SALIVARY SLANDS

CLASSIFICATION

Salivary glands are divided into two groups as major and minor glands. There are three pairs of major salivary
glands

• Parotid
• Submandibular
• Sublingual
• Hundreds of minor salivary glands lie in submucosa of upper aerodigestive tract like lips, cheek, floor of
mouth, oropharynx, trachea, larynx and palate

Histologically, salivary glands are:

• Serous: Parotid glands

• Mucus: Sublingual and minor glands
• Mixed: Submandibular gland

SURGICAL ANATOMY Parotid Gland (5)

• It is located in the retromandibular fossa in an area anterior and inferior to external auditory canal (Fig.
15.1).
• The duct of the gland (Stensen’s duct) opens in the mucosa of cheek opposite to upper second molar
tooth
• There are three important nerves in relation to parotid gland Facial nerve Greater auricular nerve
Auriculotemporal nerve
• The extracranial part of facial nerve divides the gland into superficial (80%) and deep (20%) parts.
• Facial nerve alongwith retromandibular vein makes a plane named ‘faciovenous plane of Patey’ in the
substance of parotid gland.
• Greater auricular nerve enters tail of parotid gland and it is sensory to tragus area and ear lobe.
• Auriculotemporal nerve is branch of mandibular division of 5th cranial nerve. It contains parasympathetic
fibers sent to parotid by otic ganglion.
 • Facial nerve emerges through stylomastoid foramen. The anatomical landmark for its location is the
point where tip of mastoid, cartilaginous auditory canal and posterior belly of digastric muscle meet. The
nerve enters the substance of parotid gland and divides into two main branches—upper temporofacial
and lower cervicofacial divisions. The upper division further divides into zygomatic, temporal and buccal
branches while the lower division divides into mandibular and cervical branches

Pleomorphic Adenoma
It is also known as mixed parotid tumor.
The characteristic pathological features (Fig. 15.8) are:
• Epithelial and myoepithelial cells proliferate in sheets and strands.
• Pseudocapsule (formed by compressed parotid tissue around the tumor).
• Pseudocartilage (mucoid material separating epithelial cells give appearance of cartilage).
• Pseudopodia (strands of tumor cells project through the pseudocapsule into adjoining part of the parotid
gland). Due to presence of pseudopodia, simple enucleation of tumor will leave behind residual tumor
leading to recurrence. Hence, superficial parotidectomy is the recommended treatment even for a benign
tumor.
Clinical Features
• Most tumors are located in superficial lobe.
• Clinically, it presents as a painless slow growing mass that is rubbery and nodular in consistency.
• The mass classically raises the ear lobule and obliterates the retromandibular groove
• Even in big tumor, the mass is not adherent to overlying skin or underlying masseter muscle and there is
no facial palsy.
• Deep lobe tumors present with fullness in retromandibular area along with soft palate swelling.
• Long standing pleomorphic adenoma may convert to carcinoma in 5% cases. • The signs of malignant
change are:
i. Sudden increase in tumor size.
ii. Facial nerve palsy
iii. Tumor consistency becomes hard
iv. Tumor becomes fixed to underlying structures and invades overlying skin.
v. Cervical lymph node enlargement
vi. Limited jaw movements due to mandibular invasion.
Warthin’s Tumor

• It is a benign tumor occurring next to pleomorphic adenoma.

• It forms 10% of parotid tumors. It is also called as adenolymphoma.
• It is not a true lymphoma but this name is given due to presence of lymphoid tissue in the tumor.
• It consists of cystic spaces lined by double layered epithelium.
• It usually affects middle aged or elderly males.
• It presents as a slow growing soft swelling at lower pole of parotid gland

Investigations for Salivary Gland Tumors

Radiological Evaluation

• Diagnostic imaging is not required routinely.

• Plain X-ray, USG and sialography have no definite role in salivary tumors.
• CT scan and MRI are good for evaluation of malignant masses that are deep seated and fixed.
• CT scan and MRI help in defining location and extent of tumor, evaluation of neck nodes.
• Bone destruction is best seen on CT scan.
• MRI is useful in detecting perineural invasion, intracranial extension of tumor and detecting deep lobe
parotid tumors.
• PET scan is superior to CT and MRI in detecting local recurrence and distinguishing it from past
treatment fibrosis.

