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THE SALIVARY GLANDS

Embryology Anatomy and
Surgical Applications
Grant W. Carlson, MD

PAROTID GLAND

Embryology

Because, for all practical purposes, the neck does not exist in embryos, a
discussion about the embryogenesis of the neck is impossible. To understand
the embryology of this region, one must study the embryology of each of the
organs contained there, specifically, the pharyngeal apparatus and its derivatives,
such as the thyroid, parathyroid, and thymus. Pouches, clefts, and arches de-
velop and disappear. The esophagus and vessels are elongated while other
embryologic entities, such as the diaphragm, descend.
Early in the 6th week of gestation, solid epithelial buds of ectodermal origin
form the wall of the primitive mouth and invaginate into the surrounding
mesenchyme. A groove that later becomes a tunnel develops. The future parotid
gland is formed in the blind end of the tunnel by proliferation, budding length,
and extensive branching. The end of the solid ducts forms the secretory acini.
The mesenchyme is responsible for the genesis of the capsule and the connective
parotid tissue. Later in fetal life, the solid epithelial buds and acini become
hollow. All of the salivary glands have a similar embryogenesis.A close associa-
tion between the facial nerve and the parotid ductules begins early in the fetal
period. They practically embrace each other in a way described best by McKen-
zie6 as “A creeper weaving itself into the meshes of a trellis-work fence.”

Anatomy

Because the parotid gland is located behind the lower jaw and the base of
the cranium, it cannot be palpated under normal conditions. Also, at birth,

From the Department of Surgery, Emory University School of Medicine; and the Winship
Clinic, Atlanta, Georgia

SURGICAL CLINICS OF NORTH AMERICA

-
VOLUME 80 NUMBER 1 FEBRUARY 2000 261
262 CARLSON

Figure 1. The parotid gland covers the ascending ramus of the mandible.

infants have no mastoid process, so the stylomastoid foramen is subcutaneous,

which must be taken into account during surgery for the treatment of pediatric
parotid disorders (e.g., lymphangioma).
The parotid gland is the site of 80% of salivary neoplasms. Most of these
tumors are benign, but precise knowledge of the anatomy of the parotid gland
is necessary to avoid facial nerve injury during parotidectomy. The parotid gland
is an irregular, wedge-shaped organ that envelops the posterior border of the
ascending ramus of the mandible (Fig. 1).On its superficial surface, it extends
medially to cover a portion of the masseter muscle. The body of the gland fills
the space between the mandible and the surface bounded by the external
auditory meatus and the mastoid process. Deep to the ascending ramus, the
gland extends forward to a variable degree, lying in contact with the medial
pterygoid muscle. Just below the condylar neck, above the attachment of the
medial pterygoid to the bone, the gland extends between the two. In the region
of the condyle, the gland lies between the capsule of the temporomandibular
joint and external acoustic meatus. Laterally, at the junction of the mastoid
process and sternocleidomastoid muscle, the gland lies directly on the posterior
belly of the digastric muscle, styloid process, and stylohyoid muscle. These
structures separate the gland from the internal carotid artery, internal jugular
vein, and cranial nerves IX to XII. Practically, these anatomic entities form the
parotid bed, which is related to the so-called “deep lobe” of the parotid gland.
Several important anatomic entities may be remembered with the mnemonic
VANS:
V = Internal jugular vein (one vein)
A = External and internal carotid arteries (two arteries)
N = The last four cranial nerves (IX, X, XI, and XII):
Glossopharyngeal nerve
Vagus nerve
Spinal accessory nerve
Hypoglossal nerve
 THE SALIVARY GLANDS 263

