Surgical Anatomy of Salivary Glands

Dr. Mohey Eddin Elbanna

Prof. of General Surgery – Ain Shams University
Salivary Glands

2 © Prof. Mohey El-Banna

Embryology

• The major salivary glands develop from the

6th-8th weeks of gestation as outpouchings
of oral ectoderm into the surrounding
mesenchyme.
• The parotid develops first, growing
posteriorly as the facial nerve advances
anteriorly; eventually, the fully developed
parotid surrounds VII.
• However, the Parotid is the last to become
encapsulated, after the lymphatics develop,
resulting in its unique anatomy with
entrapment of lymphatics in the parenchyma
of the gland
3 © Prof. Mohey El-Banna
• Salivary epithelial cells are often
included within these lymph nodes,
leading to development of Warthin’s
tumors and Lymphoepithelial cysts
within the Parotid gland.
• The other major salivary glands do
NOT have intraparenchymal lymph
nodes. 

4 © Prof. Mohey El-Banna

Function of Saliva
 
At least 8 major functions of saliva have been identified:
1) Moistens oral mucosa. Mucin layer is the most important
nonimmune defense mechanism in the oral cavity.
2) Moistens dry food and cools hot food.
3) A medium for dissolved foods to stimulate the taste buds.
4) Buffers oral cavity contents due to high concentration of
bicarbonate ions.
5) Digestion. Alpha-amylase, contained in saliva, breaks 1-4
glycoside bonds, while lingual lipase helps break down fats.
6) Controls bacterial flora of the oral cavity. 
7) Mineralization of new teeth and repair of precarious enamel
lesions. Saliva is high in calcium and phosphate.
8) Protects the teeth. This signifies a saliva protein coat on the
teeth which contains antibacterial compounds. Thus, salivary
hypofunction results in dental caries. 

5 © Prof. Mohey El-Banna

The intraoral complications of
salivary hypofunction
• 1) Candidiasis 
• 2) Oral Lichen Planus (usually painful) 
• 3) Burning Mouth Syndrome (normal appearing oral mucosa with a
subjective sensation of burning) 
• 4) Recurrent aphthous ulcers 
• 5) Dental caries.
• The best way to evaluate salivary function is to measure the salivary
flow rate in stimulated (e.g., by using a parasympathomimetic as
pilocarpine) and unstimulated states. Xerostomia is NOT a reliable
indicator of salivary hypofunction. 
• There is a hierarchy of sensory stimuli such that
swallow>mastication>taste>smell>sight>thought.
• Stimulation results in an increase in total salivary flow from 0.3 cc/min
to >1 cc/min. The salivary response is directly related to a subject’s
state of hunger 

6 © Prof. Mohey El-Banna

The Parotid Gland

• The largest salivary gland

• Lies wedge-shaped between the mandible
and sternomastoid and over both
• Relations:
• Above: external auditory meats and temporo-
mandibular joint
• Below: post belly digastric
• Anteriorly: mandible and masseter
• Medially: styloid process and its muscles
7 © Prof. Mohey El-Banna
Structures at the Angle of the
Mandible

• Medial relations of the parotid: the

styloid process and its muscles
separate the gland from the
• internal jugular vein
• Internal carotid artery
• The last four cranial nerves
• Lateral wall of the pharynx

8 © Prof. Mohey El-Banna

Relations of the Parotid

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Parotid Bed

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Deep relations of Parotid

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Fascia

• The parotid is enclosed in a split in the

investing fascia
• The parotid lymph nodes lie both on
and below the parotid gland
• Antero-inferiorly, the fascia is
thickened to form the stylomandibular
ligament; the only structure that
separates the parotid from the
submandibular glands
12 © Prof. Mohey El-Banna
The Facial Nerve

• The parotid gland is divided into superficial

and deep lobes by three structures
traversing the gland:
• The Facial Nerve
• The retromandibular vein (post facial) formed
by the superficial temporal and maxillary
• The external carotid artery dividing at the
neck of the mandible into the superficial
temporal and maxillary

13 © Prof. Mohey El-Banna

Relation of the Facial Nerve and
Parotid

• The parotid develops in the crotch

formed by the 2 divisions of the facial
nerve
• As it enlarges it overlaps the nerve
trunks, the superficial and deep parts
fuse and the nerve becomes buried
within the gland
• It is not a sandwich

