Salivary Glands


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Salivary Glands

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