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Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
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Salivary Glands
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Salivary Glands
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Salivary Glands
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Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
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Salivary Glands
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Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
Salivary Glands
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Salivary Glands

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  • 1. Salivary glands
    Dr. Tanuj Paul Bhatia
  • 2. Anatomy
    3 major salivary glands:
    The parotid glands
    The submandibular glands
    The sublingual glands
    Many minor salivary glands in mucosa of cheeks, lips, palate.
  • 3. Parotid gland
    Largest salivary gland
    Lies b/w sternomastoid and mandible below the EAM
    Coverings :
    True capsule
    False capsule – a layer from the deep cervical fascia
  • 4. Lobes of parotid gland
    Parotid divided into superficial and deep lobes by the facial nerve
    Fasciovenous plane of Patey
  • 5.
  • 6.
  • 7. Structures within the parotid gland
    1. External carotid artery :
    Gives terminal branches in the gland
    Maxillary artery and superficial temporal artery.
    2. Retromandibular vein
    Formed by union of sup. Temporal and maxillary vein
    Joins post. Auricular vein to form the external jugular vein.
  • 8. Structures within the parotid gland
    3. The facial nerve
    Enters upper part of posteromedial border
    Passes forward and downward and divides into
    Temporal br.
    Temporofacial
    Zygomatic br.
    Main trunk
    Buccal branches
    Cervicofacial
    Marginal mandibular br.
    Cervial br.
  • 9. Facial nerve over the deep lobe of parotid
  • 10. Parotid duct
    Stensen’s duct
    5cm in length
    Comes out through anterior surface of glands.
    Peircesbuccinator and opens in buccal mucosa opposite crown of second upper molar tooth.
  • 11. Inflamatory diseases of parotid
    Acute suppurativeparotitis
    Acute parotitis (mumps parotitis)
    Recurrent subacuteparotitis / chronic parotitis
  • 12. Acute suppurativeparotitis
    Causative organisms : Staph. aureus, streptococcus viridans, pneumococci commonly.
    Route : usually from stensen’s duct, rarely blood born
    Predisposing factors :
    Dehydrated patients
    Obstructed duct
  • 13. Clinical features
    Pain and swelling on the side of face
    BRAWNY edematous swelling over parotid region with all signs of inflamation
    Fever
    If pressed pus may be seen coming from the opening of stensen’s duct.
  • 14. Treatment
    Improve general condition.
    Improve oral hygeine.
    Soft diet as chewing is painful.
    Antibiotics.
    If no response incision and drainage :
    Vertical incision on skin but transverse incision on the parotid fascia to safeguard facial nerve and branches
  • 15. Acute parotitis
    Usually due to viral parotitis.
    Rarely in association with tuberculosis, actinomycosis and cat scratch disease.
    MUMPS – commonest cause
    Non suppurative
    Initially unilateral but proceeds to bilateral affection.
  • 16. Recurrent subacute and chronic parotitis
    If on both sides, suspect Sjogren’s syndrome.
    Other causes : calculus, autoimmune
    Recurrent attacks of pain and swelling.
    Gland progressively replaced by fibrous tissue.
  • 17. Management
    Investigation : sialography
    Treatment
    Control infection by antibiotics.
    Remove stone
    Dilate the duct if it is constricted
    Total conservative parotidectomy if all above measures fail
  • 18. Neoplasms of the salivary gland
    75% occur in the parotid glands.
    In parotid glands, 80% of tumors are benign.
    Of these 80% are Pleomorphic adenomas.
    15% of salivary tumors occur in submandibular glands.
    Of these 50% are benign and 50% and malignant.
    In carcinomas mucoepidermoid ca> adenoid cystic ca > adenocarcinoma
  • 19. 10% of salivary tumors occur in sublingual and minor salivary glands
    60-70% of these are malignant
  • 20. Classification
    Epithilial tumors
    Connective tissue tumors
    Metastatic tumors
  • 21. A. Epithilial tumors
    Benign
    Pleomorphic adenoma (Mixed tumor)
    Oxyphil adenoma
    Papillary cystadenomalymphomatosum (Warthin’s tumor)
    Basal cell adenoma
  • 22. Epithilial tumors
    Malignant
    Mucoepidermoid carcinoma
    Adenoid cystic carcinoma
    Acinic cell ca
    Papillary adenocarcinoma
    SCC
    Undifferentiated ca
    Ca arising in pleomorphic adenoma
  • 23. Connective tissue tumors
    Benign
    Hemangioma
    Lipoma
    Neurilemmoma
    Fibroma
    Malignant
    Malignant lymphoma
    Above mentioned benign tumors may turn malignant.
  • 24. Pleomorphic adenoma
    ‘Mixed tumor’
    Commonest tumor of salivary glands.
