Salivary Glands

The salivary gland is exocrine gland in oral cavity,

secreting saliva, may be divided into major salivary
glands that include the parotid glands, submandibular
and sublingual and the minor salivary glands.

The minor salivary glands are many accessory glands

in the lip, buccal mucosa, tongue, palatal mucosa and
glossopalatine fold.

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 Function of Saliva in Oral Health
- Lubrication - Soft tissue repair

- Maintenance of mucous membrane integrity

- Debridement/lavage

- Antibacterial, antifungal, antiviral

- Maintenance of pH

- Maintenance of tooth integrity

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 Parotid gland:
Largest salivary gland
- 60 to 65% of total saliva.
- Pyramidal in shape.
- Superficial portion of
gland is located
subcutaneously, in front
of the external ear &
deeper portion lies behind
ramus of mandible.

Important structure that run through the

parotid gland:

1. Branch of facial nerve.

2. Terminal branch of external carotid artery that
divided into maxillary & superficial temporal
artery.
3. The retromandibular vein ( post. Facial ).
4. Intraparotid lymph node

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 THE PAROTID DUCT:

• Stensen’s duct is 5 cm long.

open opposite the
second upper molar
tooth

Submandibular Glands
• It’s paired of gland that lie below the mandible on
either side.
• Has 2 lobes, superficial & deep.

- 2 to 30% of total saliva.

- Located at Posterior portion of floor of mouth,

medial aspect of mandible & wrapping around
posterior border of mylohyoid.

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 • Warthon’s duct
drained submandibular gland that opens into anterior
floor of mouth.
Anatomical relationship:
1. Lingual nerve.
2. Hypoglossal nerve.
3. Anterior facial vein.
4. Facial artery.
5. Marginal mandibular branch of facial nerve.

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 Sublingual gland
- Smallest major salivary gland
- 2.5% of total saliva.

- Lie on the superior surface of the mylohyoid muscle

and are separated from the oral cavity by a thin layer
of mucosa.

The ducts of the sublingual glands are called

Bartholin’s ducts.

Diagnosis of salivary gland

Depend on

- History

- physical examination.

- Radiographic examination.

- Laboratory investigation.

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 Clinical Examination

The initial step, in examination of salivary glands is

face to face observation. Through this observation any

signs of facial asymmetry, Discoloration, visible

discharging sinuses can be observed.

Examination of Parotid Gland

- Parotid enlargement: Enlargement of parotid gland
usually appears as a diffuse swelling, which when
seen from the front. The enlargement is more easily
observed when it is unilaterally.

- Palpation: Using finger tips with firm pressure over

gland To feel any well defined nodule or diffuse
swelling within the gland.

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 Intraoral examination: Occasionally parotid tumors may grow,
in parapharyngeal direction to occupy lateral pharyngeal
space. In such cases the tumor may be represented as a mass
in retromolar fossa.

- Parotid Duct: Using a lacrimal probe passed through the

duct to detect any obstruction or stricture.

- Nature of the flow: The gland is milked using extraoral

pressure on the gland while observing the opening of duct.
Normally the gland excretes watery clear saliva. Diseased
gland excrete saliva containing purulent, debris or mucous.

Examination of Submandibular Gland

- Enlargement: Submandibular gland swelling may be diffuse
or nodular. Swelling appears extraoral in submandibular
region. Diffuse swelling of Submandibular gland simply adds
fullness to submandibular region.

- Palpation: Performed bimanually by placing, the finger of

one hand intraorally on the floor of mouth and the fingers of
other hand extraorally at submandibular region and the gland
is palpated between the two hands.

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 - Examination of submandibular duct: The orifice of
duct can be located, at floor of mouth near the
midline, by expressing saliva from gland. A thin
lacrimal probe is then inserted and advanced along
the duct to detect any obstruction or stricture.

- Nature of salivary flow: The gland can be milked by

firm pressure with one or two fingers placed just
medial to the angle of mandible and advanced
forward. Normally the saliva should be clear viscous.

