You are on page 1of 47

Salivary Glands

Dr. Y. Snigdha
Anatomy
Salivary glands are divided into two groups as major
(90%) and minor glands (10%).
There are three pairs of major salivary glands:
- Parotid (serous)
- Submandibular (mixed)
- Sublingual (mucous)
450 Minor glands (mucous) distributed in the lips,
cheeks, palate, floor of mouth, oropharynx, larynx,
trachea and paranasal sinuses.
Total saliva secreted is 1500ml/day. It lubricates the
oral cavity and keeps it moist.

Parotid Gland
Largest salivary gland. It is a serous type of gland.
Situated in the retromandibular fossa anterior and inferior
to acoustic meatus.
It is enclosed by a capsule formed from deep cervical
fascia Parotid fascia.
It has a superficial part over the posterior part of ramus
of mandible and deep part behind the mandible and medial
pterygoid muscle.
Prolongates above the parotid duct (stensons duct) to form
the accessory parotid.
The parotid duct opens into the oral mucosa opposite to the
crown of upper second molar tooth.
There are three nerves in relationship to Parotid gland:
- Facial nerve along with 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
Facial nerve emerges through stylomastoid foramen.
The nerve enters the substance of parotid gland and
divides into two main branchesupper temporofacial and
lower cervicofacial divisions.
The upper division further divides into zygomatic
(orbicularis oculi), temporal (frontalis) and buccal
(orbicularis oris and buccinator) branches while the
lower division divides into mandibular (lower lip muscles)
and cervical (platysma) branches.

Submandibular Gland
Located deep in the digastric
triangle
Has superficial and deep parts
Superficial part is located in
the submandibular space within
the digastric triangle overlying
mylohyoid and hyoglossus
muscles.
Deep part is deep to mylohyoid
muscle.
The two parts join round the
posterior free edge of
mylohyoid muscle
Nerves related to submandibular gland are:
- Mandibular nerve
- Sublingual nerve
- Hypoglossal nerve
The facial artery enters the posterior aspect of
the deep surface of the gland and grooves it.
The Whartons duct runs from the deep lobe
and opens on the floor of the mouth lateral to
the frenulum of the tongue.

Diseases of Salivary glands
Mucous retention cyst
Develops from an
obstructed minor salivary
gland.
Painless, translucent
swelling in oral mucosa
mostly in the lower lip or
cheek.
Larger cysts need surgical
intervention. Smaller ones
resolve spontaneously.
Ranula
Mucous extravasation cyst originating in sublingual salivary
gland.
Translucent cystic swelling with a bluish tinge situated on
floor of mouth on one side of fraenum linguae -
characteristically described as frogs belly appearance.
Plunging ranula when the extravasation involves bothe
submandibular and sublingual gland, it extends into the
neck and becomes bimanually palpable.
Similar to sublingual dermoid. Though dermoid contains
sebaceous content and is non transilluminant.
Treatment is excision of the cyst along with the involved
gland/glands. Simple excision leads to recurrence.
Approach is usually trans oral unless its a plunging ranula
where the approach is cervical.
Sialography
Sialography is the radiographic examination of
the salivary glands.
It usually involves the injection of a small amount
of contrast dye (lipiodol or sodium diatrizoate) into the
salivary duct of a single gland, followed by routine X-
ray projections
Indications:
- Salivary fistulas
- Sialectasis (abnormal dilation of the ducts)
- Congenital conditions
- Extra glandular masses
- Parotid duct stones
Salivary Calculus
Submandibular Gland:
- 80% common
- 80% radiopaque
- Seen in xray
- Sialogram isnt needed.
Parotid gland
- 20% incidence
- Radioluscent
- Not seen in plain xray
- Identified by sialogram
Calculi are more common in submandibular gland because:
- Viscous nature and mucin content
- Calcium content
- Non dependant drainage
- Stasis
- Hooking of the submandibular duct by the nerve.
Sialadenitis
Causes:
- Bacterial Most common, due
to obstruction and stasis
- Trauma over duct causing
oedema and stasis
- Viral Mumps
Symptoms:
- Partial obstruction: Mildly
painful submandibular swelling.
- Complete obstruction: painful
swelling appears during meals
and disappears after 1-2
hours. Duct opening may
exude pus.

