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Salivarygland DISORDER
Salivarygland DISORDER
SALIVARY GLANDS
ANATO
MY
PAROTID GLAND
•ANATOMY
It 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 form a capsule (parotid capsule)
to enclose the gland.
• Facial Nerve
It emerges from the stylomastoid foramen lying between
external auditory meatus and mastoid process.
• Branches are –
1. Temporal (auricularis anterior and superior part of
frontalis),
2. Zygomatic (frontalis and orbicularis oculi),
3. Upper buccal and lower buccal (buccinator,
orbicularis oris, elevators of the lip)
4. Mandibular (lower lip muscles)
5. Cervical (platysma)
• Blood Supply :-
It is from external carotid artery; and venous drainage is by external
jugular vein.
• Nerve Supply :-
It is from autonomic nervous system, parasympathetic is secretomotor
from auriculotemporal nerve, sympathetic is vasomotor from plexus
around the external carotid artery.
Clinical
Features
1. Discharging:-fistula in the parotid region of the face, and discharge is
more during eating.
2. Tenderness and induration.
3. Trismus.
Diagnosi
s
• Sialography to find out the origin of the fistula whether from parotid
gland or duct or ductules.
• Fistulogram or CT fistulogram.
• Discharge study.
• MRI.
TREATME
NT
• Anticholinergics—hyoscine bromide (probanthine).
• Radiotherapy.
• Repair or reinsertion of the duct into the mucosa.
• Newman Seabrock’s operation—probe is passed into the parotid duct
through the opening in the mouth. Another probe is passed through the
fistula. Duct and fistula are dissected over the probe. After removal of the
fistula track severed duct ends are identified; and ends are trimmed.
• If still persists, auriculotemporal nerve which supplies secretomotor
component of parotid is cut.
• If there is stenosis at the orifice of the Stenson’s duct, papillotomy at the
orifice may help.
• Total conservative parotidectomy is done in failed cases.
SJÖGREN’S
SYNDROME
• It is an autoimmune disease causing progressive destruction
of salivary and lacrimal glands, leading to
keratoconjunctivitis sicca (dry eyes), and xerostomia (dry
mouth).
• Types
1. Primary Sjögren’s Syndrome (Primary Glandular
Sicca Syndrome)
2. Secondary Sjögren’s Syndrome
1. Primary Sjögren’s Syndrome (Primary Glandular Sicca
Syndrome)
• Severe dry mouth.
• Severe dry eyes.
• Widespread dysfunction of exocrine glands.
Investigations
FNAC .
CT scan to know the status of deep lobe, local extension and spread.
MRI
TREATME
NT
• Surgery—first line treatment.
• If only superficial lobe is involved, then superficial parotidectomy
is done wherein parotid superficial to facial nerve is removed.
• If both lobes are involved, then total conservative parotidectomy is
done by retaining facial nerve
ADENOLYMPHOMA (Warthin’s Tumour,
Papillary Cystadenoma Lymphomatosum)
• It is a misnomer. It is not malignant, it is not lymphoma.
• It is a benign tumour that occurs only in parotid, usually in the lower
pole. It is said to be due to trapping of jugular lymph sacs in parotid
during developmental period.
• It composed of double layer of columnar epithelium, with papillary
projections into cystic spaces with lymphoid tissues in the stroma.
• It usually involves only superficial lobe of parotid gland. It may also be
multicentric.
• Smoking (40%/8 times more risk than nonsmokers) and radiation
exposure may be the cause.
Features
• It presents as a slow growing, smooth, soft, cystic, fluctuant
swelling, in the lower pole, often bilateral and is nontender.
• It is common in males—4:1.
• Common in smokers.
• Common in old people – 60 years.
• Its incidence is 10%. Common in Whites.
• It is 2nd most common benign tumour.
• It is often bilateral—10%.
Investigation
spertechnetate scan—it is diagnostic (Due to high mitochondrial
• Adenolymphoma produces a “hot spot” in 99Technetium
content).
• FNAC. Adenolymphoma does not turn into malignancy. But
occasionally it can simultaneously be associated with pleomorphic
adenoma, carcinoma or lymphoma of parotid.
Treatment
• Superficial parotidectomy
ONCOCYTOMA (Oxyphil
Adenoma)
• It is <1% of salivary tumours.
• Usually benign, originating from oncocytes (oxyphilic cells).
• Radiation and occupational hazards are the causes.
