly denatures when exposed to a pH less
than4,suchaswhenincontactwiththeacidicsecretions
ofthestomachUpto75%ofthecarbohydratecontentin
a meal, however, is broken down by the enzyme within
thestomachTisisduetothefactthatasignifcantpor-
tionofaningestedmealremainsunmixedwithintheoral
region,andthusthereisadelayinthemixtureofgastric
juiceswiththefoodbolusStarchdigestionisnotslowed
in the absence of ptyalin because pancreatic amylase is
identical to salivary amylase and is thus able to break
downallcarbohydrateswheninthesmallintestineTe
salivaryglandsofthetongueproducelingual lipase,which
functionstobreakdowntriglyceridesUnlikeptyalin,this
enzymeisfunctionalwithintheacidicstomachandprox-
imalduodenumbecauseitisoptimallyactiveatalowpH
Salivaalsoservestodissolveandtransportfoodparticles
awayfromtastebudstoincreasetastesensitivity
Temucusconstituentofsalivafacilitatesthelubrica-
tion of food particles during the act of chewing, which
servestomixthefoodwithsalivaLubricationeasesthe
processesofswallowingandofthebolustravelingdown
the esophagus Salivary lubrication is also crucial for
speech
Te antibacterial properties of saliva are due to its
many protective organic constituents Te binding gly-
coprotein for immunoglobulinA (IgA), known as the
secretory piece, forms a complex with IgA that is immu-
nologicallyactiveagainstvirusesandbacteriaLysozyme
causes bacterial agglutination and autolysin activation
to degrade bacterial cell walls Lactoferrin inhibits the
growth of bacteria that need iron by chelating with the
element Saliva also serves as a protective bufer for the
mouth by diluting harmful substances and lowering the
temperature of solutions that are too hot It washes out
foul-tasting substances from the mouth and neutralizes
gastricjuicetoprotecttheoralcavityandesophagusXe-
rostomia,ordrymouth,duetolackofsalivation,canlead
tochronicbuccalmucosalinfectionsordentalcaries
Comprisedofbothinorganicandorganiccompounds,
saliva is distinguished by its high volume compared to
salivaryglandweight,highpotassiumconcentration,and
low osmolarity (Fig15) Te large relative volume of
salivaproductionisduetoitshighsecretionrate,which
cangoupto1mlpergramofsalivaryglandperminute
Saliva is mostly hypotonic to plasma, but its osmolarity
increaseswithincreasingrateofsecretion,andatitshigh-
est rate saliva approaches isotonicity Te concentration
of electrolytes in saliva also changes with varying secre-
tionrates
Withinthesalivarygland,potassium(K
+
)concentra-
tion is always high while sodium (Na
+
) concentration is
low compared to that found in plasma With increasing
fow rates, however, Na
+
concentration increases, while
K
+
concentrationinitiallydecreasesslightlyandthenlev-
els of to a constant level Chloride (Cl

) concentrations
followthesamegeneralpatternasNa
+
concentrationsIn
otherwords,Na
+
andCl

aregenerallysecretedandthen
slowlyreabsorbedalongthecourseofthesalivarysystem,
fromacinustoductTesalivaryconcentrationofbicar-
bonate(HCO3

)ishypertoniccomparedtoinplasmaex-
ceptatlowerratesofsecretion
Initially within the salivon, the acini frst produce a
primary secretion that is relatively isotonic to plasma
As the saliva travels through the ducts, Na
+
and Cl

are
11 Anatomy,Iunction,andvaIuation Chapter1
reabsorbed, while K
+
and HCO3

are secreted into the

fuid Less time is available for the movement of these
electrolyteswhenthefowrateofsalivaishigherAthigh
fowrates,therefore,plasmaandsalivaaresimilarincon-
centration At lower secretion rates, K
+
concentration is
higher in the saliva, while Na
+
and Cl

concentrations
aresignifcantlylowerBicarbonateconcentratesremains
fairly hypertonic relative to in plasma even with higher
fow rates due to its secretory stimulation by most sali-
varyglandagonistsSalivaismostlyhypotonictoplasma
duetothefactthatreabsorptionofNa
+
andCl

