Translational Research in Anatomy 25 (2021) 100152

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Translational Research in Anatomy

journal homepage: www.elsevier.com/locate/tria

Anatomy of the parotid duct: Assessing variations of the parotid gland

drainage pattern
E. Heidmann *, K.J. Baatjes , J. Correia
Division of Clinical Anatomy, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: The parotid duct drains the parotid gland, the largest of the human salivary glands. The PD receives
Anatomical variation an accessory PD from the accessory PG, a variation of the PG often mistaken for a soft tissue mass. The PD’s
Parotid gland drainage pattern superficial location contributes to the occurrence of iatrogenic and traumatic duct injuries. Case reports suggest
Parotid duct
that variations in the form of duplicated PDs, have resulted in clinical complications. Therefore, an observational,
Stensen’s duct
cross-sectional study was designed to determine the anatomical variations in the PG drainage pattern via the PD.
Materials and methods: The left and right parotid regions of 20 embalmed cadavers (N = 40) at Stellenbosch
University were dissected. Latex was injected into the oral papilla for better visualisation of the duct. The duct
lengths were measured and classified. The anatomical variations of the PD were documented.
Results: Six of the 40 parotid regions were excluded due to damage. Bilateral PD duplication was observed in one
cadaver (5.88%), while the remaining 94.12% presented with single PDs. The mean duct length on the left and
right sides were found to be 48.5 mm and 45.9 mm respectively. Additionally, accessory PGs were identified in
50% of cadavers.
Conclusions: While rare, bilateral double PDs were identified in this sample. This highlights the importance of
understanding anatomical variations of the PG drainage pattern via the PDs, including the incidence of accessory
PGs, to limit the occurrence of unnecessary iatrogenic injury, such as compression of the duct causing salivary
retention in the PD following a Rhytidectomy, and effectively repair traumatic duct injuries. Further research
should be conducted to investigate the branching pattern of the PD within the PG.

1. Introduction
The parotid gland (PG) is the largest of the three paired salivary
glands and is located below the zygomatic arch and superficially to the
masseter muscle [1]. The PG can be divided into two lobes, the super­
ficial and deep lobes, by the relationship of the gland tissue to the five
branches of the facial nerve [1,2]. The PG is encapsulated in fascia of
varying thickness and can be subdivided into lobules by the fascia,
which extends into the parenchyma of the gland [1]. The superficial
musculoaponeurotic system (SMAS) is seen to invest posteriorly into the
parotid-masseteric fascia, a thin fascia layer covering the PG, parotid
duct (PD), masseter muscle and branches of the facial nerve [3]. The
gland opens into the oral cavity, opposite the second molar, via the PD
[1,2,4].
The PD, also referred to as Stensen’s Duct, is commonly described as
a single duct and has a tree-like branching pattern [1,2]. The ducts
decrease in length and diameter and increase in branch number proxi­
mally towards the terminal acini [1]. The PD originates at the anterior
border of the PG, and travels superficially to the masseter muscle, buccal
fat pad and courses at a 90-degree angle medially to pierce the bucci­
nator muscle [1,2,4,5]. Whilst running superficially to the masseter
muscle the duct is situated between the upper and lower branches of the
buccal branch of the facial nerve and receives the accessory parotid duct
from the accessory parotid gland (APG) [2,4]. The duct courses in an
oblique and inferior direction between the buccinator muscle and oral
mucosa, terminating opposite the crown of the second molar, in the
papilla of the buccal mucosa [1,2,4,5].
The superficial location of the PD makes it prone to injury related to
facial trauma of the buccal and masseteric regions, as well as iatrogenic
injury during diagnostic and surgical procedures of the parotid area

Abbreviations: Accessory Parotid Gland, APG; Parotid Duct, PD; Parotid Gland, PG.
* Corresponding author. Division of Clinical Anatomy, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University,
France van Zijl Drive, Parow, Cape Town, 7505, South Africa.
E-mail address: hdmemm001@myuct.ac.za (E. Heidmann).

https://doi.org/10.1016/j.tria.2021.100152
Received 16 August 2021; Received in revised form 13 October 2021; Accepted 13 October 2021
Available online 15 October 2021
2214-854X/© 2021 Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
E. Heidmann et al. Translational Research in Anatomy 25 (2021) 100152