• Common in parotid; but rarely can occur in submandibular
salivary gland.
• Gross—small, tan coloured, well circumscribed encapsulated
solid tumour.
• Microscopy—large oncocytes with swollen granular cytoplasm due
to abundant mitochondria. Tyrosine crystals are present in glandular
spaces.
BASAL CELL
ADENOMA
• It is rare, benign, now classified under monomorphic adenoma
containing isomorphic basaloid cells with basal layer and basement
membrane.
• It is common in minor salivary glands; in major salivary glands it
is multicentric.
• Grossly it looks like lymph node.
• Microscopy—isomorphic basaloid cells with solid/trabecular/
tubular/membranous pattern.
MUCOEPIDERMOID
TUMOUR
• It is the commonest malignant tumour in parotid.
• It occurs both in major as well as minor salivary glands. Parotid is the
commonest site; palate is the commonest minor salivary gland site (In the
palate adenoid cystic carcinoma is common).
• Radiation is the commonest etiological factor.
• Gross—unencapsulated solid tumour with cystic spaces.
• Microscopy—biphasic with mucin secreting (+ve for PAS, – ve for
diastase) low grade and epidermoid with high grade; clear cell with
intermediate type.
TYP
ES
• Low grade—mucous cells mainly—spreads to regional nodes.
• Intermediate—clear cell variety.
• High grade—epidermoid cells mainly—spreads to regional nodes and
also shows high propensity for distant spread.
FEATURES
• Swelling in the salivary (parotid or submandibular) region, slowly
increasing in size, eventually attaining a large size, which is hard,
nodular, often with involvement of skin and lymph nodes
ADENOID CYSTIC
CARCINOMA
• It is most common tumour in submandibular and sublingual salivary
gland.
• It is slow growing but highly malignant with remarkable capacity for
recurrence. But it is classified under low grade malignancy.
• Microscopy: Cribriform, tubular, and solid are 3 types .
• It has got high affinity for perineural spread along mandibular and
maxillary divisions of trigeminal (common) nerve and facial nerve.
• Radical parotidectomy/wide or radical excision of submandibular and
sublingual glands with neck nodal dissection and postoperative RT is
the treatment of choice
ACINIC CELL
TUMOUR
• It is a rare, slow growing tumour that occurs almost always in parotid
and is composed of cells alike serous acini.
• It is more common in women. It occurs in adult and elderly.
• It is 3% of salivary tumours; 90% occurs in parotid.
• Microscopically, it can be microcystic (commonest), papillary,
follicular, medullary etc.
• It can involve facial nerve or neck lymph nodes.
• Clinically, it is of variable consistency with soft and cystic
areas.
MALIGNANT MIXED TUMOUR
• It(MMT)
is 10% of salivary malignancy in incidence with epithelial and
mesenchymal elements.
• It carries worst prognosis.
TYPES
• Carcinoma ex pleomorphic adenoma: It is the commonest type. It is the
most aggressive salivary malignancy. Radical parotidectomy is the
treatment.
• Primary malignant mixed tumour: It shows components of both
carcinoma and sarcoma.
• Metastasizing mixed tumours: It contains structures typical of
benign mixed tumour both at original and at metastases sites.
ADENOCARCINOMA OF SALIVARY
GLANDS
• It is 3% of parotid and 10% of submandibular and minor salivary gland
tumours.
• It is equal in both sexes.
• It is common in children
• It can be tubular, papillary and undifferentiated.
• 20% involve facial nerve clinically.
• Undifferentiated type is aggressive.
SQUAMOUS CELL CARCINOMA OF SALIVARY
GLANDS
• It is rare in salivary glands.
• In salivary glands, parotid is the common site.
• It occurs in 6th or 7th decade. It is aggressive
nonencapsulated tumour arising from ductal system.
• It grows rapidly causing pain, facial palsy, skin fixity, ulceration.
• It spreads commonly to neck nodes and carries poor prognosis.
• Radical parotidectomy and RT is the treatment of choice.
SUBMANDIBULAR SALIVARY GLAND
TUMOURS
Benign tumours:
• They are commonly pleomorphic adenomas, are smooth, firm or hard,
bidigitally palpable, without involving adjacent muscles or hypoglossal
nerve or mandible bone.
• Diagnosis is by FNAC, Orthopantomogram (OPG) and CT scan.
• Excision of both superficial and deep lobes of the gland is done.
