Salivary Glands:

Anatomy and Clinical

Examination
By:
Dr. Aishwarya K
1st year Postgraduate
Department of General Surgery
 CLASSIFICATION OF SALIVARY GLANDS
According to size:
-Major salivary glands: Parotid
Submandibular
Sublingual

-Minor salivary glands: Carmalt’s glands- Molar/Retromolar

Glands of Von Ebner-Posterior Lingual
Glands of Blandin&Nuhn- Anterior Lingual
Weber’s Gland- Tonsillar
Buccal glands
Labial glands
Palatine glands
Oropharynx, Hypopharynx, Larynx
According to nature of secretion:

-Pure serous : Parotid & Posterior lingual glands

-Pure mucous : Sublingual & Anterior lingual glands

Labial, Buccal & Palatine glands

-Mixed : Submandibular & Anterior tongue

According to ductal systems:

- Simple : Minor Salivary Glands

- Compound : Major Salivary Glands

 PAROTID GLAND

Para-around; otic-ear
• Largest serous salivary gland
• Weighs around 15 gms
• It is situated below the external
acoustic meatus, between the
ramus of the mandible and the
sternocleidomastoid.
• The gland overlaps the
masseter muscle anteriorly
• A part of this forward anterior extension is often detached, and is known
as the accessory parotid and it lies between the zygomatic arch and the
parotid duct.
Development:
• Ectodermal in origin
• Develops from buccal epithelium, just lateral to angle of mouth.
• Branching– duct system and acini
• Mesoderm- forms intervening connective tissue septa.
CAPSULE OF PAROTID
GLAND:
• Mainly from investing layer
of deep cervical fascia
• The fascia splits between
the angle of the mandible
and the mastoid process to
enclose the gland.
• Superficial lamina-thick,
adherent to the gland, and
is attached above the
zygomatic arch.
• Deep lamina- attached to the styloid process, angle of mandible and
tympanic plate.
• Portion of it is thickened to form the Stylomandibular ligament which
separates the parotid gland from the submandibular salivary gland.
Ligament is
pierced by
the
External
Carotid
Artery.
Clinical Anatomy: due
to unyielding nature of
parotid fascia, parotid
swellings are
extremely painful
 External Features:
• The gland resembles a three sided pyramid.
• Apex - directed downwards.
• Four surfaces:
1. Superior(base of the pyramid)
2. Superficial
3. Anteromedial
4. Posteromedial

• Surfaces of the gland are separated by three borders:

1. Anterior
2. Posterior
3. Medial/Pharyngeal
Relations: Superior surface (Base)
• External Acoustic Meatus- cartilaginous part
• Posterior surface of Tempero-mandibular joint
• Superficial temporal vessels
• Auriculotemporal Nerve
Borders:
Anterior border: separates superficial from anteromedial surface
• Extent- anterior part of superior surface to apex of gland
• Structures emerging:
• Parotid duct
• Terminal branches of Facial Nerve
• Transverse Facial Vessels

Posterior border: separates superficial from posteromedial surface

• Overlaps Sternocleomastoid muscle

Medial border: separates anteromedial from posteromedial surface

• Related to lateral wall of pharynx
STRUCTURES WITHIN THE PAROTID GLAND
PATEY’S FASCIOVENOUS PLANE:
• Connection of large superficial and small deep part of the
gland.
• Facial nerve divides along this plane.

Clinical Anatomy:
The facial nerve must be traced from behind forwards as it emerges
from the Stylomastoid foramen and enters the parotid gland.
The nerve is surrounded by a leash of veins called the Neuro-
venous Plexus of Patey which must be followed with fine
dissection, preferably under a microscope, during Parotidectomy.
Accessory processes of Parotid Gland:
• Facial process- along the parotid duct
• Pterygoid process- between Ramus of mandible and Medial Pterygoid
• Glenoid process- between External Acoustic Meatus and Tempero-
mandibular joint
• Post-styloid process- behind the styloid process
• Emerges from middle of Anterior border of the
gland
• Runs forwards and slightly downwards on Masseter
muscle
Relations-
Superiorly:
• Accessory Parotid Gland
• Transverse Facial Vessels
• Upper Buccal branch of Facial Nerve
Relations-
Inferiorly:
Vascular supply:
• Arterial supply- External Carotid Artery and its branches
• Venous drainage- External and Internal Jugular Veins

Nerve Innervation:
• Parasympathetic nerves- Secretomotor – reach gland via the
Auriculotemporal Nerve

• Preganglionic fibres- inferior salivatory nucleus>>Tympanic branch of

Glossopharyngeal nerve>>Tympanic plexus>>Lesser petrosal
nerve>>RELAY in OTIC GANGLION>>Postganglionic
fibres>>Auriculotemporal Nerve>>Parotid Gland
• Clinical Anatomy: FREY’S SYNDROME
Parotid lymph nodes:
• Lie partly in superficial and partly deep fascia over the gland
• Draining areas:
• Temple
• Side of scalp
• Lateral surface of auricle
• External Acoustic Meatus
• Middle Ear
• Parotid Gland
• Upper part of cheek
• Parts of eyelids and orbit

