Surgical anatomy of salivary glands

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Surgical anatomy of salivary glands

  1. 1. Surgical Anatomy of Salivary GlandsSurgical Anatomy of Salivary Glands Dr./ Ihab Samy M.D. Surgical Oncology Lecturer of Surgical Oncology NCI – Cairo University 2011
  2. 2. 2 Salivary GlandsSalivary Glands
  3. 3. 3 EmbryologyEmbryology • The major salivary glands develop from theThe major salivary glands develop from the 6th-8th weeks of gestation as outpouchings6th-8th weeks of gestation as outpouchings of oral ectoderm into the surroundingof oral ectoderm into the surrounding mesenchyme.mesenchyme. • The parotid develops first, growingThe parotid develops first, growing posteriorly as the facial nerve advancesposteriorly as the facial nerve advances anteriorly; eventually, the fully developedanteriorly; eventually, the fully developed parotid surrounds VII.parotid surrounds VII. • However, the Parotid is the last to becomeHowever, the Parotid is the last to become encapsulated, after the lymphatics develop,encapsulated, after the lymphatics develop, resulting in its unique anatomy withresulting in its unique anatomy with entrapment of lymphatics in the parenchymaentrapment of lymphatics in the parenchyma of the glandof the gland
  4. 4. 4 • Salivary epithelial cells are oftenSalivary epithelial cells are often included within these lymph nodes,included within these lymph nodes, leading to development of Warthin’sleading to development of Warthin’s tumors and Lymphoepithelial cyststumors and Lymphoepithelial cysts within the Parotid gland.within the Parotid gland. • The other major salivary glands doThe other major salivary glands do NOT have intraparenchymal lymphNOT have intraparenchymal lymph nodes.nodes.
  5. 5. 5 Function of SalivaFunction of Saliva At least 8 major functions of saliva have been identified:At least 8 major functions of saliva have been identified: 1) Moistens oral mucosa. Mucin layer is the most important1) Moistens oral mucosa. Mucin layer is the most important nonimmune defense mechanism in the oral cavity.nonimmune defense mechanism in the oral cavity. 2) Moistens dry food and cools hot food.2) Moistens dry food and cools hot food. 3) A medium for dissolved foods to stimulate the taste buds.3) A medium for dissolved foods to stimulate the taste buds. 4) Buffers oral cavity contents due to high concentration of4) Buffers oral cavity contents due to high concentration of bicarbonate ions.bicarbonate ions. 5) Digestion. Alpha-amylase, contained in saliva, breaks 1-45) Digestion. Alpha-amylase, contained in saliva, breaks 1-4 glycoside bonds, while lingual lipase helps break down fats.glycoside bonds, while lingual lipase helps break down fats. 6) Controls bacterial flora of the oral cavity.6) Controls bacterial flora of the oral cavity. 7) Mineralization of new teeth and repair of precarious enamel7) Mineralization of new teeth and repair of precarious enamel lesions. Saliva is high in calcium and phosphate.lesions. Saliva is high in calcium and phosphate. 8) Protects the teeth. This signifies a saliva protein coat on the8) Protects the teeth. This signifies a saliva protein coat on the teeth which contains antibacterial compounds. Thus, salivaryteeth which contains antibacterial compounds. Thus, salivary hypofunction results in dental caries.hypofunction results in dental caries.