14 © Prof. Mohey El-Banna

Facial Nerve

15 © Prof. Mohey El-Banna

The Facial Nerve

• Emerges from the stylomastoid foramen

• Winds laterally to the styloid process
• Surgical Exposure
• In the inverted V between the bony external
auditory meatus and the mastoid process
• Just beyond the point the nerve dives into
the post aspect of the parotid and bifurcates
almost immediately into its two main
divisions

16 © Prof. Mohey El-Banna

Branches of the Facial N
• The nerve then gives rise to 2 divisions:
• 1) Temperofacial (upper) 
• 2) Cervicofacial (lower) 

• Followed by 5 terminal branches:

• 1) Temporal 
• 2) Zygomatic 
• 3) Buccal 
• 4) Marginal Mandibular 
• 5) Cervical 

17 © Prof. Mohey El-Banna

Branches

• The two divisions may be completely

separate, may form a plexus of
intermingling fibers, or may form cross-
communications that be divided safely
during dissection

18 © Prof. Mohey El-Banna

Nerve Injury

• Clinical examination of the Parotid should

include examination of the Facial nerve
• Malignant tumors of the parotid may involve
VII and cause facial palsy, while benign
tumors never affect VII
• During Superficial Parotidectomy, the nerve
is exposed posteriorly in the space bet the
bony canal of external auditory meatus and
the mastoid process
• It is then traced anteriorly into the gland to
excise the gland superficial to nerve
branches
19 © Prof. Mohey El-Banna
The Parotid Duct

• Stensen’s duct is 5 cm long.

• Arises from the anterior part of the
gland and runs over the masseter one
finger below the zygomatic arch to
pierce the buccinator and open
opposite the second upper molar tooth

20 © Prof. Mohey El-Banna

Parotid Duct orifice

• Clinical examination of the parotid

gland should include examination of
the duct orifice opposite the upper 2nd
molar for signs of inflammation, and
palpated for stone
• Parotid Sialogram is performed by
injecting a contrast through a canula
placed in the orifice of the duct

21 © Prof. Mohey El-Banna

22 © Prof. Mohey El-Banna
Submandibular Gland

• Large superficial lobe and a small deep

lobe, that connect around the
mylohyoid
• Superficial lobe lies at the angle of the
Jaw, wedged bet the mandible and
mylohyoid and overlapping the
digastric

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24 © Prof. Mohey El-Banna
Superficial and Deep
Relations
• Superficially: The skin, the platysma, the
capsule (deep fascia), the cervical branch of
Facial Nerve, and the Facial Vein
• Deeply: the deep aspect lies against the
mylohyoid for the most part. But posteriorly
lies on the hyoglossus and comes in contact
with the lingual and hypoglossal nerves.
• Both nerves lie on the hyoglossus as they
pass forward to the tongue

25 © Prof. Mohey El-Banna

 The facial Artery
• Posterior
• Arches over its
superior aspect to
reach inferior
border of the
mandible and then
ascends on to the
face in front of the
masseter

26 © Prof. Mohey El-Banna

27
Facial artery © Prof. Mohey El-Banna
The Submandibular Duct

• Arises from the deep part of the gland, runs

forward to open at the side of the frenulum
linguae
• Lies beneath the mucosa of the floor of the
mouth along the side of the tongue
• Lingual nerve loops around the duct, double-
crossing it, by passing from lateral beneath,
then medial
• The sublingual salivary gland is also medial
to the duct.

28 © Prof. Mohey El-Banna

Clinical Applications

• Submandibular LN are adherent to the gland

and partly between it and the mandible
• Differentiating bet submandibular LN and
Salivary gland:
• The salivary gland can be palpated
bimanually as it extends into the floor of the
mouth.
• The Lymph Nodes are only felt below the
mandible.
• LN may be multiple and a space separates
them from the mandible

29 © Prof. Mohey El-Banna

Clinical Applications

• A stone in the submandibular duct can

be felt bimanually in the floor of the
mouth and can be seen if large
• The presence of LN adherent to the
gland makes removal of the gland part
of block neck dissection

30 © Prof. Mohey El-Banna

Autonomic Innervations
• Parasympathetic Stimulation results in abundant,
watery saliva with a decrease in [amylase] in saliva
and an increase in [amylase] in the serum.
Acetylcholine is the active neurotransmitter, binding
at muscarinic receptors in the salivary glands. The
parasympathetic nervous system is the primary
instigator of salivary secretion.
• Parasympathetic Interruption to salivary glands
results in atrophy, while sympathetic interruption
doesn’t cause a significant change.
• It was once thought that the sympathetic nervous
system antagonizes the parasympathetic nervous
system, but this is now known not to be true

