Lecture on salivary gland disorders for medical students. Encompasses basic sciences, classifications and principles of management.

1. Salivary gland disorders
Chea Chan Hooi
Surgeon
Sibu Hospital

2. Content
• Anatomy
• Histology
• Physiology
• Disorders
• Clinical features
• Principles of management

3. Anatomy
Major
• Outside oral cavity
• Long ducts
• Three pairs
– Parotid
– Submandibular
– Sublingual
Minor
• Within oral cavity except
– Gingiva
– Anterolateral aspect of hard
palate
• Submucosal
• Short ducts
• Examples
– Labial
– Lingual
– Palatal
– Buccal
– Glossopalatine
– Retromolar

4. • Parotid
– Largest
– Purely serous
– Divided into superficial & deep lobes by CNVII
– Stensen duct = its main duct
– 80% of tumours

5. • Submandibular
– Second largest
– Mixed serous-mucous secretion (S>M)
– Wharton duct
• Its main duct
• Opens into sublingual papillae, lateral to lingual
frenulum

6. • Sublingual
– Smallest
– Mixed, M>S
– Ducts of Rivinus
• Multiple
• Opens directly into oral cavity

7. Histology
• Composed of acini that produce saliva into a branched
system of ducts that coalesce into a major drainage duct to
empty into oral cavity
• “like a bunch of grapes”
• 3 components
– Acini
• Serous cells
• Mucous cells
• Myoepithelial cells
– Duct
• Intercalated ducts
• Striated ducts
• Terminal ducts
– Connective tissue

8. Disorders
• Infective
– Obstructive – sialolithiasis, mucus plug, FB, stricture
– Non-obstructive – viral, TB, mycotic
• Neoplastic
– Benign
– Malignant
• Congenital
– Aplasia/hypoplasia, atresia, accessory duct (most common), diverticuli, fistula
• Autoimmune
– Sjogren
• Trauma
– Mucocele/ranula
• Endocrine
– Malnutrition, alcoholism

9. Sialolithiasis
• Salivary calculi within ductal system
• Swelling & severe pain with meals ± infection
• Mucosa overlying calculi may ulcerate
• Sites : SM > P > SL
• Calculi may be radiopaque vs mucus plug
• Sialography
• Management
– Manual manipulation
– Incision over SM gland
– Excision of gland if within other glands

11. Tumours
• Benign tumours
– Pleomorphic adenoma (75%)
• Malignant tumours
– Parotid – mucoepidermoid adenocarcinoma
– Others – adenoid cystic adenoca
• Non-neoplastic epithelial lesions
• Benign soft tissue lesions
• Haemtolymphoid tumours

12. Parotid Submandibular Sublingual
% of tumour 80%
Risk of tumour
being malignant
20% 50% 80%
Remarks Majority within
superficial lobe
Usually palpable at
floor of oral cavity

13. • Risk factors
– Radiation
– Smoking
– EB virus, simian virus 40

14. • Clinical presentation
– Mass
– Facial nerve compression (parotid)
– Trismus
– Red flags
• Pain
• Rapid growth
• Cranial nerve palsies
• Fixation to underlying structure
• Associated LN enlargement

16. Differential diagnoses
Mid-line
• Skin & subcutaneous
• Thyroid
• Thymus
• Dermoid cyst
• LN
Lateral
• Submandibular triangle
– LN
– SM gland
– Plunging ranula
– Oral cavity
• Carotid triangle
– Artery
– Carotid body tumour
– Branchial cyst
– Sternomastoid tumour
• Posterior triangle
– SCLN
– Lateral aberrant thyroid
– Cystic hygroma
– Pharyngeal pouch
– Cervical rib

17. • Investigations
– Radiology
• USG
• CECT scan or MRI
• Staging CT thorax – lung >bone> liver mets (33% risk)
– FNAC
• Never perform biopsy

18. • Treatment
– Parotid tumours
• Surgery
– 90% within superficial lobe – superficial parotidectomy
– Deep lobe – total parotidectomy
– Adjacent soft tissue – radical parotidectomy
– Frey syndrome
» Gustatory sweating  ANS fibres redirected to dermal sweat glands
• Adjuvant radiotherapy
– Other major glands
• Gland excision ± en bloc resection of any affected surrounding
structures
• Adjuvant radiotherapy (EBRT or brachytherapy)

19. Mucocele, ranula
• Pseudocyst of mucus extravasated from traumatised/ obstructed salivary ducts
• Mucocele
– AKA mucus retention cyst/mucus escape reaction
– Usually affect minor glands
– Commonly superficial
– Occurs during meals & then gradually disappears
– Might be infected
– Management – excision, cryosurgery, intralesional steroids
• Ranula
– Major glands, esp.SL
– Types
• Oral
– Pooling superior to mylohyoid muscle
• Cervical/plunging
– Along fascial planes of neck
– Management – excision, marsupialisation

21. Cystic hygroma

22. TQ. Q&A?