Examination of Salivary glands

Parotid gland
• Parotid gland is the largest of the
salivary gland, situated below the acoustic
meatus between the ramus of mandible and
sternomastoid muscle.

• The deep cervical fascia splits to

• Parotid swelling occupies below,
behind, in front of the ear lobule,
obliterating the normal hollow below the
ear lobule. The parotid gland compartment
is roughly triangular in shape, bounded
superiorly by the zygomatic arch,
posteriorly by the external auditory canal,
and inferiorly by the styloid process, the
styloid muscle, and the jugular and internal
carotid vessels; anteriorly it is bounded by
the masseter muscle.
form a capsule (parotid capsule) to enclose
the gland. The superficial layer is thickened
and adherent to the gland. Parotid gland is
deep to parotid fascia (Parotid capsule),
superficial to masseter. When patient opens
the mouth, parotid fascia stretches and
swelling may become less pre-eminent but
this test is difficult to elicit.
When patient clinches his teeth, masseter
contracts and parotid becomes more
prominent.

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 Examination of Salivary glands

Parotid (Stensen’s) duct:

is 2-3 mm in diameter, 5 cm in length,

Parts of parotid gland: Parotid gland
is divided into two parts by facial nerve.
emerges from anterior surface of the gland,
runs over the surface of the masseter
muscle, passes through the buccinator
muscle, and opens into the oral mucosa
opposite to the crown of upper 2nd molar
tooth. It is palpated bidigitally, one
fingerbreadth below the zygomatic bone
with index finger inside and thumb outside,
in front of masseter which is felt during
clinching of teeth. Transverse facial artery
is above the parotid duct. Duct is 1 cm
below the zygomatic arch.

Superficial part (80%)—lies over the

posterior part of the ramus of mandible.

Deep part (20%)—lies behind the mandible

and medial pterygoid muscle; in relation to
mastoid and styloid process.

Vasculature:

Blood is supplied by the posterior auricular

and superficial temporal arteries. They are
both branches of the external carotid artery,
which arise within the parotid gland itself.

Venous drainage is achieved via the

retromandibular vein. It is formed by

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 Examination of Salivary glands

unification of the superficial temporal and

maxillary veins.

Sympathetic innervation originates from

the superior cervical ganglion, part of the
paravertebral chain. Fibres from this
ganglion travel along the external carotid
artery to reach the parotid gland. Increased
Innervation: activity of the sympathetic nervous system
inhibits saliva secretion, via
The parotid gland receives sensory and vasoconstriction.
autonomic innervation. The autonomic
innervation controls the rate of saliva
production.
Lymphatics:
Sensory innervation is supplied by the
It drains into parotid lymph glands which
auriculotemporal nerve which is a branch
are partly intraglandular and partly
of mandibular division of Trigeminal nerve
extraglandular (preauricular and
(gland) and the great auricular nerve
infraauricular). Mainly intraglandular
(fascia).
nodes are involved which later drains into
The parasympathetic innervation to the deep cervical lymph glands. Parotid lymph
parotid gland has a complex path. It begins nodes also drain from temple, side of scalp,
with the glossopharyngeal nerve (cranial lateral part of auricle, external acoustic
nerve IX). This nerve synapses with the otic meatus, upper part of cheek, parts of
ganglion (a collection of neuronal cell eyelids and orbit.
bodies). The auriculotemporal nerve then
carries parasympathetic fibres from the otic
ganglion to the parotid gland.
Parasympathetic stimulation causes an
increase in saliva production.

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 Examination of Salivary glands

structure. Within the facial canal, three

important events occur:
Facial nerve:
i. Firstly the two roots fuse to form the
The facial nerve is associated with the facial nerve.
derivatives of the second pharyngeal arch: ii. Next, the nerve forms the geniculate
ganglion (a ganglion is a collection
Motor – muscles of facial expression,
of nerve cell bodies).
posterior belly of the digastric, stylohyoid
iii. Lastly, the nerve gives rise to:
and stapedius muscles.
Greater petrosal nerve –
Sensory – a small area around the concha of parasympathetic fibres to mucous
the external ear. glands and lacrimal gland. Nerve to
stapedius – motor fibres to stapedius
Special Sensory – provides special taste muscle of the middle ear. Chorda
sensation to the anterior 2/3 of the tongue tympani – special sensory fibres to
via the chorda tympani the anterior 2/3 tongue and
parasympathetic fibres to the
Parasympathetic – supplies many of the
submandibular and sublingual
glands of the head and neck, including:
glands.
• Submandibular and sublingual
The facial nerve then exits the facial canal
salivary glands.
(and the cranium) via the stylomastoid
• Nasal, palatine and pharyngeal
foramen. This is an exit located just
mucous glands.
posterior to the styloid process of the
• Lacrimal glands.
temporal bone.
Anatomical course: Anatomically, the
course of the facial nerve can be divided
into two parts:

Intracranial course: The nerve arises in

the pons, an area of the brainstem. It begins
as two roots; a large motor root, and a small
sensory root (the part of the facial nerve that
arises from the sensory root is sometimes
known as the intermediate nerve). The two
roots travel through the internal acoustic
meatus, a 1cm long opening in the petrous
part of the temporal bone. Here, they are in
very close proximity to the inner ear. Still
within the temporal bone, the roots leave
the internal acoustic meatus, and enter into
the facial canal. The canal is a ‘Z’ shaped

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 Examination of Salivary glands

• Temporal branch (Innervates the

frontalis, orbicularis oculi and
corrugator supercilii.)
• Zygomatic branch (Innervates the
orbicularis oculi.)
• Buccal branch (Innervates the
orbicularis oris, buccinator and
zygomaticus.)
• Marginal mandibular branch
(Innervates the depressor labii
inferioris, depressor anguli oris and
mentalis.)
• Cervical branch (Innervates the
platysma.)

These branches are responsible for

innervating the muscles of facial expression.

Extracranial course: After exiting the skull,

the facial nerve turns superiorly to run just
anterior to the outer ear.

The first extracranial branch to arise is the

posterior auricular nerve. It provides motor
innervation to the some of the muscles
around the ear. Immediately distal to this,
motor branches are sent to the posterior
belly of the digastric muscle and to the
stylohyoid muscle.

The main trunk of the nerve, now termed

the motor root of the facial nerve, continues
anteriorly and inferiorly into the parotid
gland (note – the facial nerve does not
contribute towards the innervation of the
parotid gland, which is innervated by the
glossopharyngeal nerve). Within the
parotid gland, the nerve terminates by
splitting into five branches:

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 Examination of Salivary glands

Faciovenous Plane of Patey:

Within the gland, the Facial nerve & its

branches and retromandibular vein (RV) lie
in one plane. In this plane, the gland can be
split sagitally into two parts, superficial and
deep parts without injuring the nerve. The
branches of facial nerve enter forwards via
the isthmus. The plane between the
superficial and deep lobes where nerves
and veins are located has been designated
by Patey as faciovenous plane. This plane
helps the surgeons to eliminate the parotid
tumor without damaging the nerve.
External carotid artery dividing into
superficial temporal artery and maxillary
artery is deeper to venous plane.

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 Examination of Salivary glands

Submandibular Gland Submandibular duct (Wharton’s

duct):
Submandibular salivary glands are paired
glands located in anterior part of This is approximately 5cm in length and
submandibular triangle. It also has 2 lobes emerges anteromedially from the deep arm
/ arms. The positioning of these arms is in of the gland between the mylohyoid,
relation to the mylohyoid muscle, which the hypoglossus and genioglossus muscles.
gland hooks around. The duct ascends on its course to open as 1-
3 orifices on a small sublingual papilla
Superficial arm / lobe – comprises the (caruncle) at the base of the lingual
greater portion of the gland and lies
frenulum bilaterally.
partially inferior to the posterior half of the
mandible, within an impression on its
medial aspect (the submandibular fossa). It
is situated outside the boundaries of the
oral cavity.

Deep arm / lobe – hooks around the

posterior margin of mylohyoid through a
triangular aperture to enter the oral cavity
proper. It lies on the lateral surface of the
hyoglossus, lateral to the root of the tongue.

Relationship to nerves:

Both the submandibular gland and duct

share an intimate anatomical relationship
with three principal nerves; the lingual
nerve, hypoglossal nerve and facial nerve
(marginal mandibular branch). The courses
of these nerves are briefly outlined:

Lingual nerve: Beginning lateral to the

submandibular duct, this nerve courses
anteromedially by looping beneath the
duct and then terminating as several medial
branches. The terminal branches ascend on
the external and superior surface of