isgreater
than the secretion of K
+
and HCO3

within the salivary

ducts
Severalorganiccompoundspresentinsalivahaveal-
ready been discussed: -amylase, lingual lipase, mucus,
lysozymes,glycoproteins,lactoferrin,andtheIgAsecre-
tory piece Saliva is also comprised of the organic blood
group antigensA,B,AB,andOKallikreinissecretedby
the salivary glands during increased metabolic activity
Kallikrein enzymatically converts plasma protein into
bradykinin,avasodilator,inordertoincreasebloodfow
totheglandsSalivacontainsapproximatelyonetenththe
totalamountofproteinasthatfoundinplasma
Tesecretion,bloodfow,andgrowthofsalivaryglands
aremostlycontrolledbybothbranchesoftheautonomic
nervous system Even though the parasympathetic ner-
vous system has more infuence on the secretion rate of
the salivary glands than the sympathetic system, secre-
tionisstimulatedbybothbranches
Parasympathetic innervation of the major salivary
glands follows branches of the facial and glossopharyn-
geal nerves Parasympathetic stimulation activates both
acinar activity and ductal transport mechanisms, lead-
ingtoglandularvasodilationaswellasmyoepithelialcell
contraction Acetylcholine (ACh) serves as the parasym-
patheticneurotransmitterthatactsonthemuscarinicre-
ceptorsofthesalivaryglandsTesubsequentformation
ofinositoltrisphosphateleadstoincreasedCa
2+
concen-
Fig. 1.5:Electrolytesecretion
bytheacinarandductalcells
12
1
I.ChristopherHoIsingerandDana7.8ui
trationswithinthecell,releasedfromeitherintracellular
Ca
2+
stores or from the plasma Tis second messenger
signifcantly efects salivary volume secretion Glandu-
lar secretion is sustained by acetylcholinesterases, which
inhibit the breakdown of ACh Te muscarinic antago-
nistatropine,however,decreasessalivationbycompeting
withAChforthesalivaryreceptorsite
Tesympatheticsupplytothesalivaryglandismainly
from the thoracic spinal nerves of the superior cervical
ganglionLikeparasympatheticinnervation,myoepithe-
lial cell contraction also results Changes in blood fow,
however, are biphasic: vasoconstriction due to -adren-
ergic receptor activation is followed by vasodilation due
to buildup of vasodilator metabolites Binding of the
neurotransmitter norepinephrine to -adrenergic recep-
tor results in formation of 3',5'-cyclic adenosine mono-
phosphate(cAMP),whichthenleadstophosphorylation
of various proteins and activation of diferent enzymes
Increases in cAMP result in increased salivary enzyme
andmucuscontent
Within saliva, K
+
concentrations increase while Na
+