Examination of Sublingual Gland

Enlargement of sublingual gland appears as an
elevation in floor of mouth. The gland palpated
bimanually with one finger exerts pressure at
submental region and the other is placed intraorally.

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 Examination of Minor Salivary Glands
- Enlargement of minor salivary glands appears as
discrete nodules within the substance of submucosa.
Palpation should be done bidigital when ever
possible. This can be performed for examining minor
glands in lips and cheek. Those of palate are
compressed against the bone of hard palate

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 a. Plain Radiography
Suitable to demonstrate the presence of salivary calculi.

- Calculi situated in Wharton's duct best demonstrated by

intraoral occlusal film.

- Calculi situated on submandibular gland can be

demonstrated by occlusal and/or extraoral films as lateral
oblique view.

- Calculi on parotid gland can be demonstrated by periapical

film held against the inside of cheek while those situated on
substance of parotid demonstrated by extraoral films.

b. Sialography Is a radiographic visualization of ductal

system of gland. It is applicable for the parotid and
submandibular glands. It is not applicable for sublingual
gland because of multiductal nature. This visualization of
ductal system is made possible by the use of radiographic
contrast solution introduced into the duct. Contrast
media is introduced into gland by soft rubber catheters.
Films then taken to visualize the ductal system of the
gland. There are wide varieties of contrast media which
can generally classified into water-soluble and fat-soluble.

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 Indications For Sialography

To detect
- Calculi or foreign bodies within the gland or its duct

- Ductal obstruction that is too small or poorly

calcified stones that can not be detect by plain
radiograph.

- Intraglandular neoplasms.

Useful in the following clinical situations

- Acute swelling of salivary glands, especially during eating.
This situation is suggestive for an obstructive lesion.

- Gradual progressive or chronic enlargement of gland.

Suggestive for chronic infection, benign or malignant
tumors . - Presence of a clinical palpable mass

- Recurrent sialoadenitis.

- Dryness of mouth, to identify the cause.

- Pain of unknown origin.

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 Surgical considerations

- To determine amount of damage, to gland.

- To indicate proper site for biopsy.

- To demonstrate an intrinsic or extrinsic mass and its

site in the gland.

- To determine the relation of an intrinsic parotid

mass to the facial nerve.

Therapeutic indication
- Dilatation of ductal system during procedure may aid
in drainage of ductal debris and removal of mucous
plugs.

- Iodinated contrast medium is thought to have

bacteriostatic properties may aid in sterilization of
ductal system.

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 Contraindications For Sialography
- Acute infection of gland, as the ductal epithelium is
disrupted and escape of media may occur

- Patients sensitive to contrast media.

- In malignancies when clinical diagnosis is satisfactory

Ideal Characteristics Of Sialographic Contrast Media

• Physiologic properties similar to those of saliva.

• Absence of local or systemic toxicity.

• Pharmacological inertness

• Low surface tension and low viscosity to allow filling of

fine structures of ductal system.

• Easy elimination but durable enough to allow time for

satisfactory radiography

• Residual contrast media that can be absorbed by

salivary gland and detoxified in liver and excreted by kidney

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 c. Computed Tomography (CT)
The method of choice for examination of masses in
and about salivary glands.
Role Of CT In Diagnosis Of Salivary Glands Disorders
- Determine the presence of a mass, its size, extent
and origin.
- Determine whether a mass is circumscribed or
invasive.
- Has limited role in examination of calculi and
obstructive lesions as well as inflammatory conditions
- Gives no information about the glandular secretory
function.

d. Magnetic Resonance Imaging

(MRI) Also used for diagnosis of salivary glands
disorders. It’s superior to CT in determining vascular
tumors involving salivary glands especially the parotid
gland.

