Salivary Gland Diseases Copyright by Oral & Maxillofacial Surgery Department, UDM

1. Htay Htay Yi
U.D.M.( Mdy)

2. SALIVARY GLANDS
Major salivary glands - paired
structures (total - 6 )

3. Parotid
- the largest
- superficial to the posterior
aspect of the messeter
muscle and ramus of the
mandible
- VII CN divide the
superficial and deep lobe
-serous secretion
- Stenson’s duct 3-4mm in
diametre and 6 cm in length
-open into the oral cavity
through the oral mucosa
opposite maxillary first or
second molar

5. Stenson’s duct opening ? Anomaly growth

6. Submandibular
-located in the submandibular
triangle ,
- mixed secretion
-Wharton’s duct , 2-4mm in
dimetre and 5cm in length

7. Wharton’s duct runs along the
superior surface of the
mylohyoid
-lingual nerve loops under the
wharton duct
-from lateral to medial in the
posterior floor of the mouth
- opens into the floor of the
mouth
- through punctum
( constricted portion of the
duct ) located close to the
incisors

8. Sublingual lies on the superior surface of mylohyoid muscle ,
in the sublingual space , mucous
Sublingual duct
-acinar of the sublingual glands are
called Bartholin’s ducts
- coalase to form 8-20 ducts of Rivinus
- short and small in diametre
- either open individually into the
anterior floor of the mouth on the crest
of mucosa ( sublingual plica )
-or open indirectly through
submandibular duct

9. Minor salivary glands
approximately 800 - 1000 are found through out the oral cavity
exceptions such as anterior third of the hard palate , the attached
gingiva , the dorsal surface of anterior third of the tongue
referred to as , labial , buccal , palatine , tonsillar ( weber’s gland ) ,
retromolar ( Carmalt’s glands ) and lingual glands ( inferior apical -
glands of Blandin Nuhn , , taste buds -Ebner’s glands , posterior
lubricating glands )

10. Diagnosis modalities
 History and clinical examination

11. Salivary gland radiology
85% stone are radiopaque
madibular occlusal film for sublingual and
submandibular gland
Puffed cheek view for parotid stone

12. Sialography ;
gold standard in diagnostic
0.5 to 1 ml of contrast material ( water soluble and oil based ) is
injected into the duct and gland
series of radiograph are taken during this process
Distinct phases
 Ductal phase - immediately after injection
 Acinar phase - gland parenchyma becomes filled subsequently
 Evacuation phase - which assess normal secretory clearance, retention
beyond 5 mins is considered abnormal

18. 15-20% stone are radiolucent
useful in assessment of extent of destruction of salivary gland or duct or
both as a result of ;
 Obstruction
 Inflammatory
 Traumatic
 neoplastic
 therapuetic manuevur , since the ductal system if dilated during the study .
Three contraindications to perforning the sialogram
 (1) Ac. salivary gland infection - pain , foreign body reaction , spread of
infection
 (2) iodine hypersensitivity
 (3) before thyroid gland study

19. Salivary scintigraphy
radioactive isotope scanning )
technetium Tc99m , IV , check for uptake
Increased uptake of radioactive isotope in an Ac. inflammed gland
Decreased uptake in Ch inflammed gland or mass lesion ( benign and
malignant )

20. Salivary gland endoscopy ( Sialoendoscopy )
small video camera with a light at the end of flexible cannula
introduce into the ductal orifice
demonstrate strictures and kinks in the ductal system as well as
mucous plug and calcification
used to dilate small stricture and flush clear mucous plug

21. Sialochemistry
electrolyte composition of the saliva

22. Biopsy
is inadvisable in three paired salivary glands
possibility of seeding
Frozen section may be uncertain
lip labial biopsy for major gland in SS
FNAC - usually inadequate , immediate determination of the benign
and malignant