Cytopathological Diagnosis

• Preoperative tissue diagnosis is not required in discreet parotid swelling.

• FNAC is done when there is high clinical suspicion of malignancy.
• Open biopsy is not done routinely due to risk of injury to facial nerve and spreading of tumor cells.

Treatment of Salivary Gland Tumors

• Benign and slow growing neoplasm confined to superficial lobe of parotid gland is treated with
superficial parotidectomy with facial nerve conservation. In deep lobe tumors, first superficial
parotidectomy with identification of facial nerve is completed. Then with blunt dissection, deep lobe
tumor is removed from in-between nerve branches.
 • Malignant and high grade parotid tumors require superficial/total/radical parotidectomy with or
without sacrifice of facial nerve depending on tumor extent.
i. Radical parotidectomy may include removal of whole parotid gland with facial nerve, adjoining
muscles (masseter, pterygoids) and mandible.
ii. Most important aim of surgery in malignant tumor is “To achieve clear margins of resection”.
Clearance of surgical margins can be confirmed by intraoperative frozen section of the excised
specimen
iii. If biopsy of resected specimen even in radical parotidectomy shows positive margins for
tumor, there is high-risk of recurrence and decreased survival (
iv. On the other hand, if surgical margins are negative even in superficial parotidectomy, it is
adequate.
v. Thus more surgery does not improve survival.

Superficial Parotidectomy (Box 15.7) Important steps of surgery are:

• ‘Lazy S’ incision is given which extends from preauricular to mastoid and then in cervical region.
• Skin flaps are raised to expose parotid gland anteriorly and sternomastoid and posterior belly of
digastric muscle posteriorly.
• An avascular plane is developed in preauricular area anterior to mastoid tip requiring division of
greater auricular nerve.
• By further dissection, facial nerve trunk is identified with the help of various anatomical landmarks
• Bipolar cautery is used for hemostasis to prevent facial nerve damage.
• After identification of facial nerve trunk, its branches are dissected towards periphery by dissecting in
perineural plane
• Facial nerve can be traced retrograde as well by identifying one of its branches at periphery.
• The superficial lobe along with tumor is removed in toto.
• The wound is closed over a negative suction drain.

Role of Radiotherapy

• It is always indicated in high grade malignant tumors for improving local control.
• Area of radiotherapy includes preoperative extent with 2 cm margin.
• In adenoid cystic carcinoma, radiotherapy is also given to named nerve roots up to the base of skull.
• In inoperable tumors, radiotherapy is given for palliation.
• In case of recurrent malignant tumors, if resection is not possible, then high dose radiotherapy is given
as: External beam RT, Neutron RT or Brachytherapy

RT in Pleomorphic Adenoma: Indications

• Deep lobe tumors • Recurrence after surgery • Microscopically positive margins • Significant tumor spillage
 General features of malignant salivary tumors

• Fixation.
• Resorption of adjacent bone.
• Pain and anesthesia 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).

MANAGEMENT OF MALIGNANT SALIVARY TUMORS

Specific investigations

• FNAC.
• CT scan to see the deep lobe of the parotid; to look for the involvement of bone, extension into the
base of the skull; relation of tumor to internal carotid artery, styloid process
• OPG.
• Blood grouping and cross matching; required quantity of blood is keep ready.
• FNAC of lymph node.
• MRI shows better soft tissue definition than CT scan. Sialogram is not useful in assessment of tumor

Treatment

In parotid. Surgery: Radical parotidectomy is done which includes removal of both lobes of parotid, soft
tissues, part of the mandible with facial nerve. Facial nerve is reconstructed using greater auricular nerve, or
sural nerve. Often lateral tarsorrhaphy or temporal sling reconstruction is done.