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 e. Radioisotope Scans
Useful for evaluation of glandular parenchyma. The
technique involves intravenous injection of a
radioactive isotope (Technetium 99rn).

f. Ultrasonography
Ultrasound is useful in detecting space occupying
lesions as differentiation between cystic lesions and
solid mass lesions. A fluid filled space as cyst appears
echo free while solid structure appears filled with
multiple echoes and various shades of grays.
Sonography is not able to visualize deep lobe of
parotid as it lies medial to the ascending ramus of
mandible.

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 Biopsy of Salivary Glands
Incisional biopsy for major salivary glands, especially the parotid, is
rarely undertaken unless the lesion is superficial and malignancy is
suspected and can not be assured by other methods, Biopsy of
major salivary glands should be avoided when ever possible
because:

- The close relation of lesion to important structures, e.g. facial

nerve in case of parotid tumor.

- Possibility of creation of salivary fistula as repair of biopsy site is

usually difficult especially in the presence of malignancy.

- Possibility of seeding neoplastic cells outside the gland.

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 Minor salivary glands biopsy is undertaken for either
removal of pathological tissues or for microscopic
diagnosis of some diseases as Sjögren's syndrome is a
condition characterized by dryness of month due to
wasting of salivary glands that is associated with
rheumatoid arthritis and dryness of eyes.

The most common suggested procedure for biopsy of

minor salivary glands is the removal of minor glands in
lower lip.

Fine Needle Aspiration Biopsy (FNAB)

An acceptable practical and useful technique in diagnosis of
head and neck masses. The technique is simple and rapid and
need no expensive instruments. The procedure performed on
out patient’s basis using 10-20 ml syringe and 22-gauge
needle. Smears are prepared for rapid cytological diagnosis.
The main reasons for performing FNAB are to know:

- If the mass originating from salivary gland or other tissue.

- If the mass benign or malignant.

- Whether or not further investigations are necessary.

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 Aspiration biopsy results in accurate diagnosis in 90%
of mixed tumors which are the most common tumors
of salivary glands.

The major limitation of FNAB is the inability to

examine some aspirates due to lack of suitable cellular
materials and the need for an expert cytologist for
accurate interpretation.

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 Developmental Anomalies
Aplasia is congenital absence of salivary glands and
it’s rare.

Atresia is a congenital absence or occlusion of ducts

and it is also rare.

Aberrancy is abnormally placed salivary tissues.

Functional Disorders
1. Sialorrhea

Is excessive salivary flow, may result from:

- Conditions affecting the central nervous system: Includes

mental retardation, epilepsy, and other mental and
psychological disturbances.

- Local factors that stimulate salivary flow: The most common

cause is acute oral inflammation as herpetic stomatitis,
infection and aphthus ulcers. Other causes include teething
and ill-fitting dentures. Treatment by removal of cause.

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 2. Xerostomia
Dryness of mouth results from diminished salivary
secretion.

Xerostomia may be idiopathic or due to local and

systemic causes. Local causes include: mouth
breathing, salivary gland inflammation, irradiation and
aging changes. Systemic causes: include anemias,
emotional and anxiety status and fluid loss.

Signs And Symptoms Of Xerostomia

- Dryness of the mouth.

- Tongue redness with papillary atrophy and fissuring.

- Taste disturbances.

- Denture wearing difficulties.

- Increase carious index.

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 Treatment of cases of xerostomia is usually the
removal of underlying factors while treatment of
idiopathic cases is usually symptomatic.

Mouth wash containing citric acid, lemon essence and

glycerin in addition to good dental home care and
frequent dental treatment visits. This is important to
prevent dental and oral complications which may
develop.

Obstructive Disorders
1. Mucocela

Is a fluid or semi-fluid filled cavity that is surrounded

by compressed granulation tissues of epithelium. The
lesion is due to obstruction of salivary duct which
results in accumulation of salivary flow and dilatation
of duct wall. This type is referred to as a Retention
cyst and it may be considered as a true cyst as it is
lined by epithelium tissue.

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 Extravasation mucocele is not a true cyst, it is due to
rupture of the duct with escape of salivary flow into
the surrounding connective tissue. The resultant
mucous pool is lined by compressed granulation
tissue.