23. Salivary gland diseases
Developmental anomalies
Infections and other inflammatory diseases - Bacterial ,
Viral , Sialadenitis of the minnor glands , Post irradiation
sialadenitis , sarcoidosis
Obstructive and traumatic lesions - Salivary calculi ,
mucocele
Sjorgren’s syndrome and related idsorders
Sjorgeren’s syndrome
Benign lymphoepithelial lesion
Sialosis
Salivary gland tumours

24. Developmental anomalies

25. Aplaisa/agenesis
complete absence of one or more salivary glands , very rare , but
occasionally parotid gland
Duct atresia
also rare , usually effects the submandibular duct results in
retention cysts of submandibular gland
Salivary gland hypoplasia
feature of Melkerson-Rosenthal syndrome , may be secondary to
atrophy of paraqsympathetic nerves
Congenital salivary fistula
in association with branchial clefts
Abberent salivary tissue
common in cervical lymph nodes , middle ear cleft , Stafne’s bone
cavity
Accossories ducts and lobes
common as to form normal variation 50% in parotid

26. Infections and other inflammatory
diseases

27. Acute Bacterial Sialadenitis
- Ascending infection usually affects the parotid gland
- reduced salivary flow is the major predisposing factor but infection
may also follow
- The parotid duct is of larger calibre than the submandibular duct
and the opening of the duct at the papilla , unlike that of
submandibular is not guarded by a spincter like mechanism
- inadequate salivary flow and oral sepsis in dehydrated surgical
patient
-as a results of Sjorgren’s syndrome , radiation damage , side effect of
Tricyclic antidepresents


28. C/F - onset is rapid , parotid gland hot , redness of the overlying skin ,
tender and swollen , pyrexia , lymphadenopathy , fluctuation present
if parotid abscess formation , pus may be expressed from the affected
duct
Management - Antibiotics - Emperical ( pyogenic Staphylococci and
Streptococci ) , metronidazole for anaerobic , follow according to
( C&S)
- if an abscess forms it must be drained
Sialogram should never be taken in the acute phase

29. Chronic bacterial sialadenitis
- nonspecific infection with duct obstruction and low grade assending
infection
- Submandibular are more frequently affected , usually unilateral
- viscid mixed secretion and narrower duct of the submandibular
gland
- often follows an acute infective episode or associated with chronic
obstruction
- recurrent and nontender
- painless tumour like firm mass ( a kuttner tumour )
- obstruction due to calculus or stricture
- only effective treatment is excision
- for the parotid , superficial lobectomy with tying of the parotid duct

30. Recurrent Parotitis
- Seen in children starting at about 6 yrs of age and recurring
- usually adolescence
- boys are affected twice
- unilateral or bilateral parotid swelling
- particularly at mealtimes
Sialography shows widespread punctate sialectasis with snow storm
appearance
Management - will resolve progressively in 5-10 days common adenitis
, if persistent superficial lobectomy with tying off of the main duct

31. Viral sialadenitis
- caused by Paramyxovirus
- direct contact with the infected saliva and by droplet infection ,
incubation period of 2-3 weeks
- mumps , most common acute parotitis
- disease of childhood , can affect to non-immune adult
- 70% parotid , unilateral or bilateral , submandibular gland may also
invovlved
- nonspecific prodromal symptoms - fever , maliase
- gradually subsided over a period about 7 days
- virus present in the saliva 2-3 days before the onset of sialadenitis ,
for about 6 days afterwards

32. Management - complement fixation test - mump antibody
no specific treatment
in adults internal organs are involved - testes , ovaries and CNS and
pancreas
Orchitis , encephalitis and deafness

33. Sialadenitis of minor glands
Necrotizing sialadenitis
 minor salivary glands of the palate
 cigarette smoker
 middle aged male are predominantly affected

34. Obstruction and Trauma

35. Papillary obstruction
- trauma to parotid papilla , submandibular papilla although having
a small orifice rarely becomes obstructed
- result of cheek biting , abrasion from the rough tooth , calculus or
denture flange or occasionally apthous ulcer can cause inflammatory
odema
- acute pain and swelling of the affected gland at meal times or other
gustatory stimuli
Management - surgically papillotomy

