Salivary Glands

 6 Main Salivary Glands

 2 Submandibular Glands
 2 Parotid Glands
 2 Sublingual Glands
 Multiple Minor Salivary Glands
 400 in number
 Parotid Gland
 Lies In Recess Bounded By
 Ramus of the Mandible
 Base of Skull
 Mastoid Process
 Lies On
 Carotid Sheath
 XIth & XIIth Cranial Nv
 Extends over masseter muscle
 Parotid Sheath encloses the gland
 It is derived from deep CERVICAL FASCIA
 Structures Running Through The Parotid
Gland
 Pes Anserinus (Branches of facial nv)
 Terminal branches of ECA(Ext Carotid artery)
i. Sup Temporal Artery
ii. Maxillary Artery
 Retro Mandibular vein
 Intraparotid lymph nodes.
 Parotid gland divided into
 Superficial lobe
 Deep lobe

 Accessory lobe (seen in <50%)

 Superficial lobe and deep lobe is separated by

the Facial Nerve.
 80% of parotid lies superficial to facial nerve.
 20% lies Deep to the nerve
 Diseases of parotid gland
 Inflammatory Disorders
 Parotid stones
 Parotid tumors.
 Inflammatory Swelling of Parotid
 Most common –mumps which is acute painful swelling of parotid.
Seen in children which is caused by virus.
 Acute bacterial parotitis Idiopathic.
 Acute ascending bacterial sialadenitis which is seen in dehydrated
elderly patients
 Obstructive parotitis causing swelling at the time of meals due to
trauma to parotid duct papila.
 Chronic parotitis in children –pathonomonic of HIV in children.
 Parotid Stones
 Much rarer than Submandibular gland stones
 20% of all salivary gland stones.

 80% occur in submandibular gland

 Radiolucent

 Rarely visible on X-Ray

 Parotid gland SIALOGRAPHY or USG of parotid

gland required.
 Removed surgically by exposing the duct.
 Parotid Tumors

Classification Of Salivary Gland Tumors

 Adenoma
 Plemorphic (pl-adenoma)
 Monomorphic (warthin’s tumor)
 Carcinoma
 Low grade( Adenoid cystic CA and Acinic cell CA)
 High grade(Squamous cell CA)
 Non Epithelial tumors
 Hemangioma
 Lymphomas
 Lymphomas
 Primary Non Hodgkin's lymphoma
 Secondary lymphomas seen in SJOGREN’S Syndrome
 Secondary tumors(Metastatic)
 Local from head and neck tumors
 Distant

 Unclassified tumors
 Tumor like lesions
 Solid (Adenomatoid hyperplasia)
 Cystic (salivary gland cysts)
 Parotid Gland
 Most common site of salivary tumors.
 80-90% of tumors of parotid gland are benign

 Most tumors arise in the superficial lobe

 Most parotid tumors of superficial lobe present as slow

growing painless swelling.

 Location –below the ear, in front of the ear ,or upper

neck.
 Accessory lobe tumors present as persistent swelling.
 Tumors from deep lobe of parotid as Parapharangeal
mass.
 Symptoms ---difficulty in swallowing and snoring
 o/e ----diffuse firm swelling in soft palate tonsil.
 Malignant tumors
 Low grade (Acinic cell CA of parotid behave as benign)
 High grade (Radical growing and often painful swelling)
 Present as diffuse hard swelling of gland or discrete mass and
infiltration of overlying skin.
 Cervical lymph node metastasis may be present
 Facial nerve weakness if present ,is sign of malignancy.
 Investigation
 FNAC
 CT