S = ztyloid process + three muscles:

styloglossus
Styloglossus pharyngeus
Styloglossus hyoid
With regard to the topographic anatomy of these structures, physicians should
remember:
Vein = Deep in the floor of the parotid bed
Artery = Anterior to the vein
Nerves :
Glossopharyngeal = Related to the styloid muscles
Vagus = Between internal carotid artery and jugular vein
Spinal accessory = Superficial to the carotid sheath but proceeding down-
ward behind the posterior belly of the digastric muscle
Hypoglossal = Same course as the spinal accessory
The posterior belly of the digastric muscle is an excellent anatomic landmark
because, behind it, the following anatomic entities may be found: the carotid
arteries, jugular vein, cranial nerves (X, XI, and XII), and sympathetic chain.
Stensen’s duct passes from the anterolateral edge of the parotid gland over
the masseter muscle. At the anterior margin of the muscle, it turns medially to
pierce the buccinator muscle and enters the oral cavity at the level of the upper
second molar tooth. In some cases, the accessory gland is found along the course
of the duct (Fig. 1). It follows a line from the floor of the external auditory
meatus to just above the commissure of the lips. These are important landmarks
in evaluating facial lacerations with possible duct injury.
No natural plane exists between the parotid gland and the overlying skin.
Surgical exposure requires raising the cheek flap in the subcutaneous plane just
beneath the hair follicles. The gland is fixed by fibrous attachments to the
external acoustic meatus, mastoid process, and fibrous sheath of the sternocleido-
mastoid. These must be released to mobilize the gland facilitating exposure of
the facial nerve. One of the fascia1 attachments is the stylomandibular ligament.
It passes deep to the gland from the styloid process to the posterior border of the
ascending ramus just above the angle, separating the parotid and submandibular
glands. Together with the mandibular ramus, it forms a tunnel through which a
process of the gland can extend into the parapharyngeal space (Fig. 2). In some
cases, tumors develop in this process, resulting in swelling in the facial and
lateral pharyngeal areas rather than externally.
The facial nerve is intimately associated with the gland. It emerges from the
skull through the stylomastoid foramen immediately posterior to the base of the
styloid process and anterior to the attachment of the digastric muscle (Fig. 3).
The main trunk of the facial nerve is always located in the triangle that is
formed by the mastoid, angle of the mandible, and cartilaginous ear canal, with
a medial location to the mastoid, almost at a point between the mandible and
the cartilaginous ear canal. Before entering the gland, the nerve has three
branches: (1) to the posterior auricular muscle, (2) to the posterior belly of the
digastric muscle, and (3) to the stylohyoid muscle. The nerve enters the posterior
surface of the gland approximately 1 cm after exiting the skull. It is superficial
to the external carotid artery and the posterior facial vein. The ne,rve branches
into an upper temporofacial division, which takes a vertical course, and a lower
cervicofacial division, which is a transverse continuation of the main trunk. The
point of branching is called the pes anserinus, From the pes, the nerve divides
into five branches: (1) temporal, (2) zygomatic, (3) buccal, (4) mandibular, and
264 CARLSON

Figure 2. Deep lobe parotid tumors may extend into the parapharyngeal space and present
in the mouth.

(5) cervical. The temporal and zygomatic branches share the motor supply of
the orbicularis oculi, and the temporal branch alone supplies the forehead
musculature. The cervical branch supplies the platysma, and the remaining
buccal and mandibular branches share the supply of the remaining facial mus-
cles. The primary division is constant, but considerable variation exists in the
origins, inter-relationships, and distribution of the peripheral branches (see Fig.
3). The pattern of branching is especially variable, and rami often communicate
between branches, sometimes within the gland but more often in front of its
anterior border.' The presence of these communicating rami explains the occur-
rence of unexpectedly mild paralysis following the division of a branch.
The facial nerve runs within the substance of the gland, but within the
gland, the facial nerve is superficial, the veins are deeper, and the arterial
branches are deepest. Traditionally, the path of the nerve has been used to
separate the parotid gland into superficial and deep lobes, but no true facial
planes separate the two lobes. In 1956, two important but controversial articles
in the literature discussed the unilobar formationloand bilobar formation' of the
parotid gland. Both types have been found, but they were not well defined or
separated (John E. Skandalakis, MD, personal communication, 1996). Tumors
generally develop superficial or deep to the plane of the nerve, hence the
distinction of superficial and deep lobe tumors. In some cases, tumors arise in
the plane of the nerve, separating the branches.
Parotidectomy requires precise identification of the facial nerve. The main
trunk is constantly found between the base of the styloid process and the
mastoid process. The tail of the parotid gland must be separated from the
sternocleidomastoid muscle. Lateral traction of the muscle exposes the digastric
muscle, which is followed to its insertion on the mastoid tip. The nerve lies
 THE SALIVARY GLANDS 265