36. Papillary stricture
- duct strictures are secondary to ulceration of the duct wall from
calculi
- mostly affect the submandibular duct

37. Calculi ( sialolithisis)
- occur in any age but common in middle aged adults , rare in
children
- radio-opaque calculi consists predominantly of calcium phosphate
and small amount of carbonate which crystalize round an organic
nidus usually cellular debris or casts from the duct walls ,
microorganisms , deposition of organic and inorganic material would
produce a lamellated calculus

38. Submandibular calculi
70- 90 % majority of calculi form
potential areas of stasis of the salivary flow
obstruction due to precipitated material , mucous and cellular debris
more easily trapped in the tortous
lengthy duct
especially when the orifice is its most elevated location - against the
force of gravity
because of viscid and mixed secretion
concentration of calcium is twice abundant
alkaline pH
anatomic factors - longest duct , two sharp curves in its course - at the
posterior border of the mylohyoid muscle and near the opening at the
anterior

39. Submandibuar sialolith
floor of the mouth ( frequent site
of the stone )
punctum of the submandibular
duct is smaller
calculi may be detected by
palpation
usually unilateral
multiple stones in the same gland
are not uncommon

40. whitish hard object noticed with discomfort at meal time
anterior stone in mandibular occlusal radiograph
exclusion for multiple stones must be considered

41. under LA, incision was given and stone was removed
care must be taken not to crush the stone while picking up

42. Symptomatic ;
 acute pain and swelling at meal times
 when saliva production is maximum
 salivary flow is stimulated against the fixed obstruction
 swelling is sudden and painful
 gradually reduction of the swelling follows
 reoccur when salivary flows is stimulated again
 until complete obstruction , infection or both occurs
Asymptomatic
Progressive atrophy and fibrosis of the affected gland

43. mandibular occlusal radiograph; 90 degree occlusal
anterior or posterior stones in relation to transverse line between the
mandibular first molars

44. Mangement - depends upon duration of symptoms , number of
repeated episodes , the size of the stone , site of the stone
- near the opening - by milking
- distal 2/3 is straight forward , under LA , stay suture inserted around
the duct proximal to calculus to prevents the stone to backwards
towards the gland , linear incision is made along the submandibular
duct , to expose the clculus which is then easily teased out , wound
irigation , incision in the duct is left open to avoid stricture formation
- for the calculus in the proximal third of the duct or within the
submandibular gland , excision of the gland from the external
approach , avoid damage to the marginal brnch of the facial nerve ,
lingual and hypoglossal nerve

45. - Parotid calculus -
- Piezoelectric shock wave liththotripsy

46. Mucoceles
damage to the duct and obstruction to the drainage of the minor
salivary gland
the common site is the lower lip , retromolar pad and cheek from the
occlusal trauma

47. Mucocele at lower lip ( Rt
side )
Overlying mucosal smooth

48. Mucocele at lower lip ( Lt side )
surface ulceration of the overlying mucosal
history of rupture and reappearance of the swelling

49. Mucocele at lingual frenum

50. Phenominum;
usually mucous extravasion rather than retention cysts , immediate
the epithelium
occasionally obstruction causes the duct to become distended ,
resulting true retention cyst lined by duct epithelium

51. Treatment - if untreated eventually burst and discharge
spontaneously , the secretion accumulates again , mucocele recurs
the lesion excised in toto together with the underlying minor gland of
origin , recur if not completely excised
Other option - cryosurgery , laser surgery

54. the lesion excised in toto together with the underlying minor gland of origin

55. Ranula
damage to the duct of the sublingual gland causes the formation of a
mucous extravastion cyst
 tense bluish swelling
 anterior floor of the mouth
 just to one side
 Submucosal lies entirely above the mylohyoid muscle
 may reach to 3-4 cm in diametre and cause speech disturbances