 MRI

 Open surgical biopsy( Contraindicated except where it

is clearly a case of overt malignancy

 And preoperative systemic examinination required for

radical parotidectomy.
 Parodtidectomy

 Superficial
 Radical

Superficial parotidectomy:
 Aim –To remove the tumor with a Cuff (Rim) of normal tissue
around it while avoiding any injury to facial nerve
 Done With Endotracheal G.A
 Skin incision – lazy “S” incision.
 Pre –Auricular Mastoid
 Cervical incision
Various landmarks used to identify the facial nerve are:
 Inferior portion of cartilaginous canal
 Upper border of posterior belly of digastrics
Radical Parotidectomy:
 When clear Histological evidence of “High Grade”
 Malignant tumor with extensive facial nerve infiltration
 “Low Grade" malignancy managed by superficial Parotidectomy.
 It’s a removal of all parotid tissue.
 Elective sectioning of facial nerve luvally main trunks.
 Ipsilateral masseterm
 Ipsilateral neck disection for removal of lymph nodes if clinical
radiological or cytological evidence of L.N meet.
 Complications of parotid gland surgery
 Hematoma
 Infection

 Temporary facial nerve weakness

 Transection of facial nerve and permanent facial

weakeness
 Facial numbness

 Frey syndrome

 Permanent facial weakness after radical parotidectomy.

 Numbness of ear lobe associated with GR Auricular

nerve transection.
 The submandibular gland
 Large superficial lobe
 Small deep lobe surrounded by capsule derived from deep clinical
fascia
 Continuous around posterior border of myolohyoid muscle.
Anatomical Relation
 Anterior facial vein runs over surface of the gland.
 Facial artery also found.
Deep part of gland
 Lies on hyoglossus muscle
 Related to lingual nerve and hypoglossal nerve
 Duct-WHARTON’S Duct.
Diseases of Submandibular Gland
 Inflammatory (acute submandibular sialadeintis)
condition.
 Viral-mumps
 Bacterial-sec to obstruction
 Chronic submandibular sialadentis
 Due to sialolithiasis within submandibular gland and duct.
 80% of all salivary stones occur in submandibular gland.
 Cause is salivary muchs with viscosity
 80% of submandibular stones –radio opaque.
 Can be seen on plain xray
 C/F – acute painful swelling in the
submandibular region precipitated by eating.
 Enlarged ,tender submandibular gland.
 T/P-Incision (longitudinal
 INVESTIGATION
 FNAC
 CT

 MR 9

 Open surgical Biopsy is contra-indicated.

(as there is risk of seeding in surrounding tissue planes)

MANAGEMENT OF SUBMANDIBULAR GLAND TUMOURS
 For small tumor- intracapsular submandibular gland ex….
 For benign tumor- which are large.
 Suprahyoid neck dissection is done.

 Preserving lingual nerve, hypoglossal nerve and

mandibular branch of ferial nerve.

 In case of submandibular gland malignancy
 Modified neck dissection or radical neck dissection is done along
with removal tumor mass.
 Lingual nerve and hypoglossal nerve may have to be sacrificed.

Indications of submandibular gland ex…..

 Salivary tumors.
 Stones proximal to lingual nerve.
 Sial adenitis.
 Complications of submandibular gland ex…