• Efferents from these nodes pass to Upper deep cervical lymph nodes
Parotid Gland- Clinical examination
History
Swelling:
• Onset
• Exact site- in case of Adenolymphoma- lower part of parotid gland, at
the level of lower border of mandible (slightly lower than site of
Pleomorphic Adenoma).
• Duration
• Growth pattern: slow growing- Pleomorphic Adenoma
• Rapid growth with pain- Malignant transformation of
Adenoma
• Dehydrated with poor oral hygiene, painful enlargement of both
parotid glands- s/o Acute parotitis.
• Brawny, oedematous swelling with pain- s/o Parotid Abscess
• Any generalised enlargement of all salivary glands- s/o MIKULICZ
SYNDROME
• Any association with dry eyes and generalised arthritis- s/o
SJOGREN’S SYNDROME
• Any association with meals- if swelling increases in size with pain on
eating- s/o Obstruction of Parotid Duct with calculus
Pain:
• Throbbing, excruciating pain- Parotid Abscess
• Colicky pain- Parotid duct obstruction with a calculus or stricture

Discharge:
• Watery discharge from sinus in region of parotid gland or duct during
meals- s/o Parotid Fistula
Inspection & Palpation:
 Swelling:
• Position- below, behind and slightly in front of the lobule of the ear
Swelling will obliterate hollow just below the lobule of the ear.
• Fixity to Masseter Muscle- Procedure:
• Ask patient to clench teeth.
• Mobility of swelling is tested over contracted masseter muscle
• Bimanual palpation:- to palpate deep lobe of parotid
• One hand- inside mouth- retromandibular region
• Other hand finger- externally, behind ramus of mandible
 Skin:
• Brawny, oedematous with pitting pressure, warm and extremely
tender - s/o Parotid Abscess
• Note: Fluctuation is a very late feature of parotid abscess- due to a
strong parotid fascia overlying parotid gland
• Scar/Fistula
Duct:
• Position- starts just deep to anterior border of parotid gland and runs superficial
to the masseter muscle, then curves inwards to open on the buccal surface of
the cheek opposite crown of upper 2nd molar tooth.
• Procedure- retract cheek with spatula. One can feel the duct by rolling the finger
over the taut masseter muscle.
• Terminal part of duct- bimanual palpation- index finger inside mouth and thumb
on cheek/mandible.
• Note: Gentle pressure over gland- purulent saliva comes out of orifice of duct-
s/o Suppurative Parotitis.
• - bloody discharge- s/o malignant growth within gland
 Fistula:
• Position- in relation to the parotid gland or parotid duct
• (Masseteric of Premasseteric)
Facial Nerve examination: - mostly involved in Malignant growths of
parotid gland.
Lymph nodes examination:- Preauricular, Parotid lymph nodes.
Movements of Jaw:- restricted if malignant growth and involvement
of periarticular tissue of temporomandibular joint.
Sialography- with Neohydriol (lipoidal substance) >> Skiagram taken
 SUBMANDIBULAR SALIVARY GLAND
• It is situated in the anterior part of the digastric triangle.
• Size of a walnut, J shaped, being indented by the posterior border of the
mylohyoid which divides it into a larger part superficial to the muscle,
and a small part lying deep to the muscle.
• The gland is partially enclosed
between two layers of deep
cervical fascia.

• The superficial layer of fascia

covers the inferior surface of
the gland and is attached to
the base of the mandible.