    There is cartilage besides epithelial cells on histology.
    Sites : 90%  Parotids
    7% Submandibular gland
    3% rest
  • 25. Pathology
    Macro : rubbery, bosselated, on cut section, mucoid appearance with zones of cartilage.
    Micro : pleomorphicstroma with pseudocartilage, lymphoid, myxoid and fibrous elements besides epithelial cells.
  • 26. Clinical features
    Age : any age but common around 40 yrs
    Sex : slightly more incidence in females.
    Painless swelling since years.
    Slow growth.
    Site : usually below the lobule of ear.
    Variable consistency : firm and rubbery
  • 27.
  • 28. Malignant transformation
    Malignant transformation may occur in 3% to 5%
    Signs of malignant transformation :
    Long duration (10-20yrs)
    Becomes painful
    Starts growing rapidly
    Becomes stony hard
    Facial nerve involvement
    L. node involvement.
    Jaw movement restriction.
  • 29. Treatment
    The tumor is radioresistant.
    Excision is the treatment of choice.
    For diagnosis FNAC can be done but incisional biopsy is contraindicated.
    Superficial parotidectomy is the treatment of choice.
    Submandibular gland : submandibular gland excision.
  • 30. Warthin’s tumor
    Represents 5-15% of parotid tumors.
    Occurs only in parotid.
    Almost always in lower portion of parotid gland.
  • 31. Pathology
    Gross : soft and frequently cystic
    Micro : cores of papillary processes with abundant lymphoid tissue.
  • 32. Clinical features
    Age : middle and old age
    Sex : much more common in males
    Painless slow growing tumor over angle of jaw
    May be bilateral
    Surface is smooth
  • 33. Management
    FNAC
    Hot spot in 99mTC pertechnate scan
    Treatment : superficial parotidectomy
  • 34. Mucoepidermoid carcinoma
    Slow growing
    Invade local tissues to a limited degree
    Occasionally metastasise to lymph nodes, lungs or skin.
    Clinically they are hard, become fixed when very large.
  • 35. Acinic cell tumor
    Almost all occur in parotid gland
    Composed of cells resembling acini
    Women > Men
    Rare and slow growing
    Tend to be soft and occasionally cystic
  • 36. Adenoid Cystic Carcinoma
    Consists of myoepithelial and duct epithelial cells
    Slow growing but more invasive than the above described malignant tumors
    Tumor is always more extensive than the physical or radiological appearance
    Minor glands > submandibular > parotid
  • 37. Adenocarcinomas, Epidermoid ca & Undifferentiated Ca
    Resemble various glandular elements seen in salivary glands
    Divided according to predominant cell type
    Demonstrate fixation to adjacent bone, pain, anesthesia of skin and paralysis of muscles
  • 38. In case of parotid gland, facial nerve irritability occurs first, later gives rise to facial paralysis
    Limitation of jaw movements
  • 39. Submandibular gland
    Composed of superficial part and deep part
    Divided by mylohyoid muscle
    Superficial part lies in the submandibular triangle b/w 2 bellies of digastric muscle
    Deep part lies abv & deep to mylohyoid in the floor of mouth
  • 40.
  • 41. Submandibular duct (Wharton’s duct)
    About 5 cm long
    Runs fwd from the deep part of the gland to enter floor of the mouth
    Opens on a papilla beside the frenulum of the tongue
  • 42.
  • 43. Structures in relation to submandibular gland
    The Lingual nerve
    The Facial artery
  • 44. Sialography
    Radio opaque liquid like
    Hypaque (Sodium diatrizoate)
    Lipiodol
    Injected into duct system of the gland and radiograph taken
    Volume of 0.5-2ml used
  • 45. Shows
    Obstruction, Dilatation & narrowing of duct
    Position and size of salivary neoplasm
    Extraglandular mass
    Fistula and abscess cavities
  • 46.
  • 47. Acute suppurativesialadenitis of submandibular gland
    Usually secondary to obstruction of Whartons duct
    Organism – S. aureus common
    Responds well to antibiotics and improved oral hygiene
    Rarely, I & D is required
  • 48. Recurrent subacute and chronic sialoadenitis
    These inflamations are always secondary to obstruction or autoimmune disease.
    Recurrent attacks of pain and swelling
    Sialography confirms the diagnosis and gives a clue about the cause
    Treatment is of the primary condition
  • 49.
  • 50. Tumors of submandibular glands
    Tumors in this gland are uncommon
    Enlargement is more due to calculus
    Of all tumors, mixed tumor is most common
    Swelling is hard but not stony hard and should be differentiated from submandibular lymph node
  • 51.
  • 52. Obstruction of a major salivary gland duct
    Characteristic symptom : Recurrent painful swelling of the affected gland at mealtimes.