Treatment is by surgical excision

of lesion with the surrounding

salivary tissues.

2. Ranula
Is a mucocele occur on

anterior part of floor of mouth. Usually superficial and

unilateral with average size of 2-3 cm. On palpation
the lesion soft and fluctuant and has bluishviolet
color. Walls of the ranula are very thin and composed
of epithelium of compressed granulation tissue and it
contains viscous mucoperiosteum fluid. Treatment is
surgical marsupialization of lesion.

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 3. Sialolithiasis (Salivary stones)
Is the formation of calcific

within ductal system of

salivary glands. It is one

of the most common disorders of salivary glands.

Submandibular glands is the most common site for
salivary stones (80%) followed by parotid gland (19%)
while it is uncommon in sublingual or minor glands.

Signs and symptoms of salivary stones vary. However,

intraglandular stone generally cause less sever
symptoms than extraglandular intraductal stones.
Sialolithiasis presented clinically in three forms:
Symptom free, transient swelling and acute
suppurative inflammation. Diagnosis of salivary stone
usually done by palpation and radiographic
examination. Palpation along the course of duct will
confirm presence of hard stone.

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 Stensen’s duct stones: May occur in intraglandular part,
extraglandular part lateral to buccinator muscle, submucosal
part or impacted at the papilla. Usually can be seen on
radiographic examination and palpated except in
intraglandular part of duct.

Whartone's duct stones: Salivary stones are the most

common disorder of submandibular gland. The most common
location of stone is extraglandular part of duct. Stones in
Whartone's duct may reach large size and yet remain painless
and symptom free.

Treatment Is essentially surgical by removing calculi.

Surgery is not allowed during inflammatory phase.
Antibiotics, analgesics and antipyretics are given until
subsidence of acute phase before surgery.

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 4. Ductal Stricture
Results from resolution of ulceration of ductal lining
which occur due to presence of salivary stone.
Horizontal incision of duct during surgical removal of
stone may result in stricture while longitudinal
incision does not. Stricture near the papilla treated by
papillotomy while those situated more posterior
treated by sialodochoplasty. Stricture close to the
gland requires removal of entire gland.

Treatment

- Dilatation: Stricture of parotid duct managed by

dilatation using probes that pass one after another
through the duct. The procedure may need to be
repeated 2-3 times at two weeks interval.

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 - Papillotomy:
When the stricture is close to the papilla, the portion
of duct anterior to the stricture is laid opened using
fine scissor after insertion of fine probe to serve as a
guide for the duct. Starting from papilla the cut is
carried posteriorly until the dilated area proximal to
stricture is reached. The duct lining then sutured to
the mucosa of floor of mouth using 5-0 chromic
suture.

- Sialodochoplasty:
Means implantation of submandibular duct into floor
of mouth. The duct must be divided and implanted
into a new position. It is used when papillotomy is not
successful and the opening is closed after short time.

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 Inflammatory Disorders
1. Acute Sialoadenitis

Occurs more common on parotid gland than in

submandibular gland. Non specific forms of
sialoadenitis occur due to mixed infection that ascend
to gland via the duct, while specific forms, (e.g.
Mumps) are mostly blood borne. Generally the
condition is a disease of elderly, dehydrated,
malnourished patient.

Signs And Symptoms Of Acute Sialoadenitis

- Painful swelling of gland accompanied with decrease
function.

- Skin over the gland is reddened and tender.

- Purulent discharge may be milked from duct.

- Low grade fever, malaise and headache.

- Leucocytosis (increase in WBCs) is shown in blood

picture.

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 Treatment Modalities Of Acute Sialoadenitis
- Complete bed rest.

- Fluids and high caloric diet.

- Antibiotics and analgesics.

- After subsidence of acute stage duct may be dilated

to facilitate drainage.

- Salivary washing action using sialogauge (drug

promotes secretion of saliva).