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 Examination of Salivary glands
hypoglossus to provide general somatic
afferent innervation to the mucus
membrane of the anterior two-thirds of the
tongue.
Hypoglossal nerve: Lies deep to the
submandibular gland and runs superficial
to hyoglossus and deep to digastric muscle.
Facial nerve (marginal mandibular
branch): Exits the anterior-inferior portion
of the parotid gland at the angle of the jaw
and traverses the margin of the mandible in
the plane between platysma and the
investing layer of deep cervical fascia
curving down inferior to the submandibular
gland.
Vasculature:
Arteries: The submandibular gland is
supplied by the submental artery (branch
of facial artery) and sublingual artery
(branch of lingual artery).
Veins: Its venous drainage is by two
vessels. Facial vein – empties directly into
the internal jugular vein. Sublingual vein –
drains into the lingual vein and then
internal jugular vein.
Innervation:
The submandibular glands receive
autonomic innervation through
parasympathetic and sympathetic fibres,
which directly and indirectly regulate
salivary secretions respectively.
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Parasympathetic: Parasympathetic
innervation originates from the superior
salivatory nucleus through pre-synaptic
fibres, which travel via the chorda tympani
branch of the facial nerve (CNVII). The
chorda tympani then unifies with the lingual
branch of the mandibular nerve (3rd
division of CNV) before synapsing at the
submandibular ganglion and suspending it
by two nerve filaments.
Post-ganglionic innervation consists of
secretomotor fibres which directly induce
the gland to produce secretions, and
vasodilator fibres which accompany
arteries to increase blood supply to the
gland. Increased parasympathetic drive
promotes saliva secretion.
Sympathetic: Sympathetic innervation
originates from the superior cervical
ganglion, where post-synaptic
vasoconstrictive fibres travel as a plexus on
the internal and external carotid arteries,
facial artery and finally the submental
arteries to enter each gland. Increased
sympathetic drive reduces glandular blood
flow through vasoconstriction and
decreases the volume of salivary secretions,
resulting in a more mucus and enzyme-rich
saliva.
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 Examination of Salivary glands

History Taking was first appeared (changes in

size/overlying skin/sinus formation,
1.Name: etc. Recent increase in size of
swelling is important which
2.Age: Salivary gland tumors are rarely suggests malignant transformation
seen in children, and their incidence probably from a pre-existing
increases especially after the age of 40 pleomorphic adenoma.
years. Mumps most commonly affects Adenolymphoma is slow growing
children between the ages of 2 to 12 who tumour from lower pole of the
haven't received the mumps vaccine. parotid.) , does the lump ever
However, adolescents and adults can get disappeared, ask about multiplicity
mumps despite being vaccinated against it. (Bilateral enlargement of parotid
This occurs because there's waning along with other salivary glands and
immunity of the vaccine after several years. lacrimal gland is called as Mikulicz
syndrome.) and what the patient
3.Gender: Pleomorphic adenoma think about the cause of lump.
incidence is slightly more in females than in • Pain: Inquire according to
males (2:1 ratio). SOCRATES (Site, Onset, Character,
Radiation, Associated symptoms,
4.Marital status: Time/duration, Exacerbating &
relieving factors and Severity).
5.Address: Mostly it is covered under the
question when you inquire about the
6.Occupation:
symptoms of lump. Sudden onset of
severe pain is a feature of acute
7.Presenting complaints:
parotitis. Throbbing excruciating
• Swelling – site & duration. pain may be a feature of parotid
• Pain – duration. abscess. Colicky pain during meals
• Fever – grade & duration. is a feature of salivary calculus with
• Difficulty in opening mouth – sialadenitis. Stone is more common
duration. in submandibular salivary gland but
can also occur in parotid gland.
8.History of Presenting illness: • Fever: Fever is a feature of acute
sialadenitis or abscess. Acute
• Swelling: Ask about when noticed,
sialadenitis with suppuration is
where noticed (in front of
common in parotid. Parotid abscess
ear/underneath lower jaw/under
is usually unilateral. Mumps in
tongue in floor of mouth, right/left
children is bilateral. Neoplastic
side, etc), how noticed, what are the
condition once necrosed can cause
symptoms of the lump (pain,
fever.
difficulty in opening of moth,
• Difficulty in opening mouth: can
difficulty in swallowing or breathing,
occur in acute parotitis,
etc) , has the lump changed since it

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 Examination of Salivary glands

submandibular sialadenitis, and glands is called as Sjogren syndrome.

malignancy extending into the soft Treatment and investigations done for this
tissues. should be asked.
• History of excess salivation during
meals/more pain during 10.Personal History: Personal history
meals/swelling becoming more of alcohol intake is relevant in bilateral
prominent during meals: should parotid enlargement.
be asked. It is a feature of stone in
the salivary duct. 11.Family History:
• Presence of sinus/fistula: its
location, formation, discharge, etc.
should be asked. Discharge from
sinus/fistula is usually saliva. Its
quantity, duration, colour whether
increases while taking food should
be clarified.
• History of impairment of function:
like drooling of saliva, inability to
close eyes, tears in the eye,
asymmetry of face, difficulty in
opening of the mouth should be
asked (related to involvement of
Facial nerve).
• History suggestive of metastases:
in case of malignant salivary
tumours like of lungs, bone, brain
should be asked.