    First indication may be acute/ subacute infection
  • 53. Causes of obstruction
    Salivary calculi
    Strictures of the duct wall
    Edema or fibrosis of the papilla
    Pressure on the duct
    Invasion of the duct by malignant neoplasm
  • 54. Salivary calculi
    Submandibular calculi are most common
    Easily demonstrated on plain X ray
    Calculi within the duct  removed via floor of mouth
    Calculi within the gland or chronic infection  excision of the gland
  • 55.
  • 56.
  • 57. Sublingual and minor salivary gland diseases
    Mucous cyst (retention cyst) : pink, soft swellings on inner surface of lips and cheeks
    Cyst and associated minor gland should be excised together
    Tumors : usually malignant
    palate > upper lip > rest
    Treatment : wide excision and grafting
  • 58.
  • 59. Ranula
    Extravasation cysts arising from a damaged sublingual duct
    Ranula = frog (latin)
    Transluscent bluish swelling in the floor of mouth with vessels running over it
    May flow over post margin of mylohyoid and present as a plunging ranula
    Rx : excision, marsupilization
  • 60.
  • 61.
  • 62. Mikulicz’s disease
    Characterized by
    Enlargement of all salivary glands
    Enlargement of both lacrimal glands
    Dry mouth
    This occurs due to replacement of glandular tissue by lymphocytes
    Occurs b/w 20 and 40 yrs of age
    Thought to be autoimmune process
  • 63. Sjogren’s syndrome
    All features of Mikulicz’s disease plus
    Dry eyes (Keratoconjuntivitissicca)
    Generalized arthritis
  • 64. Surgery of salivary glands
  • 65. Frey’s syndrome
    Also called as auriculo-temporal syndrome
    Occurs due to damage to the autonomic innervation of the salivary gland
    Inappropriate regeneration of parasympathetic fibers
    Stimulation of sweat glands of overlying skin with stimulus of salivation
  • 66. Causes :
    Surgery of the parotid gland
    Injury to parotid gland
    Clinical features : sweating and erythema at the site of parotid surgery by smell or taste of food.
  • 67. Investigation :
    Starch iodine test :
    After painting the area with iodine Starch applied over the area becomes blue on gustatory stimulus.
  • 68. Prevention
    Sternomastoid muscle flap
    Temporalisfascial flap
    Artificial membranes
    Form a barrier between skin and parotid bed to minimise inappropriate regeneration of autonomic nerve fibres.
  • 69. Treatment
    Initially conservative management
    Most recover in 6 months
    Anti-perspirants
    Denervation by tympanic neurectomy
    Injection of botulinum toxin into the afected skin.
  • 70. Parotidectomy
    Types :
    Superficial parotidectomy : superficial to facial nerve
    Total conservative parotidectomy : for benign diseases involving deep lobe. Facial nerve is preserved.
    Radical parotidectomy :
    For carcinomas
    Facial nerve, fat, facia, muscles and lymph nodes are removed.
    Later reconstruction using hypoglossal or greater auricular nerve.
  • 71. Incision
    Lazy ‘S’ incision
    Pre-auricular—mastoid-cervical incision
  • 72.
  • 73. Identificaton of facial nerve
    Conley’s pointer : inferior portion of cartilagnous canal. Facial nerve is 1cm deep and inferior to its tip.
    Upper border of posterior belly of the digastric muscle. Fascial nerve immediately superior to this.
    By nerve stimulator
  • 74. How To Save The Facial Nerve During Parotid Salivary Gland Tumor Surgery.flv
  • 75. Complications of parotid surgery
    Haematoma formation
    Infection
    Temporary facial nerve weakness
    Permanent facial nerve weakness
    Sialocele
    Facial numbness
    Frey’s syndrome
  • 76. Facial nerve injury(Lower motor neuron lesion)
    Causes
    Trauma
    Parotid surgery
    Compression of facial nerve(Bell’s nerve)
  • 77. Clinical features
    Inability to close the eye lid
    Difficulty in blowing and clenching
    Drooping of the angle of mouth
    Obliteration of naso-labial fold
  • 78. Treatment
    Usually temporary, recovers in 6 months
    Nerve grafting
    Suspension of angle of mouth to zygomatic bone
    Lateral tarsorrhaphy
  • 79. Submandibular gland excision
    Indications :
    Chronic sialoadenitis
    Stone in submandbular gland
    Submandibular gland tumors
  • 80. Incision
    Placed 2-4 cm below thmandie, parallel to it
    Preserve :
    Marginal mandibular nerve
    Lingual nerve
    Hypoglossal nerve
  • 81.
  • 82. Complications
    Hemorrhage
    Infection
    Injury to mandibularnerve, lingual nerve , hypoglossal nerve
  • 83. THANK YOU

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