Figure 3. The facial nerve has considerable variation in the distribution of peripheral
branches. It has a constant location anterior to the attachment of the digastric muscles as
it exits the stylomastoid foramen.

between the insertion of the muscle and the styloid process (see Fig. 3). In
difficult cases, the nerve can be found by removing the mastoid tip with an
osteotome, which exposes the nerve in the descending portion of the facial canal
as it exits through the stylomastoid foramen. If the tumor mass overlies the
main nerve trunk, physicians can identify the posterior facial vein as it enters
the gland. The marginal mandibular nerve can be seen crossing superficial to it
and can be followed to the main trunk.
The external carotid artery enters the inferior surface of the gland and
divides into the maxillary and superficial temporal arteries at the junction
between the middle and upper thirds of the gland. The superficial temporal
artery gives off the transverse facial artery to supply the face before continuing
upward to emerge from the upper border of the gland. The maxillary artery
passes forward and slightly upward behind the condylar neck in the part of the
gland lying deep to it. The artery emerges from the gland and passes into the
infratemporal fossa.
266 CARLSON

The venous drainage of the area varies, but the superficial temporal vein
typically enters the superior surface and receives the internal maxillary vein to
become the posterior facial vein. Within the gland, it divides into a posterior
branch, which joins the posterior auricular vein to form the external jugular
vein. The anterior branch emerges from the gland to join the common facial
vein. The facial nerve is superficial to the vessels, the artery is deep, and the
veins lie between them.
Knowledge of the lymphatics of the parotid gland is important in evaluating
skin cancers of the head. Preauricular lymph nodes in the superficial fascia drain
the temporal scalp, upper face, and anterior pinna. Lymph nodes within the
parotid substance drain the gland, nasopharynx, palate, middle ear, and external
auditory meatus. These lymphatics drain into the internal jugular and spinal
accessory nodes.
The parotid gland is innervated by sympathetic and parasympathetic fibers.
The function of the sympathetic fibers is most likely vasoconstriction, and the
function of the parasympathetic fibers (IX nerve) is most likely secretory.
The greater auricular nerve emerges from the posterior border of the sterno-
cleidomastoid muscle at Erb's point (Fig. 4). It crosses the midportion of the
muscle approximately 6.5 cm beneath the external auditory r n e a t u ~ It
. ~travels
parallel and superior to the external jugular vein to supply sensation to the ear
and preauricular region. It passes on the surface of the parotid gland and can
be preserved unless invaded by tumor by retracting it posteriorly. If the nerve
must be sacrificed, it is preserved in saline solution for possible use as a nerve

Cervical v.

Figure 4. Erb's point (circle) is an important landmark in the posterior triangle. n = nerve;
v = vein.
 THE SALIVARY GLANDS 267

graft. Loss of the branches to the ear can cause disturbing numbness of the
lobule, making earrings difficult to wear and, in some cases, causing frostbite.
The auriculotemporal nerve is a branch of the mandibular division of the
trigeminal nerve. It traverses the upper part of the parotid gland and emerges
from the superior surface with the superficial temporal vessels. It carries sensory
fibers from the trigeminal and secretory fibers from the glossopharyngeal nerve
by the otic ganglion.
Frey's syndrome is localized sweating and flushing during the mastication
of food. It is a common disorder that occurs in 35% to 60% of patients after
parotidectomy with facial nerve dis~ection.~,The syndrome usually presents
several months after surgery and has varying degrees of severity. It may result
from aberrant regeneration of nerve fibers from postganglionic secretomotor
parasympathetic innervation to the parotid gland occurring through the severed
axon sheaths of the postganglionic sympathetic fibers that supply the sweat
glands of the skin. Most affected patients do not seek treatment.

Surgical Applications

Preoperative Preparation
The history and physical examination are often diagnostic of parotid masses.
A slow-growing mass that has been present for many years is most likely a
pleomorphic adenoma. Facial nerve paralysis usually indicates a malignant
process. CT scanning can be useful in equivocal cases when a deep lobe tumor
or malignancy is suspected.
Fine-needle aspiration cytology is useful in cases in which malignancy is
suspected. It aids in preoperative counseling regarding the risk for nerve injury
but should not determine operability.