Types:
- Acute: Bacterial due to
obstruction/stasis. Can
lead to abcess. Viral
Mumps
- Chronic: Common after
partial obstruction of
submandibular gland duct
or hilum proximal to the
level of crossing of the
lingual nerve over the
duct.
Differential diagnosis
Submandibular Sialadenitis
Submandibular tumour
Submandibular lymphadenopathy
Plunging ranula
Cystic hygroma
Treatment
The stone lying in the duct can be removed by incising the duct over stone
in floor of mouth. After stone removal, the opening in the duct should be
left unsutured for free drainage of saliva.
If stone is palpable in proximal duct, it should not be removed through
intraoral route since there is risk of damage to lingual nerve that hooks the
duct in this region. In such cases or in cases having stone in the gland,
treatment is submandibular gland excision.
Complications
- Bleeding and hematoma formation.
- Infection.
- Injury to marginal mandibular nerve (drooping of angle of mouth).
- Injury to lingual nerve (anaesthesia of anterior 2/3rd of tongue).
- Injury to hypoglossal nerve (unilateral tongue paralysis).
Acute parotitis
Acute painful swelling of parotid gland
due to inflammation.
Causes:
- Viral: Mumps most common in
children of 4-6 years. Symptoms are
fever with malaise and headache
followed by painful swelling of one or
both parotids. Treatment is fluids and
antibiotics.
- Obstructive causes :
- 1) Papillary obstruction due to
trauma due to ill fitting denture.
Presents with painful swelling during
meal times. Teatment is papillotomy
allowing free drainage of saliva.
- 2) Parotid calculi

Granulomatous Sialadenitis
Tuberculosis: The organism usually gains access to the
salivary glands by a lesion in oral cavity, teeth or tonsil
and presents as a painless mass in the gland. FNAC is
the investigation of choice and ATT helps in curing the
ailment.
Actinomycosis: Extension into the salivary glands occurs
from adjacent sites causing firm, indurated mass. It
leads to fistula formation producing yellow sulphur
granules. Treatment is with extended course of
penicillin.
Sarcoidosis
Sarcoidosis: It mostly affects
the parotid gland producing
localized tumor like swelling
(sarcoid pseudotumor).

Heerfordt syndrome
(uveoparotid fever) is a form of
sarcoidosis characterized by
fever, parotid swelling, uveitis
and facial palsy. The diagnosis is
confirmed by biopsy revealing
noncaseating granulomas.
Treatment is with steroids.
Cat Scratch Disease
It usually affects children and
caused by Bartonella henselae.
A pustule forms at the site of
infection following a scratch by a
cat.
It is followed by cervical
lymphadenopathy and parotid
gland enlargement. It is a self-
limiting condition and resolves
without treatment.
Salivary gland tumours
Etiology
Exact etiology is unknown.
Risk factors include:
- Low dose ionizing radiation to head and neck (in dental
X-rays). High dose radiotherapy has no role.
- EB virus.
- Occupational hazard: Exposure to hard wood dust,
nitrosamines (rubber industry).
- Tobacco: Warthins tumor is strongly associated with
smoking.
Histological classification
A. Epithelial Tumours
Adenoma:
- Pleomorphic adenoma
- Warthins Tumour
Carcinoma
- Low grade: Acinic cell
carcinoma, Adenoid cystic
carcinoma, Low grade
mucoepidermoid carcinoma
- High grade: Squamous cell
carcinoma, Adenocarcinoma,
Carcinoma in pleomorphic,
Adenoma, High grade
mucoepidermoid carcinoma
B. Non-Epithelial Tumours
Angioma
Lipoma
Neurofibroma
Lymphoma
Sarcoma
Metastatic tumors
Parotid Gland Tumours
Pleomorphic Adenoma
It is a mixed parotid tumour.
Pathologically it has the following features:
- 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 tumour cells project through the
pseudocapsule into adjoining part of the parotid gland).
Due to presence of pseudopodia, simple enucleation of tumour will
leave behind residual tumour leading to recurrence. Hence,
superficial parotidectomy is the recommended treatment even for
a benign tumour.
Clinical features
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.
Pleomorphic Adenoma
The signs of malignant change
(Fig. 15.11) are:
- Sudden increase in tumor size.
- Facial nerve palsy.
- Tumor consistency becomes hard.
- Tumor becomes fixed to underlying
structures and invades overlying
skin.
- Cervical lymph node enlargement.
- Limited jaw movements due to
mandibular invasion.