9.Past Medical and Surgical

History: Past history of surgery for
parotid or submandibular swellings should
be asked. Recurrent parotid tumours are
known to occur in pleomorphic adenoma
and malignancies. Detailed history of
surgery, its nature of biopsy, postoperative
management should be taken. Past history
of radiotherapy in head and neck region;
past history of other malignancy in the body.
Past history related to medical syndrome
involving salivary glands should be taken.
For example, excessive salivation, joint
pain along with enlargement of all salivary

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 Examination of Salivary glands
Local Examination
(patient should be sitting, ideally on a
chair and head & neck should be
exposed.)
A. INSPECTION
1.Site/Situation: Parotid swelling is below,
behind and in front of the ear lobule. Parotid
enlargement shows typically raise in ear
lobule.
Submandibular swelling is underneath
lower jaw (Swollen submandibular glands
are usually caused by tiny stones blocking
the ducts that channel saliva into the mouth,
otherwise most of the swellings in this
region are due to enlarged lymph nodes).
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2.Shape: The shape of the lump must be
noted whether it is ovoid, pear-shaped,
kidney-shaped, spherical or irregular.
Sometimes the students, by mistake, utter
the term 'circular' to describe the shape of
the lump. A lump cannot be circular as we
do not know about the deeper dimension of
the lump. So it is wiser to say 'spherical' to
describe this lump.
3.Skin overlying the swelling: any color
change; any scar mark (previous surgery
or biopsies etc.); sinus or salivary fistulas,
etc. Redness suggests sialadenitis.
Sialadenitis is inflammation of the salivary
gland.
Ulceration or fungation may develop in
advanced carcinoma parotid. Sinus or
salivary fistula should be inspected for
discharge and location. If parotid fistula is
in masseteric relation then it is from the
gland; it will be premasseteric if it is from
the duct.
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 Examination of Salivary glands

B. PALPATION:

1.Temperature: Check with back of your

fingers & compare with that of forehead skin
or skin of normal contralateral region.

2.Tenderness: Gently palpate the swelling

(either parotid or submandibular) and look
towards facial expression of the patient.
Tenderness suggests that it could be
4.Swelling is superficial to masseter abscess, necrosis in a tumour or deeper
muscle (only for swelling in parotid infiltration.
region): Ask the patient to clench the teeth.
This will contract the masseter muscle. The
parotid gland is superficial to the masseter
and therefore it will become more
prominent.

5.Loss of facial expressions, deviation of

angle of mouth, excessive tearing or
salivation can be seen as well.

6.Neck: Inspection of neck region for

enlarged cervical nodes is also done.

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 Examination of Salivary glands

3.Site, Size, Extent: Swellings arising from 4.Surface: With palmar surface of fingers
parotid gland occupy area in front, below the clinician should palpate the entire
& behind ear and lifting the ear lobule. swelling. Surface could be either smooth
Submandibular gland swellings occupy (pleomorphic adenoma, abscess, Warthin’s
area beneath lower jaw and sometimes tumor) or nodular (malignancy,
extending in neck specially posteriorly and lymphnode).
upto angle of mandible when very large.
5.Edges: Edges should be defined as
But it never lifts ear lobule. Measure size of
regularly / irregular & well defined / ill-
enlarged gland in two perpendicular
defined.
directions using measuring tape.

6.Consistency: Swelling could be soft

(Warthin’s, Ranula of sublingual gland),
firm (pleomorphic adenoma, sialadenitis),
rubbery (lymphnode), stony hard
(malignancy).

7.Fluctuation: Keep two fingers of the left

hand (mostly index finger and thumb) on
the swelling so as to fix it and are called
'watching fingers'. Right index finger is
used {'displacing finger') to press on the
swelling to displace fluid inside the
swelling which is felt by the 'watching
fingers'. This test should be done only in
swellings having soft consistency,
otherwise skip this step.

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 Examination of Salivary glands

8.Transillumination test: Only done in push it beyond zygomatic bone and Curtain
swellings in which fluctuation is positive or sign will be negative.
you suspect fluid inside cavity of swelling,
otherwise skip this step too.

9.Pulsatility, compressibility &

reducibility: usually are not seen in
swellings related to salivary glands.

10.Skin Fixity: Check mobility and

pinchability of overlying skin at difference
points over the swelling. Skin is fixed to the
swelling if either swelling is arising from
skin and subcutaneous tissue or malignant
swelling is invading skin.

12.Mobility: It is checked by moving the

swelling in two directions (perpendicular to
each other).

11.Curtain sign (for swellings in Parotid

region): Deep fascia / parotid fascia is
attached above to the zygomatic bone .
Parotid gland is enclosed in this fascia. So if
the swelling is of Parotid gland origin, this
attachment of parotid fascia to zygomatic
bone wouldn’t allow you to displace it /
move it beyond zygomatic bone and
Curtain sign will be positive. If swelling is
not arising from parotid gland (for example
lipoma in this region) you will be able to

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 Examination of Salivary glands

for any discharge, inflammation or

stone (if parotid gland is enlarged).
If swelling is immobile it means it is
attached to deeper structures, most
probably bone. In case of Parotid gland
swelling, initially mobility is checked
without teeth clenching then clinician give
command to clinch the teeth and patient
clinches his/her teeth. Again mobility is
checked in both directions. If mobility is
reduced after teeth clenching, but not
before, it means that the swelling is
attached to the masseter muscle.