[5–7]. The separation of the fascial layers during surgical procedures
such as Rhytidectomies, have resulted in PG and PD injuries [3,8],
possibly due to poor recognition of the anatomical borders between the
SMAS and the parotid-masseteric fascia [3]. These duct injuries result in
duct compression and obstruction, which may ultimately result in sali­
vary retention in the PD, as reported by Mandel and Silver [3].
An APG, a variation of the anterior extension of the PG, is present in
approximately 20% of the population and is characterized by its com­
plete detachment from the PG [1,9]. The APG tends to be located
adjacent to the PD, as it runs superficially to the masseter muscle [1].
The APG lies between the masseter muscle and skin and has an indi­
vidual accessory excretory duct, which enters the PD [1,9].
While Taheri et al. [10], Astik and Dave [4] and Aktan et al. [11], all
reported duplicated PDs which varied in length and fused at different
points, Ferreira-Arquez [12] described duplicated PDs which originated
as a single PD and bifurcated anterior to the masseter muscle [4,10–12].
These ducts coursed anteriorly and were seen to cross just prior to
piercing the buccinator muscle as two separate PDs, forming double
parotid papillae in the oral cavity [12] [Table 1].
The anatomy of the PG and PD have been extensively studied, but
minimal research exists on the variations of these structures. Though
uncommon, the variations remain significant to specialists working in
the parotid region [13]. For the purposes of this study, the drainage
pattern of the PG refers to variations in the number of ducts identified
between the anterior border of the PG and the buccinator muscle. The
branching patterns of the PD refer to the variations in the number of
tributaries within the PG that merge to form the main PD. This study
aimed to provide a detailed analysis of the variations of the parotid
gland drainage pattern via the parotid duct, by evaluating the presence
of unilateral and bilateral duplicated parotid ducts in the Stellenbosch
University cadaveric population.
Table 1
Summary of parotid duct lengths in reported cases of duplicated parotid ducts.
Reference Side Parotid Duct Length (mm) Point of Fusion
2. Methods and materials
This observational, cross-sectional study was conducted at the Di­
vision of Clinical Anatomy, Faculty of Medicine and Health Sciences at
Stellenbosch University. The Undergraduate Research Ethics Committee
(UREC) at Stellenbosch University (reference number U19/03/014 and
project ID number 9358) granted ethical consent. Informed consent was
granted by proxy by the Inspector of Anatomy.
All cadavers with a history of surgical procedures or facial trauma in
the parotid region were excluded.
The left and right parotid regions of twenty embalmed cadavers (10
male and 10 female) were dissected. An incision was made from the base
of the ala of the nose to the join between the corresponding philtrum and
vermillion border. Another incision was made from the lower vermillion
border in line with the incision on the upper lip to the corresponding
mental tubercle. These incisions extended completely through the upper
and lower lips lateral to the midline on the left and right side of each
cadaver. The oral papilla was located on the lateral aspect of the oral
cavity, near the upper second molar. A cannula, from a 20-gauge
intravenous (IV) catheter, was inserted into the opening of the PD in
the oral cavity and saline solution was injected into the cannula, opening
the duct and removing blockages.
The parotid region was cleaned and the SMAS was removed. The PG
and duct were located, and the surrounding adipose tissue and fascia
were removed through dissection. A coloured latex solution was injected
into the PD through the cannula.
The normal drainage pattern was defined as a single PD located
externally to the PG, extending from the anterior border of the PG to the
point at which the duct pierces the buccinator muscle. The number of
PDs were identified and recorded in Table 2 and Table 3. The drainage
pattern of each gland was classified as “single” or “double” PD. The
length of the duct was measured from the origin of the duct at the
anterior border of the PG to the point at which the duct penetrates the
buccinator muscle, using a piece of non-stretchable string (In the pres­
ence of a facial process, the exposed duct was measured). The PG
drainage pattern in both parotid regions of each cadaver were digitally
recorded through photographic imaging using a Nikon COOLPIX P520
camera. Each image includes a 1 cm scale for reference length.