concentrations decrease in the presence of antidiuretic

hormone (ADH) or aldosterone Unlike other digestive
glands, however, these two hormones do not afect sali-
varyglandsecretionrate
About1lofsalivaissecretedbyanormaladulteach
dayDuringunstimulatedsalivation,69%ofsalivaiscon-
tributedbythesubmandibularglands,26%bytheparotid,
and 5% by the sublingual glands Te relative amounts
suppliedbytheparotidandsubmandibularglands,how-
ever, are switched during stimulation, where two thirds
ofsecretionisthenfromtheparotidglandOftotalfow,
78% is due to the minor salivary glands regardless of
stimulationTepresenceoffoodinthemouth,theactof
chewing,andnauseaallstimulatesalivation,whilesleep,
fatigue,dehydration,andfearinhibititSalivarysecretion
rates are not dependent on age, and fow rates remain
constant despite the degeneration of acinar cells during
theagingprocessMedicationsideefectsorsystemicdis-
easearemorelikelytoberesponsibleforhypofunctionof
salivaryglandsinelderlypatients[15,17]
vaIuationoftheSaIivaryGIands
Symptomsindicativeofsalivaryglanddisordersarelim-
ited in number and generally nonspecifc Patients usu-
ally complain of swelling, pain, xerostomia, foul taste,
andsometimessialorrhea,orexcessivesalivationDespite
theprevalenceofmoderntechnologyintheidentifcation
of salivary gland disorders, a detailed history and thor-
ough physical examination still play signifcant roles in
theclinicaldiagnosisofthepatient,andgreatcareshould
betakenduringtheseinitialstepsofevaluation
History
When taking a patients history, the practiced skills of
attentive listening and patience are required for subse-
quentdiagnosisandpropertreatmentmostfttingtothe
patients expectations and needs Te medical profle of
thepatientcanprovidehelpfulcluestothecurrentcondi-
tionofthesalivaryglands,fordysfunctionoftheseglands
isofenassociatedwithcertainsystemicdisorderssuchas
diabetesmellitus,arteriosclerosis,hormonalimbalances,
andneurologicdisordersEitherxerostomiaorsialorrhea,
for instance, may be due to factors afecting the medul-
larysalivarycenter,autonomicoutfowpathway,salivary
glandfunctionitself,orfuidandelectrolytebalance
Te factors of age group and gender are also impor-
tant,forseveraldiseasesareofenrelatedtoageorgender
Te autoimmune disorder known as Sjgrens syndrome,
for example, is common in menopausal women, while
mumps, parotid swelling due to paramyxoviral infec-
tion,usuallyoccursinchildrenbetweentheagesof4and
10years
Drughistoryofthepatientshouldalsobeconsidered,
forsalivaryfunctionisofenafectedbydrugusageXe-
rostomiaisofenduetotheuseofdiureticsandotheran-
tihypertensivedrugs[9,18]
Acarefuldietaryandnutritionhistoryshouldbeob-
tainedPatientswhoaredehydratedchronicallyfrombu-
limiaoranorexiaorduringchemotherapyareatriskfor
parotitis Swelling and pain during meals followed by a
reduction in symptoms afer meals may indicate partial
ductalstenosis
Xerostomiaisadebilitatingconsequenceofradiation
therapytotheheadandneckandahistoryofpriorradia-
tionshouldbesought
PhysicaIxamination
Tesuperfciallocationofthesalivaryglandsallowsthor-
ough inspection and palpation for a complete physical
examination Initial inspection involves the careful ex-
aminationoftheheadandneckregions,bothintraorally
13 Anatomy,Iunction,andvaIuation Chapter1
andextraorally,andshouldbecarriedoutinasystematic
waysoastonotmissanycrucialsigns
During the initial extraoral inspection, the patient
should stand three to four feet away and directly facing
in front of the examiner Te examiner should inspect
symmetry,color,possiblepulsationanddischargingofsi-
nusesonbothsidesofthepatientEnlargementofmajor
orminorsalivaryglands,mostcommonlytheparotidor
submandibular,mayoccurononeorbothsidesParotitis
typicallypresentsaspreauricularswelling,butmaynotbe
visibleifdeepintheparotidtailorwithinthesubstance
oftheglandSubmandibularswellingpresentsjustmedial
andinferiortotheangleofthemandibleSalivarygland
swellingcangenerallybediferentiatedfromthoseoflym-
phaticoriginasbeingsingle,larger,andsmoother,butthe
twotypesareofeneasilyconfusedSignifcantneurologic
defcitsshouldbeexaminedaswellFacialnerveparalysis