2. Chronic Sialoadenitis
Is similar to that of acute form but symptoms are less
severe. There is no erythema and tenderness of skin
overlying the gland. In submandibular gland the
condition is almost a complication of ductal
obstruction which causes ductal dilatation and
salivary stasis.

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 Treatment Of Chronic Sialoadenitis
- Removal of ductal obstruction if present.

- Ductal dilatation to ensure adequate drainage of

gland.

- Antibiotics, analgesics.

- Recurrence is quite common and sometimes it is

necessary to remove the whole gland.

3. Chronic Recurrent Parotitis

Occurs mostly in children at age of 3-6 years. It is
characterized by its unilateral occurrence and
spontaneous healing.

Sialograms show normal ductal structure.

Treatment is symptomatic.

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 The condition must be differentiated from mumps by
the following criteria:

- The condition occurs unilaterally while mumps is

always bilaterally.

- Purulent material could be expressed from the gland

in chronic recurrent parotitis.

- In mumps virus can be detected in saliva by

complement fixation test.

4. Mumps
Is a non-suppurative, acute sialoadenitis of viral
origin. It is highly infectious disease presented
clinically as a painful enlargement of one or more of
salivary glands. Usually affects children 6-8 years of
age. The most common affected salivary gland is
parotid and in 10% of cases submandibular gland
affected.

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 The virus may affect other organs as pancreas, testis
and ovaries. Mumps usually resolves spontaneously
within 5-10 days. Accordingly, treatment includes
symptomatic relief of pain and fever and prevention
of dehydration. Persistent of recurrent cases are
indicative for development of chronic bacterial
sialoadenitis secondary to viral mumps.

Signs And Symptoms Of Mumps

- Fever, headache and painful swelling of one or more
of salivary glands, most commonly the parotid.

- Incubation period is 2-3 weeks.

- A swelling of sudden onset starts in gland and

reaches it maximum in 3-7 days.

- The swelling then diminished over 3-7 days

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 Laboratory Investigations
- Complete blood count reveals presence of
leukopenia (decrease in WBCs).

- Mumps viral antibodies can be detected in saliva by

complement fixation test.

- Sometimes there may be increase in amylase level.

Complications Of Mumps
- Pancreatitis should be expected if patient complains
of abdominal pain or tenderness during course of
disease.

- Orchitis occur in 20% of male patients. Testis become

swollen and tender. Testicular atrophy occur in 50% of
cases.

- Mumps meningitis, inflammation of brain and its

covering membranes.

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 5. Post Irradiation Sialoadenitis
Patient receiving radiation for malignancies in head
and neck usually develop acute inflammatory reaction
within salivary glands. There may be xerostornia, and
swelling of parotid and submandibular gland which
increase for 12-24 hours then rapidly subside without
treatment. Over the period of irradiation therapy
degenerative changes occur may lead to atrophy of'
gland.

6. Post Surgical Parotitis

Develops 4-6 days after surgery and the symptoms are
very similar to those of acute sialoadenitis.
Predisposing factor is diminished salivary flow after
surgery probably due to dehydration and fever and
trauma to gland by prolonged pressure from
anesthetic mask. Treatment includes fluid intake,
stimulation of salivary flow, antibiotics and analgesics.

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 7. Salivary Gland Inclusion Disease
“Cytomegalic Inclusion Disease” results from infection
by cytomegalovirus. Majority of cases occur in infants
below 2 years of age. The disease may be acquired in
utero or at any time postnatally. Organs mostly
affected are salivary glands, kidneys, pancreas, liver,
lungs and thyroid gland.

8. Necrotizing Sialometaplasia

Affects mostly the minor salivary glands of hard

palate. Occurs more commonly in men. Clinically the
lesion may be mistaken for mucoepidermoid
carcinoma or squamous cell carcinoma. Appears
clinically as ulceration on mucous membrane 1-3 cm.
Swelling and feeling of fullness, pain is not a common.