Superior Inferior Single PD 3. Results

PD PD

Aktan et al. Right 48.00 7.00 Not recorded Thirty-four parotid regions (n = 19 cadavers) were dissected
(2001) -
following the methods previously described and six excluded in accor­
Turkey
Fernandes Right 26.49 37.25 3.25 Between
dance with the exclusion criteria specified in the Methods and Materials.
et al. anterior border The 19 cadavers (9 male and 10 female), ranged from the age of 28–78
(2009) - of masseter years, with a mean age of 49 years. The raw data was tabulated in Ta­
Brazil muscle and bles 2 and 3, including the sides and sex of the cadavers that were
perforation into
excluded, and summarized data was included in Table 4 and Fig. 1.
buccinator
muscle While the researchers acknowledge that the APG and FP are not the
Astik & Dave Left 28.00 34.00 Not Anterior border same structures, it was not possible to differentiate between these two
(2011) - Right 29.00 36.00 recorded of masseter structures in all cadavers. Therefore, these results were combined to
India muscle allow for a more accurate overall representation of accessory tissue
Taheri et al. Right 28.00 37.00 25.00 Accessory
(2015) - parotid gland
which was present surrounding the PD. Fig. 1 provides a graphic rep­
Iran resentation of the results as a summary of the comparison between the
Itoo et al. Right 21.00 23.00 44.00 Anterior border frequency of APG or facial process (FP), single duct and double duct
(2015) - of masseter presence in the right and left parotid regions.
India muscle
Mangalgiri Right Not recorded
& Mahore
(2016) - Table 2
India Summary of raw data obtained from the right parotid regions.
Üҫerler et al. Left 10.00 27.30 16.00 Superficial to
Sex Accessory Single Double Average Duct Excluded
(2016) - Right 12.14 20.82 20.02 masseter
Gland/ Facial Duct Duct Length (mm)
Turkey muscle
Process
Ferreira- Left 49.80 52.90 10.00 Entered oral
Arquez (originated cavity as two Male 2 8 0 45.0 0
(2017) - as single) separate Female 7 9 1 46.8 2
Colombia papillae Total 9 17 1 45.9 2

2
E. Heidmann et al. Translational Research in Anatomy 25 (2021) 100152

Table 3 The results of the PG drainage pattern via the PD were described in
Summary of raw data obtained from the left parotid regions. terms of single and double PDs on each side of the cadaver, as well as the
Sex Accessory Single Double Average Duct Excluded duct course and variations in the size and shape of the PGs is illustrated
Gland/ Facial Duct Duct Length (mm) in Figs. 2–4 by the dotted black lines.
Process It was noted that all PDs originated at the anterior border of the PG,
Male 3 9 0 46.0 1 coursed superficially to the masseter muscle, turned medially and
Female 5 6 1 50.9 3 pierced the buccinator muscle. Thirty two of the 34 parotid regions
Total 8 15 1 48.5 4 (94.12%) exhibited single ducts [Figs. 2 and 3], while double PDs were
identified in two parotid regions (5.88%) [Fig. 4]. The right sides
revealed a mean duct length of 45.9 mm while the left sides had a mean
Table 4 length of 48.5 mm. The details for the lengths of the superior, inferior
Results of the bilateral double parotid duct. and single PDs in the left and right parotid regions of the cadaver with
Duct Location Accessory Gland/Facial Process Duct Length in mm bilateral double PDs can be found in Table 2.
Left Superior Yes 57.0
The left and right parotid regions of all cadavers were compared and
Inferior No 37.2 indicated variations in the presence and absence of FPs and APGs be­
Single No 16.0 tween each region. All APGs and FPs varied in size and location relative
Right Superior Yes 35.2 to the PG and PD and were identified in 50% (17) of the parotid regions
Inferior Yes 45.0
dissected (9 right and 8 left) [Fig. 3].
Single No 26.5

Fig. 1. Graphic comparison between the results obtained from the right and left parotid regions.