  6. 6. 6 The intraoral complications ofThe intraoral complications of salivary hypofunctionsalivary hypofunction • 1) Candidiasis1) Candidiasis • 2) Oral Lichen Planus (usually painful)2) Oral Lichen Planus (usually painful) • 3) Burning Mouth Syndrome (normal appearing oral mucosa with a3) Burning Mouth Syndrome (normal appearing oral mucosa with a subjective sensation of burning)subjective sensation of burning) • 4) Recurrent aphthous ulcers4) Recurrent aphthous ulcers • 5) Dental caries.5) Dental caries. • The best way to evaluate salivary function is to measure the salivaryThe best way to evaluate salivary function is to measure the salivary flow rate in stimulated (e.g., by using a parasympathomimetic asflow rate in stimulated (e.g., by using a parasympathomimetic as pilocarpine) and unstimulated states. Xerostomia is NOT a reliablepilocarpine) and unstimulated states. Xerostomia is NOT a reliable indicator of salivary hypofunction.indicator of salivary hypofunction. • Stimulation results in an increase in total salivary flow from 0.3 cc/minStimulation results in an increase in total salivary flow from 0.3 cc/min to >1 cc/min. The salivary response is directly related to a subject’sto >1 cc/min. The salivary response is directly related to a subject’s state of hungerstate of hunger
  7. 7. 7 The Parotid GlandThe Parotid Gland • The largest salivary glandThe largest salivary gland • Lies wedge-shaped between the mandibleLies wedge-shaped between the mandible and sternomastoid and over bothand sternomastoid and over both • Relations:Relations: • Above: external auditory meats and temporo-Above: external auditory meats and temporo- mandibular jointmandibular joint • Below: post belly digastricBelow: post belly digastric • Anteriorly: mandible and masseterAnteriorly: mandible and masseter • Medially: styloid process and its musclesMedially: styloid process and its muscles
  8. 8. 8 Structures at the Angle of theStructures at the Angle of the MandibleMandible • Medial relations of the parotid: theMedial relations of the parotid: the styloid process and its musclesstyloid process and its muscles separate the gland from theseparate the gland from the • internal jugular veininternal jugular vein • Internal carotid arteryInternal carotid artery • The last four cranial nervesThe last four cranial nerves • Lateral wall of the pharynxLateral wall of the pharynx
  9. 9. 9 Relations of the ParotidRelations of the Parotid
  10. 10. 10 Parotid BedParotid Bed
  11. 11. 11 Deep relations of ParotidDeep relations of Parotid
  12. 12. 12 FasciaFascia • The parotid is enclosed in a split in theThe parotid is enclosed in a split in the investing fasciainvesting fascia • The parotid lymph nodes lie both onThe parotid lymph nodes lie both on and below the parotid glandand below the parotid gland • Antero-inferiorly, the fascia isAntero-inferiorly, the fascia is thickened to form the stylomandibularthickened to form the stylomandibular ligament; the only structure thatligament; the only structure that separates the parotid from theseparates the parotid from the submandibular glandssubmandibular glands
  13. 13. 13 The Facial NerveThe Facial Nerve • The parotid gland is divided into superficialThe parotid gland is divided into superficial and deep lobes by three structuresand deep lobes by three structures traversing the gland:traversing the gland: • The Facial NerveThe Facial Nerve • The retromandibular vein (post facial) formedThe retromandibular vein (post facial) formed by the superficial temporal and maxillaryby the superficial temporal and maxillary • The external carotid artery dividing at theThe external carotid artery dividing at the neck of the mandible into the superficialneck of the mandible into the superficial temporal and maxillarytemporal and maxillary
  14. 14. 14 Relation of the Facial Nerve andRelation of the Facial Nerve and ParotidParotid • The parotid develops in the crotchThe parotid develops in the crotch formed by the 2 divisions of the facialformed by the 2 divisions of the facial nervenerve • As it enlarges it overlaps the nerveAs it enlarges it overlaps the nerve trunks, the superficial and deep partstrunks, the superficial and deep parts fuse and the nerve becomes buriedfuse and the nerve becomes buried within the gland.within the gland.
  15. 15. 15 Facial NerveFacial Nerve
  16. 16. 16 The Facial NerveThe Facial Nerve • Emerges from the stylomastoid foramenEmerges from the stylomastoid foramen • Winds laterally to the styloid processWinds laterally to the styloid process • Surgical ExposureSurgical Exposure • In the inverted V between the bony externalIn the inverted V between the bony external auditory meatus and the mastoid processauditory meatus and the mastoid process • Just beyond the point the nerve dives intoJust beyond the point the nerve dives into the post aspect of the parotid and bifurcatesthe post aspect of the parotid and bifurcates almost immediately into its two mainalmost immediately into its two main divisionsdivisions