Skin Incisions and Surgical Exposure

Parotidectomy is performed under loupe magnification while the surgeon
wears a headlight. A bipolar cautery device is used to protect the facial nerve
from conducted electricity. Meticulous hemostasis is necessary to permit safe
exposure of the nerve. No muscle relaxation is used, and in some cases, a nerve
stimulator is helpful to identify nerve branches.
Patients are placed in the supine position with the head extended and
rotated to the opposite side. Draping allows for exposure of the entire external
ear, facial skin, and neck. A petroleum gauze plug is placed in the ear to prevent
blood accumulation. A preauricular incision that may extend up to the zygoma,
depending on the location of the tumor, is made. The incision curves around
the ear and proceeds down the neck in a transverse skin crease (Fig. 5). The
anterior skin flap is developed in the subcutaneous plane just below the hair
follicles. This is not a natural surgical plane, and the incision is usually made
with a scalpel. Dissection continues medially onto the surface of the masseter
muscle. The posterior flap is developed in the subplatysmal plane over the
anterior border of the sternocleidomastoid muscle (SCM). The skin flaps are
secured with sutures (Fig. 6).
After surgical exposure is obtained, the dissection begins at the inferior
portion of the gland. The posterior facial vein is divided between clamps. The
greater auricular nerve is identified crossing the SCM. The nerve may have to
be divided if it crosses the superficial aspect of the gland. If the nerve is
268 CARLSON

Figure 5. Incision for a parotidectomy curves around the ear and proceeds down the neck
in a transverse skin crease. (From Carlson GW: Lateral neck. In Wood WC, Skandalakis
JE (eds): Anatomic Basis of Tumor Surgery. St. Louis, Quality Medical Publishing, 1999, p
128; with permission.)

sacrificed, it is placed in saline-moistened gauze to possibly be used later as a

nerve graft.
The tail of the parotid gland is grasped with mosquito clamps and carefully
dissected off of the SCM. The anterior muscle border is identified from the
mastoid process to the inferior end of the incision. Careful dissection is per-
formed anterior and deep to the SCM. The posterior belly of the digastric muscle
is identified as coursing in an oblique direction from the SCM. The internal
jugular vein and internal carotid artery are deep to this muscle. All of the
salivary tissue is retracted anteriorly and superiorly to the digastric muscle. The
earlobe is retracted, and the dense, fibrous attachments between the parotid
gland, mastoid tip, and cartilaginous auditory canal are divided, which exposes
the tragal pointer. The facial nerve lies 1 cm deep and slightly inferior to the
pointer. During separation from the ear canal, bleeding from the superficial
temporal vessels is controlled with the bipolar cautery device.

Identification of the Facial Nerve

Parotidectomy requires precise identification of the facial nerve. The main
trunk is consistently found between the base of the styloid and mastoid proc-
esses. The tail of the parotid gland must be separated from the sternocleidomas-
toid muscle. Lateral traction of the muscle exposes the digastric muscle, which
 THE SALIVARY GLANDS 269

Figure 6. Surgical exposure of the parotid gland. (From Carlson GW: Lateral neck. In
Wood WC, Skandalakis JE (eds): Anatomic Basis of Tumor Surgery. St. Louis, Quality
Medical Publishing, 1999, p 129; with permission.)

is followed to its insertion on the mastoid tip. The nerve lies between the
insertion of the muscle and the styloid process (see Fig. 3). In difficult cases, the
nerve can be found by removing the mastoid tip with an osteotome, which
exposes the nerve in the descending portion of the facial canal as it exits through
the stylomastoid foramen. If the tumor mass overlies the main nerve trunk, an
optional approach is to identify the posterior facial vein as it enters the gland.
The marginal mandibular nerve crosses superficial to it and can be followed to
the main trunk. Approximately 1.0 cm to 1.5 cm from the stylomastoid foramen,
the nerve divides into the upper zygomaticofacial and lower cervicofacial divi-
sions at the pes anserinus.