56. anterior floor of the mouth
just to one side ( Lt )

57. Submucosal Ranula ( Lt ) in child

58. anterior floor of the mouth
just to one side ( Rt )
3-4 cm in diametre

59. Marsupialization ( Deroofing )under LA
Tie over sutures were for location of cyst boundary

60. Cyst wall and mucosal of the floor of the mouth were sutured
Gauze pack was kept by Tie over sutures

61. Deep ranula ( Plunging ) lies within the submentle
space
may be plunging and hourglass shape
lying partly superficial and partly deep to the
mylohyoid
passes through the developmental dehiscence in the
mylohyoid muscle
difficult to excise , usually ruptures during surgery

62. Permanant cure is
achieved by excision of
the affected sublingual
salivary gland
in case of plunging
ranula , recommended
transoral

63. Ductoplasty of the transected submandibular duct

65. Sjorgren’s syndrome
- common chronic connective tissue disorder
- characterized by dry mouth (xerostomia) , dry eyes
( keratoconjuntivitis sicca ) due toinfiltration of the salivary an
dlacrimal glands by T & B lymphocytes and acini destruction
- Primary SS ( Sicca syndrome ) dry eyes and dry mouth with the
absence of of any connective tissue disease , glandular destruction
tends to be severe and more often associated with lymphomatous
changes
- Secondary SS - triad of dry eyes , dry mouth and connective tissues
disorder usually rheumatoid arthritis

66. - C/F ; dry mouth - disturbed tase sensation , needs to tske fluid with
food , soreness of the mucosa , speech may be impaired as a result of
tongue sticking to the palate, depapillated tongue
- Candidal infection
- redness and soreness of the mucosa
- intermittent gland enlargement of the salivary gland in 20% ,
persistent in 4%
Management ; labial minor salivary gland biopsy under LA confirm
the diagnosis , auto antibody profile ,
- Treatment is largely palliative , lubricant eye drops , frequent sips of
water , meticulous oral hygiene , fluoride and chlorhexidine mouth
wash , antifungal for candidal infection

67. Mikulicz’s disease and syndrome
- Mikulicz’s disease - benign lymphoepithelial lesion of the parotid
glands particularly when bilateral
- Mikulicz’s symdrome - less common clinical condition of bilateral
enlargement of the parotid , other salivary and lacrimal glands by a
definable disorders such as sarcoidosis , lymphoma or sialosis

68. Sialosis ( Siaadenosis )
- uncommon condition consisting of bilateral , soft and painless
enlargement of the parotids
- pathogenesis is unknown
- in association with variety of diseases - hormonal , metabolic , drug
associated

69. Conditions associated with chronic salivary gland
enlargement;
parotid swelling may occur either unilaterally or bilaterally
- Sjorgren’s syndrome - benign lymphoeithelial lesion
- Neoplasm - lymphoma , adenoma , carcinoma
- Sarcoidosis
- Infections - bacterial , actinomycosis , TB
- Metabolic conditions - malnutrition , Diabetes mellitus , Chronic
alcoholism

70. Salivary gland tumour (after Thackray and Sobin , 1972 )
Epithelial
 Adenoma - Pleomorphic adenoma
Monomorphic adenoma - Adenolymphoma( Warthin’s tumour ) ,
Oxyphilic adsdenoma (Oncocytoma) ,other monomorphic adenoma
 Mucoepidermoid tumour
 Acinic cell tumour
 Carcinomas - Adenoid cystic carcinoma , Adenocarcinoma , Epidermoid carcinoma ,
Squamous cell carcinoma , Undifferentiated carcinoma , Carcinoma in
Pleomorphic adenoma
Non-epithelial
 Haemangioma
 Lymphangioma
 Neurofibroma
 Lipoma
 Others including malignant variants of the above
 Lymphoma