  17. 17. 17 Branches of the Facial NBranches of the Facial N • The nerve then gives rise to 2 divisions:The nerve then gives rise to 2 divisions: • 1) Temperofacial (upper)1) Temperofacial (upper) • 2) Cervicofacial (lower)2) Cervicofacial (lower) • Followed by 5 terminal branches:Followed by 5 terminal branches: • 1) Temporal1) Temporal • 2) Zygomatic2) Zygomatic • 3) Buccal3) Buccal • 4) Marginal Mandibular4) Marginal Mandibular • 5) Cervical5) Cervical
  18. 18. 18 BranchesBranches • The two divisions may be completelyThe two divisions may be completely separate, may form a plexus ofseparate, may form a plexus of intermingling fibers, or may formintermingling fibers, or may form cross-communications that be dividedcross-communications that be divided safely during dissectionsafely during dissection
  19. 19. 19 Nerve InjuryNerve Injury • Clinical examination of the Parotid shouldClinical examination of the Parotid should include examination of the Facial nerveinclude examination of the Facial nerve • Malignant tumors of the parotid may involveMalignant tumors of the parotid may involve VII and cause facial palsy, while benignVII and cause facial palsy, while benign tumors never affect VIItumors never affect VII • During Superficial Parotidectomy, the nerveDuring Superficial Parotidectomy, the nerve is exposed posteriorly in the space betweenis exposed posteriorly in the space between the bony canal of external auditory meatusthe bony canal of external auditory meatus and the mastoid processand the mastoid process • It is then traced anteriorly into the gland toIt is then traced anteriorly into the gland to divide the gland superficial and deep bydivide the gland superficial and deep by nerve branchesnerve branches
  20. 20. 20 The Parotid DuctThe Parotid Duct • Stensen’s duct is 5 cm long.Stensen’s duct is 5 cm long. • Arises from the anterior part of theArises from the anterior part of the gland and runs over the masseter onegland and runs over the masseter one finger below the zygomatic arch tofinger below the zygomatic arch to pierce the buccinator and openpierce the buccinator and open opposite the second upper molar toothopposite the second upper molar tooth
  21. 21. 21 Parotid Duct orificeParotid Duct orifice • Clinical examination of the parotidClinical examination of the parotid gland should include examination ofgland should include examination of the duct orifice opposite the upper 2the duct orifice opposite the upper 2ndnd molar for signs of inflammation, andmolar for signs of inflammation, and palpated for stonepalpated for stone • Parotid Sialogram is performed byParotid Sialogram is performed by injecting a contrast through a canulainjecting a contrast through a canula placed in the orifice of the ductplaced in the orifice of the duct
  22. 22. 22
  23. 23. 23 Submandibular GlandSubmandibular Gland • Large superficial lobe and a small deepLarge superficial lobe and a small deep lobe, that connect around thelobe, that connect around the mylohyoidmylohyoid • Superficial lobe lies at the angle of theSuperficial lobe lies at the angle of the Jaw, wedged bet the mandible andJaw, wedged bet the mandible and mylohyoid and overlapping themylohyoid and overlapping the digastricdigastric
  24. 24. 24
  25. 25. 25 Superficial and DeepSuperficial and Deep RelationsRelations • Superficially:Superficially: The skin, the platysma, theThe skin, the platysma, the capsule (deep fascia), the cervical branch ofcapsule (deep fascia), the cervical branch of Facial Nerve, and the Facial VeinFacial Nerve, and the Facial Vein • Deeply:Deeply: the deep aspect lies against thethe deep aspect lies against the mylohyoid for the most part. But posteriorlymylohyoid for the most part. But posteriorly lies on the hyoglossus and comes in contactlies on the hyoglossus and comes in contact with the lingual and hypoglossal nerves.with the lingual and hypoglossal nerves. • Both nerves lie on the hyoglossus as theyBoth nerves lie on the hyoglossus as they pass forward to the tonguepass forward to the tongue
  26. 26. 26 The facial ArteryThe facial Artery • PosteriorPosterior • Arches over itsArches over its superior aspect tosuperior aspect to reach inferiorreach inferior border of theborder of the mandible andmandible and then ascends onthen ascends on to the face in frontto the face in front of the masseterof the masseter
  27. 27. 27 Facial arteryFacial artery
  28. 28. 28 The Submandibular DuctThe Submandibular Duct • Arises from the deep part of the gland, runsArises from the deep part of the gland, runs forward to open at the side of the frenulumforward to open at the side of the frenulum linguaelinguae • Lies beneath the mucosa of the floor of theLies beneath the mucosa of the floor of the mouth along the side of the tonguemouth along the side of the tongue • Lingual nerve loops around the duct, double-Lingual nerve loops around the duct, double- crossing it, by passing from lateral beneath,crossing it, by passing from lateral beneath, then medialthen medial • The sublingual salivary gland is also medialThe sublingual salivary gland is also medial to the duct.to the duct.