Malignant tumours of submandibular salivary gland:
• They are hard, nodular, often get fixed to skin, muscles, hypoglossal
nerve and mandible.
• Diagnosis is by FNAC of primary tumour and of lymph nodes
when involved, CT scan and OPG.
TREATME
NT
• Wide excision, with removal of adjacent muscle, soft tissues
and mandible.
• If lymph nodes are involved, block dissection of neck (Classical
neck dissection) is done
TNM Staging of Malignant Salivary Tumours (AJCC,
7th Edition, 2010, Clinical Staging)
T—Tumour
Tx —Tumour cannot be assessed.
T0 —No evidence of primary tumour.
T1 —Tumour < 2cm without extraparenchymal spread
T2 —Tumour 2–4 cm, without extraparenchymal extension
T3 —Tumour >4 cm. —or with extraparenchymal spread. —but no facial
nerve spread
T4a —Spread to facial nerve, skin, mandible, ear canal
T4b—or spread to base of skull, pterygoid plates, encased external carotid
artery.
N—Lymph node
Nx — Nodes not assessed.
N0 — Regional nodes not involved.
N1 — Single ipsilateral node < 3 cm.
N2a — Single ipsilateral node 3–6 cm.
N2b — Multiple ipsilateral nodes < 6 cm.
N2c — Bilateral or contralateral nodes < 6 cm.
N3 — Single node spread > 6 cm.
M—Metastases
M0 — No blood spread.
M1 — Blood spread present.
Staging
Stage I – T1N0M0
Stage II – T2N0M0
Stage III – T3N0/N1Mo
Stage IVA – T4aN2N1N0M0
Stage IVB – T4b any NM0; any T N3M0
Stage IVC – Any T any N M1 Note
SPECIFIC
INVESTIGATIONS:-
FNAC:-
• FNAC confirms possibility of (35% of patients)
lymphoma/inflammatory masses.
• FNAC allows preoperative counselling regarding nature of tumour,
likely extent of resection (conservative/radical), management of facial
nerve (high grade adenoid cystic), and likelihood of neck dissection
(high grade).
MRI
• It is very useful to find out perineural spread, bone marrow
involvement, skull bones, internal architecture and intracranial
extensions, recurrent tumours
CT SCAN:-
• It is to see the deep lobe of the parotid: the involvement of
bone, extension into the base of the skull; relation of tumour to
internal carotid artery, styloid process, deep lobe tumour,
parapharyngeal space extension. Neck nodes are better assessed.
TREATME
NT
SURGERY
• T1, T2, T3 tumours of low grade—total conservative parotidectomy
• T4 tumours, high grade tumours, SCC—radical parotidectomy It
includes facial nerve sacrifice, may involve resection of skin,
mandibular ramus, masseter muscle, infratemporal fossa dissection,
subtotal petrosectomy.
COMPLICATIO
NS
• Haemorrhage
• Infection, flap necrosis
• Fistula
• Frey’s syndrome
• Facial nerve palsy
• Facial numbness
• Numbness in ear lobule due to injury to great auricular nerve
• Sialocel
• Postoperative radiotherapy It is quite useful to reduce the chances of
relapse. Usually, external radio therapy is given. It is given in all carcinomas
Indications for radiotherapy
• T3, T4 tumours
• High grade tumours
• Perineural spread
• Adenoid cystic carcinomas
• Deep lobe tumour
• Vascular involvement
• Close clearance margin
• Multiple neck nodes involvement
• Recurrent malignant tumours.
• CHEMOTHERAPY
5 FU, cisplatin, doxorubicin, epirubicin, cetuximab are used.
• PREOPERATIVE RADIOTHERAPY
It is given in large tumours to reduce the size and make it better
operable, i.e. to down stage the disease.
MINOR SALIVARY GLAND
TUMOURS
• It is 10% of salivary tumours.
• It is common in — palate (40%) — lip — cheek — sublingual
glands.
• Palate is the commonest site.
• 10% are benign—commonly pleomorphic adenomas.
• 90% are malignant—commonly adenoid cystic carcinomas.
• They present as swelling with ulcer over the summit.
• If it is malignant, then extension into the palate, maxilla, pterygoids
can occur often with involvement of the lymph node
Investigation
s
1. Incision biopsy.
2. CT scan.
3. X-ray maxilla.
4. FNAC of lymph node.
Treatment
• Wide excision often with palatal excision or maxillectomy is done—for
malignancy.