inconjunctionwithaparotidmass,forexample,should
remind us of a malignant parotid neoplasm, although it
doesoccurrarelywithbenignneoplasmsaswell
In addition to signs of possible asymmetry, discolor-
ation, or pulsation, intraoral inspection also includes as-
sessment of the duct orifces and possible obstructions
Te proper lighting with a headlight should always be
usedwheninspectingwithintheoralcavityandpharynx
TeopeningsofStensensandWhartonsductscanbein-
spectedintraorallyoppositetheseconduppermolarand
attherootofthetongue,respectivelyDryingofthemu-
cosaaroundtheductswithanairblowerandthenpress-
ingonthecorrespondingglandswillallowtheexaminer
to assess the fow or lack of fow of saliva Sialolithiasis
can sometimes be found by careful intraoral palpation
Dental hygiene and the presence of periodontal disease
shouldalsobenotedsincedefcientoralmaintenanceisa
majorpredisposingfactortovariousinfectiousdiseases
Size, consistency, and other qualities of the salivary
glands and associated masses can be evaluated through
extraoral and intraoral palpation Bimanual assessment
shouldbeperformedwheneverpossiblewiththepalmar
aspectofthefngertips
During extraoral palpation of the face and neck, the
patientsheadisinclinedforwardtomaximallyexposethe
parotidandsubmandibularglandregionsTeexaminer
maystandinfrontoforbehindthepatientItshouldbe
notedthatobservablesalivaryorlymphaticglandswell-
ingsdonotrisewithswallowing,whileswellingsassoci-
atedwiththethyroidglandandlarynxdoelevate
Finally,bimanualpalpation(extraoralwithonehand,
introral with the other) must be performed to exam-
ine the parotid and submandibular glands One or two
gloved fngers should be inserted within the oral cavity
topalpatetheglandsandmainexcretoryductsinternally,
whileusingtheotherhandtoexternallysupportthehead
andneckByrollingthehandsovertheglandsbothinter-
nallyandexternally,subtlemasslesionscanbeidentifed
Inthesubmandibulargland,lymphnodesextrinsictothe
gland can ofen be distinguished from pathology within
the gland itself using this technique Te neck should
thenalsobecarefullyexaminedforlymphadenopathy
Finally, a careful survey of minor salivary gland tis-
sueshouldbeperformed,especiallyintheanteriorlabial,
buccal,andposteriorpalatalmucosaIncreasedsalivation
fromtheductorifcesduetopressureexternallyapplied
totheglandsmayindicateinfammation[9,18]Finally,
rareclinicalentities,suchashemangiomasandothervas-
cularanomalies,maybeidentifedbyauscultation
RadioIogicandndoscopic
xaminationoftheSaIivaryGIands
Although a thorough history and complete physical ex-
amination are crucial steps in the diagnosis and even-
tual treatment of any salivary gland disorder, patients
occasionally provide little more than vague complaints
of pain and/or swelling For patients with these unclear
symptomsandnophysicalsigns,radiographicdiagnostic
studies,suchassialography,plain-flmradiography,com-
putedtomography,andmagneticresonanceimaging,can
play in important role in clarifying the etiology of such
nonspecifcsymptomsForpatientswithknowndisease,
imaging can assist in treatment selection and planning
Tis fnal section will provide a brief introduction to
these various techniques, which will then be covered in
greaterdetailinsubsequentchapters
Sialographyreliesontheinjectionofcontrastmedium
intoglandularductssothatthepathwayofsalivaryfow
can be visualized by plain-flm radiographs Correct ex-
posureandpositioningisachievedbytakingpreliminary
plain radiographs prior to the injection of a radiopaque
medium [9] Te most common indication for sialogra-
phyisthepresenceofasalivarycalculus,whichisade-
posit of mostly calcium salts that can block fow of sa-
liva and cause pain, swelling, and infammation or lead
to infection Patients with calculi usually complain of a
recurrent and acute onset of pain and swelling during
eatingOfen,sialographicexaminationisunnecessaryif
the preliminary radiographs detect the calculus before-
14
1
I.ChristopherHoIsingerandDana7.8ui
hand Other indications for sialography include gradual
or chronic glandular enlargement (which can be due to
sarcoidosis, infection, sialosis, Sjgrens syndrome, be-