Fig. 2. Image A and B indicate the right (A) and left (B) parotid regions of a single cadaver with bilateral single parotid ducts which are seen to emerge from the
parotid gland at point 1 and pierce the buccinator muscle at point 2. A single duct with a facial process is present in image B superior to the parotid duct. Where PD-
parotid duct; PG-parotid gland; FP-facial process; FN-facial nerve; MM-masseter muscle; FA-facial artery and BM-buccinator muscle.

3
E. Heidmann et al.
Fig. 3. Image A and B indicate the right (A) and left (B) parotid regions of a single cadaver with bilateral single parotid ducts which are seen to emerge from the
parotid gland at point 1 and pierce the buccinator muscle at point 2. A facial process can be identified on the right and an accessory parotid gland on the left. Where
PD-parotid duct; PG-parotid gland; APG-accessory parotid gland; FP-facial process; MM-masseter muscle; and BM-buccinator muscle.
4. Discussion
This study provides a detailed description of the variations of the PG
drainage pattern via the PD encountered at Stellenbosch University. The
results highlight the importance of understanding anatomical variations
of the PG drainage pattern via the PDs, including the incidence of
accessory PGs, in clinical anatomy.
The results indicate that 32 of the 34 parotid regions (94.12%)
exhibited single ducts, 17 on the right and 15 on the left. The course
followed by the single PDs in both the left and right parotid regions in
this study were the same as described in the literature [Table 1]. The
right sides tended to have a mean duct length of 45.9 mm (range: 19.1
mm–58 mm) while the left sides had a mean duct length of 48.5 mm
(range: 24 mm–69 mm). A comparison between the literature utilized in
Table 1 and the current study results indicate that the mean duct lengths
on both the left and right sides were shorter than the duct lengths re­
ported in the literature. However, the average lengths of the PD were not
reported specifically to the right and left sides in the literature described
in Table 1 and therefore cannot be directly compared by side.
The current study correlates with Richards et al. [2], as all single PDs
appeared to originate deep to the branches of the facial nerve and would
4
Translational Research in Anatomy 25 (2021) 100152
Fig. 4. Image A and B indicate the right (A)
and left (B) parotid regions of a single
cadaver with bilateral double parotid ducts
which are seen to emerge from the parotid
gland at point 1, merge at point 2 and pierce
the buccinator muscle at point 3. Where SD-
single parotid duct; SPD-superior parotid
duct; IPD-inferior parotid duct; SPL-
superficial parotid lobe; DPL-deep parotid
lobe; APG-accessory parotid gland; F-facial
nerve; MM-masseter muscle; FA-facial artery
and BM-buccinator muscle.
therefore be classified as originating in the deep lobe of the PG. How­
ever, this was not the case for the double PDs identified in this series.
A double PD was identified on both the left and right sides of a 58-
year-old female cadaver and classified as a bilateral duplication of the
PD. The two PDs coursed superficially to the masseter muscle in both the
left and right parotid regions, with both the superior and inferior ducts
having an APG located superiorly to the duct in the right parotid region
as seen in image A of Fig. 4. While only the superior PD had an APG and
duct which was situated superiorly to the duct in the left parotid region
as illustrated in image B of Fig. 4. Each APG drained directly into the
respective duct via a single accessory PD.
Unilateral double PDs were reported by Fernandes et al., Itoo et al.,
Ferreira-Arquez et al., Aktan et al. and Taheri et al. [10–12,14,15].
Bailey et al. [16] was the only study conducted to evaluate the incidence
of double PDs in the general population and concluded it to be 7%
[14–16]. The incidence rate reported by Bailey et al. [16] is similar to
that of the current study, which while conducted on a small sample, was
able to conclude a double PD incidence of 5.88%.
The present study results differed from Aktan et al. [11], which
described that the double PD merged 48 mm from the anterior border of
the PG, 7 mm from the buccinator muscle [11]. Aktan et al. [11]
E. Heidmann et al.
described a descending duct emerging from the superior portion of the
PG, while an ascending duct emerged from the inferior portion of the
PG. These results differed from our findings, as the superficial lobe of the
PG was located lateral and inferiorly to the deep lobe in both the left and
right parotid regions as determined by the location of the facial nerve
illustrated in Fig. 4. The inferior PD and superior PDs appeared to
originate in the superficial and deep lobes of the PG respectively, at the
anterior border of the PG. The superior ducts coursed horizontally on
both the left and right sides, while the inferior ducts coursed in a more
