Treatment of

salivary neoplasm
 The Salivary glands and ducts
01 02
SUBMANDIBULA
PAROTID GLAND
R
20 % of saliva, Stensen‘s duct. 70% of saliva, Wharton’s duct.

03 04

SUBLINGUAL
5% of saliva, bartholin‘s duct
 ANATOMY OF SALIVARY GLAND
PAROTID GLAND

• 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

to enclose the gland. The superficial layer is thickened and adherent to the gland.

• It is deep to parotid fascia, superficial to masseter. So parotid swelling occupies below, behind,
in front of the ear lobule, obliterating the normal hollow below the ear lobule. When patient
opens the mouth,

Parts of the Parotid Gland

• 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.
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
Lymphatic Drainage
It drains into parotid lymph glands which are
partly intraglandular and partly extraglandular
(preauricular and infraauricular). Mainly
intraglandular nodes are involved which
www.mybusiness.com
later drains into deep cervical lymph glands.
 Faciovenous Plane of Patey
• Faciovenous plane of Patey is of surgical importance.
Facial nerve is superficial to this plane which contains
retromandibular vein and posterior facial vein. External
carotid artery dividing into superficial temporal artery and
maxillary artery is deeper to venous plane
 STENSEN’S DUCT
• Parotid (Stensen’s) duct is 2-3 mm in diameter, 5 cm in length.
• It emerges from anterior surface of the gland, runs over the
surface of the masseterpasses through the buccinator
muscle,and opens into the oral mucosa opposite to the crown
of upper second molar tooth
 FACIAL NERVE
• It emerges from the stylomastoid foramen lying between external
auditory meatus and mastoid process. It passes around the neck of
the condyle of mandible and becomes superficial

• Division : temporofacial and cervicofacial branches which in turn divides into

many branches. Some of these may be interconnected as pes anserinus
(goose foot).
• Branches are – temporal , zygomatic upper
buccal and lower buccal,mandibular and cervical.

• While exiting the skull through stylomastoid foramen it gives posterior auricular nerve
and motor nerves to posterior belly of digastric and stylohyoid. Trunk is initially 1 cm
from posteromedial surface (extraglandular) and intraglandular
for 1 cm before giving divisions
SUBLINGUAL
GLAND
• minor salivary glands one
on each side;
• It is located in the anterior
aspect of the floor of the
mouth in relation to
mucosa, mylohyoid muscle,
body of the mandible near
mental symphysis.
• Gland drains directly into
mucosa or through a duct
which drains into
submandibular duct. This
duct is called as Bartholin
duct.
SUBMANDIBULAR
GLAND
It is a ‘J’ shaped salivary gland situated in the anterior
part of the digastric triangle.
Parts
Superficial part: Lies in submandibular triangle,
superficial to mylohyoid and hyoglossus muscles,
between the two bellies of digastric muscle.
Deep part is in the floor of the mouth and deep to the
mylohyoid.
Submandibular (Wharton’s) duct (5 cm), emerges from
the anterior end of the deep part of the gland, enters the
floor of the mouth, on the summit of papilla beside the
frenulum of the tongue.
 PAROTIDECTOMY

Superficialparotidectomy:
Radical parotidectomy:
the removal of superficial
lobe
Total conservative Both lobes of parotid are
removed along with facial nerve,
parotidectomy: fat, fascia, muscles , lymph
nodes.
both lobes are removed with
preservation of facial nerve.
 STEPS OF 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;

never beyond. After identification of sternocleidomastoid great
auricular nerve is identified and can be sacrificed

• Location of stylomastoid branch of posterior auricular artery

is anterior to facial nerve trunk which enters the stylomastoid foramen.
Thrust the mosquito haemostat 5 mm in front of facial nerve; open the blades for 5 mm; lift
the blades for 5 mm.
 IDENTIFICATION OF FACIAL NERVE

Facial nerve is 1 cm deep and below the tip of the inferior portion
of the cartilaginous canal—Conley’s point
By nerve stimulator
It is inferomedial to tragal point
Deep to digastric muscle and tympanic plate

Nerve is just lateral to the styloid process

Tracing branch from distal to proximal

Dissection of the gland off the facial nerve using bipolar cautery.
Removal of parotid—superficial/both.
Distilled water (hypertonic) irrigation to kill spilled tumour cells. Haemostasis
and closure with a suction drain.
COMPLICATIONS OF PAROTIDECTOMY

Salivary fistula &

Haemorrhoge 01 02
Flap necrosis
FACIA
L
NERV
E
INJUR
Y Sialocele
Frey’s syndrome Greater auricular
03 04 nerve injury
 FACIAL NEREVE INJURY

Loss of forehead wrinkling, wide palpebral fissure,

Epiphora, inability to close the eyelid,obliteration of

nasolabial fold

Drooping of angle of mouth, difficulty in blowing and

clenching
 TREATMENT

• 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.
 FREY’S SYNDROME

.
• It is due to injury to the auriculotemporal nerve.
• 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
postganglionic parasympathetic fibres from the otic ganglion become united to
sympathetic nerves from the superior cervical ganglion (Pseudosynapsis). There is
inappropriate regeneration of the damaged parasympathetic autonomic nerve
fibres to the overlying skin
 CLINICAL FEATURES:

• Flushing, sweating, erythema, pain and hyperaesthesia in the skin

over the face innervated by the auriculotemporal nerve.
• Involved skin is painted with iodine and dried. Dry starch applied
over this area will become blue due to more sweat in the area —Minor's Starch
iodine test

TREATMENT
• Initially conservative and reassurance.. Antiperspirants, anticholinergics like
scopolamine 3%, glycopyrrolate 1%, methyl sulfate, radiation 50 Gy are used.
• Jacobsen neurectomy (tympanic)
• Dermal/fat graft.
THANKS!

CREDITS: This presentation template was created by Slidesgo,

including icons by Flaticon, and infographics & images by Freepik