13.Examination of Oral Cavity:

• Inspection - Use light source. Deep

lobe of parotid enlargement is
checked by inspecting the oral
cavity for any bulge in the tonsil and
lateral wall of pharynx. Floor of the
mouth should be inspected for
enlargement of deep lobe of the
submandibular salivary gland and
sublingual salivary gland after
raising the tip of the tongue over the
palate. Opening of the
submandibular salivary duct
(Wharton’s) may be inflamed and
oedematous with discharging pus
from it. Often stone may be visible in • Palpation – Use gloved hands.
the duct orifice. Orifice is situated on Enlarged deep lobe of the parotid
either side of the frenum linguae. can be palpated by bidigital
Duct with impacted stone blocks the palpation with index finger of one
salivary flow and hence that side hand placed inside the mouth in
orifice looks dry whereas normal front of the tonsil and behind the 3rd
side orifice looks wet due to normal molar tooth and fingers of the other
salivary flow. After retracting cheek hand placed outside behind the
with spatula Stenson’s parotid duct ramus of the mandible over the
opening should be inspected enlarged swelling.
opposite to 2nd upper molar tooth Parotid duct should be palpated
using one finger inside the cheek

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 Examination of Salivary glands

and thumb outside the cheek. Duct

can be better felt when masseter is
taut. Only anterior part of the duct is
felt. Also pressure is applied on
enlarged parotid gland externally
and then clinician observes any
discharge coming out of opening of
Stensen’s duct.
Best way of palpating the
submandibular salivary gland is by
bidigital palpation. It confirms
swelling as submandibular salivary
gland and also deep lobe and duct
can be palpated. First dentures if
present should be removed. Index
finger of one hand is placed over the
floor of the mouth medial to alveolus
and lateral to tongue pushing the
finger as deep as possible; fingers of
other hand are placed outside under
the mandibular margin to push the
swelling upwards. By this way the
finger inside the oral cavity not only
helps to feel the deep lobe of the
salivary gland which is deep to
mylohyoid muscle; but also the
superficial lobe and often duct can
be better assessed by this method.
Submandibular lymph node is not
bidigitally palpable as it is outside
the mylohyoid muscle, superficial to
the gland. Stone in the Wharton’s
duct also can be palpated by this
method. Shape, size, consistency
can be assessed by this method.

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 Examination of Salivary glands

14.Examination of neck / lymphnode 15.Examination of Facial nerve (parotid

palpation: Clinician should be standing gland swelling): Functions of facial nerve
behind the patient. Follow this sequence; should be checked. It is involved in
submental → submandibular → pre- malignant growth where nerve is infiltrated.
auricular → postauricular → occipital → It is involved early in adenoid cystic
anterior cervical (superior, middle & carcinoma; carcinoma ex pleomorphic
inferior jugular) → pretracheal → adenoma. It is involved late in
paratracheal → suprasternal → mucoepidermoid carcinoma.
supraclavicular (by shrugging the
Patient finds difficulty in closing eyes
shoulders) → posterior cervical. Don’t
(orbicularis oculi); eye contains tear which
palpate right and left anterior cervical
does not fall; difficulty in chewing food
groups simultaneously, rest of the groups
(buccinator); difficulty in talking, laughing,
(right and left) are palpated simultaneously.
blowing, and whistling (orbicularis oris).
Give rolling movements to the fingers of
palpating hands while palpating the • Upper face:
lymphnode groups. Orbicularis oculi - In facial nerve
paralysis eyes can be easily opened
by the examiner when patient closes
his eyes tightly.

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 Examination of Salivary glands

Frontal belly of occipitofrontalis - Levator anguli oris - Deviation of

Absence of furrowing in the angle of mouth towards opposite
forehead while looking upwards. side while showing teeth.
Give command to look upwards
towards ceiling without moving
his/her head (place one hand on
patient’s head so that he/she can not
move his/her head).

In supranuclear (upper motor neuron lesion)

paralysis upper face escapes due to
bilateral cortical representation.

16.Palpation of superficial temporal

artery pulsation (during examination of
• Lower face:
Parotid swelling): Should be done in front
Buccinator - While blowing with
of the tragus over the zygomatic bone. If it
mouth closed, tone can be felt in the
is absent, it means that it is involved by
cheek.
malignancy.

17.Temporomendibular joint movement

(during examination of Parotid swelling):
becomes restricted if growth is malignant
and involves the periarticular tissue of
temporomandibular joint (TMJ). Movement
is checked by palpating both joints (feel
movement of condyle of mandible in front
of tragus) while patient repeatedly opens &
closes his mouth.