  29. 29. 29 Clinical ApplicationsClinical Applications • Submandibular LN are adherent to the glandSubmandibular LN are adherent to the gland and partly between it and the mandibleand partly between it and the mandible • Differentiating bet submandibular LN andDifferentiating bet submandibular LN and Salivary gland:Salivary gland: • The salivary gland can be palpatedThe salivary gland can be palpated bimanually as it extends into the floor of thebimanually as it extends into the floor of the mouth.mouth. • The Lymph Nodes are only felt below theThe Lymph Nodes are only felt below the mandible.mandible. • LN may be multiple and a space separatesLN may be multiple and a space separates them from the mandiblethem from the mandible
  30. 30. 30 Clinical ApplicationsClinical Applications • A stone in the submandibular duct canA stone in the submandibular duct can be felt bimanually in the floor of thebe felt bimanually in the floor of the mouth and can be seen if largemouth and can be seen if large • The presence of LN adherent to theThe presence of LN adherent to the gland makes removal of the gland partgland makes removal of the gland part of block neck dissectionof block neck dissection
  31. 31. 31 Autonomic InnervationsAutonomic Innervations • Parasympathetic Stimulation results in abundant,Parasympathetic Stimulation results in abundant, watery saliva with a decrease in [amylase] in salivawatery saliva with a decrease in [amylase] in saliva and an increase in [amylase] in the serum.and an increase in [amylase] in the serum. Acetylcholine is the active neurotransmitter, bindingAcetylcholine is the active neurotransmitter, binding at muscarinic receptors in the salivary glands. Theat muscarinic receptors in the salivary glands. The parasympathetic nervous system is the primaryparasympathetic nervous system is the primary instigator of salivary secretion.instigator of salivary secretion. • Parasympathetic Interruption to salivary glandsParasympathetic Interruption to salivary glands results in atrophy, while sympathetic interruptionresults in atrophy, while sympathetic interruption doesn’t cause a significant change.doesn’t cause a significant change. • It was once thought that the sympathetic nervousIt was once thought that the sympathetic nervous system antagonizes the parasympathetic nervoussystem antagonizes the parasympathetic nervous system, but this is now known not to be truesystem, but this is now known not to be true
  32. 32. 32 Autonomic InnervationAutonomic Innervation • In the case of the parotid,In the case of the parotid, parasympathetic fibers originate fromparasympathetic fibers originate from CN IXCN IX • In the case of the Submandibular andIn the case of the Submandibular and Sublingual glands, the parasympatheticSublingual glands, the parasympathetic fibers originate in CN VIIfibers originate in CN VII
  33. 33. 33 Sympathetic InnervationSympathetic Innervation • Stimulation by the sympathetic nervous systemStimulation by the sympathetic nervous system results in a scant, viscous saliva rich in solutes withresults in a scant, viscous saliva rich in solutes with an increase in [amylase] in the saliva and no changean increase in [amylase] in the saliva and no change in [amylase] in the serum.in [amylase] in the serum. • For all of the salivary glands, these fibers originateFor all of the salivary glands, these fibers originate in the Superior Cervical ganglion and travel within the Superior Cervical ganglion and travel with arteries to reach the glands:arteries to reach the glands: • 1) External Carotid artery for the Parotid1) External Carotid artery for the Parotid • 2) Lingual artery for the Submandibular, and2) Lingual artery for the Submandibular, and • 3) Facial artery in the case of the Sublingual.3) Facial artery in the case of the Sublingual.
  34. 34. 34 The Most Common TumorsThe Most Common Tumors • Histologically, salivary gland tumors are theHistologically, salivary gland tumors are the most heterogenous group of tumors of anymost heterogenous group of tumors of any tissue in the bodytissue in the body • Of salivary gland neoplasms, >50% areOf salivary gland neoplasms, >50% are benignbenign • Approximately 70% to 80% of all salivaryApproximately 70% to 80% of all salivary gland neoplasms originate in the parotidgland neoplasms originate in the parotid • The palate is the most common site of minorThe palate is the most common site of minor salivary gland tumorssalivary gland tumors • The frequency of malignant lesions variesThe frequency of malignant lesions varies by site.by site.
  35. 35. 35 Malignant TumorsMalignant Tumors • Approximately 20-25% of parotid, 35-40% ofApproximately 20-25% of parotid, 35-40% of submandibular tumors, 50% of palate tumors, and >submandibular tumors, 50% of palate tumors, and > 90% of sublingual gland tumors are malignant90% of sublingual gland tumors are malignant • The most common benign salivary tumor isThe most common benign salivary tumor is pleomorphic adenoma, comprising 50% of allpleomorphic adenoma, comprising 50% of all salivary tumors and 65% of parotid gland tumorssalivary tumors and 65% of parotid gland tumors • The most common malignant salivary tumor is theThe most common malignant salivary tumor is the mucoepidermoid carcinoma,mucoepidermoid carcinoma, comprising 10% of allcomprising 10% of all salivary gland neoplasms and 35% of malignantsalivary gland neoplasms and 35% of malignant salivary gland neoplasms, occurring most often insalivary gland neoplasms, occurring most often in the parotid gland.the parotid gland.