Tumor Resection
Resection of a parotid mass should be considered an attack on the tumor,
not the gland. Most tumors of the parotid gland arise in the superficial portion.
The underlying nerve usually limits the removal of tumors in this portion
unless it is sacrificed. A pleomorphic adenoma has a well-defined capsule, but
enucleation results in an unacceptable recurrence rate. When nerve branches
disappear into the tumor, malignancy should be suspected. Nerve resection is
270 CARLSON

indicated when the nerves are clinically involved. The greater auricular nerve
can be used as a nerve graft. A total parotidectomy is typically performed to
treat malignant neoplasms.
During dissection, the individual nerve branches are dissected with a fine
mosquito clamp. The overlying parotid mass is divided with a no. 12 knife blade
(Fig. 7). Hemostasis is controlled with the bipolar cautery device. Lesions deep
to the facial nerve necessitate removal of the superficial parotid tissue first. The
remaining tissue can then be carefully dissected out between nerve branches.

SUBMAXILLARY GLAND
The submandibular salivary gland is the site of approximately 10% to 15%
of salivary neoplasms. Approximately 30% to 55% of these tumors are malignant,
with adenoid cystic carcinoma being the most common type of cancer. Most
neoplasms are asymptomatic, but if a patient shows evidence of neural involve-
ment, such as marginal mandibular or hypoglossal paresis or loss of sensation,
an aggressive malignant neoplasm is probable. Bimanual examination through
the mouth allows assessment of possible extension under the mylohyoid muscle.

Anatomy
The submaxillary gland and associated lymph nodes fill the triangle over-
lapping the digastric muscles and extending upward deep to the mandible5(Fig.
8). Differentiating the gland from the lymph nodes may be difficult. The gland
sends a prolongation of tissue with the submaxillary, or Wharton’s, duct under
the mylohyoid muscle (Fig. 9). The duct opens into the mouth on the side of the
frenulum of the tongue. Superficial to the gland, the facial vein crosses the
submaxillary triangle to reach the anterior border of the mandible. The facial
artery enters the triangle under the posterior belly of the digastric and stylohyoid
muscles. It ascends to emerge above or through the upper border of the gland.

Figure 7. Individual facial nerve branches are dissected with a fine mosquito clamp, and
the overlying parotid gland is divided with a No. 12 knife blade. (From Carlson GW: Lateral
neck. In Wood WC, Skandalakis JE (eds): Anatomic Basis of Tumor Surgery. St. Louis,
Quality Medical Publishing, 1999, p 130; with permission.)
 THE SALIVARY GLANDS 271

Figure 8. The contents of the submaxillary triangle just deep to the platysma muscle. a =
artery; v = vein; n = nerve.

The marginal mandibular branch of the facial nerve courses through the triangle
beneath the platysma muscle. It is the only important structure encountered
above the digastric muscle in a submaxillary dissection. The course of the nerve
varies, and this nerve commonly has multiple branches. Dingman and Grabb2
found the nerve to be located above the anterior ramus of the mandible in 81%
of cadaver dissections. In the author’s experience, the nerve loops below the

Figure 9. The superficial portion of the submaxillary salivary gland has been removed to
reveal structures deep in the triangle. m = muscle.
272 CARLSON

mandible to a varying degree in most patients. Skandalakis et als, reported that

in 50% of cases, the mandibular branch lies above the mandibular border and
outside of the submaxillary triangle. It courses over the facial vessels as it travels
upward to supply the depressor anguli oris and the depressor labii inferioris
muscles. To prevent injury during neck dissection, the facial vessels are divided
below the nerve and used to retract the nerve above the mandible. Lymph nodes
are present around the vessels, and the nerve may need to be sacrificed to
facilitate removal. Injury to the nerve can result in facial asymmetry and, in
some cases, drooling. The hypoglossal nerve descends between the internal
jugular vein and internal carotid artery, giving branches to the thyrohyoid and
geniohyoid muscles, and supplies the superior limb of the ansa cervicalis, which
supplies the infrahyoid strap muscles. It enters the triangle deep to the posterior
belly of the digastric muscle. It lies on the surface of the hyoglossus muscle and
courses deep to the mylohyoid muscle to supply motor function to the tongue.
The lingual nerve, a branch of the mandibular nerve, is found under the border
of the mandible on the hyoglossus muscle above the hypoglossal nerve. It is
attached to the submaxillary gland by the submaxillary ganglion and courses
deep to the mylohyoid muscle to provide sensation to the anterior tongue and
floor of the mouth (Fig. 10).