Warthins Tumour
It is also called as adenolymphoma.
Not a true lymphoma but this name is given due to
presence of lymphoid tissue in the tumor.
Consists of cystic spaces lined by double layered
epithelium.
Usually affects middle aged or elderly males.
Presents as a slow growing soft swelling at lower pole of
parotid gland
Other parotid tumours
Acinic cell tumour: low grade tumor and is composed of serous acini. It is
soft and cystic. Rarely it may metastasize.
Mucoepidermoid Tumor: Composed of sheets and masses of epidermoid
cells and cystic spaces lined by mucus secreting cells. Low grade tumor has
more cystic spaces and fewer cells, slow growing with rapid metastasis to
lymph node while high grade tumor has more cells, less cystic spaces,
metastasizes to lungs. It is most common salivary neoplasm in children.
Clinically, patients present with a hard mass in the gland.
Adenoid Cystic Carcinoma: It is most common malignant salivary tumor. It
consists of myoepithelial and duct cells, which are arranged in sheets and
cords and give cribriform or lace like appearance. Its characteristic
feature is perineural invasion and bone invasion. Thus, tumor is always
more extensive than seen clinically or on radiograph. Clinically, it presents
as a hard fixed mass. Later, patient may complain of pain, anesthesia of
overlying skin and muscle paralysis due to involvement of related nerves.
Submandibular Gland Tumours
They are uncommon and usually present as a painless
slow growing swelling in submandibular triangle.
In 50% cases, they are benign in nature.
The submandibular gland tumor is bimanually palpable.
This clinical sign helps in differentiating it from
submandibular lymphadenopathy which is not palpable
bimanually.
Treatment is submandibular gland excision with a cuff
of normal tissue.
Minor Salivary gland tumours
They arise from mucous glands of upperdigestive tract
and majority are malignant.
Commonest site is on hard palate followed by lip and
retromolar region.
Commonest type is adenoid cystic carcinoma.
It usually presents as a firm mass which later undergoes
necrosis and ulceration. It may invade adjoining soft
tissues, bone and nerve.
Treatment is wide excision with plastic reconstruction
Investigations
Radiological Investigations
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.
Cytopathology
Preoperative tissue diagnosis is not required in discreet parotid swelling.
FNAC is done when there is high clinical suspicion of malignancy.
Surgery is modified if report is lymphoma. In suchcase, only incision biopsy
is done instead of tumor excision so as to grade the tumor.
If report is Warthins tumor in an old patient, the treatment is
conservative (no surgery).
FNAC is also useful in recurrent and inoperable tumors for planning
radiotherapy as initial treatment.
Open biopsy is not done routinely due to risk of injury to facial nerve and
spreading of tumor cells.
Biopsy is indicated in following conditions:
- Repeated FNAC inconclusive in a hard fixed mass.
- In case of lymphoma for tumor grading.
Treatment
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.
- Radical parotidectomy may include removal of whole parotid gland
with facial nerve, adjoining muscles (masseter, pterygoids) and
mandible.
- 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
Superficial Parotidectomy
Treatment for pleomorphic adenoma
Superficial lobe along with tumor is removed
Facial nerve branches are identified and
preserved
Avoids tumor spillage and removes pseudopodia
Simple enucleation will leave behind residual
tumor leading to recurrence
Complications: Flap necrosis, Fluid collection
(haematoma, infection), Facial Nerve palsy,
Fistula (salivary), Freys syndrome, sensory loss
to lower pinna.
Facial Nerve Mgt.
Preoperative functional status of facial nerve should be assessed by physical
examination and look for any partial or total facial nerve palsy.
In case of absence of clinical nerve involvement and presence of surgical
plane between tumor and the nerve during operation, the facial nerve should
be preserved.
In case of preoperative facial palsy and operative findings of nerve invasion
by the tumor, the involved area of nerve should be resected.
After nerve resection, immediate reconstruction by sural or greater auricular
nerve should be done and its success rate is 75%.
Rehabilitation procedures should be performed simultaneously in form of:
- Gold weight upper eyelid implants.
- Lower lid tightening.
- Static facial slings.
Mgt. Of Neck Nodes:
Neck dissection should be done in node positive cases
only.
Modified radial neck dissection is the preferred
technique.
In high grade tumors with clinically negative neck nodes,
frozen section of suspicious nodes should be done.
There is no benefit of elective node dissection in
clinically negative neck.
Radiotherapy
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
Freys Syndrome
Also known as gustatory sweating.
Occurs from damage to salivary innervation during dissection.
There is inappropriate regeneration of parasympathetic fibres
leading to stimulation of sweat glands of overlying skin. As a result,
sweating and skin flush occurs during salivary stimulation.
Freys syndrome can be prevented by inserting temporalis fascial
flap between skin and parotid bed during parotidectomy.
Treatment is with
- Topical anticholenergic agent (1% Glycopyrrolate).
- Botulinum toxin injection into affected skin.
- Denervation by division of lesser superficial petrosal nerve.
Sjgrens Syndrome
It is an autoimmune syndrome causing progressive destruction of
salivary and lacrimal glands.
Primary Sjgrens syndrome is characterized by presence of dry
eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). If
associated with some other disorder, its called secondary Sjgrens
syndrome.
Females are affected ten times more than males.
There is painful enlargement of salivary glands.
Sialography shows punctate sialectasis.
Biopsy of minor salivary glands show focal lymphocytic infiltration.
Treatment is symptomatic in form of artificial tears for dry eyes
and oral hydration along with salivary substitutes for dry mouth.
There is increased risk of developing lymphoma especially in
primary Sjgrens syndrome.