31 © Prof. Mohey El-Banna

Autonomic Innervation

• In the case of the parotid,

parasympathetic fibers originate from
CN IX
• In the case of the Submandibular and
Sublingual glands, the parasympathetic
fibers originate in CN VII

32 © Prof. Mohey El-Banna

Sympathetic Innervation

• Stimulation by the sympathetic nervous system

results in a scant, viscous saliva rich in solutes with
an increase in [amylase] in the saliva and no change
in [amylase] in the serum.
• For all of the salivary glands, these fibers originate
in the Superior Cervical ganglion and travel with
arteries to reach the glands:
• 1) External Carotid artery for the Parotid
• 2) Lingual artery for the Submandibular, and
• 3) Facial artery in the case of the Sublingual.

33 © Prof. Mohey El-Banna

The Most Common Tumors
• Histologically, salivary gland tumors are the
most heterogenous group of tumors of any
tissue in the body
• Of salivary gland neoplasms, >50% are
benign
• Approximately 70% to 80% of all salivary
gland neoplasms originate in the parotid
• The palate is the most common site of minor
salivary gland tumors
• The frequency of malignant lesions varies by
site.
34 © Prof. Mohey El-Banna
Malignant Tumors
• Approximately 20-25% of parotid, 35-40% of
submandibular tumors, 50% of palate tumors, and >
90% of sublingual gland tumors are malignant
• The most common benign salivary tumor is
pleomorphic adenoma, comprising 50% of all
salivary tumors and 65% of parotid gland tumors
• The most common malignant salivary tumor is the
mucoepidermoid carcinoma, comprising 10% of all
salivary gland neoplasms and 35% of malignant
salivary gland neoplasms, occurring most often in
the parotid gland.

35 © Prof. Mohey El-Banna

Other types of malignant tumors

• Monomorphic Adenoma (Warthin’s

tumor)
• Malignant mixed salivary tumor
(Malignant Pleomorphic carcinoma)
• Adenoid Cystic Carcinoma
• Acinic cell cancer
• Adenocarcinoma
• Squamous cell carcinoma
36 © Prof. Mohey El-Banna
Q&A

1- Mark following statements as true (T) or false (F):

A-The Parotid gland is the last to be encapsulated

B-The Parotid gland has intraparenchymal lymphatics
C- The hypoglossal nerve divides the parotid gland into
superficial and deep lobes
D-The parotid duct opens in the floor of the mouth
E-The parotid secretion is mucus and viscous

37 © Prof. Mohey El-Banna

Q 2

2- Mark following statements as true (T) or false (F):

A-The Parotid gland is separated from the
submandibular gland by the stylomastoid ligament
B- Benign tumors of the parotid may cause facial never
palsy
C- The facial Nerve divides into 2 trunks, each giving 3
branches
D- The superficial and deep lobes of the parotid gland
are completely separated by the facial nerve
E- The facial nerve trunk may be injured during
superficial parotidectomy

38 © Prof. Mohey El-Banna

Q3

3-Mark following statements as true (T) or false (F):

A-The submandibular gland consists of a large deep
lobe and a small superficial lobe
B-Both lobes of the submandibular gland are separated
by the facial nerve
C-Salivary stones form more commonly in the
submandibular duct
D-Submandibular sialadenectomy is part of block neck
dissection
E-Hypoglossal N runs below the deep part of the
submandibular gland
39 © Prof. Mohey El-Banna
Q4

4-Mark following statements as true (T) or false (F):

A- Pleomorphic adenoma is the most common salivary
gland tumor
B- Mucoepidermoid carcinoma is the most common
salivary gland tumor
C- Parotid gland tumors are most commonly malignant
D- Sublingual gland tumors are most commonly
malignant
E- Malignant Salivary gland tumors are treated by
Surgical excision followed by postoperative
radiotherapy

40 © Prof. Mohey El-Banna

Key to Answers

Q 1 A: T, B: T, C: F, D: F, E: F
Q 2: A: T, B: F, C: F, D: F, E: T
Q 3: A:F, B: F, C:T, D: T, E: T
Q 4: A: T, B: F, C: F, D: T, E: T

41 © Prof. Mohey El-Banna