• The deep layer covers the

medial surface of the gland
and is attached to the
mylohyoid line of the
mandible.
Superficial Part:
• Inferior surface is covered by:
-skin
-platysma
-cervical branch of the facial nerve
-deep fascia
-facial vein
-submandibular lymph nodes
• Lateral surface :
-submandibular fossa of mandible
-insertion of the medial pterygoid
-the facial artery
• Medial surface is related to :
-Myolohyoid, hyoglossus and styloglossus muscles from before backwards.
Deep part:
• Lies deep to Myloyoid muscle and superficial to Hyoglossus and Styloglossus
• Posteriorly- continuous with superficial part round the posterior border of
mylohyoid
• Anteriorly- extends upto posterior end of sublingual gland
• Relations:
• Laterlly- mylohyoid muscle
• Medially- Hyoglossus muscle
• Superiorly- Lingual nerve with submandibular ganglion
• Inferiorly- Hypoglossal nerve
Submandibular duct: (WHARTON’S
DUCT)
• -Thin walled, about 5 cms long. It
emerges at the anterior end of the
deep part of the gland and runs
forward on the hyoglossus,
between the lingual and
hypoglossal nerves.
• At the anterior border of
hyoglossus, the duct is crossed by
the lingual nerve.
• It opens on the floor of the mouth,
on the summit of the sublingual
papilla, on either side of the
frenulum of the tongue.
Submandibular Gland- Clinical Examination
History:
• Swelling with colicky pain at the time of meals, tense and painful
swelling- diagnostic of stone in submandibular duct.
• Swelling due to lymph node enlargement- majority of cases
Inspection:
• Swelling appearing after sucking lemon/lime juice- s/o stone in submandibular
duct
• Swellings of submandibular glands along with parotids and lacrimal glands- s/o
MIKULICZ’S SYNDROME.
• Orifices of Submandibular (Wharton’s duct):
• Position- either side of Frenulum Linguae
• Procedure- torch is placed on the outside of the floor of the mouth
• Noted if orifices are inflamed/swollen due to impaction of a stone in the duct- may
be impacted in the ampulla, deep to the orifice.
• Result- obstructed duct will not have saliva secretion from orifice and remains dry-
can be tested by 2 swab test.
Palpation:
• Nodular swelling either discrete/matted- s/o lymph node enlargement.
• Uniform single swelling- s/o submandibular gland enlargement
• Procedure of bimanual palpation:
• Patient asked to open the mouth- one finger- placed on floor of mouth
medial to the alveolus and lateral to the tongue and pressed back as far as
possible- can palpate deep part of submandibular gland- as this lies above
the mylohyoid muscle.
• Other finger- externally, placed medial to inferior margin of the mandible.
Fingers are pushed upwards
• This helps to palpate both superficial and deep lobes .
Vascular supply:
• Arterial supply- Facial Artery- makes 2 loops- “S” shaped- first
winding down over submandibular gland then up over the base of
mandible.
• Venous drainage- Common Facial Vein or Lingual Vein

Nerve innervation:
• Secretomotor-
Superior salivatory nucleus>>Nervus intermedius>>Facial
nerve>>Chorda tympani>>joins Lingual nerve>>RELAY>>Postganglionic
fibres>>Submandibular and Sublingual glands
• Sensory- from Lingual nerve
• Vasomotor sympathetic fibres- from plexus on Facial Artery
 SUBLINGUAL SALIVARY GLAND
• This is the smallest of the three salivary glands.
• It is almond shaped and weighs about 3-4gms.
• Site: It lies above the mylohyoid, below the mucosa of the floor of the
mouth, medial to the sublingual fossa of the mandible and lateral to the
genioglossus
• About 15 ducts emerge from the gland, opening directly into the floor of
the mouth on the summit of the sublingual fold.
• A few of them join the submandibular duct.
Relations:
• Anterior- meets opposite gland
• Posterior- deep part of Submandibular gland
• Superior- Mucous membrane of mouth
• Inferior- Mylohyoid muscle
• Lateral- Sublingual fossa
• Medial- Genioglossus muscle
Vascular supply:
• Arterial supply: Lingual and Submental Arteries
COMPARISON OF 3 MAJOR SALIVARY
GLANDS
Feature Parotid Gland
Location In relation to external ear,
angle of mandible,
mastoid process
Size Largest
Relation to fascia Enclosed by investing
layer of cervical fascia
Type of gland Purely serous secreting
Gross features 3 surfaces, 3 borders,
apex, base, 1 artery, 1
vein, 1 nerve, lymph
nodes within the gland
Submandibular Gland
Lies in submandibular
fossa, close to angle of
mandible
Medium sized
Enclosed by investing
layer of cervical fascia
Mixed- both serous and
mucous secreting
3 surfaces, 1 artery, lymph
nodes within the gland
Sublingual Gland
Lies in sublingual fossa on
the base of the mandible
Smallest
Not enclosed
Purely mucus secreting
Related closely to Lingual
Nerve and Submandibular
Duct
Feature Parotid Gland Submandibular Gland Sublingual Gland
Secretomotor Root Auriculotemporal Nerve Facial Nerve Facial Nerve
Sympathetic root Plexus around middle Plexus around facial Plexus around facial
meningeal artery artery artery
Sensory Auriculotemporal nerve- Lingual nerve Lingual nerve
gland
Great Auricular nerve-
parotid fascia
Development Ectoderm Endoderm Endoderm
Opening of the duct Vestibule of mouth, Papilla on sublingual fold 10-12 ducts open on
opposite 2nd upper molar in the floor of the mouth sublingual floor in floor
tooth of the mouth
 MINOR SALIVARY GLANDS
• They are located beneath the oral epithelium in almost all parts of the
oral cavity except in the gingiva, anterior hard palate and anterior 2/3rd of
dorsum of the tongue.
• 600-1000 in number present in small clusters of secretory units..
• Continuous slow secretory activity.
• Often supersede the activity of major salivary glands at night.
References:
• B.D. Chaurasai’s Human Anatomy: Head & Neck
• Gray’s Anatomy by Henry Gray
• Sabiston Textbook of Surgery
• Bailey & Love’s Short practice of Surgery- 27th edition
• www.google.com
Thank You