71. Modified histopathological classification
 Adenoma - Pleomorphic adenoma , Myoepithelioma , Warthin’s tumour , Oncocytoma ,
Duct adenoma , Sebaceous adenoma , Duct papilloma , Papillary cyst adenoma
 Carcinoma - Mucoepidermoid carcinoma , Acinic cell carcinoma , ACC ,
Adenocarcinoma , Papillary cyst adenocarcinoma ,carcinoma in pleomorphic adenoma ,
Myoepithelial carcinoma , salivary duct carcinoma , basal cell carcinoma , sabecious
carcinoma , oncocytic carcinoma , SCC , adenosquamous carcinoma , Undifferentiated
carcinoma etc.
 Mesenchymal tumour - angioma , lipoma , neural tumour , sarcoma
 Malignant lymphoma
 Secondary tumour
 Unclassified tumour
 Tumour like disorders - sialosis , oncocytosis , necrotizing sialomataplasia , benign
lymphoepithelial lesion , salivary gland cyst , Kuttner tumour etc.

72. Adenomas

73. Pleomorphic adenoma
- Commonest type of salivary gland tumour
- 65%of all tumours of parotid , 55% of all tumours of minor glands
- all ages but predominant in 5th to 6th decade
- preponderence of woman
- slow growing painless , rubbery swelling
- overlying mucosa is intact
- a great variety of histological appearances , does not imply cellular
pleomorphism nor mixed tumour (epithelial origin )
- benign tumour
- connective tissue capsules does not always envelop the lesion
completely
- tumour is clearly demarcated
- isolated nodules of the tumour may also seen within or even outside
the capsule

74. Histology ; epithelial duct cells line the duct like structures ,
myoepithelial type cells-polygonal , spindle or stellate , sheets ,
clumps and interlacing strands , squamous metaplasia and epithelial
formations may be present , intercellular material - myxoid ( cells
are widely saperated and surrounded by mucoid material) and/or
chondoid ( cell lying inlacinae within the mucoid material resemble
hyaline cartilage )

75. Management - tumour excised with the margin of surrounding
normal tissue , include tissue beyond the pseudocapsule , high
recurrence - deficient encapsulation and intra and extracapsular
nodules , radioresistant , superficial parotidectomy with preservation
of VII CN , resection of the submandibular gland

76. Monomorphic adenoma
- less common than pleomorphicadenoma
- have more uniform structure

77. - almost exclusively in the parotid gland , bilateral in 5-10% of the cases
- most patients are over 40 years
- predominance of males over famales
- Papillary cyst adenoma lymphomatosum - papillary cystic structure
and shows multiple irregular cystic spaces containing solid papillary
projections of the tumour
Adenolymphoma ( Warthin’s
tumour )

78. Histology - epithelial component which clothes the papillary process ,
doubled layered , comprises basal layer of roughly cuboidal cells
surrounded by columnar cells , stroma containing the variable
amount of lymphoid tissue , which often includes germinal centres
Histogenesis - uncertain , arises from the salivery duct epithelium
entrapped within the
 lymph nodes during development

79. Mucoepidermoid tumour
- relatively higher in minor salivary glands , palate
- infiltrate locally and rare occasions eventually metastasise
- regarded as a malignant
- occur at any age , highest incidence is during 4-5 decades of life
- slight female predominance
- clinically in similar manner to the pleomorphic
- grossy cystic tumours may be fluctuant
- more agressive one may be accompanied by pain and ulceration

80. Histology ; consist mainly of two distinct but contiguous cell types ,
epidrmoid ( squamous ) cells and large , pale faintly granular mucous
cells
Well differentiated tumours - mucus secreting and epidermoid
predominate , often cystic
Poorly diferentiated tumours - epidermoid and intermediate cells
predominate , cystic spaces are not predominate
Management - excise completely , high recurrence , R/T is less
predictable
salivary scintigraphy