1. Haematoma
2. Infection
3. Injury to ---
A. Lingual nerve.

B. Hypoglossal nerve.

C. Marginal mandibular nerve.

 SALIVARY GLAND TUMORS

Major glands Benign Malignant

Parotid 80-90% 10-20%

Submandibular 50% 50%
Sublingual 5% 95%
Minor glands 10% 90%
 Features of parotid swelling
 Ear lobule raised
 Swelling in parotid region
 Swelling occupying the groove
between posterior part of the mandible
and mastoid process
 Moves upwards upto zygomatic bone-
curtain sign
 Features of facial nerve palsy
 Difficulty in chewing food as food accumulates in
vestibule due to buccinator weakness
 Deviation of angle of mouth while talking, laughing,
blowing, whistling due to paralysis of orbicularis oris
 Failure of Closure of eyelids or easily opening of the
eyelids after closure- paralysis of orbicularis oculi
 Absence of furrows while looking upward- paralysis
of frontal belly of occipitofrontalis
 Absence of corrugation in the forehead during
frowing- paralysis of corrugator supercilii
 Deviation of angle of mouth towards opposite side-
paralysis of levator anguli oris
 Loss of contraction of platysma in the neck while
stretching the neck-paralysis of platysma
 Inability to blow the air by the check and on palpation
reduced tone of buccinator
 Inability to whistle-paralysis of orbicularis oris
 INVESTIGATION
 X-ray of the part often intraoral X-ray to look for
radiopaque stone in the submandibular region
 Facial nerve palsy – typical look.
 Inability to whistle – paralysis of orbicularis oris.
CT scan of the part including neck to see extent of
the tumor, deep lobe involvement, and adjacent
spread
FNAC of the swelling.
 Sialography
Indication: Salivary fistulas ;
Sialectasis ; Congenital conditions;
Extraglandular masses. Dye used is
Lipiodol or sodium diatrizoate
(Hypaque). 24-gauge cannula is passed
into either the Stensen’s duct or
Wharton’s duct and 1 ml of the dye is
injected and X-ray is taken.
Narrowing (stricture); grape-like
cluster appearance (sialectasis);
dilatations; communications
(Fistulas); mass lesions. Sialography
should never be performed in acute
inflammation. Only one ml of dye is
injected, if more dye is injected it
causes extravasation and chemical
sialadenitis
TNM staging of malignant salivary tumours

T -Tumour
TX -Tumour cannot be assessed
T0 -No evidence of primary tumour
T1 -Tumour < 2 cm without extraparenchymal spread
T2 - Tumour 2-4 cm
T3 - Tumour 4-6 cm
- or with extraparenchymal spread
- but no facial nerve spread
T4 - Tumour > 6 cm
- or facial nerve spread
- or base of skull spread.
TNM staging of malignant salivary tumours
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 node < 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.
 GENERAL FEATURES OF
MALIGNANT SALIVARY TUMORS
 Fixation, resorption of adjacent bone, pain and
anasthesia in the skin and mucosa
 Muscle paralysis, skin involvement and nodularity
 Involvement of jaw and masticatory muscle
 Nerve involvement (facial nerve in parotid or
hypoglossal nerve in submandibular salivary gland)
 Mandibular branch of 5th cranial nerve may be
involved when tumour tracks along the
auriculotemporal nerve to the base of skull causing
severe pain in the distribution area
 Blood spread to lungs can occur
 Salivary gland tumours are usually benign in
adult.
 It is rare in children but when it occurs, it is
commonly malignant.
 Clinical and FNAC are diagonostic methods.
 Open biopsy is contraindicated.
 Sialogram is not useful in salivary tumours.
 CT or MRI are often needed.
 Nerve should be preserved in benign lesions.
 Nerve can be sacrificed to achieve clearance in
malignancies.
 Salivary calculi in Salivary calculi in
submandibular gland parotid gland
 80% common  20% incidence (Rare)
 80% radio-opaque  Radiolucent
 Seen in plain X-ray  Not seen in plain X-
(intraoral) ray
 Sailogram is not  Identified by
needed sailogram
 Caliculi are common in
submandibular salivary gland
 Because –
* Viscous nature and mucin content
* Calcium content
* Non dependent drainage
* Stasis.
 REMEMBER ABOUT SALIVARY FISTULA

 Commonly from the parotid

 It can be internal draining into the mouth or can be
external draining outside
 It is acquired commonly but rarely can be congenital
 It can be due to surgery, trauma due to sepsis
 Fistula arising from the gland parenchyma drains
through suture line but usually closes spontaneously.
Leakage will more during meals. Saliva is confirmed
by its high amylase content compared to
seroma/serous fluid
 REMEMBER ABOUT SALIVARY FISTULA
 Fistula due to ductal disruption leaks profusely and
invariably needs surgery to close it
 Submandibular gland fistula commonly closes
spontaneously, rarely if not, requires complete
removal of the gland.
 Anticholinergics, irradiation, denervation of the
gland, duct ligation are done to reduce saliva
production.
 Excission of fistula , repair of the duct, diversion of
the duct into the mouth are other options.
 In severe intractable cases removal of gland/total
conservative parotidectomy is needed.