  36. 36. 36 Other types of malignant tumorsOther types of malignant tumors • Monomorphic Adenoma (Warthin’sMonomorphic Adenoma (Warthin’s tumor)tumor) • Malignant mixed salivary tumorMalignant mixed salivary tumor (Malignant Pleomorphic carcinoma)(Malignant Pleomorphic carcinoma) • Adenoid Cystic CarcinomaAdenoid Cystic Carcinoma • Acinic cell cancerAcinic cell cancer • AdenocarcinomaAdenocarcinoma • Squamous cell carcinomaSquamous cell carcinoma
  37. 37. 37 Q & AQ & A 1- Mark following statements as true (T) or false (F):1- Mark following statements as true (T) or false (F): A-The Parotid gland is the last to be encapsulatedA-The Parotid gland is the last to be encapsulated B-The Parotid gland has intraparenchymal lymphaticsB-The Parotid gland has intraparenchymal lymphatics C- The hypoglossal nerve divides the parotid gland intoC- The hypoglossal nerve divides the parotid gland into superficial and deep lobessuperficial and deep lobes D-The parotid duct opens in the floor of the mouthD-The parotid duct opens in the floor of the mouth E-The parotid secretion is mucus and viscousE-The parotid secretion is mucus and viscous
  38. 38. 38 Q 2Q 2 2- Mark following statements as true (T) or false (F):2- Mark following statements as true (T) or false (F): A-The Parotid gland is separated from theA-The Parotid gland is separated from the submandibular gland by the stylomastoid ligamentsubmandibular gland by the stylomastoid ligament B- Benign tumors of the parotid may cause facial neverB- Benign tumors of the parotid may cause facial never palsypalsy C- The facial Nerve divides into 2 trunks, each giving 3C- The facial Nerve divides into 2 trunks, each giving 3 branchesbranches D- The superficial and deep lobes of the parotid glandD- The superficial and deep lobes of the parotid gland are completely separated by the facial nerveare completely separated by the facial nerve E- The facial nerve trunk may be injured duringE- The facial nerve trunk may be injured during superficial parotidectomysuperficial parotidectomy
  39. 39. 39 Q 3Q 3 3-Mark following statements as true (T) or false (F):3-Mark following statements as true (T) or false (F): A-The submandibular gland consists of a large deepA-The submandibular gland consists of a large deep lobe and a small superficial lobelobe and a small superficial lobe B-Both lobes of the submandibular gland are separatedB-Both lobes of the submandibular gland are separated by the facial nerveby the facial nerve C-Salivary stones form more commonly in theC-Salivary stones form more commonly in the submandibular ductsubmandibular duct D-Submandibular sialadenectomy is part of block neckD-Submandibular sialadenectomy is part of block neck dissectiondissection E-Hypoglossal N runs below the deep part of theE-Hypoglossal N runs below the deep part of the submandibular glandsubmandibular gland
  40. 40. 40 Q 4Q 4 4-Mark following statements as true (T) or false (F):4-Mark following statements as true (T) or false (F): A- Pleomorphic adenoma is the most common salivaryA- Pleomorphic adenoma is the most common salivary gland tumorgland tumor B- Mucoepidermoid carcinoma is the most commonB- Mucoepidermoid carcinoma is the most common salivary gland tumorsalivary gland tumor C- Parotid gland tumors are most commonly malignantC- Parotid gland tumors are most commonly malignant D- Sublingual gland tumors are most commonlyD- Sublingual gland tumors are most commonly malignantmalignant E- Malignant Salivary gland tumors are treated byE- Malignant Salivary gland tumors are treated by Surgical excision followed by postoperativeSurgical excision followed by postoperative radiotherapyradiotherapy
  41. 41. 41 Key to AnswersKey to Answers Q 1 A: T, B: T, C: F, D: F, E: FQ 1 A: T, B: T, C: F, D: F, E: F Q 2: A: T, B: F, C: F, D: F, E: TQ 2: A: T, B: F, C: F, D: F, E: T Q 3: A:F, B: F, C:T, D: T, E: TQ 3: A:F, B: F, C:T, D: T, E: T Q 4: A: T, B: F, C: F, D: T, E: TQ 4: A: T, B: F, C: F, D: T, E: T

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