81. Adenoid cystic carcinoma ( Cylindroma )
- usually arises in middle aged or elderly patient
- slowly enlarging tumour indistingguishable from pleomorphic
adenoma
- pain and ulceration of the overlying mucosa
- parotid tumour may present with facial palsy
- spread along the nerve pathway , perineural invasion
- prolong clinical course and metastases are usually late finding
- lung is by far the most common site of metastasis, with the liver
being the second most common site


82. three major variant histologic growth patterns of ACC: cribriform,
tubular and solid. The solid pattern is associated with a more
aggressive disease course
characteristic cribriform ( Swiss cheese ) pattern , epithelial
component conists of polygonal cells with basophilic cytoplasm -
myoepithelial type , ductal lining like cells are also present , brightly
eosiniphilic , PAS positive , epithelial mucins are prominent feature
,typically arranged in well circumscribed , rounded group
surrounding more or less circular spaces , a few of these tumour have
tubular pattern , Hyaline material often forms in the connective tissue
surrounding the islands of tumour

83. Management - Surgical resection, whenever possible, is the mainstay
therapy. Based on clinical experience, many centers advocate
postoperative radiotherapy to help limit local failure.surgery , high
recurrence , radical resection ( parotidectomy )sacrifice of VII CN is
unavoidable , radiotherapy for paliative care only of inoperable cases

84. Right Parotid swelling
Facial paralysis present at the time of examination

85. Right Parotid swelling
No facial palsy
Right Ear lobe was
lifted up

87. Surgical considerations;
Neurovenous plane of cleavage of the facial nerve divisions and
branches within the substance of the parotid between the superficial
and deep lobes
also superficial to retromandibular vein ( posterior facial vein )
the main trunk of the facial nerve divides into temporofacial and
cervicofacial division

88. Parotid surgery
through preauricular
approach

89. Parotid surgery
Subtotal superficial lobectomy and total parotidectomy with
preservation of the facial nerve , for removal of the benign tumour
and mallignant tumour of low grade without evidence of facial nerve
paralysis
Radical parotidectomy for high degree malignancy or associated with
facial nerve paralysis
Enbloc radical parotidectomy consist of total parotidectomy including
the facial nerve , partial mandibulectomy and radical neck dissection

90. Superficial Parotidectomy
Facial nerve was preserved

91. Post-op 7 days
Proper healing of the preauricular surgical wound – lazy S scar
Absent of facial palsy

93. Complications of parotid surgery
Bell’s palsy
Frey’s syndrome
Parotid fistula?????????????

95. Palatal swelling at the junction of hard and soft palate ( Lt side )

96. Under GA
Excision of the swelling

97. Submandibular gland surgery
Excision of the gland either extraoral approach or intraoral approach

98. Sublingual gland surgery
Excision of the gland through intraoral approach

99. Parotid injury

101. Facial trauma resulting – facial palsy , salivary fistula

102. Parotid fistula – ietrogenic cutting of the duct which lies superficially

103. Stenson’s duct ligation

104. Saliva collection due to excised parotid duct during wide excision of the tumour at buccal mucosa
Parotid duct ligation was done

106. For PG

107. Biopsy
avoid open Bx in major salivary gland lesion
due to risk of spillage/ seeding
unless frankly malignant, no cytological Dx has been
made
for minor salivary glands ,open Bx is permissible
undertaken by dermatological punch

108. TNM staging
Tx Primary tumour cannot be assessed
T0 no evidence of primary tumour
T1 Tumour >_ 2 cm in greatest dimension without
extraparenchymal extension
T2 Tumour >_ 2 cm but <_ 4 cm in greatest dimension
without extraparenchymal extension
T3 Tumour >_ 4 cm and/or tumour having
extraparenchymal extension
T4a Tumour invades skin, mandible, ear canal , and/or
facial nerve
T4b Tumour invades skull base and/or pterygoid plates
and/or encases carotid artery

109. Post operative radiotherapy
high grade
advanced stage of tumour > 4cm with high risk of
local recurrence
residual neck disease
extracapsular spread of node
following surgery for recurrent disease
ACC