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 Examination of Salivary glands

General Physical
Examination
Check Pallor, jaundice, cyanosis, vitals,
palpate head carefully for any swelling
(you can perform this step during
examination of lymph nodes), auscultate
chest for metastatic diseases and finally
check pedal edema (part of GPE).

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 Examination of Salivary glands

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 Examination of Salivary glands

Important Questions
Q3: Why calculus is more common in
Q1: Causes of Parotid gland enlargement?
submandibular gland (80%)?
Ans: These are,
Ans: Calculi are common in submandibular
salivary gland, because:

I. Viscous nature and mucin content.

II. Calcium content.
III. Nondependent drainage.
IV. Stasis.
V. Hooking of nerve by submandibular
duct.

Q4: Features of acute sialadenitis

(inflammation of salivary gland)?

Ans: Pain, swelling, tenderness is seen in

submandibular region and floor of the
mouth. Dysphagia, trismus, fever. Double
chin appearance due to spreading of
oedema downwards. Duct is inflamed and
swollen. Diagnosis is mainly clinical but
aided by using USG or X-rays, rarely CT-
Q2: Causes of submandibular gland
scan is needed. Treatment is antibiotics,
enlargement?
anti-inflammatory drugs.
Ans:

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 Examination of Salivary glands
Q5: What is the gold standard investigation
for sialolithiasis?
Ans: Sialography is considered the gold
standard because it provides a clear image
not only of the stones but also of the ductal
morphologic structure.
Q6: PAROTIO ABSCESS (SUPPURATIVE
PAROTITIS)?
Ans: It is an ascending bacterial sialadenitis,
due to reduced salivary flow, dehydration,
starvation, sepsis, after major surgery,
radiotherapy for oral malignancies and
poor oral hygiene. Parotid fascia is densely
thick and tough and so parotid abscess
does not show any fluctuation until very late
stage.
Causative organisms: are Staphylococcus
aureus(commonest), Streptococcus
viridans and often others like gram-
negative and anaerobic organisms.
Dr Imran
Features: Pyrexia, malaise, pain and
trismus. Red, tender, warm, well-localised,
firm swelling is seen in the parotid region
(brawny induration). Tender lymph nodes
are palpable in the neck. Features of
bacteraemia are present in severe cases.
Pus or cloudy turbid saliva may be
expressed from the parotid duct opening.
Investigations: USG (ultrasonography) of
the parotid region; Pus collected from duct
orifice is sent for culture and sensitivity;
Needle aspiration from the abscess is done
to confirm the formation of pus.
Complications of Parotid abscess:
septicemia, severe trismus, rupture into the
external auditory canal.
Treatment: Antibiotics are started
depending on culture report. When it is
severely tender and localised, incision and
drainage is done under general
anaesthesia using Blair’s incision (Skin is
incised in front of the tragus vertically and
then parotid sheath (pyogenic membrane)
is opened horizontally. Pus is drained using
sinus forceps and sent for C/S. Antibiotics
are continued.)
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 Examination of Salivary glands

Areas in which one should not wait for

abscess to form:

1) Parotid
2) Breast
3) Ischiorectal fossa
4) Thigh

Q7: What are the causes of Parotid fistula?

Ans: After superficial parotidectomy, after

drainage of abscess, ruptured abscess,
after biopsy, trauma, recurrence of
malignant tumor.

Q8: Types of Parotid fistula?

Ans: Duct fistula (arising from Stensen’s
duct) and Gland fistula (arising from raw
gland).
Q9: Investigations to diagnose parotid
fistula?
Q10: What is salivary colic?
Ans: During salivation, there will be pain
and increase in size of the swelling, which
is typically seen in submandibular salivary
duct stones.

Ans: Sialography to find out the origin of the

fistula whether from parotid gland or duct
or ductules; Fistulogram or CT fistulogram;
Discharge study; MRI.

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 Examination of Salivary glands

Q11: Classification of salivary gland tumors? Q14: What is the most important differential

Ans: diagnosis for a small parotid swelling?

Ans: Preauricular lymph nodes

(enlargement secondary to infection or
metastasis).

Q15: What are the primary foci for enlarged

preauricular lymph nodes?

Ans:

Q16: What is the distinguishing clinical

feature of the lymph node?

Q12: Why pleomorphic adenoma is called
mixed parotid tumor?
Ans: It is called mixed parotid tumor
because it has got both epithelial and
mesodermal elements.
Ans: It is the mobility of the lymph node—
The preauricular lymph node is outside the
capsule of the gland and usually very
mobile, unlike the tumor in the parotid
which has got restricted mobility. So in case
of lymphnode enlargement Curtain sign is
negative.