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 The most likely etiology is local ischemia of minor
salivary gland that results in squamous metaplsia of
ductal epithelium. The cause of this local ischemia is
unknown. Alcohol, tobacco, drugs, diabetes and
wearing ill fitted dentures are the predisposing
factors. The condition is self-limiting and heals by
secondary intention over 6-8 weeks. Lesion
debridement and use of saline mouth wash aid in
healing process.

Neoplastic Disorders

A. Benign Neoplasms
(i) Pleomorphic adenoma

(ii) Monomorphic adenoma

(iii) Adenolymphoma

(iv) Oxyphilic adenoma

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 1. Benign Pleomorphic Adenoma (Benign Mixed
Tumor) Is the most common neoplasm of all salivary
glands tumors. Comprises 90% of benign tumors and
50% of all tumors affecting salivary glands.

- Clinical Features Of Pleomorphic Adenoma.

- Parotid gland the common site.

- Submandibular gland the least affected

- Palatal glands the most common among the minor

salivary glands.

Clinical Features Of Pleomorphic Adenoma.

- Parotid gland the common site.

- Submandibular gland the least affected

- Palatal glands the most common among the minor

salivary glands.

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 Nature of growth

- Starts as a small painless nodule increases slowly in

size. It is not fixed to underlying structure of overlying
skin

- May reach very huge size.

- Ulceration never occurs.

- Tumor has a pesudocapsule.

Treatment and prognosis

The tumor is radioresistant and the only treatment is

surgical removal. Surgical removal of the whole gland
necessary in cases of submandibular and sublingual
glands. For parotid tumors surgical excision ranges
from removal of the entire involved lobe to careful
local excision. This is due to presence of important
vital structures that pass through the substance of
parotid.

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 These are facial nerve, external carotid artery and
retromandibular vein. Minor salivary glands lesions
treated by removal of tumor mass with margin of
surrounding normal tissues. Prognosis is very good
and recurrence is not more than 1%.

B. Malignant Neoplasms

(i) Mucoepidermoid tumor (high-grade)

(ii) Carcinoma in pleomorphic adenoma

(iv) Adenoid cyctic carcinoma

(v) Acinic cell tumor

(vi) Squamous cell carcinoma

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 Mucoepidermoid Carcinoma: The most common
malignant tumor of major salivary glands. Parotid is
the commonly affected while palatal glands are the
commonly affected of minor salivary glands. Usually
occurs between 4th and 6th decade of life and has no
sex predilection.

Clinically and histologically of mucoepidermoid

carcinoma has two types:

- Low-grade tumor: appears as soft, slowly growing

painless mass, small in size (5 cm). The mass may be
Cystic and containing mucoid material. Histologically
composed of mucous and epidermoid cells arranged
in duct like pattern.

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 - High-grade tumor: appears as a firm less cystic
rapidly growing mass. Pain is an early symptom.
Histologically composed of epidermoid and
intermediate cells. Cysts and ductal elements are
absent. Both forms are

not encapsulated. Treatment is

surgical excision.

Recurrence is common.

Allied Conditions
Sjögren's Syndrome

Disease consists of chronic inflammation of lacrimal

and salivary glands, keratoconjunctiyitis sicca,
xerostomia and rheumatoid arthritis which occurs in
50-60% of cases. Often affects females over 50 years.
When it is not associated with rheumatoid arthritis it
is called "Sicca syndrome".

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 In some cases there is enlargement of salivary glands
usually the parotid bilaterally. The disease is
suggested to have an autoimmune nature. A genetic
predisposition has also been suggested.
Microscopically there is focal lymphatic sialoadenitis
of major and minor salivary glands. Accordingly, minor
glands biopsy is diagnostic.

Patients suffering form this condition has a strong

tendency for development of extrasalivary lymphatic
abnormalities, e.g. malignant lymphomas. Treatment
is a challenge and is usually symptomatic. Clinical
evidences suggests improvement after removal the
affected salivary glands.

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