superior direction, predominantly in the right parotid region.
To our knowledge, only two reports exist on the occurrence of
bilateral double PDs. Astik and Dave [4] conducted a study in India and
reported bilateral double PDs, which were seen to fuse at the anterior
border of the masseter muscle, which agrees with the point of fusion of
the double ducts described in this study [4]. Üҫerler et al. [17] reported
a cadaver with bilateral double PDs in Turkey, with right superior and
inferior PDs which were 12.14 mm and 20.82 mm, respectively [17].
The two ducts fused to form a 20.02 mm long single duct which coursed
superficially to the masseter muscle and ran horizontally to pierce the
buccinator muscle. The left superior and inferior PDs were 10 mm and
27.3 mm respectively and merged 16 mm from the point of termination
in the buccinator muscle [17]. In the study conducted by Astik and Dave
[4] the left and right superior PD lengths were 28 mm and 29 mm
respectively, while the left and right inferior PDs measured 34 mm and
36 mm in length respectively [4]. The results for the current study
indicate that the left superior PD was 57.0 mm in length while the
inferior PD was 37.2 mm. The two ducts merged 16.0 mm from the point
at which the single duct pierced the buccinator muscle. While, on the
right, the superior PD was 35.2 mm and the inferior PD was 45.0 mm.
The two ducts merged to form a single duct 26.5 mm from the point of
termination in the buccinator muscle.
In the left parotid region, the superior PD was 19.8 mm longer than
the inferior PD, while on the right, the superior PD was 9.8 mm shorter
than the inferior PD. Üҫerler et al. [17] indicated that the superior PDs
on the left and right were shorter than the inferior PDs by 17.3 mm and
8.68 mm respectively [17]. Astik and Dave [4] identified that the left
and right superior PDs were 6 mm and 7 mm shorter than the left and
right inferior PDs respectively [4]. The studies conducted by Astik and
Dave [4] and Üҫerler et al. [17] concurred that on both the left and right
sides the superior PDs were shorter than the inferior PDs. However, the
results of the current study are only in agreement with these studies on
the right side as on the left the superior PD is seen to be longer than the
inferior PD.
Several studies reported APGs with incidence ranging between 21
and 70% [12,18,19], however, unlike the current study, facial processes
were excluded. Mangalgiri et al. [20] reported an APG incidence of only
7.5%, despite a sample size similar to the current study [20]. The vari­
ations in the incidence rate found by Mangalgiri et al. [20] and the
current study may be attributed to the geographically isolated popula­
tion groups [20]. However, further studies with larger sample sizes are
required to investigate this.
Understanding the incidence of APGs in specific geographical pop­
ulation groups is important due to the high recurrence rate of pleo­
morphic adenomas in PGs. It is suggested that this high recurrence rate
results from the lack of boundaries which allows for significant soft
tissue infiltration, especially into the APG due to its proximity to the PG
[21]. The high recurrence rate may also result from failure to identify
and remove the APG in a parotidectomy [20].
Studies have proposed numerous different branching patterns of the
PD [2,22]. A study performed by Richards et al. [2] was able to deter­
mine five major branching patterns of the PD [2]. Of these five
branching patterns, pattern A and B accounted for the branching pattern
identified in 80% of the cadavers [2]. It was noted that both Type B and
Type E, originate from the fusion of two major tributaries. Type B
originates deep within the PG, while Type E is represented as the fusion
of two major tributaries externally to the PG, anterior to the anterior
5
Translational Research in Anatomy 25 (2021) 100152
border of the PG. However, Type E does not define the distance from the
PG at which the ducts fuse, and therefore brings into question how one
might differentiate between a Type E PD branching pattern variation
and a PG drainage pattern variation in the form of duplicated PDs. The
duplicated PDs described in case reports, vary based on the distance of
fusion as seen in Table 1.
Astik and Dave [4] suggests that the PD is formed at the anterior
border of the PG from the fusion of two or three tributaries or smaller
ducts, and it has been suggested by Aktan et al. [11] that the occurrence
of a double PD is the result of late merging of these two tributaries su­
perficially to the masseter muscle, externally to the PG [4,11]. Based on
this knowledge and the classifications suggested by Richards et al. [2]
regarding the branching patterns of the PD, the researchers suggest that
the double PD in this study and future double PDs, may be classified as a