Q13: Can pleomorphic adenoma occur

bilaterally? Q17: What is parotid sandwich?

Ans: Yes. Ans: The facial nerve is passing through the

substance of the parotid gland, dividing the
gland into a superficial lobe and deep lobe.
Therefore the gland is called parotid
sandwich.

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 Examination of Salivary glands

Q18: What is Pes anserinus? (myoepithelial cells surrounding the

tubules).
Ans: The pes anserinus is the main • After surgery for recurrence,
bifurcation of the facial nerve into the upper
radiotherapy is indicated even
(temporofacial) and lower (cervicofacial) though it is benign.
branches. The facial nerve further divides
• Benign pleomorphic adenomas
into 5 branches (the first 3 from the
metastasize inexplicably —
temporofacial division and rest of the 2 from metastatic pleomorphic adenoma —
cervicofacial division).
it is not malignant.

Pes anserinus means goose foot. • It is a tumor readily implanted

during removal in the residual
parotid.

Q20: What are the malignant parotid tumors

in order of frequency?

Ans:

Q19: Features of pleomorphic adenoma?

Ans: Features are,

Q21: What is the difference between low
• It is considered a benign tumor with grade and high grade mucoepidermoid
long quiescent periods and short carcinoma?
periods of rapid growth.
Ans: High grade lesions have propensity
• Potential for recurrence if tumor
for both regional and distant metastasis.
excision is not complete.
• Potential for malignant change.
• The capsule is incomplete and the
tumor will have extensions beyond
the capsule.
• Tumor contains both epithelial and
mesodermal elements

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 Examination of Salivary glands

Q22: What is the regional node spread in Q24: What is the CT sign of inoperability in
parotid tumor? parotid carcinoma? (PG)

Ans: Intraglandular node → Periparotid Ans: Involvement of the masseteric space

node → Submandibular node → Upper and (pre masticator space) is suggestive of
mid-jugular nodes (occasionally to inoperability. It is divided by zygoma into
retropharyngeal nodes). supratemporal (contains temporalis muscle)
and infra temporal space (contains lateral
and medial pterygoid muscles).

Q23: What are the causes for bilateral

parotid tumors?

Ans: Warthin’s tumor & Acinic cell

carcinoma (2% bilateral).

Q24: What is the test for

temporomandibular joint involvement? (PG)

Ans: These are;

• The little finger is introduced to the

external auditory meatus with the
pulp of finger forwards and
simultaneously assess the
difference in range of movement.
• Inter incisor distance measurement
with maximal mouth opening
(normal >5cm / admits 3 fingers).

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 Examination of Salivary glands

Q25: What is the investigation of choice in Q30: Which type of facial palsy is seen in
parotid tumors? parotid tumors?

Ans: Clinical examination and Fine needle Ans: Lower motor neuron type of facial
aspiration cytology (FNAC). palsy is seen (involvement of both lower
and upper half of the face).

Features of Facial nerve palsy

Q26: Indications of CT scan in parotid gland
tumours?
Ans: If deep lobe tumor is suspected, If
extension to deep lobe is suspected,
Trismus.
Q27: Indications for MRI in parotid gland
tumors?
Ans: When facial nerve is involved.
Q28: What are the clinical features of
malignancy in the parotid?
1) Difficulty in chewing food as food accumulates in vestibule
due to buccinator weakness.
2) Deviation of angle of mouth while talking, laughing,
blowing, whistling due to paralysis of orbicularis oris.
3) Failure of closure of eyelids or easily opening of the eyelids
after closure due to paralysis of orbicularis oculi.
4) Absence of furrows while looking upwards due to paralysis
of frontal belly of occipitofrontalis.
5) Absence of corrugation in the forehead during frowning
due to paralysis of corrugator supercilii.
6) Deviation of angle of mouth towards opposite side due to
paralysis of levator anguli oris.
7) Loss of contraction of platysma in the neck while stretching
the neck due to paralysis of platysma.
8) Inability to blow the air by the check and on palpation
reduced tone of buccinator due to paralysis of buccinator.
9) Inability to whistle due to paralysis of orbicularis oris.

Ans: Clinical features of malignancy are;

Pain, Rapid increase in size, Very hard

consistency, Facial palsy, Enlarged
metastatic regional node, Skin involvement
(skin tethering), Fixity to deeper structures,
Trismus (involvement of pterygoid muscle
by deep parotid lobe malignancy).

Q29: Surgical options in parotid gland

pathology?

Ans: Superficial parotidectomy, deep

parotidectomy, radical parotidectomy,
extra-capsular dissection.