Complications of surgery

• Hemorrhage.
• Infection.
• Fistula.
• Frey’s syndrome.
• Facial nerve palsy.
 Postoperative radiotherapy is quiet useful to reduce the chances of relapse. Usually external radiotherapy
is given.
 It is given in all carcinomas, but more useful in adenoid cystic and squamous cell carcinomas.
 Chemotherapy is also given. Drugs given here depend on tumor type.
 Intra-arterial chemotherapy is beneficial.
 Preoperative radiotherapy is given in large tumors to reduce the size and make it better operable, i.e. to
down stage the disease.
 If lymph nodes are involved, which is confirmed by FNAC, radical neck dissection is done.
 In submandibular salivary gland: Wide excision is done, with removal of mandible, and soft tissues around.
If lymph nodes are involved, then block dissection of the neck is done.

SJÖGREN’S SYNDROME

It is an autoimmune disease causing progressive destruction of salivary and lacrimal glands, leading to
keratoconjunctivitis sicca (dry eyes), and xerophthalmia (dry mouth).

Types 1. Primary. 2. Secondary.

Secondary Sjögren’s Syndrome

• Dry mouth.
• Dry eyes.
• With association of connective tissue disorders like.
i. Primary biliary cirrhosis (near 100%).
ii. SLE (30%).
iii. Rheumatoid arthritis (RA) (15%).

Primary Sjögren’s Syndrome

• Severe dry mouth.

• Severe dry eyes.
• Widespread dysfunction of exocrine glands.
• Incidence of developing lymphomas is high.
• There is no association of connective tissue disorders.

Clinical Features

• It is common in middle-aged females who present with dry eyes, dry mouth, enlarged parotids and
enlarged lacrimal glands.
• Often they are tender.
• Super added infection of the mouth, with Candida albicans is common

Investigations

• Autoantibody estimation—Rheumatoid factor, antinuclear factor, salivary duct antibody.

• Sialography.
• Estimation of salivary flow.
• Slit-lamp test of eyes
• Schirmer test—to detect lack of lacrimal secretion.
• FNAC of parotids and lacrimal glands. • 99Technetium pertechnetate scan for gland function.

Treatment is Conservative
• Artificial tears.
• Artificial saliva.
• Frequent drinking of water.
• Treat the cause.

SIALOLITHIASIS

taken care off. Mylohyoid is retracted so as to remove the deep portion of the gland. Drain is placed aft

taken care off.

Mylohyoid is retracted so as to remove the deep portion of th

Drain is placed after removal of the gland

Calculi are common in submandibular salivary gland • Viscous nature and mucin content. • Calcium
content. • Nondependent drainage. • Stasis.

PAROTID ABSCESS (ACUTE SUPPURATIVE SIALADENITIS OF PAROTID)

 It is a result of an acute bacterial sialadenitis of parotid gland.

  It is an ascending bacterial parotitis, due to reduced salivary flow and poor oral hygiene.
 Causative organism are Staphylococcus aureus, Streptococcus viridans, and often other
gramnegative and anaerobic organisms.

Causes of Acute parotitis (Differential diagnosis of suppurative parotitis) • Viral—Mumps. • Bacterial—

Staphylococcus aureus. • Allergic. • HIV infection. • Radiotherapy. • Specific infections like syphilis.

Clinical Features

• Pyrexia, malaise, pain and trismus.

• Red, tender, warm, well-localized, firm swelling is seen in the parotid region.
• Tender lymph nodes are palpable in neck.
• Features of bacteremia are present in severe cases.
• Pus or cloudy turbid saliva may be expressed from the parotid duct opening.

Investigations

• Ultrasound of parotid region

• Pus collected from duct orifice is sent for culture and sensitivity
• Needle aspiration from the abscess to confirm the formation of pus.
• NOTE- Sialogram is contraindicated in acute phase, as it causes retrograde infection leading into
bacteremia.

Treatment

• Antibiotics are started depending on culture report.

• When it is severely tender, localized, incision and drainage has to be done under G\A.
• Skin is incised in front of the tragus vertically and then parotid sheath is (pyogenic membrane) opened
horizontally.
• Pus is drained using sinus forceps and sent for C/S.
• Antibiotics continued (Blair’s incision)

Complications of suppurative parotitis and abscess:

• Septicemia.
• Severe trismus.
• Rupture into the external auditary canal.