Type E branching pattern variation [2]. This could also suggest that the
branching pattern variation and drainage pattern variation, may both be
referred to as branching pattern variations, with Type E varying in
distance prior to fusion of the branches. However, the gland of the two
parotid regions in which these double ducts were identified were not
dissected in this study and further research should be conducted to
confirm that these two PDs arise from the PG as single major tributaries
and that each duct does not originate from the fusion of major tributaries
within the PG.
5. Limitations
Due to the intricacies of the dissection, limited access to the samples
and limited time available in which to conduct this study only the
drainage pattern of the PG was identified and classified as either a single
or double PD. Future studies are necessary to identify and classify the
branching pattern of the PD within the PG, into one of the five categories
described by Richards et al. [2].
Staples were present in either the left or right parotid regions of four
cadavers, indicating possible damage to the parotid region and therefore
four parotid regions, two left and two right, were excluded from the
study. Freezer burn was identified in both the left and right parotid re­
gions of one cadaver, which prevented the dissection of both parotid
regions and therefore excluded this cadaver from the study.
The sample size of 20 cadavers from Stellenbosch University, was
restricted by the one-year period in which to complete this research and
limited cadaver access, limited the results of this study and the ability to
extrapolate these results to the Western Cape or South African
population.
Another limitation of the study was the inability to evaluate the
prevalence of double PDs by sex, as well as possibly significant length
differences. A larger sample size and further research would be required
to evaluate this potential difference.
6. Conclusion
This study investigated the presence of anatomical variation in the
drainage pattern of the PG via the PD encountered at Stellenbosch
University, which identified the PDs and APGs, and classified the
drainage patterns. Results indicated that anatomical variation in the
drainage pattern of the PG, as indicated by the presence of bilateral
double PDs and APGs or facial processes are similar to the variations
previously described in case studies. A larger sample size is required to
allow for a more accurate indication of the incidence of PD variants in
South Africa.
Understanding the anatomy and possible variations of the PD and the
incidence of these variations is of importance in clinical practice relating
to disease conditions and procedural injuries. Future studies should be
conducted to investigate the branching pattern with imaging methods
such as Computed Tomography and Magnetic Resonance Imaging
scanning.
E. Heidmann et al.
Ethical statement
Ethical approval for this project was granted by the Undergraduate
Research Ethics Committee (UREC) at Stellenbosch University, with
UREC reference number U19/03/014 and project ID number 9358.
Stellenbosch University obtains donated and unclaimed cadavers for
the purpose of research and education in accordance with the National
Health Act, Act 61 of 2003.
Consent was obtained from the Head of the Division of Clinical
Anatomy for the primary investigator to make use of the facial regions of
25 cadavers. The K-Number and the date on which the Inspector of
Anatomy gave proxy consent for the cadaver to be utilized by Stellen­
bosch University for the purposes of research and education, as well as
the letter of approval from the Head of the Division of Clinical Anatomy
are available on request. In order to maintain each cadaver’s confiden­
tiality, the university provides each cadaver with a K-Number upon
arrival.
The General Notice for Authorization to Retain Human Tissue for
Stellenbosch University may also be made available on request.
Data availability statement
The raw data is available on request from the corresponding author.
CRediT authorship contribution statement
E. Heidmann: Conceptualization, Methodology, Validation, Inves­
tigation, Resources, Writing – original draft, Visualization. K.J. Baatjes:
Conceptualization, Methodology, Writing – review & editing, Supervi­
sion. J. Correia: Conceptualization, Methodology, Writing – review &
editing, Supervision.
Declaration of competing interest
The authors have no conflicts of interests to declare.
Acknowledgements
The authors would like to acknowledge those who donated their
bodies to science as well as their families, so that anatomical research
could be performed [23]. Anatomical research may provide results that
can improve patient care as well as our overall knowledge [23].
Therefore, we sincerely thank the donors and their families for their
contribution.
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