Surgical Applications

Tumors involving the submandibular gland are usually contained within

the gland, and resection is confined to the gland and surrounding fat or lymph
nodes. A curvilinear incision, extending from the midline of the jaw to the
mastoid following the course of the digastric muscles, provides good exposure.

Figure 10. The entire submaxillary gland is removed to show the floor of the triangle. m =
muscle; n = nerve; br = branch; CN VII = facial nerve.
 THE SALIVARY GLANDS 273

Submental and Submandibular Dissection

Submental and submandibular dissection begins with the identification of the
marginal mandibular nerve, whch typically has multiple branches that run in
areolar tissue between the platysma and the fascia surrounding the submandibular
gland. The facial vessels crossing the inferior border of the mandible at the anterior
border of the masseter muscle are identified. The nerve branches course above
these vessels. The vessels are ligated below the nerve and retracted superiorly to
remove the marginal nerve branches from the operative field.
The submental dissection begins by incising the deep cervical fascia off of the
contralateral anterior digastric muscle and along the inferior border of the mandi-
ble. The dissection begins by grasping the fascia with mosquito clamps. The fascia
is carefully dissected off of the mylohyoid muscle, whch forms the floor of the
submental triangle. The dissection is continued laterally to the ipsilateral digastric
muscle, where the submental vessels branching from the facial vessels are encoun-
tered. These vessels are ligated and divided, and submandibular dissection is be-
gun.
The digastric muscles provide a safe plane in which to operate. The subman-
dibular gland is retracted laterally to expose the mylohyoid muscle (see Fig. 9).
The free posterior margin of the mylohyoid is key to submandibular dissection.
It is retracted medially to reveal the deep portion of the submandibular gland
lying on the hyoglossus muscle. The lingual nerve is located superiorly under
the mandible and is attached to the gland by the submandibular ganglion. It
must be carefully ligated to avoid troublesome bleeding. Wharton’s duct lies
deep to the lingual nerve and is ligated carefully to avoid nerve injury. The
hypoglossal nerve is located inferiorly below the digastric muscle (see Fig. 10)
and is accompanied by a plexus of veins. The fascia and gland are mobilized
laterally by using mosquito clamps as retractors. The facial artery is ligated as it
courses around the posterior surface of the gland.

References
1. Davis RA, Anson BJ, Budinger JM, et al: Surgical anatomy of the facial nerve and
parotid gland based upon a study of 350 cervicofacial halves. Surg Gynecol Obstet
102:385, 1956
2. Dingman RO, Grabb WC: Surgical anatomy of the mandibular ramus of the facial
nerve based on dissection of 100 facial halves. Plast Reconstr Surg 29:266, 1962
3. Gordon AB, Fiddian R V Frey’s syndrome after parotid surgery. Am J Surg 132:54, 1976
4. Hays LL, Novack AJ, Worsham JC: The Frey syndrome: A simple, effective treatment.
Otolaryngol Head Neck Surg 90:419, 1982
5. Johns ME, Kaplan MJ: Surgical therapy of tumors of the salivary glands. In Thawley
SE, Panje WR (eds): Comprehensive Management of Head and Neck Tumors. Philadel-
phia, WB Saunders, 1987, p 1104
6. McKenzie J: The first arch syndrome. Dev Med Child Neurol 8:56, 1966
7. McKinney P, Katrana DJ: Prevention of injury to the great auricular nerve during
rhytidectomy. Plast Reconstr Surg 66:675, 1980
8. Skandalakis JE, Gray SW, Rowe JS Jr: Surgical anatomy of the submandibular triangle.
Am Surg 45:590, 1979
9. Skandalakis JE, Gray SW, Rowe JS Jr: The neck. In Anatomical Complications in
General Surgery. New York, McGraw-Hill, 1983, pp 3-17
10. Winsten J, Ward GE: The parotid gland: An anatomic study. Surgery 40:585, 1956
Address reprint requests to
Grant W. Carlson, MD
Winship Clinic
13658 Clifton Road
Atlanta, GA 30322