nignlymphoepitheliallesion,oraneoplasm),aclinically
palpable mass in one of the glandular regions (possible
tumor,cyst,orfocalinfammation),recurrentsialadeni-
tis,ordrynessofthemouth
Although conventional sialography can be clinically
useful in the diagnosis and the determination of treat-
ment for various salivary disorders, its efectiveness re-
mains arguable while its rate of usage is highly variable
[25,30]Tismethodshouldnotbeperformedwhenthe
patienthasanacutesalivaryglandinfection,hasaknown
sensitivity to iodine-containing compounds, or is an-
ticipatingthyroidfunctiontestsTus,othermethodsof
radiographic diagnosis are currently preferred and have
largelyreplacedsialographicexamination
Computedtomography(CT)isnowmorewidelyused
toassesstheparotidandsubmandibularglandsTead-
vantageofCTimagingisthetwo-dimensionalviewofthe
salivaryglands,whichcanelucidaterelationshipstoadja-
centvitalstructuresaswellastoassessthedrainingcervi-
callymphaticsTeparotidglandhaslowattenuationdue
to its high fat content and is therefore easily discernible
byCTscanningTesubmandibularglandhasalowerfat
contentandhigherdensitycomparedtotheparotidgland
andthushasamuchhigherattenuation,althoughextrin-
sicandintrinsicmassdiferentiationiseasiertoevaluate
Althoughstonescanbeidentifed,salivaryglandinfam-
mationisnotgenerallyanindicationforCTWhileCTis
ofen utilized as a primary screening tool for the detec-
tion of parotid and submandibular gland abnormalities,
indifcultcases,ahigher-sensitivityapproachusingboth
CT and sialography (CT-sialography) can be used [24]
Diferencesbetweenintrinsicandextrinsicparotidgland
masses, however, are ofen difcult to assess especially
whenpresentintheparapharyngealspace[27]
Magneticresonanceimaging(MRI)ismoreofenused
for assessment of parapharyngeal space abnormalities
MRI provides better contrast resolution, exposes the pa-
tienttolessharmfulradiation,andyieldsdetailedimages
on several diferent planes without patient repositioning
Tis technique therefore is preferred in the evaluation of
parapharyngealspacemasses,especiallyindiscriminating
between deep lobe parotid tumors and other pathology,
suchasschwannomaand/orglomusvagaleMRI,however,
isinferiortoCTscanningforthedetectionofcalcifcations
andearlyboneerosionChronicinfammationofthesali-
varyglandsandcalculiarenotindicationsforMRI
Sialendoscopy is a minimally invasive technique that
inspectsthesalivaryglandsusingnarrow-diameter,rigid
fberoptic endoscopes [20] Endoscopic visualization of
ductalandglandularpathologyprovidesanexcellental-
ternativetotheindirectdiagnostictechniquesdescribed
aboveAssuch,sialendoscopyhasopenedupanewfron-
tier for both evaluation and treatment of salivary gland
disease[21]Lacrimalprobesareusedtogentlydilatethe
ductalorifceandthentheendoscopeisintroducedun-
der direct visualization During lavage of the glandular
ductofinterest,directinspectionoftheductandhilumof
theglandisperformedTus,inonesetting,atthetimeof
diagnosis, treatment and therapy for benign lesions can
be performed (see Chapter6, Sialendoscopy) Trough
a CO2-laser papillotomy, sialolithectomy can be easily
performed[21]Pharmacotherapyandlaser-ablationcan
alsobeperformedSialendoscopyhasalsobeenshownto
have a signifcantly low complication rate and is gener-
allywell-tolerated[31]Tisrelativelynewtechniquehas
shown much promise in the diagnosis and treatment of
chronicobstructivesialadenitis(COS),sialolithiasis,and
otherobstructivediseasesofthesalivaryglands
7akeHomeMessages
Salivary gland development is the result of
branching morphogenesis Molecular biology
is beginning to unravel signaling pathways im-
plicated in both craniofacial development and
salivary gland histogenesis, including the sonic
hedgehog(Shh)andthefbroblastgrowthfactor
family
Humansalivaisnotonlyimportantforlubrica-
tionintheoralcavity,butplaysacrucialrolein
digestiveandprotectiveprocesses
Bothvisualinspectionwithoptimallightingand
bimanualpalpationiscrucialintheprecisephys-
icalexaminationofthemajorandminorsalivary
glands
Sialendoscopyisanovelmodalityfordiagnostic
evaluationaswellastherapeuticinterventionfor
disordersofthesalivaryglands