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 Examination of Salivary glands

Q31: What is the treatment of pleomorphic Q33: What is radical parotidectomy?

adenoma?
Ans: Radical parotidectomy involves
Ans: Superficial parotidectomy is the removal of all parotid gland tissue and
minimum surgical procedure. There is no elective sectioning of the facial nerve
role for enucleation and excision (because usually through the main trunk. The
of the reasons mentioned above under surgery removes ipsilateral masseter
question of “features of Pleomorphic muscle in addition. If there is clinical,
adenoma”). Facial nerve should be spared radiological, and cytological evidence of
if a plane exists and when it is not involved. lymph node metastasis a simultaneous
Facial nerve is scarified only if it is involved radical neck dissection is carried out.
or it is totally encased as in cases of
It is done for: • High grade malignant tumors
carcinomas.
• Squamous cell carcinoma.

Q32: Incision for superficial parotidectomy?

Q34: What are the complications of parotid
Ans: A lazy ‘S’ incision (modified Blair surgery?
incision) is used (Preauricular - Mastoid -
Ans: Complications are;
Cervical incision). Starts in front of the ear,
underneath the earlobe and down into a 1. Seroma
cervical crease.
2. Wound infection

3. Permanent facial palsy (transection of the

nerve)

4. Temporary facial nerve weakness

5. Facial numbness

6. Permanent numbness of the ear lobe (due

to great auricular nerve transection)

7. Sialocele

8. Frey’s syndrome (Gustatory sweating)

9. Parotid fistula.

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 Examination of Salivary glands

Q35: What is Frey’s syndrome (Auriculo-
temporal syndrome, Gustatory sweating)?
Ans: Occurs in 10% of cases. It is due to
injury to the auriculotemporal nerve,
wherein postganglionic parasympathetic
fibres from the otic ganglion become united
to sympathetic nerves from the superior
cervical ganglion (Pseudosynapsis). There
is inappropriate regeneration of
damaged parasympathetic autonomic
nerve fibres to the overlying skin.
Auriculotemporal nerve has got
branches:
• Auricular branch supplies external
acoustic meatus, surface of
tympanic membrane, skin of auricle
above external acoustic meatus.
• Temporal branch supplies hairy
skin of the temple. Sweating and
hyperaesthesia occurs in this area of
skin.
Causes:
more sweat in the area in Frey’s
syndrome—Minor's Starch iodine
test.
Management:
• Prevention: It can be prevented
by placing a barrier between the
skin and parotid bed to prevent
inappropriate regeneration of
the
autonomic nerve fibers. The
following methods are useful; 1.
Temporalis fascial flap, 2.
two
Sternomastoid muscle flap, 3.
Artificial membrane between
the skin and parotid bed.
• Management of established
syndrome: Following options
are opted; 1. Tympanic
neurectomy, 2. Injection of
botulinum toxin into the affected
skin (Simple and effective
method), 3. Antiperspirants—
Aluminium chloride.

• Surgeries or accidental injuries to

the parotid. Q36: If the facial nerve is involved by the
• Surgeries or accidental injuries to tumor what is the treatment option?
temporomandibular joint.
Ans: The nerve is excised and a nerve graft
Clinical Features: is done with Great auricular nerve.

• Flushing, sweating, erythema, pain

and hyperaesthesia in the skin over
Q37: What is the management of facial
the face innervated by the
nerve injury? (PG)
auriculotemporal nerve, whenever
salivation is stimulated (i.e. during Ans: Management options are;
mastication or by sight of
food).Condition causes real 1) Nerve transection is managed by
inconvenience to the patient. nerve suturing.
• Involved skin is painted with iodine 2) Loss of a segment is managed by
and dried. Dry starch applied over cable graft using great auricular or
this area will become blue due to sural nerve.

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 Examination of Salivary glands

3) If the proximal end of the nerve is Q42: Indications for radiotherapy in parotid
not available for suturing, gland tumor? (PG)
hypoglossal nerve transposition or
Ans: Radiation therapy for salivary gland
redirection is done.
tumors involves sending high-energy
particles (usually photons or protons)
through the skin toward the tumor.
Q38: If facial palsy is identified
postoperatively, what is the management?
(PG)

Ans: Management options are;

1) Give steroids (prednisolone) and

wait for improvement.
2) If there is no improvement re-
exploration and repair is an option.
3) Masseter transfer can be done for
the deviation of the angle of mouth.
4) Temporalis transfer can be done for
the orbicularis oculi function. Q43: Why open biopsy is contraindicated in
salivary gland tumors?

Ans: It is contraindicated due to;

Q39: Is nerve grafting a contraindication for
radiotherapy? 1) Seedling of the tumor will occur.
2) Chance for parotid fistula is there.
Ans: No.
3) Chance for facial nerve injury.

Q40: What is the timing of radiotherapy?

Ans: 3 – 6 weeks after surgery.

Q41: Is there any indication for

chemotherapy?

Ans: No.

……

Dr Imran 30