• If the tumour is less than 1 cm in size excision biopsy is done with
1 cm clearance margin.
• If the tumour is more than 1 cm in size, initially incision biopsy is done
and then wide excision is done.
• Reconstruction by dental plates, skin grafting, or flaps are done.
• Lymph node block dissection of the neck is done if involved.
PAROTID
LYMPHOMA
• Parotid lymphoma can occur from the lymph nodes in the gland or
from parotid parenchyma.
• It can occur in HIV patients; lymphoepithelial diseases and
in Sjögren’s syndrome.
• Disease may be confined to parotid gland or may involve other nodes
in neck, mediastinum.
• When it is confined to parotid,total parotidectomy with radiotherapy
and later chemotherapy is the treatment..
PAROTIDECTO
MY
Types
1.Superficial parotidectomy: It is the removal of superficial lobe of the
parotid (superficial to facial nerve). Done in case of benign diseases of
superficial lobe of the parotid.
2.Total conservative parotidectomy: It is done in benign diseases of parotid
involving either only deep lobe or both superficial and deep lobes. Here both
lobes are removed with preservation of facial nerve.
3.Radical parotidectomy: Both lobes of parotid are removed along with
facial nerve, fat, fascia, muscles (masseter, pterygoids and buccinator), lymph
nodes. It is done in case of carcinoma parotid. Later facial nerve reconstruction
is done using great auricular nerve graft.
4.Suprafacial parotidectomy is done in lower pole parotid tumours wherein
all branches of the facial nerve need not be dissected.
STEPS IN
PAROTIDECTOMY
• Lazy ‘S’ incision—modified Blair's/Sistrunk's approach and raising the skin flaps
• Mobilisation of the gland
• Flap is reflected in front just up to anterior margin of the parotid. After
identification of sternocleidomastoid great auricular nerve is identified
• Location of stylomastoid branch of posterior auricular artery is anterior to
facial nerve trunk which enters the stylomastoid foramen.
• Identification of facial nerve trunk.
• Dissection of the gland off the facial nerve
• Removal of parotid—superficial/both.
• Distilled water irrigation to kill spilled tumour cells.
• Haemostasis and closure with a suction drain.
Complications of
parotidectomy
• Facial nerve injury
• Haemorrhage
• Salivary fistulas
• Infection—Flap necrosis is common
• Frey’s syndrome
FREY’S SYNDROME (Auriculotemporal
Syndrome, Gustatory Sweating)
• 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).
• Auriculotemporal nerve has got two 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
CAUS
ES
• Surgeries or accidental injuries to the parotid.
• Surgeries or accidental injuries to temporomandibular joint
CLINICAL
FEATURES
• Flushing, sweating, erythema, pain and hyperaesthesia in the skin
over the face innervated by the auriculotemporal nerve,
whenever salivation is stimulated (i.e. during mastication). .
• Involved skin is painted with iodine and dried. Dry starch
applied over this area will become blue due to more sweat in the
area in Frey’s syndrome—Minor's Starch iodine test.
TREATME
NT
• Reassurance
• Jacobsen neurectomy (tympanic)
• Injection of botulinum toxin to the affected skin
• Antiperspirants like aluminium chloride
• Syndrome can be prevented on table by placing muscle
(sternomastoid) or fascial (temporalis) flaps or artificial membranes
over parotid bed, under the skin
FACIAL NERVE INJURY (Lower Motor
Nerve Lesion, Surgically Related)
Causes:-
• Trauma
• Surgery—parotidectomy, drainage of parotid abscess.
• Compression of facial nerve—Bell’s palsy.
• Temporary/transient facial nerve palsy after parotidectomy.
Clinical
Features
• Inability to close the eyelid.
• Difficulty in blowing and clenching.
• Drooping of the angle of the mouth.
• Obliteration of nasolabial fold.
• Loss of forehead wrinkles.
• Wide palpebral fissure.
• Epiphora
TREATME
NT
• Nerve grafting using greater auricular nerve, sural nerve, lateral
cutaneous nerve of thigh or hypoglossal nerve.
• Suspension of angle of mouth to zygomatic bone using temporal
fascia sling.
• Lateral tarsorrhaphy—to prevent corneal ulceration.
• Medial canthus reconstruction—to reduce epiphora.
• Cross-facial nerve transplantation from opposite side using its
insignificant branches.
• Dynamic neurovascular muscle graft.
• Upper lid gold weights to protect cornea
THANK YOU