15 Anatomy,Iunction,andvaIuation Chapter1
References
1 Arey LB (1974) Developmental anatomy; a textbook and
laboratory manual of embryology Revised 7th ed WB
Saunders,Inc,Philadelphia
2 Bernfeld M, Banerjee S, Cohn R (1972) Dependence of
salivaryepithelialmorphologyandbranchingmorphogen-
esisuponacidmucopolysaccharide-protein(proteoglycan)
attheepithelialsurfaceJCellBiol52:674689
3 BhattacharyyaN,VarvaresM(1999)Anomalousrelation-
shipofthefacialnerveandtheretromandibularvein:acase
reportJOralMaxillofacSurg57:7576
4 CarrauRL,JohnsonJT,MyersEN(1997)Managementof
tumors of the parapharyngeal space Oncology (Williston
Park)11:633640;discussion640,642
5 Davis RA, Anson BJ, Budinger JM, et al (1956) Surgical
anatomyofthefacialnerveandparotidglandbasedupona
studyof350cervicofacialhalvesSurgGynecolObstet102:
385412
6 FrommerJ(1977)Tehumanaccessoryparotidgland:its
incidence, nature, and signifcance Oral Surg Oral Med
OralPathol43:671676
7 Garatea-Crelgo J, Gay-Escoda C, Bermejo B, et al (1993)
MorphologicalstudyoftheparotidlymphnodesJCranio-
maxillofacSurg21:207209
8 Gibson MH (1983) Te prenatal human submandibular
gland: a histological, histochemical and ultrastructural
studyAnatAnz153:91105
9 GraamansK,vonderAkkerHP(1991)Historyandphysi-
calexaminationIn:GraamansAK(ed)DiagnosisofSali-
varyGlandDisordersKluwerAcademicPublishers,Dor-
drecht,Germany,pp1-3
10 GrantJ(1972)AnAtlasofAnatomy,SixthednWilliams&
Wilkins,Baltimore
11 Hollinshead WH (1982) Anatomy for Surgeons: Volume
I,TeHeadandNeck,TirdedJBLippincottCompany,
Philadelphia
12 Jaskoll T, Melnick M (1999) Submandibular gland mor-
phogenesis: stage-specifc expression of TGF-alpha/EGF,
IGF,TGF-beta,TNF,andIL-6signaltransductioninnor-
mal embryonic mice and the phenotypic efects of TGF-
beta2, TGF-beta3, and EGF-r null mutations Anat Rec
256:252268
13 Jaskoll T, Leo T, Witcher D, et al (2004) Sonic hedgehog
signalingplaysanessentialroleduringembryonicsalivary
gland epithelial branching morphogenesis Dev Dyn 229:
722732
14 JohnsM(1977)Tesalivaryglands:anatomy&embryol-
ogyOtolaryngolClinNorthAm10:261
15 JohnsonLR(ed)(2003)SecretionElsevier,Amsterdam
16 JunqueriaL,CarneiroJ(2003)BasicHistology:Text&At-
las,TenthednMcGraw-Hill,NewYork
17 Kontis TC, Johns ME (2001) Anatomy and Physiology
of the Salivary Glands In: Bailey BJ (ed) Head and Neck
SurgeryOtolaryngologyLippincottWilliams&Wilkins,
Philadelphia
18 Mason D, Chisholm D (1975) Salivary Glands in Health
andDiseaseWBSaunders,London
19 MyersEN,ConleyJ(1970)Gustatorysweatingaferradical
neckdissectionArchOtolaryngol91:534542
20 Nahlieli O, Baruchin AM (1997) Sialoendoscopy: three
yearsexperienceasadiagnosticandtreatmentmodalityJ
OralMaxillofacSurg55:912918;discussion919920
21 Nahlieli O, Baruchin AM (2000) Long-term experience
withendoscopicdiagnosisandtreatmentofsalivarygland
infammatorydiseasesLaryngoscope110:988993
22 Orabi AA, Riad MA, ORegan MB (2002) Stylomandibu-
lar tenotomy in the transcervical removal of large benign
parapharyngeal tumours Br J Oral Maxillofac Surg 40:
313316
23 PogrelM,SchmidtB,AmmarA(1996)Terelationshipof
thebuccalbranchofthefacialnervetotheparotidductJ
OralMaxillofacSurg54:7173
24 QuinnHJJr(1976)Symposium:managementoftumorsof
the parotid gland II Diagnosis of parotid gland swelling
Laryngoscope86:2224
25 Rabinov K, Weber AL (1985) Radiology of the Salivary
GlandsGKHallMedicalPublishers,Boston
26 RoarkDT,SessionsRB,AlfordBR(1975)Freyssyndrome-
atechnicalremedyAnnOtolRhinolLaryngol84:734739
27 Som PM, Biller HF (1979) Te combined computerized
tomography-sialogram A technique to diferentiate deep
lobeparotidtumorsfromextraparotidpharyngomaxillary
spacetumorsAnnOtolRhinolLaryngol88:590595
28 Uehara T (2006) Localization of FGF-6 and FGFR-4 dur-
ingprenatalandearlypostnataldevelopmentofthemouse
sublingualglandJOralSci48:914
29 Woodburne RT, Burkel WE (1988) Essentials of Human
Anatomy,EighthednOxfordUniversityPress,NewYork,
Oxford
30 Yune H (1977) Sialography and dacrocystography In:
MillerR,SkucasJ(eds)RadiographiccontrastagentsUni-
versityParkPress,Baltimore,pp485492
31 Ziegler CM, Hedemark A, Brevik B, et al (2003) Endos-
copyasminimalinvasiveroutinetreatmentforsialolithia-
sisActaOdontolScand61:137140
16
1
I.ChristopherHoIsingerandDana7.8ui
http://www.springer.com/978-3-540-47070-0